The New Cold War
America, China, and the Echoes of History
After 15 years of heralded progress on pandemic preparedness, tuberculosis control, tobacco regulation, and health metrics, the World Health Organization faces confusion over its future. In 2011, after a yearlong consultation with member states, WHO Director-General Margaret Chan described the agency as overextended and unable to respond with speed and agility to today's global health challenges. The most serious examples: the WHO's inability to address noncommunicable disease (NCD) prevention globally, to improve access to health systems, and to set global priorities in health.
In the years after the WHO was founded in 1948, the organization plucked a lot of low-hanging fruit. It helped governments improve hygiene and environmental health. It also supported the development and application of new technologies to control major infectious diseases such as malaria, syphilis, tuberculosis, and yaws. These missions largely went hand in hand with postwar reconstruction efforts. The WHO's most cited success from its early years was its initiative to eradicate smallpox, which began in 1958 and was certified complete in 1979.
Yet even in this golden era, the WHO struggled with an internal debate over its fundamental mission. There was an ongoing tension between a "vertical" approach, which tackled specific diseases without addressing general health services and prevention needs, and a "horizontal" one, which looked to strengthen whole health systems and support basic-care services that would deliver broad-based, integrative, and long-term improvements in public health. Bilateral donors in particular favored vertical interventions because measurable results were easier to demonstrate over a short time frame, by quantifying, say, the number of bed nets delivered or vaccines administered. These programs are also easier to control, given that they typically have separate funding proposal and allocation processes, delivery systems, and budgets. However, champions of primary care believed the WHO should dedicate resources and efforts to a horizontal approach because short-term advances in certain diseases or vaccination coverage run the risk of fragmenting general health services and weakening the role of governments as the main stewards of national health systems.
Like a pendulum, the vertical-versus-horizontal debate has regularly swung over the past 50 years. The result: The WHO has embraced elements of both approaches. There are vertical programs for AIDS, tuberculosis, and malaria. At the same time, the WHO pushes for universal health coverage and improved health systems in many countries, focusing especially on broad issues such as maternal and child health.
Yet, over the last two decades, as globalization expanded, urbanization accelerated, and lifestyles grew more sedentary, a baseline shift transformed the public's health demands. NCDs such as diabetes, cardiovascular disease, cancer, and depression started to displace the classic diseases of poverty and child mortality: Rising wages reduced the former, and successful health campaigns lowered the latter. Of course, emerging and developing countries must still cope with both. Brazil, for example, has had to create policies and health services to tackle maternal mortality and depression; India struggles with widespread undernutrition and type II diabetes; South Africa and Eastern Europe, meanwhile, must fight multidrug-resistant tuberculosis while combating alcohol abuse. According to data from 2005, the most comprehensive and recent available, NCDs account for three out of five deaths worldwide, with 80 percent of these deaths occurring in low- and middle-income countries.
Underscoring the point, in 2011 the prevention and control of NCDs were the focus of a dedicated high-level meeting of the UN General Assembly. The talks resulted in the adoption of a major political declaration that called on governments, nongovernmental organizations (NGOs), and the private sector to commit to reducing risk factors and creating health-promoting environments, strengthening national policies and health systems, bolstering international cooperation and partnerships, and promoting research and development.
But the WHO has been unable to adapt its practices. WHO-promoted health services still focus on acute episodic care and not on long-term needs. And NCD prevention is not adequately addressed. The General Assembly may have adopted a declaration, but member states have not funded the WHO's work on the issue in earnest, and most countries have not implemented concrete prevention and treatment strategies to combat the four main risk factors: diet, smoking, alcohol, and physical inactivity. Unlike the first UN General Assembly special session on HIV/AIDS in 2001 -- in which mobilized NGOs, the private sector, and UN agencies were coordinated by UNAIDS to press for specific financial, policy, and leadership commitments -- the NCD summit was characterized by fragmentation among key actors. The WHO was sidelined.
The main problem is that the agency has not captured the political support of key governments in high-income and emerging economies. Unlike infectious diseases, which are well within the expertise of ministries of health, the new health challenges require a whole-of-government approach, one in which ministries of agriculture, transportation, finance, and foreign affairs have a say. Addressing NCDs' specific risk factors requires buy-in from ministries that are not within the WHO's sphere of influence. For example, ministries of finance need to develop innovative fiscal policies that incentivize individuals and companies to adopt and maintain healthy behaviors, and ministries of agriculture must help eliminate national and regional subsidies that disfavor healthy foods. Ministries of trade should prioritize public health while negotiating trade and investment treaties. And ministries of urban planning must keep the focus on physical activity when designing walkways, bike paths, roads, and transportation grids.
To be effective, the WHO needs to assert the importance of health in decision-making at the national level. Its mandate requires that it does so, and moreover, the organization's biggest advantage is that it has the data to back up its arguments. The WHO needs to be at the table when global trade and financial decisions are negotiated. Stronger diplomatic abilities adapted from the trade and finance regimes, in addition to a well-articulated case for linkage to major global debates on sustainable development, human rights, and security, will earn the WHO its right in settings where health can truly flourish. And this also needs to occur at the country level, where the WHO works directly with local health ministries.
Improving health is not just about better medical services or cutting-edge technology but also about better government. For example, one of the most effective ways to curb NCDs is to reduce smoking. The best way to do that is by taxation -- a responsibility of finance ministries. Similarly, improving under- and over-nutrition in the long term requires significant changes to agricultural policies that drive which foods are grown and how they are processed and marketed.
There are already good models to follow. Julio Frenk, during his tenure as Mexico's minister of health, demonstrated that clear economic and epidemiological evidence can be used to convince other parts of government to invest in health. Under his stewardship, the ministry employed academic analysis to argue that lacking health insurance was driving families into poverty. Drawing on evidence-based policy to build consensus across party lines, Frenk was able to promote a major legislative reform establishing comprehensive national health insurance. The scheme, Seguro Popular, has covered 40 million people as of 2010, and Mexico is on track to achieving universal health coverage before the end of this year.
The WHO also needs to embrace the private sector. By giving responsible partners in industry a seat at the table, the agency will benefit from their expertise in science, operations, financing, and marketing. Unlike the tobacco and alcohol industries, which market and sell dangerous products, the food and beverage, pharmaceutical and medical, and sporting goods industries have clear interests in being part of the conversation. Firms recognize that markets are stronger when they are populated with healthier consumers. To embrace industry, the WHO will have to overhaul its budget process and rally support within the World Health Assembly. But given resistance from member states to open governance processes to nonstate actors, this has been a tough sell. In recent years, the World Economic Forum has played a leadership role in bringing the private sector together with the WHO to develop common approaches to NCDs.
But no agency can fulfill its mandate if it is not given the resources. And in the WHO's case, nearly 80 percent of its funding comes from short-term extrabudgetary sources that are earmarked for specific diseases or purposes, rather than core UN-assessed contributions. In this climate, the WHO secretariat is forced to compete to raise funds with NGOs, academics, and other multilateral organizations such as the Global Fund and the GAVI Alliance. Instead, the WHO should create a central fundraising unit so that the best scientific minds can focus on technical and normative work, while the people with the right skills can raise money. With an appropriate mandate and the resources to carry it out, the WHO can be the leader in global heath that it needs to be.