Is the WHO Becoming Irrelevant?

Why the world's premier public health organization must change or die.

Among the many victims of Haiti's deadly cholera outbreak may be an unexpected casualty: the World Health Organization. As the epidemic broke out on the island, spreading quickly from rural areas to the capital, Port-au-Prince, the World Health Organization (WHO) and its regional division, the Pan American Health Organization (PAHO), sent expert teams, mapping the epidemic and advising the government on how to best defeat the outbreak. Relief workers hustled to contain the disease in rural areas before it spread to the capital, where living spaces are more compact, sanitation systems are overwhelmed with raw sewage, and more than a million earthquake survivors are still huddled in tent camps. But reach Port-au-Prince it did, and today at least 1,800 Haitians have fallen victim. Cholera, like most any outbreak, demands a nimble, fast-moving, and adaptive response. Unfortunately, that's just about everything the WHO is not. The 11 months since Haiti's earthquake, coupled with the relentless rise of pandemics in impoverished countries in recent years, have made painfully clear that the agency can no longer adequately perform the job of being the world's chief defender against disease.

The WHO -- for 62 years the world's go-to agency on all public health matters -- is today outmoded, underfunded, and overly politicized. In a world of rapid technological change, travel, and trade, the WHO moves with a bureaucracy's speed. Its advice to health officials is too often muddied by the need for consensus. Regional leadership posts are pursued as political prizes. Underfunded and over strapped, the organization has come under attack for being too easily swayed by big pharma. In a world where foundations, NGOs, and the private sector are transforming global health, the WHO has simply not adapted. This isn't just about the WHO losing its edge. Taken together, these myriad dysfunctions are rendering the WHO closer and closer to irrelevancy in the world of global health.

How did it get so bad? When the WHO was created as a U.N. technical agency shortly after World War II, governments' health ministries were the predominant global health authorities. The new U.N. body was meant to serve as a reservoir of expertise and knowledge at the service of countries needing a hand. The WHO essentially became a health consultancy to developing countries, supplying advice, analyses, and best practices, though stopping short of directly implementing health programs. That was an invaluable service at the time. But today, its mission and operations remain largely unchanged.

The WHO's stagnation is juxtaposed with a world of public health that is changing more and more quickly than ever. Legions of new drugs, vaccines, and diagnostics have fortified the medical profession. Governments are no longer the sole stewards of public health; new players are entering the field, both public and private. The eight-year-old Global Fund to Fight AIDS, Tuberculosis and Malaria, for example, is now the go-to coordinator for international funding to combat these diseases. The Bill and Melinda Gates Foundation has revolutionized global health, investing $13 billion in health grants in everything from research into malaria vaccines to treatment of tuberculosis to HIV/AIDS programs on the ground. Even the U.S. government has gotten in on the world of change, forcefully responding to HIV/AIDS in Africa with a $25 billion program that has put some 3.2 million people in treatment in just half a decade. What differentiates these pioneering efforts from the WHO is that they are nimble, well-funded, and less encumbered by red tape. It's hard to see how the WHO can compete.

In fact, in this new atmosphere, where organizations are taking health into their own hands, it's unclear exactly what role the WHO should even play anymore. Offering up its expertise is not as straight forward as it once was; the biggest players in global health aren't asking for assistance as governments once did. Nor can the WHO set its own advising priorities, since its funding comes from donors, primarily national governments. In recent years, the agency's $2.3 billion annual budget has been increasingly divvied up before it ever reaches the WHO, earmarked by donors for their favored causes, be they specific diseases or treatments to fight them. With its limited resources, the WHO is caught in a trap, appealing to donors' interests in fighting specific diseases such as polio, HIV/AIDS, or malaria, while giving broader health priorities -- notably, the development of basic health-care infrastructure -- short shrift. The WHO is no longer setting the agenda of global health; it's struggling to keep up.

