[Auto-generated transcript. Edits may have been applied for clarity.] To clear. Pandemic, as we saw, has impact on the economic development of the world.
Does it mean that you'll react the same way? But 911 is we all have seen it, you know, so it's synchronised at the moment.
Covid, but they might differ. The shocks that were considered real shocks internal for the organisation.
Then what might be the global shocks. Welcome to Global Shocks, the podcast of the Oxford Martin program on changing global borders.
My name is John Aitken and I'm a research fellow in international relations.
And in this podcast we're going to explore how international organisations deal with global shocks.
Global shocks are all around us, from humanitarian emergencies to war, financial crises to pandemics.
So how can international organisations respond to them, adapt to them and survive such turbulent times?
To find out, we are entering the conversation with leading figures from these organisations to find out how they're affected by crisis and turbulence,
what lessons they draw from the past and what future prospects they have.
Meeting for the first time. On July 24th, 1948,
the World Health Organisation short W.H.O. became the specialised agency of the United Nations responsible for international public health.
The fact that public health challenges across borders had, of course, long been recognised before this.
And indeed, the show has a long history that spans the League of Nations Health organisation,
as well as even further back the International Sanitary conferences of the 19th century, created to tackle the spread of cholera.
Today, the W.H.O. is located in Geneva, Switzerland, with a further six regional offices as well as 150 field offices.
Its main body is the World Health Assembly, the central meeting place of its 194 member states.
Delegates. The Assembly in turn, elects an executive board of 34 health experts.
Over the years, the organisation has played a pivotal role in shaping global health policy,
responding to epidemics and pandemics, and advancing efforts to achieve health equity worldwide.
Its achievements include major contributions to the eradication of smallpox and the development of an Ebola vaccine.
But of course, most recently, it's played a more controversial role during the Covid 19 pandemic.
Critics have pointed to its inability to ensure international cooperation and its in
efficacy in the face of national and regional divides in the fight against Covid 19.
So today, let's discuss a couple of key questions. What is the W.H.O. do exactly?
How has it dealt with past public health crises, and how can it learn from its own experience?
To find out, I'm joined by Ilona Kate Bush, a global public health expert with many years of experience working for the W.H.O.
I'm delighted to welcome Professor Eleanor Bush,
who's a global public health expert with several decades of experience working at the World Health Organisation.
Professor Bush was responsible for the Ottawa Charter for Health Promotion in 1986.
She took the lead in the first comparative study by the W.H.O. on women's health in Europe,
and she has worked academically on global health programs at Yale University,
the University of Saint Gallen, and today at the Graduate Institute of International and Development Studies in Geneva.
Since 2018, Professor Bush has also served on the Joint world Bank W.H.O. Global Preparedness Monitoring Board.
In short, a leading global public health policymaker with extensive experience both in the policy world and academically.
So hello and welcome to Global Shocks. Elena, it's an honour to have you.
Well, I'm very pleased and look forward to the conversation.
In your own words, why would you say, from your perspective, does thinking about global shocks matter to us?
Why is it important for us to think about global shocks? Well, to think about global shocks is important.
Uh, first of all, because they are global and a shock in one place of the world, as we have seen, can, in this day and age, go global very quickly.
And therefore, practically every part of the world needs to be prepared, needs to work on resilience, and, uh, needs to think how to respond.
And of course, in our health world, that has been particularly the case with the infectious disease outbreaks.
And, uh, most recently, obviously with the Covid 19 pandemic, uh, through that,
this whole notion of preparedness that we are also looking at in the Global Preparedness Monitoring Board has become very much more, uh, in focus.
And it's something that, of course, it's inter sectoral.
You can't just have, you know, the health world prepared for this.
It has impacts on so many parts of society as we've seen.
So this notion of global shocks, I think, is something that everyone needs to think about.
And it's not just a shock, you know, it comes and goes. A lot of these shocks stay around for quite some time.
