Foreign Affairs Committee
Oral evidence: Multilateral Organisations—the World Health Organisation, HC 513
Tuesday 15 September 2020
Ordered by the House of Commons to be published on 15 September 2020.
Members present: Tom Tugendhat (Chair); Chris Bryant; Neil Coyle; Alicia Kearns; Henry Smith; Graham Stringer.
Questions 94 - 116
Witnesses
I: Dr David Nabarro, Co-Director and Chair of Global Health, Institute of Global Health Innovation, Imperial College; and Professor Ilona Kickbusch, Independent Global Health Consultant.
Witnesses: Dr Nabarro and Professor Kickbusch.
Q94 Chair: Welcome to this afternoon’s session of the Foreign Affairs Committee. May I welcome our two witnesses, Dr David Nabarro and Professor Ilona Kickbusch, and ask them very briefly to introduce themselves?
Professor Kickbusch: I am affiliated with the Graduate Institute of International and Development Studies in Geneva, where I founded the Global Health Centre. I was for a while professor of global health at Yale University, and currently I am dealing with a number of advisory issues and running a Lancet commission. I am a political scientist by training. I worked for WHO for a while and was very atypical there in the context of many medical colleagues.
Dr Nabarro: I am a public health practitioner. I worked at the United Nations for about 18 years. Currently, I am chair of global health at the Institute for Global Health Innovation, Imperial College. I am strategic director of a leadership centre in Geneva, Switzerland, called 4SD, and I am working as special envoy on Covid for Tedros, director general of WHO.
Q95 Chair: Thank you both very much for joining us.
May I kick off by asking Professor Kickbusch a brief question? I know I am being very rude when you have kindly volunteered your time, but may I ask you to keep answers as brief as possible so we can get through as many questions as possible?
What are the key benefits or unique selling points of the World Health Organisation?
Professor Kickbusch: It is a United Nations organisation with 194 member states, which means that nearly all countries of the world, depending on how you define it, work together based on common values. It sets norms and standards of incredible value to all countries in relation to medicines and treatment of diseases. It brings together people who might otherwise not work together, because until recently health was one of the areas where people were always able to find common ground. That has proved to be important for many other foreign policy issues, if you have particular areas where you can work together.
WHO also sets treaties. It has two treaties: the framework convention on tobacco control and the international health regulations, which are very much in focus right now, to try to get countries to work together according to certain rules, particularly in disease outbreaks.
It has run major campaigns. You all remember smallpox eradication, which is now closed, and it is now working with other partners to eradicate polio. There are many other infectious disease areas.
It is both a technical organisation and an organisation that sets new agendas: think of non-communicable diseases, which it brought into the agenda. It brings together scientists, politicians and policy people. It is an extraordinary platform.
It works at various levels. Its headquarters are in Geneva, where there are many other health organisations and they work together to a global action plan. It has regional offices—sometimes that is both a strength and a weakness—and 150 country offices.
Many other organisations rely on the World Health Organisation and its local base, so to speak, in countries where it is very closely linked to ministries of health.
Q96 Chair: Clearly, for many countries it is the public health authority. Here we have Public Health England, similarly in Scotland, Wales and Northern Ireland, but for many countries in the world it is the only public health authority, so it has a particular national jurisdiction, as well as an international one.
Professor Kickbusch: There is definitely very close co‑operation. It will always be the member states that take the decision. WHO is a member state-driven organisation. You can well imagine that to get 194 member states to agree on something is not always easy. That opens the door to some member states trying to exercise political influence in a variety of ways. That is both a strength and weakness of such organisations, but, as you rightly say, it has a very important role for the poorest and developing countries, which it helps to develop health policies and health systems and co‑ordinate donors in many cases.
We must not forget that, increasingly, it is important for the developed world. It is really important that it is not an organisation for the developing world or an aid organisation; it is an organisation that gets countries to work together. We now see with Covid-19 how important it can be for the developed world. It is truly global.
The WHO’s international classification of diseases is obviously important for everyone around the world so that medical people can work together on a common normative basis.
Q97 Alicia Kearns: As you are aware, this review is about how we build up the resilience of multilaterals to make sure they are strong and can be protected. What vulnerabilities to unacceptable interference by member states and Governments and, separately, operations would you identify the World Health Organisation is suffering from, or being at risk of? David, do you want to kick off?
Dr Nabarro: Yes, but on all questions I would always defer to Ilona.
As this is my first intervention, I will answer by saying that I have been asked to make the following remark. I want to thank you for inviting me as a resource person. I should mention that anything I provide in the way of information is on a voluntary basis and without prejudice to any of the privileges and immunities enjoyed by the World Health Organisation, its staff and experts.
