A medical worker in a protective suit checks the body temperature of a car passenger at a checkpoint outside the city of Yueyang in China after an outbreak of the coronavirus disease on January 28, 2020.

In late 1918, saloons, dance halls, and cinemas stood shuttered across the United States. Streets were largely empty. Many cities required residents venturing outdoors to wear masks, while the millions who remained indoors grew lonely as months of quarantining wore on.

Does this sound familiar?

Then, as now, the world was battling a deadly pandemic. The disease—commonly known as the Spanish flu—claimed roughly fifty million lives in just six months, a greater death toll than World War I. 

Though the world finds itself in a similar situation today, the tools used to fight global health challenges have evolved over the past century. Many governments implemented new policies after the 1918 influenza. Russia instituted a centralized health-care system, and the United States strengthened a national disease reporting program.

Black and white photo of dozens of doctors and nurses sitting in a medical auditorium in 1924.

While the World Health Organization typically takes a leading role in coordinating international efforts to stop the spread of diseases, the WHO has several predecessors:

First International Sanitary Conference (1851): Doctors and diplomats from twelve European countries gathered in Paris in 1851 for the first International Sanitary Conference, in which they discussed quarantine procedures for trade ships suspected of carrying cholera. The conference marked a milestone for countries cooperating on cross-border health issues.

International Sanitary Bureau: In 1902, U.S. President Theodore Roosevelt helped found the International Sanitary Bureau. Atop the organization’s agenda was fighting epidemics like yellow fever. The International Sanitary Bureau is now called the Pan American Health Organization (PAHO), which serves as a regional office for the World Health Organization and is one of the world’s oldest continuously functioning international organizations.

L’Office International d’Hygiene Publique (1907): In 1907, the French government founded the first international organization for disease cooperation—L’Office International d’Hygiene Publique (OIHP). Unlike previous conferences and health organizations, the OIHP expanded beyond cholera containment to address a wide range of public health issues.

Health Organization of the League of Nations (1919): The League of Nations emerged after World War I, intending to promote international cooperation on global security, trade, and public health. Among other initiatives, it sought to bring all regional and international public health institutions under one office: the Health Organization of the League of Nations (HOLN). However, the HOLN failed to achieve its mission given that many countries, like the United States, did not join the League of Nations.

UN Conference on International Organization (1945): After World War II, countries sought ways to ensure the world never again devolved into such horrific conflict, resulting in the creation of the United Nations. Like its predecessor, the United Nations sought to create a single global health authority. The result was the World Health Organization, which absorbed the HOLN, OIHP, and PAHO.

People standing near circular table in front of many different country's flags, participating in the UN charter signing ceremony.

But pandemics recognize no borders, and thus fighting these diseases requires not only strong domestic policies but also international cooperation. Such cooperation began in earnest following World War II with the creation of the World Health Organization (WHO). As the preeminent authority on global health, the WHO is responsible for coordinating responses to various threats, including border-hopping diseases. However, the COVID-19 crisis has highlighted the agency’s shortcomings—namely its inability to hold members accountable and its serious funding challenges. 

This lesson examines the WHO’s mandate and explores the obstacles—present and future—that threaten global health coordination.

What does the WHO do?

Founded in 1948, the WHO is a UN agency. Its mission is to pursue “the attainment by all peoples of the highest possible level of health,” which today translates into work such as malaria prevention, combating obesity, and monitoring the health consequences of issues like climate change and genetically modified foods. While contagious diseases like COVID-19 attract the world’s attention, much of the WHO’s work focuses on diseases such as cancer or diabetes that aren’t transmitted between people. These are called noncommunicable diseases, and they account for 73 percent of the world’s deaths.

The WHO partners with national health agencies and nongovernmental organizations (NGOs) to tackle local health challenges. The WHO doesn’t provide direct medical care; rather, it equips health agencies with resources, such as medicine and protective equipment, and guidance on how to effectively deliver health care. These local projects are wide ranging and include advising on tobacco taxes in Angola, electronically surveilling public health in Jordan, and reporting road traffic fatalities in Thailand. 

In addition to assisting with country-specific challenges, the agency coordinates global responses to international health crises such as epidemics and humanitarian disasters. The WHO has helped nearly eradicate polio and has provided millions of vaccine doses in response to outbreaks of cholera, meningitis, and yellow fever. The agency’s biggest success was coordinating mass smallpox vaccination campaigns, which culminated in the eradication of the disease in 1980—a milestone credited with saving hundreds of millions of lives.