The problems extend to personnel. The WHO's greatest resource is its ability to leverage its objective expertise -- to bring in knowledge, draw conclusions, and disseminate them quickly in a way that is unthreatening and apolitical no matter the location. Unfortunately, that very expertise is starting to fade away. Today the organization is critically short on experts to cover cancer and diabetes, two of the most common diseases in an aging world. The WHO's network of HIV/AIDS advisors is at risk of being disbanded altogether if more funding cannot be found. Even with more funding, there would be roadblocks. The U.N. personnel system pushes the organization to uphold a linguistic and geographic balance, which can obstruct and delay the hiring of key experts. Those not hired by the WHO will be quickly snatched up by the new global health players.

The WHO's governance system is also archaic, stemming from an era in which transportation and communications between continents were slow. The WHO is not a singular entity but operates more akin to a federation of six regional offices, each headed by a director who is elected by the countries in such groupings as Africa or Southeast Asia. These six directors wield authority within their zones that can conflict and compete with that of the Geneva-based director-general, complicating messaging and policy coordination. For example, the Pan American Health Organization considers itself to be the dean among the six regions, with a lineage going back 100 years and an independent financial base; PAHO chafes at the thought of being lumped in with WHO and pushes its moniker over the WHO's when operating in the Americas. Most recently, PAHO announced a global health technology initiative with the U.N. Development Program, a broad mission that arguably ought to have been originated from Geneva.

With competition between branches and body, the assignments of WHO country representatives often involve extensive negotiations between the power in Geneva and the power in the region. Key appointments have many a time been blocked not by qualifications of the individuals but for political reasons. Recognizing the need to knit better relations among the regions and Geneva, WHO Director General Margaret Chan and her senior team spend significant amounts of time jetting to consult with the six regional directorates. Progress is being made, but it is precious time that could be saved in a streamlined organization.

Perhaps what's needed is a move away from the region-centric approach toward a strategy that would allow the WHO to devote more resources to country-level work. As it stands today, the WHO staff are typically housed in a country's ministry of health. The WHO could empower its country-based staff to deliver timely, accurate, and actionable advice where it is needed most -- not just at the national policymaking level, but to local health workers in communities. The WHO could become the go-between for donors, facilitating and sharing information and resources between multiple sources in such countries as Ethiopia and Tanzania. In the field, the WHO could offer its product -- expertise -- to the full range of NGOs, bilateral programs, and even private-sector entities. Rather than just advising ministries of health about how to defeat cholera in Haiti or ebola in Africa, for example, a more robust WHO country team could give that advice to the NGOs, both local and international, that are on the ground fighting outbreaks.

Another advantage of this local focus would be the opportunity to forge stronger relationships with the private organizations, such as Doctors without Borders and Partners in Health, that actually implement health programs. Rather than being pushed out by new players in public health, the WHO could bring them under its technical wing now. In fact, the WHO might consider inviting representatives of independent health groups to assume a set of rotating seats on its executive board. It's an idea that has been successfully tried before: The policy committee for UNAIDS, the U.N. agency that advocates for action on the AIDS epidemic, includes five NGO members, including a representative from communities ravaged by the disease. Likewise, the board of the Global Fund to Fight AIDS, Tuberculosis, and Malaria includes voting members from the private sector, foundations, NGOs, and affected communities. Both organizations enjoy greater legitimacy as a result.

For now, the WHO will continue to be tested, both on acute crises and on long-term problems. Today, it is responding to the cholera outbreak in Haiti; next year it might be another crisis. In many of the world's most difficult places, the WHO does still retain its prominence as the chief reference body on health matters. But it is no time for complacency. The recent barrage of health crises has revealed the WHO's value, yet its weaknesses as well. The agency cannot remain underfunded and understaffed, struggling with a system whose origin dates back to the dawn of the antibiotic era. For the WHO to be revived as the world's foremost health authority, it now needs intensive therapy itself.

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The Nobel Crackdown

Beijing's far-reaching efforts to keep Chinese supporters of Liu Xiaobo from attending the Nobel Peace Prize ceremony in Oslo reveal an increasingly anxious undercurrent in China.

On Dec. 10, for the first time since 1936, when Nazi Germany prevented Carl von Ossietzky from traveling to Norway to receive his Nobel Peace Prize, neither the laureate nor any of his family members will be able to attend the Nobel ceremony in Oslo.

