India is set to be elected Chair of the World Health Organization’s decision-making Executive Board at its 73rd World Health Assembly, 18-19 May 2020, with the Executive Board on 22 May.
Tokyo: The old adage among multilateral staff “World Health Organization (WHO) is the UN agency that knows everything but does nothing” took an ominous turn in the past months, with widespread allegations that WHO’s failure to act decisively has resulted in 4 million infected with SARS-CoV-2 and 300,000 Covid-19 deaths, with much of the world in lockdown or under emergency, when it might otherwise have been restricted to a localized outbreak in Wuhan, China. It is, therefore, neither anti-WHO nor anti-Chinese to demand to know just what happened via a properly conducted independent international inquiry.
India is set to be elected Chair of the World Health Organization’s decision-making Executive Board at its 73rd World Health Assembly, 18-19 May 2020, with the Executive Board on 22 May, the first time ever that it will be a “virtual gathering”. WHA is usually associated with much hobnobbing and “advocacy/lobbying” for various causes and interests. Doctor-politicians like to play their cards in the corridors and anterooms, not in the spotlight of virtual conferences that are recorded for posterity. WHAs are attended by Health Ministers and a multitude of staff. But since it concerns global health issues, Foreign Ministries of all countries are also involved, as are diplomats accredited to the UN’s European Headquarters at the Palais des Nations in Geneva (once home to the UN’s defunct predecessor, The League of Nations).
SIGN OF CLASHES
The prestigious German magazine Der Spiegel reported that WHO withheld information about the coronavirus, following pressure from China and referenced the German foreign intelligence agency, BND, which has kept public silence. The Dictionary of Epidemiology published by the International Epidemiological Association with Oxford University Press defines an epidemic as the occurrence in a region of cases of an illness clearly in excess of normal expectancy. As a novel disease, therefore, even in December it should have been classified as an epidemic in China, and in January as a pandemic that is defined as an epidemic occurring over a very wide area, crossing international boundaries, and affecting a large number of people. As of 3 February, over 17,000 people had been infected in China, the US, Canada, Italy, France, Germany, Russia, Australia, India, very clearly meeting the text-book definition of a pandemic. Yet, WHO declared it as a pandemic only on 11 March. WHO denied the Der Spiegel report that around six weeks had been lost in alerting the world due to dithering, but it only highlights the impending acrimony. Meanwhile, multiple publications and experts in the US and Europe have also criticized the apparent China-WHO lockstep, with Japan’s Finance Minister Taro Aso going so far as to describe WHO as Chinese Health Organization (CHO) in a parliamentary committee.
TAIWAN
It is hard to believe that China would utilise its veto as a Permanent Member of the UN Security Council to block Taiwan’s mere participation as an Observer, not a full Member, especially as Taiwan did have Observer status at WHA during years of warmer China-Taiwan relations 2009-2016. The Vatican, Red Cross, Inter-Parliamentary Union are among many entities that have Observer status. Now, the US and several other countries are demanding that Taiwan be re-admitted as an Observer. India recently received 1 million surgical masks from Taiwan and is being pressed by multiple countries to do its part for Taiwan, which has been sharing much information as well, certainly on its great success in managing Covid through usage of digital tools that I have described in another column. Taiwan’s international status is intriguing, because the Ch’ing Dynasty of China formally ceded Taiwan (then Formosa) to Japan “in perpetuity” as stated in the Treaty of Shimonoseki after the 1895 Japan-China war. After World War II ended in 1945, Generalissimo Chiang Kai-shek, on behalf of the Allies, took charge of Taiwan and it has remained separate from China even after Chiang and his army fled to Taiwan after the Chinese Communist Party under Chairman Mao took over the whole of Mainland China in 1949. Thus, there has never been any political link between the People’s Republic of China (Communist China) and Taiwan (Republic of China). Yet, in WHO and UN circles, Taiwan is declared as a province of China’s. Nevertheless, trade, investment and tourism ties are booming between China and Taiwan. In the end, I expect Taiwan to regain its Observer status under a compromise formula, in the coming years, which it lost because of Chinese objections and the WHO Director-General’s compliance (that some say is because Dr Tedros Adhanom Ghebreyesus—referred to as Dr. Tedros in WHO documents—was heavily backed in his election campaign by China).
WHO bureaucrats will attempt to unlock the frozen US funding in exchange for Taiwan’s Observer status, but such manoeuvre will likely fail because the US will not resume funding till there is clarity on a proper investigation into how Covid-19 started in Wuhan. WHO headquarters in Geneva is covered by privileges and immunities under the Vienna Convention on Diplomatic Relations, therefore treated similar to an Embassy. So what goes on inside WHO can never be known with precision because no court can compel the uber-bureaucracy to reveal any wrongdoing. What is only possible is for those countries dissatisfied to walk away and take their funding with them—but that of course weakens the cause of global public health. Nevertheless, keeping with UNESCO’s history, that is likely the trajectory that will occur.