As Ilona said, because this organisation is owned by the member states, like all of the United Nations system, it operates within the space that the member states give it. In my experience, that can be constrained, particularly on specific issues, like a problem in a tight geographical area or an issue that attracts a lot of attention because of ethical or moral aspects. Therefore, member states can constrain the space and the secretariat, which is a professional body, and it can then find itself with rather narrower room for manoeuvre, or the member states can give a lot of space when there is no contention at all and things can be dealt with with relative freedom.
We in the United Nations system are all used to that variable space. We are also used to trying to understand what the space is and sometimes testing it. In a way, that is the art of being an international civil servant. You operate within the space, but you seek to make sure that sometimes you can perhaps enlarge that space so you do your job as effectively as possible.
My own view is that there will always be efforts to limit and constrain the work that can be done by the secretariat of any United Nations organisation. We used to think that health would be less likely to be subject to restrictions imposed by member states than some other issues, such as peace and security, but we are now seeing that health is also an area where member states have very strong views about the room the secretariat can have for its work.
I think it will go on being like that unless some totally different structure for the multinational system emerges. There will always be efforts by member states to set priorities, constrain action and perhaps even to affect the actual work of the organisation.
Q98 Alicia Kearns: Professor Kickbusch, you mentioned political interference. What vulnerabilities would you identify within the WHO as unacceptable interference by member states? Have you actually witnessed any during your time?
Professor Kickbusch: It is very difficult to speak of unacceptable interference because in a UN organisation member states will always try to put their own interests first or will do so in many cases. It is their right to try to get their own preferences accepted by everyone else.
It depends what interests there are. They can be geopolitical interests or interests related to key industries that are important to a country. When I worked with WHO, on a whole number of occasions there was strong pressure in relation to guidelines on the use of sugar. There was an extraordinary amount of influence when WHO was still working on the framework convention on tobacco control. Countries did not want their own tobacco industries threatened. There is an attempt to get certain priorities up front.
As will always be where there is politics and power, there will be influence by those who also contribute significant amounts of money. In my day I experienced pressures being placed on directors general. I must say that many of the directors general I knew were strong enough to withstand that pressure, but, as David has said, it is a tough job and you need to do a very complex balancing act, and we are partly experiencing this right now.
Q99 Alicia Kearns: Perhaps I could flip the question on its head and ask what protective mechanisms the World Health Organisation currently has in place, or has put in place, to prevent such malign influence. You were very good at suggesting some examples that would not necessarily fall into my truly malign box, but I recognise they might not be ideal. What protective mechanisms does the WHO use to protect itself from those who are seeking malign influence?
Professor Kickbusch: There are the governing bodies of the WHO—for example, the executive board. Many of these things are discussed there both in public deliberation and in smaller committees. There are all kinds of working bodies there; there are the values of the organisation and the ethics of the staff. One must not underestimate that.
There have also been regular inquiries. To take an example from my time on the framework convention on tobacco control, there was an inquiry on the influence by the tobacco industry on WHO. There was also a very self-critical analysis initiated by the then director general, Dr Brundtland, which proved to be very important and effective.
The organisation ought always to have mechanisms to revisit itself both from within and through committees that are established to do that, but it realises that some countries are stronger than others and they will continue to attempt to weaken norms or recommendations, and the other way round. The countries of the global south are very insistent on their rights on issues like intellectual property and other things of that nature. As we call it, the health diplomacy is sometimes very tedious and long, and people say, “Why don’t these guys work a bit faster?”, but in that sense it is a protective mechanism. Nobody can just barge in and say, “You’re going to do what I tell you right now.” That applies also to the director general.
Q100 Alicia Kearns: Have any nation states been censured for what has been identified as unacceptable interference? We all recognise the jostle and bustle of diplomacy. I have sat at those tables, where each tries to achieve what they need, but is there actual censorship or any kind of discipline or recourse for those who have been identified as engaging in anything that is unacceptable, or in the history of the WHO has no one ever been formally recognised as being malign or unacceptable in the interference they are trying to achieve?
Professor Kickbusch: As far as I am aware, no. There is no mechanism to do that. Within the UN system one does not call countries to order in that sense. Anybody who is involved in diplomacy will know there are ways and means to bring k across that something has not been acceptable. For example, a director general—this has been part of the touchy Covid debate—in principle would never call out a member state. These are not the mechanisms with which the UN works. One tries to maintain a working relationship both between countries and between countries and the secretariat, and resolve issues in a variety of ways. David, would you agree?
Dr Nabarro: Yes. In other parts of the United Nations systems there are instruments that can be used to identify what one might refer to as unacceptable behaviour. The Human Rights Council has that capacity. There are special rapporteurs identified by the Human Rights Council who very explicitly will point fingers at anything they think is wrong. I have experienced this in some of my work with the UN Secretary-General in New York.
