The WHO’s Paradoxical Mandate
By Tine Hanrieder
In many countries around the world, the WHO is currently setting the agenda for a strategy to contain the Covid-19 pandemic. Its campaigns and recommendations on how to deal with Covid-19 are, though not entirely uncontroversial, widely distributed, while reaffirming one of its central roles: that of the epidemiological expert and crisis advisor, especially for poor countries.
Its role as an epidemiological control center is, however, characterized by a paradox. On the one hand, the WHO - founded in 1946 - has within the scope of its technocratic advisory mandate an ability to speak solely in the name of health. It is responsible for assessing how human life can be saved, while providing information that helps combat fake medical news. On the other hand, its advice is rarely heeded outside of crises. Provision works better than any cure, health systems must be prepared to fight many diseases, not just those fashionable in developmental policy, basic social security is at the core of health policy - these are all messages the WHO has spread for decades, with far too little impact. There are many reasons for this. Here, I would like to highlight two of them.
Firstly, since its establishment, the social policy initiatives of the WHO have met with massive resistance. Its work on health insurance, the impact of patents on health care as well as the wider socioeconomic conditions of health have been all but rejected by countries in the Global North. During the Cold War, the United States rejected the WHO's proposals as a "gateway to socialism". In the 1980s, comprehensive approaches to health care were swept aside by a neoliberal wave of privatization and have since been reduced to methods of "selective" primary care - punctual technologies such as vaccines or low-cost diagnostics. However, the cost-effectiveness of such "smart" investment is often calculated under the assumption that the regions affected will remain poor and underdeveloped in the medium term. Here, chronic emergency care has been inscribed as the norm.
The second reason, the ideological primacy of medicine within the larger domain of health policy, is closely related. In today’s global society, it seems as though in order to attain the position of an authority on health, one needs to confine oneself to a narrowly defined medical role, one targeting sick individuals and foregrounding the biological. The WHO has long tried to point out the social factors causing uneven distributions of health and disease. The existence of strong scientific evidence for non-medical and long-term determinants of poor health - poverty, housing deprivation, job insecurity, racism, violence, environmental pollution, or patent regulations – has rarely had any effect on policy-makers. Such an image of health acts as an ideological gatekeeper, set to ignore health's socio-economic determinants.
The WHO's budget is roughly the size of that of a well-equipped Swiss university hospital. It can only make suggestions on how to strengthen health systems or prepare for pandemics. What it cannot do, is provide proper financial assistance. It also cannot enforce acts of inter-state solidarity. Now that the pandemic is reaching Africa, the WHO is left to assume the unpleasant role of a mere crisis manager. In many cases, for example when advising local mayors to evacuate slums, it simply acts as the bearer of bad news.
The recent call for the appointment of a chief economist to the WHO could prove an important first step. Such a position would grant the WHO a stronger mandate to provide expert opinion, for example on the negative health effects of unfair trade deals or on potential political leeway - also present during recessions – in order to shield off negative effects through social security instead of bowing to the altar of austerity.
Yet unfortunately, it does not take much to imagine a series of hackathons innovating digital and remote “care”, or the construction of inflatable quarantine replacement slums in the post-Corona period, both of which will again not touch on deeper causes. From time to time, the WHO will remind us of these. We probably will not listen. As long as health is recognized as a human right only in periods of visible dying, health policy remains confined to the mere policing of illness.
14 April 2020 / FJB