From The Daily Sceptic
Finalisation of the much-heralded Pandemic Agreement, the flagship of the World Health Organisation’s pandemic agenda, has just been postponed again after another failure to resolve disagreements. Despite heavy pressure from the WHO and European Union in yet another meeting in Geneva, Switzerland, a large bloc of African states is refusing to sign on to what the states consider a clear colonialist agenda. Which of course it is, aimed at putting Covid-era wealth transfers on a more permanent footing.
The WHO, for reasons explained below, is doing what it is paid to do. Major financial sponsors of the WHO have much to gain from getting this agreement through. It has fallen on African leaders, attuned to the model of rich countries and their corporations imposing rules designed for wealth extraction, to protect the rest of us from the farce that the current public health approach to pandemics has become.
The fact that the agency tasked with building capacity and promoting sustainability of low-income health systems is instead doing the opposite now needs to become the central issue of this whole shabby episode. It is time for the international public health community to face itself and decide on which side – people or profit – it should stand.
The modern basis of multilateral health cooperation
There are obvious reasons for countries to cooperate in matters of health, as there are for neighbours in a suburban street: mutual interest in facing common threats where action by neighbouring states or access to their resources helps protect your own, as well as moral reasons based on the generally accepted ‘good’ of helping neighbours when they are in difficulty or lack resources through no fault of their own. Or because a stable and more prosperous neighbourhood (world) is good for business, and a sick one may not be.
Cooperation is not submission, and few self-respecting people would opt for that. Mutual interests and morality all dissolve fairly quickly when cooperation becomes coercion, and the interests of the most powerful player then become the goal. Health is well defined in the WHO’s constitution as physical, mental and social well-being. Accordingly, it rests on economics and social capital and is degraded by poverty and inequality. Neither aspect of wellbeing – mental, social or physical – is supported by forced compliance or slavery.
The basis of modern medical ethics hinges on Hippocrates’s assertions on physician conduct from around 400BC, commonly summarised as to do good rather than harm and respect a patient’s privacy (confidentiality). As a counter to fascism since the Second World War, we added voluntary informed consent, i.e., absence of coercion. This means the final decision in any aspect of medical care or intervention must rest with the individual concerned.
These basic medical ethics rest on the concept that all people are equal and their individual sovereignty (i.e., bodily autonomy) is inviolable. Accordingly, it is obviously unethical to force a person to be injected or undergo some other procedure just because someone else wants them to or for a third person’s benefit. Unethical, that is, outside a medico-fascist or similarly authoritarian approach that post-World War Two human rights law was supposed to suppress. There were very good reasons why we stopped all that, even if it made the streets look cleaner and we are assured it was for a ‘greater good’.
As the Hippocratic Oath and voluntary informed consent govern clinical medical practice, public health is consequently subject to the same requirements at a community, national and global level. Populations are the sum of individuals, each being imbued with equal rights and intrinsic sovereignty. Therefore, decisions made at a regional or global level can only be made by agencies over which those individuals, as a collective, exert control. This is the basis of the UN charter: sovereign states, being the best means we have of expressing the collective decisions of sovereign individuals. It is a massively flawed model – some states are dictatorships and many oppress minorities and ignore their individual sovereignty – but this is because we are working with flawed humans. Sovereign states are the basis of the modern world.
The alternative is a technocracy in which self-designated individuals make decisions and simply force or coerce others to obey – a form of fascism (an unpopular term for a relatively popular approach). This is the antithesis of modern understandings of human rights. It remains popular, including in the public health community, because it provides a sense of self-importance whilst also addressing the needs of wealthy sponsors. It also provides simple rules to live by and a group to belong to. But fundamentally fascism, like feudalism which served the same purpose in former times, relies on acceptance of inequality. This is why we need to name it when we see it, and insist on individual decision-making over any dictatorship of experts.
What should modern public health cooperation look like?
Once we accept basic human rights – individual sovereignty – as a prerequisite for legitimate public health, we can then decide what type of interventions might be useful. Given the heterogeneity of disease-risk related to differing population age structures and environments and the wide variation in human culture that influences what each of us define as important, such decisions would have to be taken at a decentralised level. Advice may be given from a distance, but action can only be decided in context or it is likely to be counterproductive. Subsidiarity rather than centralisation is therefore a prerequisite for effective decision-making, not just to protect individual rights but to achieve a meaningful and lasting impact on health. Though obvious to most people, this is really hard for many credentialled public health professionals to accept. We all have egos and think of ourselves as experts.
Fortunately, modern communications make decentralisation easy. Travel is easy, and we can meet instantaneously by digital means. Centralisation made sense for certain aspects of the Roman state – and in many ways for the WHO on its formation in 1948. The days of steam ships and elephants disrupting landlines are gone now, though the human desire for a comfortable life by a Swiss lake persists.