Within WHO, the oversight of programmes, finance and employment practices is really strong. There is a whole series of mechanisms and committees, as Ilona identified, that reports to the executive board and the World Health Assembly. It is quite a tightly monitored organisation. This leads to some people complaining that the place is bureaucratic, but it is very important to stress that some of what is defined as bureaucratic by a Government that wants to get a particular result would be seen by others as the necessary checks and balances to stop people throwing their weight around.
Q101 Graham Stringer: Professor Kickbusch gave us an analysis of realpolitik in UN organisations and the World Health Organisation, and one has to live with that. When dealing with health issues does one have to live with the withholding of information that could stop other countries responding to a health threat? That is a negative rather than a positive.
Dr Nabarro: The way the whole system is run right now is one that recognises the sovereignty of each member state in determining what information it provides to the World Health Organisation’s secretariat. One could argue that that is unstable, but that is where we are at, at the moment.
In 2005, after a two-year process, the international health regulations—one of the two treaty mechanisms that Ilona identified—were revised and agreed. Central to that agreement was that information about diseases would be made available to the World Health Organisation at the discretion of member states. That was a negotiated agreement. If that is perceived to be unsatisfactory and there is too much capacity for individual countries perhaps to conceal information, it will be necessary under the current arrangements for that to be reviewed through a renegotiation of the international health regulations and a requirement for greater inspection capacity in the hands of the secretariat than there is currently. Right now, if a country does not want to release information it does not do so, and the organisation is not permitted to provide information from any other source than what the country tells it is happening.
Professor Kickbusch: That was why there was so much discussion around this during Covid-19. As you might know, calls to revise the international health regulations have increased. The director general has called for a review committee of the international health regulations. There was a specific one after the Ebola outbreak. I was part of a review committee that asked for revision of the international health regulations, but at that point the review committee did not agree it was timely to do so.
This time around, the pressures are much greater, and it is being suggested that a whole range of mechanisms, including mechanisms from the Human Rights Council to which David alluded, should apply to the WHO: that one can assess and call out countries in new ways; that the international health regulations are made stronger; and that the organisation is given more authority and independence, but that is negotiated by member states.
Some member states, perhaps more than others, are particularly keen on what they consider to be their sovereignty and are afraid of potential economic consequences if they call attention to an outbreak early. There have been international instances where countries have been penalised because they have shared that information early on, so finding a balance is absolutely critical and we will need a revision of the international health regulations.
Q102 Graham Stringer: The World Health Organisation has been criticised for being slow to respond to the Covid-19 crisis. First, do you think that criticism is fair? Secondly, is that because information provided by Taiwan was not passed on when during the very last hours of last year it said there was human-to-human transmission? Was that one of the problems, or was it also that China was over-influential and did not pass on its basic health information at that time?
Professor Kickbusch: Maybe David will come in with some details. As far as I am informed—I was involved in some of these discussions—in the international health regulations there is a mechanism for focal points. The focal points were informed in early January that there was something going on in China. Do not forget that at the end of January—there was a whole number of other issues—information, as well as that from Taiwan, was gathered, and on 30 January the director general proclaimed an international health emergency of international concern, which is the highest warning the WHO can give.
There was very little action, at least in what we call developed country member states, throughout January, whereas already at that time countries like Korea, Taiwan, Japan and others, particularly those that had had experience of SARS, MERS and so on, put mechanisms in place. WHO was clear in its warning on the 30th. As I say, in the international health regulations that is the warning to give, but it was not taken seriously by a whole range of countries.
That is why that is also to be considered in the revision of the international health regulations. Countries woke up only when WHO used the term “pandemic” in March, but that is not a legal term in the context of the international health regulations.
David, would you complement this, please?
Dr Nabarro: This is important stuff. The information I have is that WHO received the information that there was an atypical pneumonia cluster in Wuhan on 31 December. WHO also received a message from the communicable disease community in Taiwan around the same time asking questions about what this atypical pneumonia cluster was, but, to the best of my understanding, this was not a message from Taiwan that in any way questioned the message that had come through from China; it was simply requesting more information.
That was on 31 December. By 5 January, the WHO was producing its first assembly of information about the outbreak. What was not clear right at the beginning was whether there was human-to-human transmission. It was thought to be possible.
Q103 Graham Stringer: The burden of Taiwan’s message was that there was human-to-human transmission?
Dr Nabarro: There was not a message inside WHO confirming human-to-human transmission, according to my information, before the middle of January. Indeed, in the middle of January WHO said it still could not confirm that there was human-to-human transmission.
I want to stress that this is a really difficult issue. I worked on bird flu in 2005. We had lots of sporadic human cases of bird flu, but we did not have confirmed human-to-human transmission. Dissecting a piece of information to see whether it is definite human-to-human or sporadic animal-to-human transmission is a super-important issue to work on.
