While WHO officials are certainly not beyond reproach, much of the recent criticism reflects a fundamental misunderstanding of the WHO and its mission. Many critics seem to imagine the organization as a global epidemic rescue unit that puts out fires wherever they occur. Yet that is simply not the role the WHO was built to fulfill, nor has it ever been possible for it to do so, given the structural limitations that confine the organization.
The World Health Organization was established in 1948 as part of a broader attempt to reconfigure international relations and establish a lasting postwar order, centered around the United Nations, that would guarantee peace and prosperity. It was founded as a U.N. specialized agency with a broad mandate to promote “the attainment by all peoples of the highest possible level of health,” and it defines “health” as “a state of complete physical, mental and social well-being.”
The WHO’s ability to fulfill its ambitions was hampered from the start by two main factors. First, WHO officials have always had to be content with vastly inadequate resources. In the late 1940s, member states limited the WHO budget to a measly $5 million — a decision significantly influenced by Congress imposing a strict limit on what the United States would contribute financially. Even today, its biannual budget amounts to roughly $4.5 billion, which is less than what some major U.S. hospitals get to work with.
Secondly, the WHO’s quest for “world health” has often been stymied by political conflicts regarding its mission, which has time and again prevented the organization from getting involved in crucial areas of international health work.
After the Second World War, underlying the creation of specialized agencies like the WHO was the idea that “political” questions should be separated from purely “technical” problems. The potential for strictly technical, consensual collaboration seemed high in the realm of public health, as diseases obviously did not respect national boundaries.
But the vision of pure, apolitical health work never materialized because global health politics were always shaped by debates over what was “political” (and thus outside WHO’s jurisdiction) and what was merely “technical.” The WHO’s complicated relationship to the U.N.’s human rights work illustrated the complexity of this debate.
For example, the WHO’s first director general, Canadian psychiatrist Brock Chisholm, supported the idea of health as a human right. In early 1951, he presented the U.N. Human Rights Commission with an extensive catalogue of health measures that national governments should be legally bound to implement, including legislation to guarantee certain standards of nutrition, housing and work conditions.
In the eyes of Washington, he’d overstepped and was advised to steer clear of such politically contested territory. In the United States, health care was not a universal right and, more generally, the White House rejected initiatives to extend the human rights framework beyond political and civil protections to include social and economic guarantees.
The WHO got the message: It quickly backed off and throughout the 1950s and ’60s didn’t substantively collaborate with the U.N. Human Rights Commission. Similarly, when several Catholic member states threatened to leave the organization in 1952 because it had planned to support India’s population control efforts, WHO officials learned to confine themselves to a rather narrow definition of “nonpolitical” — read: non-controversial — health work, hindering the organization’s scope and effectiveness.
As a result of both the severe budget constraints and the limitations of what member states would accept as “nonpolitical” work, the WHO has always had to concentrate on a narrow set of priorities. The fight against malaria, in particular, dominated the postwar decades and attracted significant resources from the United States. In the 1950s, Washington saw the disease as an obstacle to economic growth in the postcolonial world, which made combating it a Cold War strategy to “immunize” vulnerable states against communist advances. Post-colonial elites often shared the goal of rapid industrialization and disease eradication, even if they were not primarily concerned with containing communism.
In 1955, this constellation enabled the WHO to launch a global Malaria Eradication Program. The program focused on the use of insecticides, especially DDT, against mosquitoes. In the early 1960s, several hundred thousand spray workers applied DDT to roughly 600 million buildings multiple times per year, with projects underway in almost 90 countries and territories simultaneously. The outcomes of the program, which officially ended in 1969, were mixed: Many regions of the world saw a dramatic reduction in malaria incidence, but in sub-Saharan Africa in particular, the program never really took hold, and the large-scale use of DDT caused considerable ecological damage.
But for the WHO, the project showed its success in planning, coordinating and evaluating one of the most ambitious international undertakings of the Cold War era. Similarly, it acted as a highly effective broker between the superpowers when it embarked on a global Smallpox Eradication Program in 1967. The campaign was a massive immunization effort, depending both on U.S. funding as well as on the Soviet Union providing most of the vaccine. The last smallpox case in history was detected in Somalia in October 1977.
The “eradication era” certainly demonstrated how the WHO played a crucial role in global health politics. But it also proved how little the organization could influence the international constellations on which it relied to be effective. When a fear of overpopulation and environmental concerns began to dominate the international political landscape at the end of the 1960s, funding for many public health initiatives, such as malaria control, faded. All WHO officials could do in this situation was to react and adapt.
The entry of newly independent states in the 1950s and 60s strengthened the position of non-Western members, leading the WHO to focus on concerns emanating from the Global South. But this strained relations between Washington and Geneva from the 1970s onward and morphed into open conflict in the 1980s. In reaction to the WHO trying to regulate the global production, marketing and distribution of drugs and medical supplies, the United States withheld its membership contributions in 1985, and the Reagan administration was instrumental in the decision to permanently freeze the WHO’s regular budget.
Since the 1980s, the West’s relationship with the work of WHO has gone through phases of indifference, occasionally interrupted by erratic spikes in attention. As the WHO got more heavily involved in combating HIV/AIDS toward the late 1980s, when the virus was about to devastate the Global South, Western states started losing interest, as they had largely contained the virus. Consequently, throughout the 1990s, the WHO struggled to acquire needed funding as the pandemic spread around the globe.
Perceptions of acute danger in the West usually catapult the WHO to prominence — but they also tend to have a fairly short shelf life. Whereas there was massive attention on the 2014-15 Ebola epidemic in West Africa, since 2018 Central Africa has experienced the second-worst Ebola epidemic in recorded history — and it has barely caused a reaction. The WHO has never been able to change the fast-paced, often oblivious discourse around global public health.
No one seriously doubts that the WHO is in dire need of reform. But that alone will not solve the structural problems that have hampered the organization’s effectiveness for most of its existence: a lack of sustained interest from the West and a dramatic lack of funds on the one hand, and the need to refrain from crucial matters of global public health as they might be deemed “political” by certain members on the other. If we really care about establishing a functional World Health Organization as an important piece of the global health puzzle, this is where we should focus our attention.