Decisions must also (rather obviously) be based on evidence and be amendable to change as new information emerges. Efficiency dictates a focus on building systems and expertise that address overall health outcomes such as nutrition, sanitation and access to basic clinical care. It also suggests prioritising the largest disease burdens readily amenable to prevention or treatment such as endemic infectious diseases (malaria, tuberculosis etc.) rather than, say, diseases based on individual and deliberate lifestyle choice.
Evidence-based public health also emphasises the importance of building strong economies. Building national economies allows countries to maintain better health systems. Promoting impoverishment, such as through prolonged school closures, workplace closures or closing borders, sets everything back and so is expected to cause great long-term harm to health.
At a global level, diseases that cross borders and sudden crises such as epidemics are also good targets for cooperation. More time to prepare for an outbreak or better standards to collectively address it are a good thing. But such events are occasional and of low overall burden compared to the big killers of humankind. Addressing outbreaks in a way that undermines economies and the underlying determinants of health would obviously be foolish. As we saw during the Covid response, such poor public health responses promoted by WHO increased child marriage, child labour and deep poverty, and grew national debt. They did make some other people very wealthy, but had little impact on COVID-19 itself.
Why the WHO can no longer help
All the foregoing should be non-controversial. Some will push back on the Covid bit from a career or political viewpoint but in fact it’s orthodox public health. The agency meant to fill the role of coordinating all this today is the WHO. When the WHO started its work, colonial powers still admitted to being colonial powers and we gave Nobel Prizes for frontal lobotomies. However, WHO was supposed to help improve things. Its governance was based on one-country one-vote, and it was core-funded based on each country’s capacity. With its original intent of egalitarianism, evidence-based policy, prioritisation of low-income populations and contextual decision-making in mind, it is worth looking quickly at what the WHO has become:
- The WHO is headquartered with over a quarter of its staff in headquarters in Geneva, Switzerland, one of the most expensive cities on earth.
- The bulk of the WHO’s work is dictated by individual funders who directly specify the use of their money – making the organisation a tool for those with the most money, rather than the populations who need more assistance).
- The largest funder, Bill Gates, is from a wealthy United States background with no low-income country or hands-on public health experience but strong connections to the pharmaceutical and software industries.
- The WHO’s second largest funder over the past two years was Gavi, a public-private partnership including multinational pharmaceutical corporations. The WHO acts as a de facto market development and access agency for those corporations (which enables executives from them to justify their involvement to their shareholders).
- WHO staff receive good salaries, generous education subsidies for their children, good health insurance, are tax exempt and have a pension scheme structured to kick in after years of service and then rapidly accumulate, promoting longevity and institutional loyalty (i.e., to institution rather than mission).
The result is, as expected, a focus on commodity-heavy vertical programmes and a workforce incentivised to maintain such a model. Pharma company executives and their major investors are there to maximise return on investment, not ensure good nutrition. They may care, but their job is elsewhere. There are no large companies thriving off good diets or sanitation and accordingly no public-private partnerships to promote these. The WHO must comply with the priorities its funders dictate.
Time for a return to legitimacy
An international public health agency should prioritise building national health system capacity, independence and resilience. In contrast, the WHO has become a colonialist endeavour, serving the same partnership of powers and commercial interests while sanitising it as keeping the world ‘safe’.
The outcomes of the Covid response will be repeated: millions more children having prospects stolen and poverty ensured. Funding for nutrition – critical to build resilience against both endemic and epidemic disease – is falling while WHO and partners construct veritable fairytales to promote more profitable agendas. Resources diversion in public health is never value-neutral.
Advocating reform or replacement of the WHO is therefore not radical but intrinsically anti-colonialist, pro-human rights, pro-evidence and pro-public health. The Right to Health Sovereignty reports follow this model. But there is much invested in maintaining the status quo and a global health workforce strongly incentivised to support this.
The job of leaders of modern states is to ensure the welfare of their people, and this is the only legitimate mechanism from which meaningful change can come to international health. The United States’ withdrawal from the WHO offers an opportunity, but it is the low-income countries on the receiving end of the WHO’s capture who need to drive change. The pushback on the Pandemic Agreement suggests that this may be happening. The global health workforce needs to cease its subservience to vested interests and stop blocking progress. We need international health cooperation based on sovereignty, ethics and integrity, not a continued slide back to the failures of a bygone colonial era.
Dr David Bell is a clinical and public health physician with a PhD in population health and background in internal medicine, modelling and epidemiology of infectious disease. Previously, he was programme head for malaria and acute febrile disease at FIND in Geneva and coordinating malaria diagnostics strategy with the World Health Organisation. He is a Senior Scholar at the Brownstone Institute.
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