My understanding is that the interval between the end of December and 14 January, which was of concern to several, was because they still had not worked it out. I am sure the panel review that is being done at the moment will question whether 14 days was too slow and whether the tweet that came out saying there was no confirmed human-to-human transmission on 14 January was inappropriate.
I want to stress that it was not exactly a huge time interval. Just look at what is happening now in Europe as countries try to work out whether a resurgence is under way and whether they are going to get a lot of cases. It is taking two or three weeks for Governments to make sense of the information we have, and we have an enormous amount of epidemiological data. At that stage there was very little data available. From my own experience of working on Ebola in 2014, there was very little evidence that WHO was “slow”; it just did not have the information it needed to make certain whether there was human-to-human transmission occurring before 22 and 30 January when the two emergency committee meetings happened.
From my analysis, it is difficult to say they were super-delayed during that period. Of course, the analyses are being done now.
Q104 Graham Stringer: At the start of any epidemic, speed is absolutely critical—the SARS and MERS epidemics were got on top of very quickly because there was very quick action. I am sceptical about the replies, because Taiwan claimed it passed on the information about human-to-human transmission, and this was at the same time the Chinese Government were persecuting the doctor who was dealing with the early stages of this outbreak. You seem to be saying that that was not the country’s problem in denying there was a real outbreak in China, but it was down to the international health regulations, which we ought to change, not the way the World Health Organisation responds to information from Taiwan.
Dr Nabarro: With respect, I am going to tell you what I know. On 31 December Taiwanese authorities sent a message that read: “News resources today indicate that at least seven atypical pneumonia cases were reported in Wuhan,” and then there is more about the fact that this was not believed to be SARS, which was the coronavirus we worked on in 2003. “However, the samples are still under examination, and cases have been isolated…Please can you give us any relevant information you have?” It was a message from the authorities in Taiwan asking for information.
There is a huge amount of material around—there are media reports and so on—about what happened at the end of December/beginning of January. There is a study under way. You have information; I have information. I have said in public that I believe the really important thing to do is to wait until the panel that has been appointed at the request of the World Health Assembly provides its information before too much is decided in the way of who has faulted.
I do not think any of us wants to say that WHO, or any other part of the UN system, is perfect. Those of us who have worked in outbreaks know that at the beginning it is difficult to work out what is going on. You have incomplete information. Often, you have to make decisions under extremely difficult circumstances. We are talking about what happened in a period of three weeks. I do not want you to think I am defending anybody; I am just telling you what I know and suggesting we wait until the inquiry has produced its results before a judgment is reached.
Q105 Graham Stringer: Are you satisfied that China was transparent with the information it had about this outbreak and communicated that to the World Health Organisation?
Professor Kickbusch: I think we still have a number of things to learn about what happened in China, particularly communication between where the outbreak was—in Wuhan, the province and so on—and the central authorities in China. Some of the investigations being carried out now will teach us more about that. There are people who are very sceptical because of the experience of SARS and the political system in China, but we need to wait and see what the various investigations show us and help take that forward.
I tend to be quite insistent on that. We talk about the whole period of January. We then have the message from the World Health Organisation that there is a public health emergency of international concern, and we see a significant number of countries not taking action until the middle or end of March. You say that speed is of the essence. A whole number of countries thought they were immune to this disease and did not take action. The investigations will need to show how these various processes interact with the information strategy of China and the actions of the WHO and member states in the context of the IHR.
Q106 Chris Bryant: I sat in on the breakfast meeting with Mike Pompeo when he claimed that the WHO was a terrible organisation and was utterly useless because its senior officers had been bought by the Chinese Government. What would you say to that?
Professor Kickbusch: I would not accept that. That is geopolitics of the purest nature. If you have had the time to read Bob Woodward’s book, I think that statement will be confirmed.
Q107 Chris Bryant: When you say “purest”, you mean “impurest”—“least pure” or “least good”.
Professor Kickbusch: Least good, yes.
I want to accentuate what Ilona Kickbusch has said. Since the end of January, WHO has given out one pattern of advice: it is a coronavirus; it is not flu. You need to contain it quickly and robustly. If you do not do so it builds up exponentially and becomes deeply entrenched in your country, and you will find it very hard to get rid of. Speed is of the essence, which was exactly what was said previously by Mr Stringer.
I want to stress that this is an organisation whose values are global and are for equity and justice, and the people working there are all in that vein. They are such amazingly committed people. I have seen absolutely no evidence of anybody, particularly in the emergencies programme, showing any kind of bias. I do not recognise what the Secretary of State said when he made those comments to MPs.
Q108 Chris Bryant: To be clear, nor did I. I would suggest it is a bit difficult to argue for enforcing a rules-based order if in the meantime you dismantle most of the rules in the international community.
