The World Health Organization (WHO), whose constitution defines health as ‘a state of physical, mental and social well-being, not merely the absence of disease or infirmity,’ has recently orchestrated remarkable reversals in human rights, poverty reduction, education, and physical, mental and social health indices in the name of responding to the Covid-19 pandemic.
WHO proposes to expand the mechanisms that enabled this response, diverting unprecedented resources to addressing what in terms of history and disease are rare and relatively low-impact events. This will greatly benefit those who also did well from the Covid-19 outbreak, but has different implications for the rest of us. To address it calmly and rationally, we need to understand it.
Building a new pandemic industry
The World Health Organization (WHO) and its Member States, in concert with other international institutions, is proposing, and currently negotiating, two instruments to address pandemics and widely manage aspects of global public health. Both will significantly expand the international bureaucracy that has grown over the past decade to prepare for, or respond to, pandemics, with particular emphasis on development and use of vaccines.
This bureaucracy would be answerable to the WHO, an organization that in turn is increasingly answerable, through funding and political influence, from private individuals, corporations and the large authoritarian States.
These proposed rules and structures, if adopted, would fundamentally change international public health, moving the center of gravity from common endemic diseases to relatively rare outbreaks of new pathogens, and building an industry around it that will potentially be self-perpetuating.
In the process, it will increase external involvement in areas of decision-making that in most constitutional democracies are the purview of elected governments answerable to their population.
WHO does not clearly define the terms ‘pandemic’ and ‘public health emergency’ that these new agreements, intended to have power under international law, seek to address. Implementation will depend on the opinion of individuals – the Director General (DG) of the WHO, Regional Directors and an advisory committee that they can choose to follow or ignore.
As a ‘pandemic’ in WHO parlance does not include a requirement of severity but simply broad spread – a property common to respiratory viruses – this leaves a lot of room for the DG to proclaim emergencies and set the wheels in motion to repeat the sort of pandemic responses we have seen trialed in the past 2 years.
Responses that have been unprecedented in their removal of basic peace-time human rights, and that the WHO, Unicef and other United Nations (UN) agencies have acknowledged to cause widespread harm.
This has potential to be a boon for Big Pharma and their investors who have done so well out of the last two years, concentrating private wealth whilst increasing national indebtedness and reversing prior progress on poverty reduction.
However, it is not something that has just appeared, and is not going to make us slaves before the month is out. If we are to address this issue and restore societal sanity and balance in public health, we need to understand what we are dealing with.
Proposed International Health Regulations (IHR) amendments
The IHR amendments, proposed by the United States, build on the existing IHR that were introduced in 2005 and are binding under international law. While many are unaware of their existence, the IHR already enables the WHO DG to declare public health emergencies of international concern, and thereby recommend measures to isolate countries and restrict movement of people. The draft amendments include proposals to:
- Establish an ‘emergency committee’ to assess health threats and outbreaks and recommend responses.
- Establish a ‘Country review mechanism’ to assess compliance of countries with various recommendations / requirements of WHO regarding pandemic preparedness, including surveillance and reporting measures. This appears to be modeled on the UN’s human rights country review mechanism. Countries would then be issued with requirements to be addressed to bring them into compliance where their internal programs are considered inadequate, on the request of another State party (country).
- Expand the power of the WHO DG to declare pandemics and health emergencies, and therefore recommend border closures, interruption and removal of rights to travel and potentially internal ‘lockdown’ requirements and send teams of WHO personnel to countries to investigate outbreaks, irrespective of the findings of the emergency committee and without consent of the country where the instance is recorded.
- Reduce the usual review period for countries to internally discuss and opt out of such mechanisms to just 6 months (rather than 18 months for the original IHR), and then implement them after a 6-month notice period.
- Empower Regional Directors, of which there are 6, to declare regional ‘public health emergencies,’ irrespective of a decision by the DG.
These amendments will be discussed and voted on at the World Health Assembly on May 22-28, 2022. They only require only a simple majority of countries present to come into law, consistent with Article 60 of the WHO constitution. For clarity, this means countries such as Niue, with 1,300 people, have an equal weight on the voting floor as India, with 1.3 billion people. Countries must then signal intent to opt out of the new amendments within 6 months.
Once approved by the WHA, these measures will become legally binding. There will be heavy pressure applied to governments to comply with the dictates of the WHO DG and the unelected bureaucrats that comprise the organization, and thereby also the external actors who are influential in WHO decision-making processes.
Proposed WHO pandemic ‘treaty’
The WHO proposes a new ‘instrument’ to allow it to manage pandemics, with force of a convention under international law. This has been formally discussed within WHO since early 2021, and a special session of the WHA in November 2021 recommended it go to a review process, with a draft to be presented to the World Health Assembly meeting in Q2 2023.
This proposed treaty would give WHO powers to:
- Investigate epidemics within countries,
- Recommend or even require border closures,
- Potentially recommend travel restrictions on individuals,
- Impose measures recommended by the WHO which, based on Covid-19 experience, may include ‘lockdowns,’ prevention of employment, disruption of family life and internal travel, and mandated masks and vaccination,
- Involve non-state actors (e.g., private corporations) in data gathering and predictive modeling to influence and guide pandemic responses; and in implementing, including providing commodities for, the response;
- Impose censorship through control of, or restrictions on, information the WHO considers to be ‘mis-information’ or ‘dis-information’, which may include criticism of the measures WHO imposes.
