The World Health Organization (WHO): Testing Times for ‘Medical Internationalism’

First of two parts of “Who’s Responsible:  The WHO, Internationalism, and the Coronavirus Pandemic”

(Ninth in a series of articles on the implications of the coronavirus for our times, for human history, and for the fate of the earth.)

The World Health Organization (WHO), which is today the face of international cooperation, or what remains of it, has kicked off yet another controversy as it seeks to lead the world out of the coronavirus pandemic.  On June 5, nearly two to three months after public health authorities in most countries had directed people to start wearing masks, the WHO’s embattled Director-General, Dr. Tedros Adhanom Ghebreyesus, announced at a press conference that the organization recommended that people living in areas experiencing “widespread transmission” of COVID-19 adopt a face covering.  That it took the WHO this long to issue such a note of guidance controverts the perception that it is supposed to lead not follow countries in adopting measures to deal with a global public health emergency, though its delay in issuing this advice suggests the political difficulties in proposing public health guidelines to countries with varying political systems and differing ideas on how to neutralize and eventually eliminate the threat of COVID-19.  But that Dr. Ghereyesus shared such a recommendation suggests also that the WHO holds to the view that there can be asymptomatic transmission of COVID-19, which is all the more reason why a statement made on June 8 by Dr. Maria Van Kerkhove, an American infectious diseases epidemiologist who is the WHO’s technical lead on COVID-19 and head of its emerging disease and zoonosis unit, suggesting that asymptomatic transmission is “very rare” must have appeared to many as bizarre.

If there is no asymptomatic transmission of COVID-19, then obviously many of the guidelines urging social distancing and the use of face masks will appear to have been superfluous; indeed, the shuttering of the world economy would seem to have been unnecessary.  There is already a small and increasingly vocal segment of the population in many countries that has questioned the wisdom of lockdown and other similar measures to contain the spread of the virus, and it is unquestionably the case that the “opening up” that we are seeing in many countries, even as in many of them—India, Pakistan, Brazil, Mexico, the United States, Britain, among others—cases continue to rise rapidly, is in consequence of the pressure upon governments to lift restraining orders, have people return to work, and restore some notion of normalcy.  On June 9, Dr. Kerkhove appeared to walk back on what many construed as her message of the previous day:  as she noted at a press conference, “I did not say that asymptomatic cases cannot transmit; they can. The question is, do they? And if they do, how often is that happening?”  A number of research studies appear to suggest that asymptomatic individuals may account for as much as 45% of COVID-19 cases; on the other hand, there are studies which have seemingly established that the asymptomatic transmission rate is at best 2.2%, suggesting that asymptomatic spread is an unlikely driver of community transmission of infection.

What the present controversy over remarks by WHO officials has established, in the first instance, is that much about the coronavirus and its transmission still remains unknown. Patients may show only the slightest symptoms; or the symptoms may appear much later, and a patient may have already spread the disease before the manifestation of symptoms:  perhaps one might usefully distinguish between pre-symptomatic and asymptomatic cases.  “Experts” have been weighing in with advice, but it has been difficult to establish any consensus beyond the desirability of quarantining people who display the symptoms of the disease and the necessity to adopt a simple precautionary gesture such as washing one’s hands with soap frequently.  Though the lead has been taken by scientists, and more particularly infectious disease specialists and virologists, in helping the public understand the advance of COVID-19 and the contours of the disease, curiously “science” may have less to contribute in bringing the world out of the coronavirus than elementary public health measures, state policies that are attentive to conflicting demands, the exercise by people of some norms of social responsibility, and prudence.

It is in this context that it becomes necessary to revisit the question of the politics in which the WHO has been mired and the future of an organization which, though it appears to have seen better times, still augurs the possibility of “international cooperation”—“still” because relations between countries have become noticeably frayed and ethno-nationalisms, which were on the rise even before the emergence of COVID-19, seem to point to the tendency of nations to pursue their own political destinies.  The WHO was founded in the aftermath of World War as one of many institutions, in this case as one embedded within the United Nations, that were conceived as offering a better future, one less animated by rivalry between nation-states, for humankind.  The WHO’s Constitution, passed in 1948, contemplated “the attainment by all people of the highest possible levels of health”, an idea that seemed all the more imperative in view of the deadly toll taken by diseases that, even if they had been “conquered” in the West, continued to terrorize countries in the Global South.  In India, as an illustration, life expectancy at the cusp of independence was around 30, not even half of what it was in Australia, Britain, and the United States.  Indeed, India had been ravaged by plague, cholera, tuberculosis, smallpox, typhoid, malaria—and, as if all this this was not enough, famine in the period extending from 1875 until the Bengal Famine of the early 1940s.  By my own estimation, one can reasonably estimate that excess mortality in late colonial India, in a period of some seven decades, was not less than 100 million and perhaps more likely around 120 million.  This is a staggering number:  if it is astounding and disturbing, as it should be, it stands as a stark reminder of what British colonialism wrought in India.

The WHO’s first several decades were marked by considerable success.  The organization played a significant role in reducing substantially the incidence of yellow fever, but its greatest achievement is undoubtedly the global eradication of smallpox in 1979.  The WHO was among the principal organizations that, in 1988, launched the Global Polio Eradication Initiative:  it was able to declare the Americas polio-free by 1994, and type 2 poliovirus had been eradicated from India by 1999.  Wild poliovirus (WPV) cases in India by early 2003 had come down to fewer than 45 and by 2014 the WHO declared India, where the global eradication program had witnessed its greatest challenges, polio-free.  But polio still persisted, though in small numbers, across several other countries.  Through the course of the last ten years, there have been a number of WHO initiatives in an attempt to declare the world polio-free though it remains endemic in both Afghanistan and Pakistan, where rumours that the polio vaccine renders females sterile have made full compliance with state efforts to vaccinate everyone difficult.  Polio was endemic in Nigeria until a few years ago: there, too, similar rumours contributed to the campaign to boycott polio vaccination drives. Considering that there are fewer than 200 cases worldwide this year, the WHO’s efforts have largely paid off.

(to be continued)