My second question is one that I think quite a chunk of my constituents would ask. Are you really sure about coronavirus? Is it not just all made up? Lots of people say they contracted it last September or October and they are absolutely certain of this. They have been told by their doctor that they probably had coronavirus last September or last October, and it is all a great big conspiracy.
Professor Kickbusch: David, you are the doctor.
Dr Nabarro: To be straight with you, Chris, none of us finds the present situation anything other than horrible, grotesque and embarrassing. It is a terrible situation. A health issue has got so out of control that it is knocking the world into not just a recession but a huge economic contraction that will probably double the number of poor people and malnourished and lead to hundreds of millions of small businesses going bankrupt, and generally wreck destinations for a lot of young people who will not get educational opportunity.
We would all love to find a nice, convenient explanation for it: 5G telephone masts, or some other thing we can infer, like vaccines with microchips in them. I totally understand why people have these ideas. I do not find myself in any way wanting to disagree with them or get angry with them, because I want to find a way to explain this awfulness.
I keep asking myself: who on earth visited this on humanity? I do not mind it. I get irritated when stuff that is sent by these people undermines the capacity of a decent response. I am a little bit fed up with the anti-masking protests—they are unhelpful—but in general we have to entertain the fact that everybody everywhere is looking for an explanation. We need to level with them and say, “We quite understand it; we know how absolutely awful this is for so many hundreds of millions of people.”
That would be my answer to your constituents. I get it totally, but then I would say, “This is what I believe based on my understanding.” Almost certainly I have got some things wrong in my understanding and new facts and figures will change my understanding, but my understanding is that this virus was visited upon us at the very end of last year and we have been learning to live with it for this year. We will make sense of it and will be able to work out how to do it, but it will take us quite a bit longer.
Chris Bryant: I hope you will not mind if I clip that and put it on my Facebook page for my constituents and others. Sorry, Chair: I was diverging a bit.
Chair: It is worth being clear on these things. I am very grateful to Dr Nabarro for making that extremely clear.
Q109 Alicia Kearns: We have been told it is difficult for the WHO to be particularly critical of individual countries. Do you agree that is a difficulty? We recognise that in any diplomatic circumstance it is difficult to criticise member states, but do you think that is a particularly difficult challenge for the WHO at present?
Professor Kickbusch: It is a challenge particularly during an outbreak, not only in this case, because the tendency at both the political and individual level, as you just indicated, is to try to find where it comes from. Is there somebody we can blame? Could it have been prevented? Should not X have done this?
That is why we need better mechanisms. As we have just said in the report of the Global Preparedness Monitoring Board, we need to have better mechanisms to ensure preparedness and be able much earlier and before an outbreak to do reviews and, if you want to use the term, call out.
At the same time, even though we have those mechanisms, we did develop, for example, the global health security index and found that two of the countries right on top of that index, the United States and your own country, had great problems in responding to the virus.
It is a whole range of mechanisms about trying to find out who is really fulfilling their commitments and is prepared. Then, if you have the second step, as our Australian colleagues have suggested, we should have a weapons inspectorate-type mechanism with sanctions and all kinds of things. I think that in public health we find it very difficult to work together in that way, and weapons inspectors have not always been that successful.
If we are talking about calling out, it is an analysis that would need to be done much earlier. Who is really well prepared? Who has the mechanisms in place? It is then about finding a way of working together as a global community if a problem arises in one country.
The origins of these things are also related to ecological changes and an enormous amount of change in our society and the way we live, travel, eat and so on. Many of these things could happen anywhere. The United States thought it could resolve the issue by cancelling flights from China, but it found that the virus was spread by people who came in from Europe and Italy.
I do not think a blame game will ever help us, but we need good analyses at different points in time. Smaller countries—we had this with cholera outbreaks and Ebola—become pariahs in the international trade system and that hinders them next time round in being honest and declaring something. Therefore, it needs very well-established processes that allow for honesty and the sharing of responsibility.
Q110 Alicia Kearns: I probably have a lot more sympathy for the Australian suggestion of sanctions, but there is a very important line between creating an open space where people can take responsibility and recognise that perhaps they were not as well prepared for a certain type of pandemic as they would have been for others and nations that actively mislead the international community.
The reason I ask this is that there was a lot more evidence back in 2003 of the World Health Organisation being quite critical of China in the SARS epidemic, whereas this time round there seems to be a reluctance to do so, given a pattern of behaviour with SARS and the African swine fever outbreak in 2018. I understand that the health community, like many others, may feel that sanctions somehow fall outside their remit as humanitarians and people who support communities, but we have to recognise that the WHO and health are part of hybrid warfare and conflict, and essentially nations seeking to subvert the international order will use the WHO and a pandemic to achieve their own interest.