Notably, it envisions the setting up of a large entity within WHO to support permanent staff whose purpose is to undertake and enforce the above measures. This sounds very similar to the ‘GERM’ entity proposed recently by Mr Bill Gates, a wealthy US software developer with major pharmaceutical investments, who is the second largest funder of the WHO and one of a number of ‘billionaires’ who have greatly increased personal wealth during the Covid-19 response.
The proposed treaty would prioritize vertical structures and pharmaceutical approaches to pandemics, reflecting approaches by Gavi and CEPI, two organizations set up in the past decade in parallel to the WHO. It would create another bureaucratic structure on pandemics, not answerable directly to any taxpayer base, but imposing further support, reporting and compliance requirements.
Process, acceptance and implementation
These two mechanisms for increasing direct WHO control of pandemics have strong backing from private sector funders of the WHO, and from many national governments, starting with Western governments who adopted Covid draconian measures. To come into practice they must be adopted by the WHA and then be agreed, or ratified, by national governments.
The proposed IHR amendments modify an existing mechanism. A simple majority of States present at the WHA voting against them at the May 2022 meeting would also reject them, but this appears unlikely. To prevent their application, sufficient individual countries will need to signal non-acceptance or reservations after the coming WHA and WHO DG’s notice of adoption, so probably before the end of November 2022.
With regard to the proposed treaty, a two-thirds majority at the 2023 WHA will be required for its adoption, after which it will be subject to national ratification by processes which vary according to national norms and constitutions.
Funding for the large increase in bureaucracy proposed to support both mechanisms will be necessary – this may be partially diverted from other disease areas but will almost certainly require new, regular funding. Other mechanisms in parallel are already being discussed, with the World Bank also proposed as the home for a similar bureaucracy to manage pandemic preparedness, and the G20 mulling their own mechanism.
It is unclear whether these would be tied into the WHO’s proposed treaty and IHR mechanisms or be presented as a ‘rival’ approach. The G20 task force of the WB and WHO suggest a $10.5 billion additional annual budget for pandemic preparedness is required. With such potential financing on offer, and the promise of building powerful institutions around this pandemic preparedness agenda, there is going to be much enthusiasm and momentum, not least from institutional staff and the global health community in general, who will sense lucrative employment and grant opportunities.
While all this depends on money being available, a refusal of countries to fund may not be sufficient to prevent it, as there is considerable private and corporate interest in the treaty and related proposals. The same entities that benefited heavily financially from the Covid-19 response will also stand to benefit from an increased frequency of similar responses.
Whilst pandemics are historically rare, the existence of a large bureaucracy dependent on their declaration and response, coupled with the clear gains to be made by influential funders of the WHO, raise a strong risk that the bar to declaring emergencies, and imposing human rights restrictions on States, will be far lower than before.
Independent States are not however directly subject to the WHO, and adopting these amendments and treaties will not automatically allow the WHO to send teams across borders. Treaties must be ratified according to national processes and constitutions. If accepted by the WHA, it will however be difficult for individual States to avoid compliance unless they are particularly influential on the WHO itself.
International financial agencies, such as the IMF and World Bank, can also exert considerable pressure on non-complying States, potentially tying loans to implementation and commodity purchase as the World Bank has done for the COVID-19 response.
The IHR amendments also allow measures to be taken such as interrupting international travel that can be economically very harmful to small States, irrespective of the State providing permission. Powerful States that are highly influential on the DG election may also in practice be subject to different levels of implementation than smaller ones.
There seems at least two feasible scenarios for preventing the adoption of the two new mechanisms.
Firstly, the populations in democratic donor States, who have most to lose in terms of autonomy, sovereignty and human rights and whose taxes will predominantly fund these institutions, can stimulate open debate leading to decisions of national governments to reject the treaty at the WHA, and/or otherwise refuse to ratify.
Secondly, large blocs of countries could refuse to ratify or subsequently comply, making the treaty and IHR amendments unworkable. The latter is conceivable if, for instance, African nations perceive all this as a form of neo-colonialism that needs to be fought in the name of independence.
Some background on pandemic risk, and the WHO.
What is the risk of pandemics?
WHO records 5 pandemics in the past 120 years:
- The Spanish Flu (1918-19), killed 20-509 million people. Most died due to secondary bacterial infection, as this was before availability of any modern antibiotics.
- The 1957-58 influenza outbreaks that killed about 1.1 million people each
- The 1968-69 influenza outbreak that also killed about 1.1 million
- Swine Flu in 2009-10 killed about 120,000 to 230,000.
- Lastly, COVID-19 (2020-22) is recorded by WHO as contributing to the death of several million, but most in old age with other severe comorbidities, so actual figures are difficult to assess. As this indicates.