Therefore, the probability is very high of crossfire between the US and China occurring, with India being caught in between in India’s coming three-year term as Executive Board Chair. To avoid both the US and China seeing India as “lily-livered or unreliable and unbecoming of a potential great power” what can be done?
STAND FOR SOMETHING, ESPECIALLY PRINCIPLE
Historically, India has been very comfortable to sit inertly in between two opposing parties, claiming it is non-aligned. However, that may not be possible anymore. While everyone will expect India to be fair and impartial, as WHO Executive Board Chair, it will also be expected to be proactive, nimble and diligent. That will require dual capabilities in public health and diplomacy, something hitherto not in great demand.
My confidence in making the predictions in this article stems from efforts made including submitting the Report: “Health Research: Essential Link to Equity in Development” to the WHA 1990, now 30 years ago, as Harvard University’s International Commission on Health Research of which I was the Assistant Director. It was organized as an independent Commission with multiple grey eminences including a Nobel Prize winner who had been the Chairman of the Nobel Foundation, and executives/officials from government, NGOs, Foundations, and academics. The draft report calling for much needed global health research capacities, including epidemiological, to be built was discussed at a dedicated Nobel Conference a few months prior to that WHA with experts from around the world and thus great pains were taken to finalize the Report with broad-based consultation, including workshops held on every continent in the years before.
Indeed, it was another Nobel Prize winner, Prof Josh Lederberg and his scientist wife, Prof Esther Lederberg who propounded the theories that we now use to explain emerging infectious diseases like Covid-19, SARS and AIDS that are caused by viruses of zoonotic origin and where the viruses have “jumped” from animal to human either directly or via a laboratory. The Lederbergs explained that relentlessly mutating viruses are produced from the epidemiological brew that facilitates viral promiscuity wherein genetic material is exchanged between micro-organisms in bats, birds, cows, pigs and other animals that are reared or live in close proximity to humans in some parts of the world. From time to time, these viruses of animal origin are able to propagate into and by humans.
There are numerous coronaviruses that use bats as a reservoir, and academics from the Wuhan Institute of Virology that study bat coronaviruses themselves had predicted in a Viruses journal article last year that coronavirus outbreaks will originate from bats, and there is an increased probability that this will occur in China.
The mystery here is whether it occurred naturally or due to the now widely reported inadequate bio-safety measures at two labs (one P4 level and the other P2 level) in Wuhan where even gain-of-function research was allegedly done to enhance the pathogenicity or transmissibility of potential pandemic pathogen coronaviruses that have raised bio-safety and bio-security concerns, including the potential dual use risks associated with the misuse of the information or products resulting from such research.
There is circumstantial evidence pointing to a possible terrible lab accident, with cell-phone tower data available publicly revealing that there might have been a shutdown of roads around the Wuhan Institute of Virology in mid-October 2019, and other evidence.
I was fortunate to organize a conference on emerging infectious diseases surveillance in 1998 with Prof Lederberg, who won the Nobel Prize for Medicine in 1958 at the young age of 33, and know how much of his post-Nobel life he dedicated to alerting the world to the urgency and necessity of a system to deal with emergence, detection and response to microbial threats to health, especially the enhancement of early-warning systems around the world. Regrettably, his advocacy was mostly ignored, and it is worth recalling he had the ultimate prestige anyone could have in science—a Nobel Prize in Medicine.
Prof Lederberg lobbied and got funded two US National Academy of Sciences (NAS) Reports, in 1992 and 2003—both he co-chaired—that are regarded as advisory to the US government, as the NAS was chartered by the US Congress in 1863. Part of that work was based on the experience the world has had with HIV/AIDS. While HIV/AIDS was once regarded as a death sentence, and despite 40 years of global failures in HIV/AIDS vaccine R&D especially as HIV is a highly mutating organism, there are 38 million people living today with HIV/AIDS around the world, most thanks to Indian-made cost-effective antiretrovirals medicines.
Those looking for clues as to how many balls were dropped in global health only need to look for such examples. The usual modus operandi in the existing international system is for the outsized reputations of a few scientists, bureaucrats and politicians to be utilised to drum up demand on a serious issue such as emerging infectious diseases, followed by the allocation of millions of tax-payer dollars from multiple national governments that are then immediately cornered by multilaterals—and thereafter ordinary people never see or hear of that fund again. Meanwhile, children of multilateral staff are educated at the fund’s expense, and it contributes to bureaucrats’ inordinate salaries, benefits and pensions. It is absolutely high time to change those modalities of functioning that have brought despair and cynicism in the international system.
US Secretary of State Mike Pompeo hosted a videoconference on 11 May 2020 with Foreign Ministers of a select group of countries the US regards as partners, Japan, Brazil, Korea, Australia, and India as incoming co-chair of the WHO Executive Board. Each country posted its own summary of the call, with the US using the wording “transparency and accountability” with respect to combating Covid-19 and in addressing its causes. The readout also stressed a rules-based international order to prevent future global health crises. These are code words for a definite escalation of tensions and the strong likelihood of there being major clashes at WHA should the US actually attend. The US has already frozen its payments to WHO to show its displeasure over the serious mistakes made by WHO, but that does not preclude its attending.