During your time working for the World Health Organisation, what was the most challenging shock that you and your colleagues were,
were facing or dealing with, and what were its practical consequences for the mission of the World Health Organisation as such?
Well, the biggest shock and a shock one was duly unprepared for was HIV Aids, starting in the early 1980s.
Um, still with us 100%.
And it's actually interesting to see how little one talks about HIV Aids when one talks about Covid 19,
because one could have learned some lessons from HIV Aids and applied them around Covid 19.
So W.H.O., of course, was not really prepared for such a new pandemic.
And similar to Covid 19, for a long time, one didn't know what was actually happening when first,
you know, like with Covid 19 had to discover the virus, one had no response to it.
Basically no medical response, no medical countermeasures.
And there's a big difference here. We still obviously don't have a vaccine for HIV Aids, which we did get with Covid 19,
but I think this really led to a revolution within the World Health Organisation itself.
How do we respond to such a new challenge, particularly when it became clear that this was a challenge also for the developing countries?
Because, I mean, this was before you were born.
But initially people thought this was a strange disease of gay people who one didn't like to talk about it anyhow.
But at one point it became clear that this was much larger.
This was much bigger and truly a global pandemic.
So W.H.O. had to respond. It had no such program.
It did establish such a program. Then there was a lot of divisiveness within W.H.O.
Finally, you know, a lot of donors were mobilised.
The big new W.H.O. Aids program was created, but it started to run sort of parallel to the W.H.O. itself and led to a number of problems.
When it became clear that W.H.O., in the way it was set up,
could particularly not deal with the financial issues and the implementation issues around HIV Aids,
we saw this totally new phase of global health emerging with the new global.
Organisations that were created. So the first step was creating UNAids.
Because it was clear this was not just a health issue.
This was a social issue. This was a discrimination issue.
This was a development issue. And so that was the start of six U.N. organisations working together on a pandemic.
Some of those things were then mirrored later on in the HIV Aids.
And of course, a real break through of the role of civil society in public health.
That was the time that the HIV Aids movement started again, first in the developed world, then picked up in the developing countries.
The conflict that we have today around pandemic response, medical response, vaccine inequity, the whole issue of patents came up in the very same way.
Who would have access to the medicines? The discrimination of the Global South was there just as we have it today.
So then it was clear, you know, we needed a lot of money in this system.
And that's when the Global Fund for Aids, then Tuberculosis and Malaria was created.
So we entered this new phase of global health with many new organisations being created, public private partnerships emerging.
The role of the civil society becoming really, really central and that individual countries.
Remember, of course, other political things happened like the Iraq War.
And it was then that President Bush created the big global Aids program called Pep four, which made an enormous difference,
saved many, many lives, but is presently and was one of the bipartisan programs in the United States that was,
you know, continued for decades and is now in the polarised political situation,
threatens to continue, which basically means the death of many, many people in the developing world.
What comes with these shocks is they are a medical issue,
a problem that also needs medical solutions, but they are linked to equity, to big social issues.
And finally, of course, always to politics.
I'm curious to hear from your own experience what it means for an organisation.
And this is a very general question, but I think related to what you just said.
How does an organisation such as the W.H.O. practically respond to something like the HIV Aids, public health threats emerging?
What is involved practically? You've been working there for a long time, and you worked at the W.H.O. at that particular time.
What was that like? What did that look like?
Well, it has various dimensions because the organisation is, of course, you know, the authority, the global authority, technical authority on health.
It means, uh, obviously being able to say, what is this disease?
You know, what is it? Right. Uh, how can one respond to it?
It means setting standards for how one responds to the disease,
approving medicines that are used in the context of the disease, even defining the disease itself if it's a new disease.
So there's a whole lot of that technical work of the W.H.O., which is related to science, to innovation.
It then means, you know, giving suggestions to member states how they should respond to the disease.
And here already you get more than a medical response, because with HIV Aids, what became very clear is that one dimension of the WTO Constitution,
that health is a human right, suddenly moved to the forefront and said, people have a right.