Liu Xiaobo, this year's Nobel Peace Prize winner, is serving an 11-year sentence in a prison in northeastern China, after being convicted one year ago of "inciting subversion to state power." His wife, Liu Xia, is forcibly confined at home in Beijing by the police, and prevented from talking publicly under threat of losing her right to visit Liu. All the principal signatories and co-drafters of Charter 08 -- the manifesto calling for bottom-up political reforms that prompted Liu's arrest in December 2008 -- are under tight police surveillance, prevented from assembling, giving interviews to the media, or traveling abroad.

In selecting Liu in the face of pressure from Beijing, the Norwegian Nobel Committee has laid bare the Chinese government's overt hostility to human rights norms, at home and abroad. Since the prize was awarded in early October, the Chinese Communist Party has embarked on a sweeping crackdown on dissidents. Scores of Chinese citizens have been detained, placed under house arrested, or prevented from travelling to the ceremony in Oslo. But the prize and the ensuing clampdown may turn out to have profound consequences for how the world views China, and China's own ability to pursue its foreign-policy objectives.

In the days that followed the announcement of the prize, Liu Xia managed to circulate a letter expressing her desire to see Liu's friends and supporters attend the ceremony in Oslo; her letter included a list of more than a hundred names: Chinese writers, lawyers, academics, journalists, former party cadres, artists, and NGO activists, many with a distinguished record of patiently and peacefully challenging the limits of the one-party system. But after the letter became public, Chinese authorities informed each of those living in China that they would not be permitted to go. Some have been placed under police monitoring or confined at their homes with a retinue of police officers camping outside their doors. Countless other rights activists across the country have been harassed, summoned for questioning, or detained by the Public Security Bureau or state security officers. (The advocacy group China Human Rights Defender has compiled a helpful list of cases.)

Several prominent figures known for their outspoken views, including world-renowned artist Ai Weiwei, the top legal scholar He Weifang, China's famous criminal lawyer Mo Shaoping, and 80-year old economist Mao Yushi, have been banned from traveling ahead of the ceremony on the rationale advanced by border-security officials that such trips would "jeopardize national security."

The Chinese government has multiple motives for imposing such a radical clampdown. It wants to minimize the significance and legitimacy of the prize, especially in the eyes of Chinese citizens living abroad and therefore immune to the government's massive domestic censorship effort. It wants to prevent signatories of Charter 08 from speaking to a global audience in Oslo, and to deny Chinese domestic rights activists a platform where they could speak with authority about the country's dismal human rights record. Equally importantly, it wants to facilitate the government's propaganda effort at fanning nationalist sentiment through the portrayal of the prize as a conspiracy by "the West" designed to hobble China's rise in the world. Although there have been many voices inside China supporting the decision of the Nobel Committee, the government's pervasive Internet censorship has effectively airbrushed them from domestic cyberspace.

In reality, this unprecedented clampdown is unlikely to help Beijing's damage-control efforts. On Dec. 10, global public opinion will likely be aghast as a wider audience learns that the laureate's wife has now become a virtual prisoner in her own home. The reputation of China's legal system will take another nosedive as it becomes apparent that the government discarded all legal pretense in putting activists under effective house arrest, while calling Liu a "criminal." And the Nobel Committee's decision to honor a Chinese human rights advocate will appear all the more justified precisely because of the anti-human rights response from Beijing.

Even more problematic for Beijing is the Nobel Committee's decision not to formally award the prize at the ceremony on Dec. 10 because no one in Liu Xiaobo's family will be allowed to receive it. (Only one of the Chinese activists close to Liu, AIDS activist Wan Yanhai, will be present in Oslo on Friday.)

Admittedly, China's rulers might be ready to withstand the inevitable international blowback. After all, the regime withstood such opprobrium following the Tiananmen Square massacre in 1989 and the awarding of the Nobel Peace Prize that year to the Dalai Lama.