Should not the WHO be more willing to criticise public health failings that have an impact on the world’s health and the ability of all countries to tackle pandemics, not because one country is not as well equipped—for example, because it had fewer ventilators—but because it actively misled or withheld information, as might have been seen with Taiwan in this circumstance?
Professor Kickbusch: I would agree with you that the WHO and its secretariat would need more independence and authority to investigate and offer information, but I have to take you back to the point that people who agree on the rules and international health regulations are the member states themselves, and in 2005 some of the most powerful member states with the strongest geopolitical interests actively and consciously, as David alluded to, made sure that certain powers were not given to the World Health Organisation. I think that is really a cause for countries that want this strengthening of the secretariat, even if it is appointing an independent committee, that would do that kind of thing.
To return to SARS, Dr Brundtland recently said in an interview that today, given the international health regulations, she would not as director general of WHO be able to do what she did then—call out a particular country—because, on the one hand, everyone was proud to have a revised treaty, with a number of excellent additional points in it, but having that reworked treaty restrained WHO and the director general in having some of the “political flexibility” that Dr Brundtland had and quite rightly used.
Another very telling comment she made was that at that point in time China was a developing country; it no longer is. I will not interpret that statement, but you can understand what she was trying to say.
Q111 Henry Smith: I would like to return to a comment made a few moments ago that most of the rest of the world did not sit up and take notice with regard to the seriousness of Covid-19 until the word “pandemic” was used. We also discussed the issue that in late December/early January there was perhaps some confused messaging. Would you accept that even as late as 24 January the director general of the WHO tweeted, “I’m not declaring a public health emergency of international concern today”, and that that was one of the significant reasons why perhaps other countries that have yet to see the impact of Covid‑19 were not as quick to respond as they could have been had the information we have been discussing been communicated sooner?
Professor Kickbusch: I hate to sound so legalistic and formalistic, but the director general takes his decisions based on the advisory committee for declaring a public health emergency of international concern. He called that committee, which felt that, given the figures at that point in time—I think David has them in from of him—it was not yet a public health emergency of international concern.
That shows us another one of these weaknesses. The director general has said since he took office that in the world we now live in, with rapid communication, travel and everything else, we need different models, not PHEIC or non-PHEIC, that give us a yellow, an orange or whatever to draw people’s attention to the fact they need to act. At that time it seemed it was there in China and it might be regional, thinking back to SARS; it was not then really global, but it is an indication that the director general himself was not satisfied with the advice of his committee. That led him to travel to China, and in about a week he called that committee again and declared a public health emergency of international concern. Maybe you can illustrate it with some of the data, David.
Dr Nabarro: At its first meeting on 22 January the emergency committee could not reach an agreement. It met again on 23 January and it still could not reach an agreement. At that point there were very few cases of Covid outside China.
Two days later cases were reported in France and were picking up in other parts of the world, so Tedros called it back before it was supposed to do so. The original plan was that it would meet on the 22nd and again 10 days later. He said it should return more quickly. He also went to China in the interim. It met again on 30 January and unanimously agreed that this was a public health emergency of international concern.
Interestingly, even on 30 January, when that was declared, there were only 98 cases of Covid outside China. There were no deaths at all. Some would say this is quick, and certainly the speed of movement towards declaring something massive was going on, but Covid was much, much quicker than SARS in 2003. When you look at the numbers we have, we reckon that something was first notified on 31 December and the PHEIC was finally declared on 30 January when there were only 98 cases outside one country. That is quite extraordinary. Those of us who are comparing it with other instances see that, frankly, as quite fast.
Professor Kickbusch: In a way, we are always confronted with the public health paradox. When do you warn? When do you not warn? You will have cases where you are attacked because you cried wolf supposedly too soon. Think of some of the swine flu issues. On the other hand, you are attacked for being too late. It is a very difficult balancing act, not only at global level. When do you say, “Look, guys, here’s a real crisis”? If you say it is a real crisis, you will be attacked afterwards if it is not. You will know that also from local crises. It is something that public health also has to live with.
I would very much agree with David that calling the PHEIC with so few cases outside China was a very important decision by the WHO and the director general, but probably when people looked at the figures and said, “They’ve declared a PHEIC, but there are so few figures outside China,” many deferred their actions and did not even get as far as looking at their pandemic-preparedness plans.
Q112 Chair: Dr Nabarro, looking at the scale of the financial challenges facing the WHO, what are the opportunities for strengthening some of the mechanisms, such as the formula for assessed contributions and reliance on voluntary donations? I would be interested in your perspective.
Dr Nabarro: There has been zero nominal growth in the assessed contribution budget of WHO for quite a long time now. I cannot remember for how long it has been going on.
Professor Kickbusch: Since 1980 with Ronald Reagan and the Helms-Biden Act.
