Fifteen Eighty Four

In April 2020 U.S. President Donald Trump began to lash out at the World Health Organization, blaming it for what he claimed were missteps, failures, and prevarications in its handling of the coronavirus pandemic. On April 14 he announced that U.S. funding for WHO would be frozen for 60-90 days while his administration conducted a review to “assess the World Health Organization’s role in severely mismanaging and covering up the spread of coronavirus.” Widely seen as a transparent attempt to deflect attention from his own response to the crisis, Trump’s threatened withdrawal of funds from the WHO at a critical moment drew widespread condemnation from medical, public health, and philanthropic leaders. Richard Horton, the Editor in Chief of Lancet, called Trump’s decision a “crime against humanity.” Dr. Georges Benjamin, Executive Director of the American Public Health Association, “denounced” the Trump administration’s decision to halt U.S. contributions to WHO which, he said, would “cripple the world’s response to Covid-19.” Philanthropist Bill Gates wrote that stopping funding for WHO at this time “is as dangerous as it sounds.”

However dangerous President Trump’s freezing of WHO funds may be, it is by no means the first time that the United States has used its political muscle to coerce the WHO. In fact, the United States has bribed and bullied the WHO from the earliest days of the organization. The very notion of an international health organization was an American idea, part of its blueprint for the post World War II capitalist world. The U.S. held the purse strings of the WHO, initially contributing more than 35 percent of the multilateral health organization’s budget. The United States threw its weight on the side of a regional as opposed to a tightly centralized style of organization to preserve its influence over public health in the Americas. The United States also insisted on the early launching of a WHO Malaria Eradication Program (MEP), despite the hesitancy of some of the world’s leading malariologists. It did so because the U.S. saw malaria eradication as an effective Cold War strategy. By providing funds to the new multilateral health organization it could gain legitimacy and multiply the impact of its fiscal contribution.

These aggressive tactics were one of the reasons the Soviet Union and its allies withdrew from the supposedly multilateral organization in 1949. The USSR returned in 1956 and, at the World Health Assembly in 1958, proposed a new eradication program aimed at smallpox. The program was approved but the United States was unenthusiastic because it had major resources tied up in malaria eradication. Thus budgetary support for smallpox was meager and the program languished until the U.S. decided in the mid-sixties that smallpox eradication could serve its foreign policy objectives. The WHO then declared a major new initiative in the worldwide Smallpox Eradication Program (SEP), and worked out a deal that would combine US and Soviet resources and personnel under American leadership. Smallpox eradication proved a great public health and geopolitical success – but just as the WHO was celebrating its global triumph in 1980 it was again feeling the heavy hand of the United States.

Concurrent with the final stages of SEP was another heralded initiative of the WHO, the campaign for health equity and primary care crystallized in the Alma Ata Declaration of 1978. This call for the just distribution of health both between and within countries was the articulation of a long sought social medicine ideal and an expression of the voice of the developing world. That voice was channeled through Halfdan Mahler, charismatic Director General from 1973 to 1988. He and many others prized this Declaration as a “spiritual moment,” perhaps the most hallowed in the WHO’s history. But the United States saw it as a sign that it and other developed nations had lost control of the World Health Assembly, now numerically dominated by representatives from the Global South. These countries were often former colonies that had achieved independence and as “developing nations” claimed reparation-like economic assistance and morally justified access to services and technological aid. The U.S.’s assessment of shifted political realities was also reflected in its anger about the creation of a list of “Essential Medicines” in 1977, defined as those to which people should have access at all times at generally affordable prices.

The U.S. response came first in a small meeting in Bellagio, Italy attended by representatives of the wealthy American Ford and Rockefeller Foundations, the American dominated World Bank, and the United States Agency for International Development. The outcome of this meeting was a plan for “Selective Primary Care” as an alternative to the approach of Primary Health Care adopted at Alma Ata. With the hostility of the Reagan administration to both governmental and intergovernmental authority in the 1980s, U.S. budgetary commitment to multilateral organizations very quickly diminished. As a result of pressure from the United States (and other industrialized countries), the World Health Assembly froze the WHO budget and in 1985 the U.S. refused to pay its assessed dues on the grounds that the latest version of the Essential Medicines list was contrary to the interests of U.S. pharmaceutical companies. The United States’ actions led immediately to a massive fiscal crisis at the WHO.

The WHO was saved financially by a budgetary shift to “Extrabudgetary” or “Voluntary” contributions. The regular budget was approved by votes in the World Health Assembly but the “voluntary” budget was utilized largely according to donors’ wishes. This was an open opportunity for the World Bank, by the 1980s under the sway of “neoliberal” ideology, to exercise wide influence in international health initiatives. Not long after the World Bank asserted its new authority, it promoted new institutional entities like UNAIDS, which greatly diminished WHO’s standing in world response to HIV/AIDS, and the Global Alliance for Vaccines and Immunization, which undermined the WHO’s authority in the world’s eradication efforts.

There are many other examples of unilateral U.S. intervention in the WHO’s history, all of which hampered or sidetracked the international health agency from achieving the goals articulated with such idealism in 1948 when the organization was launched. If President Trump follows through on his threat, it will surely not be the first time that the U.S. has shown its heavy hand. And if the WHO in some fashion survives this latest assault, it will almost certainly not be the last as the organization staggers into the future.