The Foreign Service Journal, July-August 2020

THE FOREIGN SERVICE JOURNAL | JULY-AUGUST 2020 35 assembly of member states on the basis of presumed consensus around a rules-based, science-based world order. Because of the prowess of our biomedical research and epidemic surveillance, as well as our world standing, the United States has historically been WHO’s most influen- tial member, and its global accomplishments, such as the eradication of smallpox in 1980, have been significant. But COVID-19 demon- strated that WHO’s strengths are also its weaknesses. Requir- ing an implicit consensus to act, decision-making processes can be slow and deferential to member-state sensibilities. Its mandate to address all aspects of worldwide health and well-being is lim- itless, but the organization’s budget of under $4 billion per year is a tiny fraction of what bilateral donors such as the United States or major new players such as the Bill and Melinda Gates Foundation spend on global health. By comparison, the annual outlay of the Maryland state Department of Health is three times larger than WHO’s annual budget. The organization’s main roles are, therefore, to set norms and provide technical assistance to governments, not deliver health programs or clinical care itself. The United States took a leading role in revision of WHO’s International Health Regulations in 2005. Politically binding, but without enforcement authority, the IHR require member states to “detect, assess and report on” outbreaks that might endanger international health. Dozens of such reports are submitted to and evaluated by the WHO Health Emergencies program (WHE) every year and, in rare instances, referred to expert commit- tees to determine if they should be declared “Public Health Emergencies of International Concern.” On Jan. 30 this year, the novel coronavirus was so designated, with recommendations for action by China and other states and actors. WHO leadership undertook important reforms following the 2014-2015 Ebola epidemic in West Africa, in which the organi- zation initially performed poorly. They strengthened the WHE, merging two WHO divisions under a deputy director general. The deputy director general, in turn, is informed by an Inde- pendent Oversight and Advisory Committee (to give WHE more efficient governance and reporting) and a Global Preparedness Moni- toring Board. The latter issued a prescient report in 2019, high- lighting actions that political leaders, national govern- ments and the U.N. system should take to prepare for a pandemic. The WHE performed well over the past four years in confronting Zika, yellow fever and the Ebola outbreaks in the Democratic Republic of the Congo. It remains dependent, however, on emergency funding appeals, which for COVID-19 have been insufficient. And, as we saw in China, its ability to investigate or act outside restric- tions set by national governments is limited. Vaccines, Treatments and Equity The COVID-19 pandemic makes clear what the Global Pre- paredness Monitoring Board pointed out—current international structures for global health lack incentives for member states to take early action, rationalize supply chains for necessary tests, coordinate development of vaccines and treatments or, in partic- ular, adjudicate or regulate how poor people and poor countries might gain equitable access to them. China, the United States and several other countries and con- sortia launched crash programs to develop coronavirus vaccines and COVID-19 countermeasures. Unlike all other recent epi- demics, the entire populations of rich countries are at risk, and thus the market for these vaccines and countermeasures would be huge, immediate and lucrative. The competition to develop safe and effective vaccines or cures was spurred by governments wanting priority access to these products for their own popula- tions, and by corporations and laboratories that could profit enormously by being first to offer an approved vaccine. Issues of equity arose immediately. There is no “World Vaccine Development and Distribution Agency.” No international mecha- nism has existing authority or the practical ability to take control of a product shown to work, equitably determine which countries or populations (e.g., health care workers) would derive maximum benefit from being treated first, or determine the price or condi- ISTOCKPHOTO.COM/SERGIOLACUEVA