People have a right to treatment. People should not be discriminated because they have this disease.
And, you know, there were countries where people were locked up.
There were, you know, dreadful occurrences around this disease.
Um, both in developed and developing world.
So also here, something we experienced with Covid was usually one has this idea, you know, everyone likes health.
Everyone wants everyone to be healthy. And health brings people together.
But with Covid and with HIV Aids, we experienced that health pulled people apart.
And so the whole issue of health and human rights, also through the NGOs, was brought forward with enormous force.
And so also W.H.O. had to be much more prominent and make very clear statements,
even though this was not popular with some member states about, you know, how you handle this disease in a social manner.
And then, of course, when the whole issue of HIV Aids and drug use started to come together, that became even more difficult.
And W.H.O. played an incredibly important role and had to reorganise itself accordingly to find, you know, a humane,
a human rights based approach which also has additional problems because there is a U.N. agency in relation to drugs in Vienna,
which was so much more conservative on these issues.
What was a problem is, of course, that W.H.O. is not a development organisation, it's a technical organisation.
And one of the things that was needed was loads of money to be able to make those available in low and middle income countries.
And that's of course, when the Global Fund was created, and initially over the next ten, 20 years,
a sort of competitive environment started to emerge in global health, people saying, you know,
these new types of organisations that are not member state driven but have the private sector on their boards,
have civil society on their boards, etc., they are much more forward looking.
And so that was a very tough time for W.H.O., particularly also when the financial crisis hit and when the budgets for W.H.O. were reduced.
But that's where we learned. And you remember that in 2014 to 16, there was the next crisis, which didn't get as serious.
And W.H.O. was severely criticised for its response to Ebola, saying this was much too late,
etc., etc. so I was on the group that was tasked to evaluate the W.H.O. response,
and this is where my involvement in the Aids response became so important,
because we were able to learn from that mistake that the W.H.O. built up a program, then wasn't able to run it.
And, you know, a new organisation had to be created.
And actually, early on, after Ebola also, and during Covid, you might remember some people said, you know,
create a new organisation that deals with outbreaks, etc., but we sort of said, no, W.H.O. needs to be reorganised.
It needs to have a new big department which is there for pandemic preparedness and response.
And because of that follow through from Ebola, W.H.O. was much better prepared to respond to Covid.
So there was learning in the end. Mhm.
Whereas, you know, I would still say the Covid response neglected many of the social learnings of the Aids pandemic.
Definitely W.H.O. learned through this period Aids, SARS, Ebola and then Covid.
Fascinating. The comparison and the the sort of lessons from the HIV Aids situation to the Ebola
situation and then how that carries over into kind of an institutional memory,
as it were, because the next question was going to be whether these kinds of threats,
these public health threats can also, in some sense be opportunities for the organisation to readjust,
to learn and to gradually accumulate experience that will make it better prepared for the next public health threat.
So in a sense, it sounds like what you're saying is, yes, the crisis is one series aspect that needs to be tackled.
At the same time, though, the organisation needs to learn. Is that a correct characterisation of what you just said?
Absolutely. And you know, the willingness to learn, of course, would be a very, very important component in W.H.O.
That, of course, brings with it a complexity, let's say, compared with the private sector, that this is a multilateral organisation.
It's basically run by its member states, 193 of them.
So whenever you want to reform the organisation, also, you would need the full approval and a consensus among the member states who at the same time,
of course, and rightly so, expect leadership from the Director general of the organisation,
expect that the organisation, as you know,
W.H.O. has a headquarters and six regional offices that all parts of the organisation then work together, particularly in a period of crisis.
So on the one hand, what we can see is that, um,
the Aids was a real shock for the organisation because there was a strong feeling that W.H.O. was losing credibility,
W.H.O. was losing in importance, and definitely W.H.O. was losing money because, you know, of these other organisations that were created.
Also in the early 2000, following the Soros outbreak,
W.H.O. was able to reform the Sanitary Regulations, which became the International Health Regulations.