Pandemics have therefore been rare – once per generation. For context, cancer kills many more people each year in Western countries than Covid-19 at its height, tuberculosis kills 1.6 million people every year (much younger than Covid-19) and malaria kills over half a million children annually (barely affected by COVID-19).
However, as pandemics are very loosely defined by WHO, it Is not unreasonable to assume that a large bureaucracy dependent on pandemics to justify its own existence, and heavily invested in surveillance for new strains of virus, will find reason to declare far more pandemics in the future.
COVID-19 is the first pandemic in which mass lockdowns, including border closures, workplace closures and prolonged school closures, have been used on a large scale. It is worth remembering that 1969 is remembered for the Woodstock music festival more than the ‘Hong Kong flu,’ a pandemic that targeted young people more than Covid-19. Human rights and economic health did not suffer such declines in any of these prior events.
These new approaches used in the Covid-19 response have resulted in wide disruption of supply lines and healthcare access, increases in early marriage / enslavement of women, mass loss of education of children, and increases in current financial inequality and educational (so future) inequality. Many low-income countries have increased debt and undergone recession, which will reduce future life expectancy, while child deaths have increased, including from former priority diseases such as malaria.
What is WHO, and who owns or runs it?
The WHO (the World Health Organization) was set up in the late 1940s, to coordinate health standards and data sharing internationally, including support for the response to pandemics. It is the main health agency of the United Nations Organization (UN). It provides some support for low-income country health systems where local technical expertise is lacking.
It has country offices in most countries, 6 regional offices, and a global office in Geneva. It is a hierarchical organization, with the Director General (DG) at its head. It has a few thousand staff (depending on definition) and a budget of roughly $3.5 billion a year.
The WHO is controlled in theory by the member nations (most UN members, and a couple of others), on a one country-one vote basis through the World Health Assembly, that usually meets annually. As example, India, with 1.3 billion people, has the same power on the voting floor as Nuie, with 1,300 people. The WHA elects the DG through a 4-yearly vote that is often heavily accompanied by lobbying by major countries.
WHO funding was originally nearly all derived from member countries, who contributed to the ‘core’ budget. WHO would then decide on priorities for expenditure, guided by the WHA. In the past 2 decades, there has been a significant change in funding:
- A rapid increase in private funding, from individuals and corporations. Some is direct, some indirect through parallel international health organizations (Gavi, Cepi) that are heavily privately funded. The second largest contributor to the WHO budget is now a private couple in the United States heavily invested in the international pharmaceutical sector and in software / digitization services.
- The budget has moved from mainly core funding, to mainly ‘directed’ funding, in which the funder specifies the area in which the funding can be used, and sometimes the actual activities to be undertaken. The WHO therefore becomes a conduit for their funds to undertake their intended activities. Both country private funders heavily use this directed approach.
The WHO therefore retains under overall control of an assembly of countries, but day-to-day priorities are increasingly directed by single countries and private interests. Former strong rules on conflict of interest regarding private sector involvement are less externally obvious now, with WHO working more closely with private and corporate sector entities.
- WHO constitution: https://apps.who.int/gb/bd/PDF/bd47/EN/constitution-en.pdf?ua=1
- IHR 2005: https://www.who.int/publications/i/item/9789241580410
- WHO IHR proposed amendments: https://apps.who.int/gb/ebwha/pdf_files/WHA75/A75_18-en.pdf
- EU and proposed WHO treaty: https://www.consilium.europa.eu/en/policies/coronavirus/pandemic-treaty/
- WHO WHA Nov 21 Special Session draft report: https://apps.who.int/gb/wgpr/pdf_files/wgpr5/A_WGPR5_2-en.pdf
- WHO (EURO) influenza pandemic definition: https://www.euro.who.int/en/health-topics/communicable-diseases/influenza/pandemic-influenza
- WHO ‘zero draft’ of proposed pandemic treaty: https://apps.who.int/gb/wgpr/pdf_files/wgpr9/A_WGPR9_3-en.pdf
- Review of WHO pandemic definitions: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3127275/
- Unicef on harms from public health response:
- IFF harms from public health response: https://www.globalfinancingfacility.org/emerging-data-estimates-each-covid-19-death-more-two-women-and-children-have-lost-their-lives-result
- BIS on health impact of economic harms https://www.bis.org/publ/work910.htm
- On G20 and World Bank mechanisms: https://g20.org/wp-content/uploads/2022/02/G20-FHTF-Financing-Gaps-for-PPR-WHOWB-Feb-10_Final.pdf
- WHO pandemic guidelines (includes previous pandemic list): https://apps.who.int/iris/bitstream/handle/10665/329438/9789241516839-eng.pdf
- Background on evolution of the WHO: https://www.pandata.org/who-and-covid-19-re-establishing-colonialism-in-public-health/
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David Bell is a public health physician based in the United States. After working in internal medicine and public health in Australia and the UK, he worked in the World Health Organization (WHO), as Programme Head for malaria and febrile diseases at the Foundation for Innovative New Diagnostics (FIND) in Geneva, and as Director of Global Health Technologies at Intellectual Ventures Global Good Fund in Bellevue, USA. He consults in biotech and global health. MBBS, MTH, PhD, FAFPHM, FRCP