The unilateral ultimatum issued by US President Donald Trump to the World Health Organization (WHO)—"reform or else” in 30 days—raises the real possibility of a WHO without funds or governance participation from the United States. What would that mean in practice?
There is first the question of whether the United States will withdraw formally from the WHO, giving up voting rights, its seat on the executive board, and participation in the organization more broadly, or whether the United States only goes into further arrears and foregoes voting rights, as the WHO treats the Central African Republic, South Sudan, and Venezuela (bad company).
But even if the United States stays in the WHO, the loss of a fifth of the organization’s budget is a major blow, and one that has not yet been compensated by contributions from other countries. When the Trump Administration announced last month the United States would temporarily halt funding for the WHO, many countries reaffirmed their support of the organization. Some responded to the US action by increasing their own contributions: China announced an additional $30 million in funding, Ireland quadrupled its contribution, and Finland pledged an additional 5.5 million euros. Still, the additional pledges fall well short of filling the gap left by the United States, and even if other countries’ statements of support materialize into increased contributions, they likely will not be enough.
What can we expect:
Less attention to disease control objectives the United States cares about and where US voluntary contributions are concentrated—the “big 3” diseases (AIDS, tuberculosis, malaria), and polio. US contributions make up 20 percent of WHO’s total budget, but 70 percent of US contributions in 2019 went to these diseases and a few other program-specific budgets. Since these investments are part of the US bilateral global health agenda, withdrawing funding from AIDS, tuberculosis, malaria, and polio programs at WHO means the United States has little say over the guidance and norms that are used by low-income country government partners and nongovernmental organizations. That will lead to an incoherence in US global health programs, less efficiency and effectiveness, and other issues.
Less cooperation and effectiveness in places of US strategic interest—including Afghanistan, Pakistan, and Venezuela. US Secretary of State Mike Pompeo sought exceptions to the funding freeze for seven countries where he deemed WHO programs central to the fight against COVID-19 and polio. In Afghanistan and Pakistan, the threat from the United States puts WHO programs fighting polio and COVID-19 at stake; for the other five—Egypt, Libya, Sudan, Syria, Turkey—work on COVID-19 is at stake. The WHO is an essential driver of the global response to COVID-19 and other health threats and a significant factor in US national security, and Secretary Pompeo’s request for exceptions affirms this. Now more than ever, we need stronger international coordination. If the United States redirects funds to other implementers, we are likely to see more fragmented, inefficient targeting and use of resources in the global COVID-19 response.
Fewer US experts in global discussions. There are 8,106 people (plus 1,927 consultants and 3,606 special services agreements) working for WHO around the world; many of these are US nationals. The United States also hosts 82 WHO Collaborating Centers (of 800 total), 21 of which are at the Centers for Disease Control and Prevention (CDC). CDC’s Influenza Division has served as a WHO Collaborating Center for Surveillance, Epidemiology, and Control of Influenza for over six decades, analyzing and sharing potential pandemic viruses and data. Without the United States, the WHO would lose the expertise and experience these US staff and programs bring, and the United States would lose its “seat at the table” in shaping global practices and guidelines, crisis response operations, and partnerships.
Even WHO’s fiercest critics acknowledge the need for global organization, coordination, and financing in the fight against infectious diseases or agents that threaten or realize cross-border spread—sharing data, setting standards, providing guidance, and orchestrating response.
WHO’s effectiveness in carrying out these basic functions depends on its scientific excellence and ability to define and implement its comparative advantage, but even more critically on the funding, participation, and engagement of all the countries in the world. If the United States wants reform within 30 days, and the WHO agrees, the Administration needs to name specific requests (beyond the inclusion of Taiwan)—and details have not been forthcoming so far.
The United States created the WHO and the United Nations system. If there is a problem, the United States should name it and fix it, rather than giving up its seat at the table.