Dr Nabarro: What is really bizarre about this organisation is that it runs on a budget that is less than one third of that of the United States’ Centers for Disease Control and Prevention, yet it is operating in more than 100 countries with six regional bureaus and in Geneva.
It really is tight. Every year it is asked to do more by the owners—the member states—but its budget is stuck. Successive directors general have tried to boost the budget by asking for more voluntary contributions. The current budget structure is 20% regular budget contributions and 80% of what are called voluntary contributions, which are for projects. That is a really awful way to run an organisation on which the world depends, because it is the regular contributions that really matter.
At the moment there are two major member states, Germany and France—I say “major” because they are part of the G7—campaigning for a complete revisitation of the scale of contributions, so it would be possible to consider rebooting the budget and putting it up to a more sensible level for now. You could then reduce the dependence on voluntary contributions, which are much less easy to manage because they come with earmarking and often other conditions attached to them.
I am hearing—please ask Ilona about this—that there is a build‑up of interest among many of the member states in looking at either shifting the actual scale of contributions, which is the percentage of the budget each country pays, or the total ceiling of the budget so that it goes up to a more sensible level. Both of these have been considered. In my view, both must be considered because the current financing base of the organisation is unsustainable given what it is being asked to do and the extent to which the world depends on it.
Q113 Chair: Dr Nabarro and Professor Kickbusch, from your experience is there any indication at all that it is going to change, because, frankly, the position of the US and many other nations suggests that you may be right—that it should but the reality is that it will not?
Professor Kickbusch: I am partly involved in some of these discussions. As David has alluded to, Germany now has the presidency of the European Union in partnership with France. In negotiation with many other member states, it is working very hard for a combination agenda that includes a significant increase of assessed contributions and a reform agenda for the WHO.
The reform includes some issues we have already raised: independence, IHR and a whole range of matters. There is an UNDS paper out there from Germany and France, elements of which will be taken up at the special executive board meeting on 3 October, or at least in that week. Something is building up.
You will perhaps have been informed that particularly in January and February, when the first strong attacks came from the United States, there was clear movement from the European Commission and European Union to say, “We cannot let this happen. This is one of our most important multilateral organisations, and we need to show responsibility and save it.”
As a short-term answer, some countries have already made significant additional contributions to the WHO. That is why some of the statistics we still have on the largest donors do not really hold any more; we do not have total updates. Just a couple of weeks ago the German minister of health came and brought with him €500 million to stock up WHO in view of the American threat.
But countries are also very clear that it needs to be the responsibility not just of a couple of so-called donor and “rich countries”, but all the 194 countries at present—hopefully, it will remain 194—jointly have to take a decision for their organisation; they jointly have to prop it up. A doubling of the present assessed contributions will not throw even the poorest of countries into destitution. It sometimes means increasing a contribution from $2,000 to $5,000, if you look at the list. To adopt an expression that is sometimes used, we are really talking about peanuts in many cases.
One of the problems in our countries is that we have had a division in where the money comes from. The assessed contributions tend to come from a different stream of money, like the health ministry or foreign ministry, whereas the voluntary donations tend to come out of ODA budgets. That has led to an imbalance. In Germany we have addressed that. The health ministry has been given by Parliament a significant amount of funding for its co‑operation with the WHO because it is considered to be a global organisation, not a development organisation. It is looking not only at the money that arrives at WHO but from what kind of budget within a country it is coming from. With the reorganisation you have made in integrating DFID into the Foreign Office, you will have to take some decisions about these money streams and look at them very carefully, because ODA money tends to go towards specific diseases and set conditionalities—for example, “I will give you this chunk for children, vaccines, polio or whatever.”
Dr Nabarro: Britain, as well as being the No. 3 contributor, is one of the few countries that has provided unearmarked voluntary contributions, which is a very precious thing to do. It is a sign of extraordinary confidence in the organisation by the UK Government, plus a very tight monitoring programme that keeps a very close watch on where every bit of money goes.
Professor Kickbusch: Absolutely, even though I prefer all of that to be in assessed contributions. If I take my own country, it does not just come along and say, “We want the money to go there.” It has a discussion with WHO. Germany has very much supported the emergency work. There was a time when Germany was nearly the only country that gave money to the contingency fund for emergencies because nobody else thought that was an important thing. That was absolutely critical in Ebola, for example. Making some of these things more regular and less voluntary, no matter in what way, will be absolutely critical, and that is what Germany and France want to achieve.
Q114 Graham Stringer: May I transfer the focus to the United Kingdom’s Foreign Office directly? I am trying to get at how it has performed. Has it changed its performance during the Covid‑19 crisis? Has it improved? Has it learned from it? Is there anything else it could do to learn and improve? Both of you are looking blank.