However, the WHO has not always succeeded. In the early stages of the HIV/AIDS epidemic, WHO staff downplayed the severity of the crisis. After years of WHO inaction, world leaders created a new agency—the Joint United Nations Program on HIV and AIDS (UNAIDS)—to spearhead the global HIV/AIDS response. The formation of a workaround organization demonstrated that the WHO does not have a monopoly on global health interventions.

Further, the WHO has consistently struggled to address today’s biggest public health challenge: COVID-19. The agency’s pandemic response work involves delivering medical equipment, organizing global data, issuing broad public health guidelines, and creating response plans in partnership with national health agencies. But just because the WHO issues guidelines—like recommendations on mask-wearing—doesn’t mean it can force countries to comply.

WHO struggles to hold members accountable

Why do countries choose not to follow WHO guidelines that are designed to save lives? Often they feel those guidelines run counter to their national interests. Perhaps countries prioritize their own citizens by stockpiling medical supplies rather than following WHO guidance and trading with countries in the greatest need.

Whatever the reason, the WHO has few tools to enforce its guidelines. Instead, it relies on countries’ voluntary participation. This inadequate enforcement structure became evident early in the COVID-19 pandemic, when certain countries placed trade restrictions on medical supplies in defiance of the WHO’s recommendations.

Additionally, the WHO is responsible for coordinating the detection, assessment, and reporting of public health emergencies in accordance with the International Health Regulations, a legally binding agreement signed by all WHO members. However, the agency’s limited enforcement powers leave it unable to mandate regular and robust disease surveillance from member countries and reliant on governments to self-report infection numbers. These reports can be delayed or inaccurate—either intentionally, if a country wants to downplay an outbreak within its borders, or simply because of faulty disease-reporting systems. The WHO faced extensive criticism for relying on this flawed system during the 2014 Ebola crisis in West Africa and the COVID-19 outbreak in China—in which slow, inaccurate, or intentionally misleading disease reporting from member countries delayed the response.

Precarious funding model exacerbates challenges

Limited enforcement power is not the WHO’s only obstacle. The agency also has an extremely broad mandate that it often lacks the budget and staff to fulfill and faces other funding-related challenges.

WHO member countries pay annual dues, which account for approximately 20 percent of the organization’s budget. The remaining 80 percent comes from the voluntary contributions of countries and private institutions like the Bill & Melinda Gates Foundation.

Although voluntary contributions are vital for the functioning of the WHO, they can also come with strings attached. Rather than allow the WHO to set its own priorities, many funders require their donations go toward specific projects—a process known as earmarking. These restrictions leave certain projects overfunded and others underfunded. For example, the polio eradication project has 127 percent of its required funding, while the WHO’s emergency operations budget has a 46 percent shortfall. Indeed, the WHO faces severe funding shortages in responding to COVID-19, with much of the agency’s budget strictly earmarked and unable to be redirected to the pandemic response.

Additionally, critics say the WHO is slow to criticize major donors for fear of jeopardizing its funding. The agency’s director, Tedros Adhanom Ghebreyesus, came under fire for praising China’s “transparency” in handling the initial COVID-19 outbreak despite evidence of Chinese officials delaying disease reporting, undercounting cases, and silencing whistleblowers. Journalists, diplomats, and world leaders have said that China’s actions amounted to a deliberate political cover-up to protect the country’s stable and authoritative image.

With much of the WHO’s funding coming from voluntary contributions, one country’s changing politics can throw the entire agency’s operations into turmoil. The impact of this fickle behavior became clear after the United States announced in May 2020 that it would terminate its relationship with the WHO due to the organization’s perceived leniency toward China. Without U.S. funding, the WHO stood to lose 23 percent of its budget for emergency health operations in the middle of a global pandemic. Though the country reversed its retreat from the WHO in January 2021, the incident revealed how vulnerable the WHO is to one country's political upheaval.

Overcoming funding and enforcement challenges, first step in long road 

The world lacked the tools to respond to a deadly pandemic in 1918, but today the global health landscape looks markedly different thanks to foundations, NGOs, national health agencies, and the WHO.

Yet these pieces will not always work together in harmony. Who is in charge of leading the response to a public health emergency is not always clear, especially when the world’s top agency faces serious funding and enforcement challenges. The WHO’s inability to organize a response to the COVID-19 crisis has led experts to wonder whether the agency requires reform or whether an altogether new international health organization is needed.

One thing, however, is clear: coordination and cooperation are needed more than ever before as the world heads into a future marked by global challenges such as climate change, mass migration, and pandemic disease.

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