The Lancet
May 14, 2022 Volume 399 Number 10338 p1845-1916
https://www.thelancet.com/journals/lancet/issue/current

Comment
Offline: Bill Gates and the fate of WHO
Richard Horton
On the same day that Gates made his pitch, WHO published a white paper on Strengthening the Global Architecture for Health Emergency Preparedness, Response, and Resilience. It was timed to provoke debate in advance of the World Health Assembly later this month. WHO has reviewed over 300 recommendations made by recent international commissions and panels, synthesising their ideas into ten proposals. WHO suggests the formation of a Global Health Emergency Council, led by heads of state, to “break the cycle of panic and neglect that has characterized the response to previous global health emergencies”. The agency recommends revision of the International Health Regulations, stronger independent monitoring of national preparedness programmes, formation of a new global health emergency workforce (akin to GERM, but without decision-making power), and the creation of new financing instruments. These are important reforms that deserve support. But there is one assumption threaded through the white paper that should be subject to scrutiny—the idea that WHO itself should be at “the centre” of emergency preparedness. The existential anxiety within WHO is palpable. Repeated warnings about duplication and competition are designed to dissuade member states from “creating a parallel structure, which could lead to further fragmentation”. For example, according to WHO, the Global Health Emergency Council should be aligned (read subservient) to the constitution and governance of WHO and be supported (read controlled) by WHO’s Secretariat in Geneva. A new Standing Committee on Health Emergencies to complement the work of the Council would exist only as a subcommittee of WHO’s Executive Board. WHO concludes, “Finally, it is clear that at the heart of the HEPR [health emergency preparedness and response] architecture, the world needs a strengthened WHO, with the authority, financing and accountability to effectively fulfil its unique mandate as the directing and coordinating authority on international health work.” WHO’s white paper is an ambitious land grab for power.

On the same day that Gates made his pitch, WHO published a white paper on Strengthening the Global Architecture for Health Emergency Preparedness, Response, and Resilience. It was timed to provoke debate in advance of the World Health Assembly later this month. WHO has reviewed over 300 recommendations made by recent international commissions and panels, synthesising their ideas into ten proposals. WHO suggests the formation of a Global Health Emergency Council, led by heads of state, to “break the cycle of panic and neglect that has characterized the response to previous global health emergencies”. The agency recommends revision of the International Health Regulations, stronger independent monitoring of national preparedness programmes, formation of a new global health emergency workforce (akin to GERM, but without decision-making power), and the creation of new financing instruments. These are important reforms that deserve support. But there is one assumption threaded through the white paper that should be subject to scrutiny—the idea that WHO itself should be at “the centre” of emergency preparedness. The existential anxiety within WHO is palpable. Repeated warnings about duplication and competition are designed to dissuade member states from “creating a parallel structure, which could lead to further fragmentation”. For example, according to WHO, the Global Health Emergency Council should be aligned (read subservient) to the constitution and governance of WHO and be supported (read controlled) by WHO’s Secretariat in Geneva. A new Standing Committee on Health Emergencies to complement the work of the Council would exist only as a subcommittee of WHO’s Executive Board. WHO concludes, “Finally, it is clear that at the heart of the HEPR [health emergency preparedness and response] architecture, the world needs a strengthened WHO, with the authority, financing and accountability to effectively fulfil its unique mandate as the directing and coordinating authority on international health work.” WHO’s white paper is an ambitious land grab for power.

Neither Gates nor WHO seem to understand the nature or true scale of this pandemic. First, SARS-CoV-2 thrived on inequality. There is no serious discussion about the way this virus exploited deep disparities across societies and why attacking these disparities must be part of preparedness planning. Second, COVID-19 is a disease that normalised inequity—for testing, vaccines, and now antivirals. There is no sense of urgency to advance equity. And third, COVID-19 is a zoonotic disease. There is no recognition that preventing a pandemic means redefining the relationship between humans, wildlife, and the viruses that pass among us. One final warning. Do not assume that governments will be willing to invest in preparedness, despite the catastrophe we have endured. Countries are already resisting calls to invest in the next replenishment round for the Global Fund to Fight AIDS, Tuberculosis and Malaria. If governments are unwilling to support an initiative with one of the best track records in global health, it is questionable whether they will make speculative investments to prevent a future pandemic. The disagreeable truth is that we are living at a very dangerous moment, one in which careless self-satisfaction is the reward we have given ourselves for this illusory triumph.