- The COVID-19 pandemic has drawn attention to international efforts to promote public health, most notably through the World Health Organization (WHO)
- Historically, major health and political crises have eventually led to a strengthening of international cooperation in public health
- The international response to COVID-19 has been generally strong, but it suffered from delays and a lack of decisiveness that many observers argue contributed to the pandemic’s spread
- In the short term, these weaknesses have caused debate over countries’ funding for international health efforts, and may even lead to some countries, most notably the US, to temporarily pull back from their international public health commitments
- However, as in past public health crises, within the next 5-10 years, we expect that the pandemic will force governments to recognize the necessity of international coordination in public health and strengthen or reform bodies like the WHO to respond more robustly to future crises
Introduction and History
The story of international cooperation in public health begins in the early nineteenth century, during a period of rapid urbanization in Europe. The density of urban life increased the risk of infectious disease outbreaks, and a series of three cholera pandemics swept the globe in the first half of the century. The second of these pandemics, from 1826-1837, made its way to Europe and took a devastating toll on society, leaving hundreds of thousands dead.
During the second cholera outbreak, European governments imposed strict quarantine measures on maritime commerce to control the spread of the outbreak from Asia and the Ottoman Empire. These measures varied widely from country to country and were often bothersome and costly to travelers. In response, in 1834, a French government official wrote a report on the challenges presented by inconsistent public health measures. In it, he recommended that the European powers convene to standardize measures to control outbreaks with minimal disruption to international trade and travel. After some delay, this initiative finally succeeded, and the first International Sanitary Conference was held in 1851.
Subsequent International Sanitary Conferences continued regularly until the 1930s and formed the backbone of international cooperation in public health. In the early 20th century, other international groups emerged—like the Pan-American Health Organization (PAHO) or the Office International d’Hygiene Publique (OIHP)—and began standardizing efforts to control outbreaks of disease and prevent their spread across geographies. Then, after a pause in international health coordination during the two world wars, a new era in public health began in the aftermath of World War II.
During the conference to create the United Nations in April 1945, representatives of several countries proposed the inception of a new international health organization. By July 1946, the Constitution of the World Health Organization (WHO) had been adopted by 61 nations, and it was enacted in April 1948 when the requisite number of governments ratified it.1 For over 70 years since, the WHO has been the cornerstone of international public health efforts, with support from other non-governmental organizations and charitable foundations like the World Bank, Doctors Without Borders, and the Bill and Melinda Gates Foundation. These organizations have helped spearhead dramatic reductions in child mortality and increases in overall life expectancy, and they also oversaw the management of numerous disease outbreaks, including influenzas, HIV/AIDS, Ebola, SARS, and the ongoing COVID-19 pandemic. In an already divided world, their response to COVID-19 has, at times, been polarizing, and will likely shape global health institutions for decades to come.
International Response to COVID-19
The COVID-19 pandemic has undoubtedly been one of the greatest challenges that the WHO and other global health organizations have ever faced, given the scale of the pandemic and the broad public health measures enacted around the world to control its spread. Following the discovery of the virus in Wuhan, the WHO became a central source of reliable information and action plans for the management of the pandemic. Their initial response to the outbreak is outlined in Figure 2 below2.
In addition to the WHO’s response, several other non-governmental organizations have made significant contributions to the fight against COVID-19. The World Bank has collected over $12 billion dollars to provide global health and economic support. Since the beginning of the outbreak, the organization has launched over 90 projects in 77 countries with aims including healthcare, public administration, water and sanitation, and more.3 The Gates Foundation has raised over $250 million dollars to support research and development efforts. One branch of their COVID-19 relief efforts is the COVID-19 Therapeutics Accelerator, which will catalyze the creation and evaluation process for COVID-19 treatments.4 Lastly, to support frontline workers worldwide, Doctors Without Borders has provided healthcare provider support, online trainings, and technical assistance.5 This sample of organizations facilitate supplemental worldwide support for COVID-19 relief in addition to the resources the WHO provides.
To its credit, the WHO’s initial response to the coronavirus cluster in Wuhan was swift as it communicated clearly with the international community. The organization reported their findings in succinct reports and disseminated recommendations to member states via their webpage. These materials included strategic measures we continue to leverage today, such as social distancing, contact tracing, and the use of PPE. The WHO also continued to coordinate field visits as the disease progressed in new regions like Iran and Italy and the center of the epidemic shifted, and almost eight months into the pandemic, they continue to be a source of trusted information on the virus.
Despite these efforts, some elements of the WHO’s reaction to COVID-19 have been criticized. The first visit to Wuhan was inconclusive on the significance of the outbreak and led to no major action to contain the spread of the virus, causing a critical delay in international response to the pandemic. The WHO initially felt no need to recommend travel restrictions and commended China on their response to the outbreak. After that first mission, the Executive Committee decided there was not yet enough information to raise international concern, and they would revisit the topic in ten days. Before the second analysis could occur, the WHO declared the COVID-19 pandemic a public health emergency of international concern (PHEIC) due to uncontrolled international spread.