So that was another historical point. And now, following Covid, one has seen they two need to be reformed again.
The International Health Regulations and then also countries said, look,
we need to make use of the possibility that the WTO Constitution gives us to actually have a legal framework for action when a pandemic strikes.
And so two things that happened following the Covid 19 was to say we must reform the international health regulations,
and there are working groups and all kinds of things going on, and we should be negotiating a pandemic treaty.
And that would be only the second treaty that W.H.O. negotiated.
The first was the Framework Convention on Tobacco Control.
And it's very, very tough negotiations because of the issues I mentioned, particularly because of the North-South divide,
because, as you know, vaccines were not available in many parts of the world.
Intellectual property issues stood in the way, and it indicates the increasing need to involve other agencies,
in this case the World Trade Organisation, etc.
So those are two big things where the organisation is trying to learn.
Another area where the organisation is learning is to ramp up the whole area of science and innovation,
because of course, uh, nobody expected we would have a vaccine so quickly.
Uh, and in a way, the world wasn't ready to have a vaccine so quickly.
You know, the organisations actually these organisations that had competed,
you know, Global Fund, the Gavi, W.H.O., etc., Bill Melinda Gates Foundation.
So they started to work together. They created Covax, they created other initiatives, the Act accelerator, new organisational mechanisms were created,
but they were created overnight and suddenly the vaccine was there and these organisations weren't ready for it.
And then, of course, there was the political pressure in the developed world to vaccinate everyone, um, all the other issues that flowed from that.
So the treaty is trying to resolve some of that WTO negotiations are trying to do that.
So this, uh, being involved, being ready, being able to assess where are we in terms of science and innovation in these areas?
Are we working together with the best scientists in the world?
Of course, some science is always, um, unexpected.
That's clear. Uh, but still, uh, you know, there was a time when W.H.O. ramped down its research program.
We couldn't imagine this today.
And the whole issue of science and technology, you know, again, a new way of working with the private sector emerged in this context,
both in terms of the vaccines but particularly in terms of misinformation.
So this was the beginning of W.H.O. being in contact with the big tech companies, you know,
Googles of this world, to ensure that health information by the W.H.O. would always be on top of a search query.
If somebody said, what is Covid 19? You know, you would get the official W.H.O. information first.
So a lot of new things have emerged out of that, where the organisation is shifting and changing and trying to sort of really be,
uh, hopefully ready should anything like this happen again.
I was very intrigued when you mentioned a couple of times that there are these knee jerk responses,
in a sense, of creating new institutions or new actors adding to the landscape of global health,
uh, responses, but that that might not actually be the most effective way to to be better prepared for the future.
And that instead, the really important thing is,
is to evaluate carefully and to really try and learn from past experiences through things such as new international health regulations,
really fine tuning the main organisation that we already have,
rather than trying to reinvent the wheel or invent many other new organisations that potentially even sort of, uh, make it harder to coordinate.
Yes. At least that's my position. You know, there are people that would take different positions here,
and there's been a lot of talk around that, you know, is W.H.O. politically influential enough?
Is it strong enough? What does it mean if an organisation that is in principle run by health ministers, is that an organisation that strong enough?
Uh, definitely. It's an organisation that, uh, isn't rich enough.
And uh, so, uh, also following the long standing negotiations about increasing the regular budget of W.H.O.,
the assessed contributions was taken up again and a positive, uh, decision was taken to at least,
uh, increase the s contributions by 50%, which is nowhere enough.
But something is on the trajectory that people, despite criticisms that also came up, you know,
was it clear enough, uh, soon enough, about airborne transmission, you know, all those kinds of issues.
That's how more on the scientific front, how quickly can an organisation give, uh, the, uh, scientific recommendations?
You know, how sure does one have to be? How quickly, uh, does one have to react?
So all those things, uh, do remain, but yes, uh, again, in this case, there were the suggestions, you know, let's create something new.