Professor Kickbusch: I am looking to David; he is the Brit here.
Dr Nabarro: The key thing that is happening is that this is shifting from being an emergency that we have to deal with using emergency-type thinking to something that is a fact of life for every country in the world. Because it is becoming part of our collective ecosystem, every single country is going to need the capacity to work with other countries to establish how best to deal with it. Poor countries are facing particularly serious problems right now. Not only do they have to cope with the disease and work out what impact it is having and build up their health services so they can deal with new cases—in some places they are completely overloaded with staff dying—but they have to cope with the impact of containment measures on their people, with a vast increase in poverty, hunger, unemployment and so on.
My own view is that all nations of the world, but particularly the rich ones, should be looking very hard at what is happening in poor nations and thinking through what they need in cash, political support and platforms through which they can work together to deal with the non-health aspects of this crisis.
That means I am inclined to say in response to that question that the foreign ministries—in the case of the UK, the Foreign, Commonwealth and Development Office—of all the G20 or G7 wealthy nations need to be working hard not just on what is happening in their own borders or immediate regions; they must take a global perspective, because there is a real likelihood this will massively increase poverty and undo some of the gains that the UK and others have worked so hard to support in recent decades.
Professor Kickbusch: We can see in many countries that there has been an increasing involvement of foreign offices and ministries of foreign affairs in health matters, in particular during Covid‑19.
Chair: The question is about the UK’s Foreign Office, rather than anybody else’s foreign office.
Q115 Graham Stringer: I was trying to get at how our Foreign Office has performed and whether there is anything more it can do to help the World Health Organisation in sharing information and best practice among states. This has been an international discussion because it is a pandemic, but I was trying to look at how our own Foreign, Commonwealth and Development Office has performed and what it can do better.
Professor Kickbusch: First, what we see is that foreign offices have become more involved in health and they play an incredibly important role—including your own representative in Geneva—in the many negotiations on health.
If you think back a couple of years, these health negotiations lay mainly with ministries of health. We are seeing many of them shift to the foreign offices. That means the foreign offices need more expertise in health. There needs to be more co‑operation between foreign offices and health ministries. For example, in Germany we have tried to strengthen it through developing a global health strategy, which will be adopted by our Cabinet probably in October. There is a variety of ways. In the German foreign office we have a focal point for global health.
There are a number of areas where foreign offices can become more active. Some countries—for example, France—have global health ambassadors; some countries, because of the importance of health, business and so on, have health attachés in their embassies, not only in the negotiations in Geneva and New York, where it makes sense, but in big countries. It might well be a good idea, for example, to have a health attaché at the African Union and other places like that.
Q116 Chair: What lasting effects will the Covid pandemic have on the WHO and the way it functions?
Professor Kickbusch: Quite honestly, we do not know yet. Ebola—I was part of the review committee—led to significant positive change. It was because of that analysis and criticism that we had the reform of the emergency programme, the contingency fund and a whole number of issues that have taken the organisation one step forward.
I would be confident at this stage that, if the member states take up their responsibilities and the organisation is able through the various committees and reforms to move forward, it could have a long-term positive impact, because a significant number of countries have seen that they cannot do without the World Health Organisation. Much of the stuff that is constantly discussed—that we should do this or that—is now becoming really serious. Member state representatives I talk to are at present very committed and say that we need to save this organisation, reform it and pay it better. You get what you pay for.
Dr Nabarro: I have three quick points in response to your question, Chair. First, I do not think we have yet seen what Covid will do to our world. We should be looking in a year’s time because the virus is just at the beginning of its travels throughout our world. I personally believe it will have a massive negative impact on so much that has been happening, particularly undermining the development of poor nations and leading to much greater disparity between wealthy and poor all over the place.
Secondly, I think we are learning that you cannot bank on good economic growth unless you have some security about public health. If you think that public health will be undermined as a result of infectious disease, in turn that creates a lack of confidence in the prospect for economic growth, so I suspect we will see countries all over the world putting more emphasis on basic public health as a key to their economic development.
Thirdly, the World Health Organisation is as good as it probably can be within the current arrangements. I do not see any appetite among Governments to change the way in which global health is managed, but I would love to see WHO connect more with people. The compact behind the United Nations starts with the words “We The Peoples”. I believe that a world health organisation that works directly for people, as well as for Governments, is what we ought to be working towards in the future, particularly given we are going to see such enormous consequences with Governments finding it so hard to work together on managing Ebola. They criticised WHO, but, as Ilona has said, there is a lot of evidence that many did not follow the simple guidance of WHO to contain this virus quickly. That is why we have such horrendous problems in the world at the moment, which we have not yet got on top of.
Chair: Thank you very much to both of you for appearing before us this afternoon. That was enormously helpful to us. I am very grateful to you for taking the time to be with us.