But the ham-fisted response to the Nobel crisis has dramatically undermined Beijing's post-Tiananmen efforts to rehabilitate its image. Language unbecoming of a world power used to characterize the Nobel Committee members ("little clowns," in the words of Foreign Ministry spokeswoman Jiang Yu) has only made Beijing's predicament worse. Beijing's attempt to threaten European Union members through official diplomatic channels not to send their ambassadors to the Nobel ceremony has also ruffled feathers. This move has raised the stakes for EU countries -- to stay away would be understood as bowing to naked pressure -- and has turned what was routine attendance into a symbolic rebuke of Chinese interference. Although Beijing has insisted that a "vast majority" of countries would not attend the ceremony, so far only 18 have declined, including Cuba, Iran, and Russia.

Beijing may even further embarrass itself if the Chinese Embassy in Oslo goes ahead with its current plan to organize Chinese students to stage a counterdemonstration outside the ceremony venue. The irony of Chinese citizens legitimately exercising a right in Norway that the government denies them at home will not be lost on journalists and other observers.

Keeping a Nobel laureate in prison also has both immediate and long-term implications for China's diplomacy.

First, it becomes harder for China's interlocutors to sweep aside human rights in bilateral or multilateral relations. Democratic governments the world over will find themselves under pressure from human rights groups to raise Liu's case as long as he is imprisoned. For years, the reaction of foreign diplomats asked to press Beijing on human rights has been to throw up their hands and claim that they didn't know what they could achieve -- but now they know one thing: gaining Liu's release. The pressure will also increase in international rights forums, where direct criticism of China has become weaker and weaker. It will be difficult, for instance, for the U.N. high commissioner on human rights, Navanethem Pillay, who has declined to attend the Nobel ceremony in Oslo, to avoid mentioning Liu when she gives her address on International Human Rights Day on Dec. 10 without appearing to have bowed to Chinese pressure.

Second, the situation may well create a host of awkward interactions when Chinese leaders travel abroad. Hu Jintao's refusal to hold the customary press conference at the end of his visit to France last month seems to illustrate the Chinese president's fear of being asked embarrassing questions about the imprisoned Nobel laureate.

Third, having become the only country in world with a Nobel Peace Prize laureate currently in prison will hobble China's quest for soft power -- which the Chinese government sees as a necessary attribute of a rising global hegemon. Neither the considerable expansion of the Chinese state media abroad nor the multiplication of Confucius institutes -- government-funded Chinese-language programs established within foreign academic institutions -- is likely to soften China's authoritarian image or make its political system appealing if it keeps Liu in prison for the next decade. Demands for his release are unlikely to decrease over the years, as Aung San Suu Kyi's release from house arrest more than two decades after she received the Nobel Peace Prize demonstrates.

Liu's sentence is actually emblematic of the new dynamics of power within the Chinese leadership under the Hu-Wen team. In contrast to the reform era, which saw the struggle between "reformists" and "conservatives," the only debates within the leadership today seem to be about how to strengthen the existing system. The numbers speak for themselves.  The budget of the Public Security Ministry has increased 50 percent between 2008 and 2010, and according to figures from the Ministry of Finance, the overall budget allocated to "maintaining stability" is estimated to be equivalent to the entire budget of the armed forces. The recently leaked State Department cables from the U.S. Embassy in Beijing that attribute the attacks against Google as having been prompted by the displeasure of the head of the Propaganda Department at finding himself criticized online, if accurate, provide a striking illustration of the enormous power gains made by leaders of the security apparatus in recent years.

This is why the Nobel Committee should be commended. In awarding the Nobel Peace Prize to Liu Xiaobo, it has directed a powerful spotlight onto the hard reality of the single-party state in China and forced Beijing to reveal publicly how intolerant of dissent and how hostile to human rights norms and the free flow of information it remains. Although the Chinese government will do its utmost to cast the ceremony on Dec. 10 as a Western attempt to impose its values on China, the reality is that China's rulers are deeply afraid of the increasingly assertive demands of their own people for what underpins real stability: the rule of law, the free flow of information, and respect for fundamental human rights.

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