There was also the suggestion to have a so-called Global Threats Council, which would meet at the United Nations,
because supposedly, if you had the threats Council of Heads of state, they would act more quickly and with more determination.
My view was if we had a problem during Covid 19, it was with heads of state and, uh,
people not taking the political and financial decisions they should have taken.
So, you know, the all this is obviously driven by the wish to do better next time.
But I agree with you. A lot of this was knee jerk.
And it's also related to another issue.
On the one hand, W.H.O., together with many global health advocates,
has been successful in saying, first of all, you know, health is a political choice.
And because it's a political choice, it should be part of many other negotiations and many other bodies.
And it was seen as a tremendous progress to have health on the agenda of the G7, to have health on the agenda of the G20,
and to have health regularly discussed in New York, at the U.N. General Assembly,
to have high level meetings, etc., etc. also have some bodies and councils in the UN.
I served on one of them. You know, to have that in that non-health sphere, let me put it that way.
But one of the things that has emerged is that, of course, everyone that organises a meeting like that,
um, you know, in a G7, G20, you have a different organising country every year.
Once you have a tangible outcome. And what's more tangible than creating something new, you know, if you say, well,
our outcome is we will support the World Health Organisation or, you know, I said, My God, you know how boring.
If you say we will create a pandemic fund, then everyone says, wow, they're really ready to go and do something.
And then big promises are made. We do have a pandemic fund now, as you know.
Um, uh, but it has no where. The amount of money that was actually assessed that people said needs to help countries.
And at the same time, you know, so you have a pandemic fund with 10 billion at this stage,
and you have W.H.O. that has a budget of, you know, the Geneva General Hospital.
So it is, you know, it's very, very imbalanced.
But the tendency remains that it is more attractive in our world, in our political world, to be able to say, look, we created something new.
And at the same time, of course, saying we need to reform W.H.O.
There is an imbalance here, and it's definitely a political issue about, you know, how you position yourself, uh, in the international arena.
It sounds like I mean, we're faced with this complexity of intersecting crises all happening at the same time, mutually compounding each other.
And it gets hard to really know where to focus our attention.
Another thing is, of course, if everything is so complex, we really need to understand the problems that we're facing very, very well.
And so there's a 2021 report on the Covid 19 response by the 13 member Independent Panel for Pandemic Preparedness and Response,
which argues that information flows under the existing international health regulations had proven to slow during the.
A pandemic and your own experience is more and faster information.
Another key to better preparedness? Most definitely.
But you know, the starting point of it is transparency.
If you look at the International health regulations, uh, countries which you know,
are subject to these regulations should be transparent and should inform W.H.O. the minute they see something that out of the
ordinary and the long and short of it is because disease has such geopolitical consequences in terms of trade movement of people,
the way you are looked at in the world, etc., whether you're a failure or not leads countries not to report,
you know, despite the fact that the air applies to all countries, not all countries report or report quickly.
That has in a way always been the case, but has been absolutely extreme in relation,
uh, to, uh, Covid 19 and the countries that have reported quickly.
Take South Africa, for example, with a variant, then, uh, get punished and no, we will we will cut travel, uh, we will cut to economic relationships.
And in a globalised world, that, of course, has tremendous consequences,
which is also why because then in this case, also the global flow of medical countermeasures comes in.
This is why now, as one of the follow through, the whole issue of local production has become so critical.
You know, within our region, within our country, what can we produce ourselves.
But at the same time, how can we be guaranteed that we get the constituent components, uh, for whatever medicine or vaccine we are trying to develop?
And as we know, many of those components are all in one big country.
So it then becomes economic and geopolitical again very quickly, which is why, uh, the panel,
uh, said we need to find measures that ensure the transparency and the rapid reporting.
So there's been a lot of discussion around can be sanctioned countries.
What kind of pressure can exert?
Can W.H.O. exert pressure? Actually not.
But could the pressure then, for example, come through the World Trade Organisation or could it come through the financial institutions?