Even beyond the WHA there will continue to be calls for holding China responsible, formally and technically, because a host of US lawyers are planning court cases against China to seek compensatory and punitive damages potentially running into the trillions of dollars. In view of that reality, China will continue to stonewall and WHO will continue to spin, making any amicable solution highly unlikely. Since lawsuits can go forward only if Chinese sovereign immunity is overcome (a major hurdle), it will likely be an area of contention into the foreseeable future. US Senator Tom Cotton, a rising star among conservatives and who is a Harvard-trained lawyer and army veteran, has introduced legislation to amend Title 28 of the United States Code to permit US Courts to have jurisdiction over cases seeking damages from China. His bill cites death, injury and economic harm due to China’s alleged deliberate concealment and distorting information about the international public health emergency, and abuses committed against whistleblowers like Dr Li Wenliang. Should class action lawsuits be filed in the US, Indian lawyers should explore joining on behalf of millions of the poorest Indians who suffered immensely in the lockdown.
India would be well advised not to get dragged into the impossible role of a mediator. The reputations of Prime Minister Narendra Modi, Health Minister Harsh Vardhan, and External Affairs Minister S. Jaishankar would likely get tattered (although many diplomats, especially from European countries, often Norway and Sweden, would couch such invitations with obsequious hints that the three would win Nobel Prizes for Peace). Further, one can expect the usual pressure from billionaire-philanthropists. Needless to say, sitting firmly on the fence and doing nothing is also not an option.
On the WHA Agenda is Universal Health Coverage (UHC). This is mostly new terminology for the old “Health for All by the Year 2000” slogan adopted in WHO’s Alma-Ata Declaration in year 1978. That was deftly changed to “Health for all in the 21st Century” around year 2000 (when it was clear that the earlier slogan had failed) with the currently preferred term being UHC.
WHO IS A TECHNICAL AGENCY, NOT AGENCY FOR TECHNICAL GIBBERISH
Some of the most alarming statistics and projections were bandied about by multiple alleged experts with no formal training in epidemiology and deliberately complicated models or no visibly communicated models at all. In the rarefied atmosphere where top politicians and bureaucrats congregate, such predictions take a life of their own.
Rather than undertaking clinical trials on a war-footing of already approved medicines like anti-viral favipiravir and remdesivir and/or other combinations so that a resolute defence could have been prepared soonest, including personal protective equipment (PPE), much valuable time was lost in hand-wringing about scary projections that never came to pass. Couple that with the well-publicized reluctance of China to reveal vital data, and deliver vital viral samples, especially of the earliest cases, and we have a scenario of essentially alleged large-scale “murder-mysteries” (since so little is known about the index cases) with seething populations behind them while India is chairing the WHO Executive Board. India has an unenviable task.
STRUCTURAL
REFORMS
India has opined that it will focus on WHO reforms only after the Covid pandemic is under control. The issue of WHO reforms is itself fraught with risks. Each time a new head of any multilateral (or quasi-oversight body) takes office, he/she makes eloquent speeches about how the agency should re-invent itself both functionally and structurally with multiple new priorities highlighted. This exercise in “reform” soon degenerates into cynical processes that sow even more discord. In one multilateral, the team of “reinvention/reform experts” utilised the opportunity to promote themselves up the salary and ranking/grade scale and gave themselves new elevated titles. Naturally, the new leader was oblivious to all those machinations and only got a clue when there was widespread disaffection and criticisms levelled at the leader himself. The leaders of all multilaterals preen that they have accomplished great change. It was okay in decades past to make wild claims, but in today’s information age it is not as easy to camouflage that within the UN system the term “reform” is generally regarded as one big joke.
Even the most basic reforms will likely be stonewalled and/or rejected, and efforts to find out just what happened on Covid-19 since the beginning will be “spun” out of the park.
Apart from arguing about the percentage of GDP that ought to be dedicated to health, there has never been a proper costing of what it will actually take to bring good health at modest cost to everyone, and no fund for innovations to enable that to happen. If only there was a serious effort in that respect the billions of dollars squandered in financing the petty fights by numerous previously cash-rich petrodollar countries and those that specialise in exporting terrorism might all have been held accountable. Further, ways and means might have been found to link public health responses with the massive defence budgets, but in the past even a suggestion in that respect would have been met in public health circles around the world with such derision as to make the person suggesting even wish he/she had never thought of such an out-of-the-box idea.
Only if there is a clean break from relying totally and exclusively on the organisations set up in the immediate aftermath of World War II can there be effective global measures against Covid and similar microbial threats into the future. Countries like India and Japan, long blocked from permanent membership of the UN Security Council, therefore, have every incentive to move to the new era right away.
Dr Sunil Chacko holds degrees in medicine (Kerala), public health (Harvard) and an MBA (Columbia). He was Assistant Director of Harvard University’s Intl. Commission on Health Research, served in the Executive Office of the World Bank Group, and has been a faculty member in the US, Canada, Japan and India