The WHO also lacked decisiveness on the issue of human-to-human transmission, which it initially said was “possible” but with “no clear evidence” on January 14. Following the first field mission to Hubei, the organization updated its guidance and announced on January 21 that there was “very clear” evidence of human-to-human transmission of the coronavirus. The WHO was later criticized strongly for being overly conservative in these initial reports.
The WHO’s response to the coronavirus has also highlighted some of its limitations. The international body does not have the authority to mandate action from its member states, or even to actively begin field visits to those nations (it must be invited). Instead, member nations can voluntarily share information with the WHO, draw upon its resources and recommendations, and implement measures as they see fit. Furthermore, the WHO is dependent on member nations for financial and political support and has limited incentive to criticize their national health responses. These limitations ultimately make it impossible for the WHO to coordinate and enforce an international public health response without broad cooperation from its members.
Looking beyond the COVID-19 pandemic, the future of international public health efforts remains uncertain. In the short term, criticism of the WHO’s handling of the crisis will likely have a negative impact on the WHO and broader international public health initiatives. The US presidential election will no doubt have a significant effect on international cooperation, though the impact will likely be more limited than many fear, as discussed below. We believe that, in the next 5-10 years, this crisis will show that there is no alternative to cross-border co-operation when it comes to public health which will strengthen the case for reforming or renewing international non-governmental organizations.
The most obvious short-term threat to the WHO is from President Donald Trump’s decision to pull the US out of the WHO, jeopardizing a critical revenue stream for the organization. While the outcome of the election will likely have an impact on America’s stance towards the WHO, even if the US were to curtail its involvement, we believe the impact of this decision will be limited for three key reasons.
First, the US is the only the nation to propose leaving the WHO. While all other members of the G7 have expressed disagreement with the Trump administration’s decision to leave the WHO, several nations have pledged increased funding for the WHO and reaffirmed their commitment to global health.6
Second, there is a significant chance that the US will not actually withdraw from the WHO. In order to do so, the US must give a one-year notice and pay the balance of its assessed contributions. This means the US cannot formally withdraw from the WHO until July 6, 2021 and must pay $60MM for the second half of FY2020 before doing so.7 Even if President Trump is re-elected, it is unclear what authority the president has to deny congressionally approved funding for an international organization.
Finally, the WHO budget will likely prove resilient to potentially reduced funding. The United States contributed about 15% of the WHO’s budget in 2018, or around $400MM.8 This is unquestionably significant, but the WHO is accustomed to variability in its funding, and US annual contributions have ranged from a low of $212MM to a high of $513MM within the last decade.9 Furthermore, the WHO generally runs a budget surplus and has significant net assets; in the most recent available data (for FY2018), the organization ran a $442MM budget surplus and had $2B in net assets.8 These attributes of its financial organization help make it resilient to fluctuations in funding from member states.
For all these reasons, the Trump administration’s decision to pull out of the WHO is likely to have a limited effect. Instead, in the long run, international cooperation in public health is likely to be strengthened by the COVID-19 crisis, just as it has been strengthened by previous major crises. The International Sanitary Conferences emerged from the cholera pandemics of the early 1800s, just as the WHO emerged following the world wars. In the aftermath of one of the greatest public health crises in a century, we expect that the international institutions that keep us all healthy will be strengthened once again.
The COVID-19 pandemic has also proven beyond doubt that public health is fundamentally a transnational issue. The pandemic began in a single Chinese city but has since spread to almost every country in the world and infected over 15 million people. Because of increasing globalization, there is simply no credible alternative to international cooperation to combat public health crises. Groups like the WHO are thus extremely important for the sharing of information about emerging health threats and the coordination of international responses such as travel restrictions and vaccine development. As countries recognize this importance, these institutions will almost certainly be given increased power and funding.
Already, there is evidence of a renewed commitment from national governments toward public health. The UK, Germany, France, and China have all promised increased funding for the WHO in the upcoming year10, 11, 12, and the WHO’s targeted COVID-19 response fund has raised over $1.2B from national governments and private donors.13 This commitment will likely continue beyond the current crisis, as countries realize the importance of the WHO’s mission for their security and economic prosperity. It is even possible the WHO will be given new legal authorities over its member nations to make it easier for the organization to coordinate the response to the next public health crisis.
Historically, international public health cooperation has grown stronger after major crises such as the cholera pandemics and world wars. International relief efforts to the coronavirus pandemic have been commendable, albeit flawed and drew criticism in the wake of the crisis. While short-term “finger pointing” is inevitable, in the long run, this crisis is likely to demonstrate the significance of global health to countries’ national interest and will lead to the reform of and increased support for international cooperation on public health. As a result, our hope and expectation is that our public health institutions will be even better prepared to face the next pandemic.
About the Authors
Nathan Williams is an analyst in the Health Advances Boston office.
Sofia Chaluissant is an analyst in the Health Advances Boston office.
Balazs Felcsuti is a Vice President in the Health Advances Boston office.
 WHO History
 WHO Newsroom
 Associated Press
 Just Security
 Washington Post