So it's quite clear that the pressure in all probability needs to be both economic and political,
but that it cannot be exerted by the World Health Organisation, what the World Health Organisation needs to do.
And of course, this is what it then gets criticised for.
It's got to try and cajole countries, its own member states, who actually decide about the organisation, to jolly well share their data.
So it is a world also for the W.H.O. for whom, you know, politics is not new.
It's had to work during the Cold War and all of that.
But this extreme polarisation of the world makes the work of the World Health Organisation more difficult, but also much, much more important.
Now, the W.H.O. was, of course, in the spotlight throughout the pandemic.
We've already talked about that, and it's received its share of criticism regarding its effectiveness in the face
of precisely those geopolitical tensions that you were just talking about.
And this question emerged, really, of our countries collaborating here at all.
Are they putting enough of their efforts into making global public health work?
And a 2022 report by The Lancet called the Global response, and I quote, a massive global failure.
And it spoke of a failure, in particular of international solidarity.
Can the W.H.O. do more to foster international solidarity, and should we expect it to?
Well, that's actually W.H.O. is bread and butter to try and establish that global solidarity.
Of course, you know, if you have 193 countries who don't talk to each other, uh, then you have a big job to do.
And, you know, one of the attempts to create that global solidarity are international agreements,
treaties, accords, etc., etc. and, ah, well, regulations, rules, norms that everyone subscribes to.
So that's in a way as much as W.H.O. can do.
Because and that's of course, also a criticism. People say W.H.O. has no teeth.
Some wants W.H.O. to call out individual countries.
We had a director general at WTO at one stage who did that, but she could not serve more than one term.
So that was Gro Harlem. I'm Brundtland to, you know, with the sun's outbreak not only cold out China but cold out Canada, for example.
So a lot of that is what we tend to call global health diplomacy.
And it's not always visible. So that's another tricky part of the work of the organisation and the role of the Director-General.
I know you know,
somebody like Richard Horton at The Lancet would like to see the director general call out individual countries or even individual leaders.
The minute you start doing that, you could probably close down your organisation because that's not the role.
And it of course, you know, for anyone who's an advocate who wants to move things forward, people do get upset.
But it's not the role of multilateral organisations to do that.
What would you say is the best way for the W.H.O. to learn from past experiences, in order to actually improve its preparedness for the future?
What I find so interesting is actually how many times the organisation has reinvented itself,
how often it has been more innovative than some people give it credit for, but also the new areas that are being discussed in the treaty.
Really the whole issue of the production of medicines and where that is and the equity,
there was not so much an issue of the World Health Organisation.
And now, you know, smack. It's right in the middle of supply chains and everything.
The cooperation with the other organisations is really critical.
The other health organisations and obviously, you know,
every organisation needs to reform all of the time and it also has to look out to survive because we see that in very difficult geopolitical times,
the organisation tends to become more technical.
And uh, then, you know, it sort of moves forward as things become a bit clearer, it moves forward into more political arenas again.
But it can't be a geopolitical player, but it has to draw attention to the fact where health is subject to geopolitics,
um, where health is, as the organisation says, a political choice.
And that's the message to the member states. You know, we, the Secretariat, can do this much.
Sometimes we'll fail, sometimes we're not good enough.
Uh, sometimes we actually told you we should do X and you didn't approve it, right?
It needs that. That's constant back and forth.
And as you said, definitely as simplistic as it sounds, it does need a bit more money.
Right. Well, on that note, all that's left for me to say is thank you for your time and for generously sharing your insight and experience.
It's been really great to have you here at Global Shocks. Thank you. Well thank you, it's been fun and thank you for your questions.
Bye bye. You've been listening to Global Shocks, the podcast of the Oxford Martin programme on changing global orders.
My name is Yannick. I'm a postdoctoral research fellow in international relations.
And I'm the host and producer of this podcast. If you enjoyed this episode, make sure to follow us and subscribe wherever you get your podcasts.
Do have a look at the show notes for further reading on today's topic, as well as links to our website and social media channel.