The world’s first attempts to co-operate internationally to prevent pandemics were driven by alarm among European countries about the spread of cholera from India in the 19th century.
Fretting about nation-state sovereignty, rivalries for control, struggles to persuade countries to be open about outbreaks as soon as they emerge and politically contested interpretations of evidence bedevilled these efforts just as today.
At the time, emerging evidence that cholera spread through contaminated water and food struggled for acceptance against a mistaken older theory that it was caused by “miasmas” or unhealthy vapours. Each theory had different implications for how the disease could be contained and self-interest influenced how the evidence was received.
“Large commercial firms, especially if they were engaged in the importation and exportation of goods, typically overemphasised cholera’s miasmatic origin, resisted maritime quarantines and, when they were imposed, would try to convince politicians that their imposition would destroy the economy more severely than the epidemics themselves,” recount Marcos Cueto, Theodore M Brown and Elizabeth Fee, the authors of The World Health Organisation: A History.
Concerns that international accords could cause a “loss of sovereignty” among negotiating states led some to insist that agreed common health policies were “recommendations” rather than binding commitments.
“As a result, different cross-border rules continued to exist among countries, meaning that a ship with confirmed cases of cholera on board could be treated differently at different ports,” write the authors.
Friday marks 75 years since the founding of the World Health Organisation: the ultimate post-war fruition of these early efforts by countries to co-operate to combat disease.
The WHO is enjoying a newly burnished profile and importance after Covid-19 demonstrated the disruptive potential of new pandemics to the governments of wealthy countries, countering their impression that infectious disease was a developing-world concern.
But the pandemic also cast an unforgiving light on some aspects of the institution, and has made it a high-profile target amid a global surge of scepticism and anger towards science and healthcare, putting it again at the centre stage of international politics.
“We all knew it would be coming,” says Ruediger Krech, a senior WHO official who leads its health promotion. In his view, Covid-19 became a pandemic because nations had not heeded the lessons of swine flu, bird flu, ebola, and zika in the preceding two decades. “We saw that member states were not really preparing as they needed to, in order to prevent another pandemic from coming. We knew this since 2015. We always said: it’s not a matter of whether or not we’re going to see a pandemic, but only when.”
Disagreements between the WHO and national policies emerged early on, when governments began shutting down flight routes in an attempt to belatedly keep the virus out. This went against the repeated urging of WHO director general Dr Tedros Adhanom Ghebreyesus and explicit WHO advice “against the application of travel or trade restrictions to countries experiencing Covid-19 outbreaks” in February 2020.
The WHO views such responses as deeply unhelpful because they are punitive towards countries that report outbreaks and may encourage secrecy, making its core job of collating data about outbreaks harder. But faced with alarming death figures from Italy, a string of countries chose to prioritise reassurance of their public and getting control of the situation within their borders.
“The WHO really blew it,” then-US president Donald Trump railed on Twitter. “Fortunately I rejected their advice on keeping our borders open to China early on. Why did they give us such a faulty recommendation?”
Trump would later threaten to pull the US out of the organisation outright, the latest blow-up in a long-troubled relationship between the WHO and the US, which has wavered since its inception between isolationist scepticism towards the organisation and a desire to control it.
But the organisation was to come in for criticism not only from politicians, but also from the scientific community.
“FACT: #COVID19 is NOT airborne” the WHO’s Twitter account posted in March 2020.
Based on advice from the group of experts it was consulting, the organisation’s position was that the disease was spread through droplets from coughs and sneezes and contaminated surfaces. This formed the basis of its prevention advice, which emphasised hand-washing, disinfection and keeping a metre’s distance from others – the distance that droplets were understood to travel.
The tweet was wrong. Covid-19 is airborne. There was evidence to suggest this as early as February 2020. But it took the WHO until December 23rd, 2021, to include the phrase “airborne transmission” on its webpage entitled “Coronavirus disease (Covid-19): How is it transmitted?”
Throughout the pandemic, external scientists had loudly and publicly called for the WHO to adapt its advice to inform people about the role of airborne transmission.
But instead of clearly communicating that the scientific understanding of the disease had changed, the WHO instead chose to subtly adapt the words it used, starting with an acknowledgment that so-called aerosol transmission could occur in specific circumstances in October 2020, while playing down the shift when questioned by journalists.
Just as with cholera, this new understanding of how the disease spread had important implications about how to prevent it – namely, ventilation and face masks. But this information filtered down patchily to the public. National health authorities stuck with the old advice long into the pandemic. It suited many industries that the advice not change.
“We should have done it much earlier, based on the available evidence, and it is something that has cost the organisation,” the WHO’s chief scientist, Soumya Swaminathan, told the journal Science as she departed for a new role in November. “You can argue that [the criticism of WHO] is unfair, because when it comes to mitigation, we did talk about all the methods, including ventilation and masking. But, at the same time, we were not forcefully saying: this is an airborne virus. I regret that we didn’t do this much, much earlier.”
The first sentence of the WHO’s newly drafted pandemic treaty sets out what it sees as the greatest misstep of the pandemic: “the catastrophic failure of the international community in showing solidarity and equity in response to the coronavirus disease”.
For those inside the organisation, it was embittering to see wealthy nations begin to vaccinate young people with their hoard of vaccines, while their colleagues working in hospitals in poorer countries died of Covid-19, still awaiting jabs.
In the developing world, this compounded decades of deep feeling about injustice in healthcare, from the legacy of debt that hampered spending on their health systems to the rich world’s poaching of the doctors they train.
The proposed treaty sets out that countries with more resources should bear a “commensurate degree” of responsibility for pandemics and that healthcare resources should be distributed equitably, with intellectual property waived for products needed during a pandemic.
Its first clause reaffirms the “principle of sovereignty of states”. But this has not been enough to stop the treaty becoming the new focus of the conspiratorial movements that flourished during the pandemic, and the subject of an international right-wing backlash that casts it as a power grab.
On May 8th, 1980, the WHO declared smallpox to have been eradicated, the result of tireless public health work that had successfully vanquished a disease that blighted humanity for millenniums. The eradication took place despite the tensions of the cold war, and served as an affirmation of core logic of the WHO that international co-operation is key to the containment of diseases and reduction of harms to health.
For Krech, as for generations of public health workers before him, the heart of the issue is that the human world divides itself up with borders, while the microbial world does not.
“The world is so interconnected, because viruses are not confined to nations, but we’re reacting as nations,” he said. “That makes pandemics more likely.”