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BERLIN — The foundation of the World Health Organization in 1948 as one of the specialized agencies of the United Nations was a milestone in the history of global health efforts. It established not only the “highest attainable standard of health” for all people as a primary goal in the WHO constitution, but it also defined health not merely as “absence of disease or infirmity” but as “a state of complete physical, mental and social well-being.”
In addition, it confirmed health as a “fundamental right of every human being”; “fundamental to the attainment of peace and security”; and “dependent on the fullest co-operation of individuals and states.” The concept of linking global health with social well-being, human rights, international security and international cooperation made the agency a forerunner of the notion of interrelated global goods.
Yet despite these laudable goals, the WHO in practice has needed to take much smaller steps, since the member states behind the agency were not willing to let it interfere in their national health systems. Thus the WHO has not been able to carry out comprehensive health reforms to meet the agency’s overarching goals.
This lack of effective norm-setting power is expressed in the fact that the WHO has adopted only two legally binding treaties so far: the International Health Regulations, regulating worldwide cooperation in containing the spread of infectious diseases, and the Framework Convention on Tobacco Control.
The other normative texts issued by the WHO — typically called “guidelines” -– are recommendations only. Yet in evaluating the WHO, it should not be overlooked that it has set important standards in the diagnosis and treatment of diseases and — in cooperation with other UN organizations — engendered standards in the quality of food and risks of environmental factors, just to mention a few such rules.
The history of WHO has shown time and again that its true strength lies in practical measures: fighting infectious diseases and helping developing countries build up basic health services with trained workers advising and vaccinating people in rural areas. In this regard, the WHO has improved the lives of millions of people. The WHO succeeded over the decades, for instance, in improving the health of mothers and children in developing countries and in eradicating smallpox through vaccine programs as well as containing, to a certain extent, malaria and other tropical diseases. And since the late 1980s, the WHO included the fight against polio and HIV/AIDS in its agenda.
In spite of these obvious successes in the fight against infections, the WHO reached troubled waters in the mid-1990s. It faced the emergence of a large number of competing actors in global health: intergovernmental organizations, such as the World Bank or the Group of 20 as well as private foundations, equipped with vast amounts of money to fight against diseases like AIDS, tuberculosis and malaria.
The underfinanced WHO reacted to this competition without a clear orientation, attempting to make best use of the new players by cooperating with the donors in public-private partnerships. Yet it overlooked the underlying conflicts: the private donors, often connected with pharmaceutical firms, advocated huge vaccination programs and the use of pharmaceutical drugs, combining the good purpose — helping the sick — with good business; that is, the sale of large amounts of vaccines and expensive AIDS drugs, paid with charity money. Unlike the WHO, private donors were not so much interested in the strenuous efforts to improve the social and economic preconditions for health and a strong immune system for the people — like access to clean water, decent housing, sufficient food, anti-AIDS education and reliable health care.
Private donors were also not interested in providing developing countries with cheaper access to vaccines and expensive AIDS drugs by granting special licenses for their production in the respective countries. The recipient countries had to take these matters in their own hands: without any support from WHO, they achieved astonishing success in the World Trade Organization‘s taking charge of patent problems. This arrangement allowed developing countries to produce the drugs they needed at generic rates without consent of the patent owner.
For many critics of the WHO, it did not act according to its global responsibility– ensuring fair access to health for all. It also showed weakness by reacting hesitatingly and timidly to the nuclear catastrophes of Chernobyl in 1986 and Fukushima in 2011. The WHO has not tried earnestly to send its own experts in time to perform on-site inspections, including radiation measurements, and has even published reports playing down the issues.
In the case of the flu pandemic in 2009, the WHO — in the opinion of competent health experts — exaggerated the risks and asked governments to buy millions of vaccine doses that were not used, as countries did not agree with the WHO’s assessments. A report on the handling of this pandemic, commissioned by the Parliamentary Assembly of the Council of Europe, suggested that WHO’s overreaction might have been a result of having not enough distance from the pharmaceutical industry.
Many health experts recommend that the WHO give up competing with the more influential global health actors for resources for vaccination and other treatment programs. Let the others do it, they say, given that they have much more funds and can hire competent experts for a lot of money.
The core responsibility of the WHO lies in representing the interests of the poorer and weaker countries in negotiations with strong industrial countries over fair access to pharmaceutical drugs and vaccines; monitoring the development and spread of diseases; and coordinating the international measures against them. The WHO should also pursue with emphasis its responsibility in advocating for research of all diseases, independent of commercial interests, and in advising in the improvement of national health services. That way, the WHO can make progress on the way to “health for all.”
This essay is the first in a series on UN agencies.