Emergency Forum
Race Against the Pandemic: The United States and Global Health

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Introduction

On July 7, 2020, the United States notified the United Nations that it was withdrawing from the World Health Organization (WHO) over its response to the coronavirus disease 2019 (COVID-19) pandemic (1). We address the history of the WHO, its critical role in global health, the impact of the withdrawal of the United States, the WHO's structural weakness, and the need for reform.

In 1948, the United States was the principal architect behind the creation of the WHO (2). It was developed to be the premier global public health agency, with the goal of protecting the health and well-being of the world's citizens. The WHO provides evidence-based technical assistance to countries, guidance on critical health issues, the development of international health standards, and helps coordinate responses to public health outbreaks to promote global health. Since its inception, the WHO has made significant global contributions to promote vaccinations, improve primary care, eradication of small pox, control diseases like AIDS, Ebola, measles, polio, malaria, and tuberculosis, and has saved countless lives (3,4). U.S. support has been vital for the growth of the WHO, and much of the WHO's success can be attributed to the longstanding financial and technical support from the United States, whose experts are embedded deeply into the WHO's governance at its headquarters and regional offices. Their technical activities including research, reference laboratory work, and participation in advisory groups (5). U.S. experts often participate in WHO international teams to investigate public health outbreaks, such as the team that investigated China's response to COVID-19 in February 2020 (6). During a public disease outbreak, the WHO is authorized under the 2005 International Health Regulations (IHRs) to declare Public Health Emergency International Concern (PHEIC) and act as a global coordinating body to deliver a response to contain the disease (7). On January 30, 2020, the WHO declared the novel severe acute respiratory syndrome coronavirus 2 outbreak in China a PHEIC (8). Soon after the announcement, the WHO launched:

  • A solidarity response fund to help countries with greatest need to prevent, detect, and respond to the pandemic (9).

  • Steps to respond to severe medical supply shortages in several countries (10,11).

  • SOLIDARITY clinical trials comparing options against standard of care involving participation of 90 countries (12).

  • International collaboration to accelerate production and access to new diagnostics, treatments, and vaccines (13).

  • Training and technical assistance to countries (14).

The pandemic of the century has caused >245,000 deaths in the United States (as of November 15, 2020) and >1.3 million deaths worldwide (15,16). Although the United States has only 4.4% of the world population, it has more cases and fatalities than any other country in the world (15,16). COVID-19 has created an unprecedented devastating crisis for U.S. health care systems with a huge toll on supply chain, capacity, work force, and finance. The American Hospital Association estimated the financial impact of COVID-19 on hospitals at $202.6 billion between March and June 2020 (17).

The general population considers emergency departments (EDs) the primary site of care during public health emergencies (18,19). The pandemic has presented an unprecedented challenge for the practice of emergency medicine (EM). Already challenged by the excessive and often unnecessary use of EDs to manage basic health issues, COVID-19 has added more complexity and a different paradigm to the decades-old problem of ED overcrowding in the United States (20, 21, 22, 23, 24). The diagnosis and management of the initial and critical care facets of COVID-19 became core requirements for the practice of EM. These challenges are not unique to U.S. EDs but are global in nature.

The emergence and spread of infectious diseases are the epitome of globalization. In today's globalized world, communicable diseases can spread in an exponential fashion and are no longer contained to isolated geographic areas. Effective global surveillance is critical because pathogens are unaware of borders. In addition, the contagion is often disseminated before it is recognized. Given the speed with which an infection can travel, early warnings at the source is critical trigger for emergent action. For example, Global Outbreak Alert and Response Network coordinated by the WHO was able to detect severe acute respiratory syndrome in Guangdong province in China in early 2003, leading to a coordinated international response (25). On July 5, 2003, the WHO declared that the outbreak had been contained successfully (25). However, on the other side, a small outbreak of W135 meningococcal meningitis among Hajj pilgrims in 2000 in a rural area of Africa spread rapidly beyond borders when an infected person traveled to another country, resulting in a major meningitis epidemic in Africa (26). Surveillance serves as the fundamental basis for critical public health responses to new threats. As a major stakeholder on the front line, EDs play a major role in detecting infectious disease threats in the global community, leading to monitoring, triage, and investigation of emerging infections during public health emergencies (27, 28, 29).

The ramifications of the U.S. withdrawal will undoubtedly have disastrous consequences. With the United States being the largest contributor to the WHO's annual budget, this decision will cripple the agency financially and limit their ability to continue critically needed work on global public health (30). The WHO's budget is dependent on membership fees and voluntary contributions by 194 member states and private organizations (31). Revenue from membership dues is used for core activities and programs. In 2018 and 2019, only 17% of this revenue came from membership dues compared with 47% in 1998 and 1999 (31,32). The balance of their revenue is generated from voluntary contributions by members and external donors and is often restricted for earmarked projects (33). The biennial WHO budget for the 2-year cycle of 2020 to 2021 has been set at $4.84 billion (34). The United States contributed 16% of the WHO's total budget and 22% of total assessed fees in the 2018 to 2019 cycle (35,36). Critical WHO projects, such as polio eradication, influenza surveillance, and vaccine development, will likely suffer. The Global Emergency and Trauma Care initiative adapted by the WHO, which in 2018 helped save millions of lives through improvements to emergency care systems, will now likely be affected as well (37). Lack of access to global surveillance data will also potentially make the United States more vulnerable to the current and future pandemics. The global community will also undoubtedly suffer because of the loss of the expertise of U.S. scientists, who are critical for the success of WHO's mission. Another consequence of the U.S. pullout will be the forfeiture of its ability to influence global scientific standards. For example, the U.S. Centers for Disease Control and Prevention serves as 1 of the 5 collaborating centers where >100 countries send thousands of patient flu virus samples for reference and research (38). Its notable absence at the decision-making table will deprive the United States of its critical role in decision making for next season's flu vaccine. The funding shortfall will undoubtedly compromise WHO efforts to respond to global emergencies, including tracking outbreaks and providing vaccines or medical supplies to countries that cannot afford them. In turn, this may unfortunately provide the nidus of future pandemics. A reduced budget could also limit international research like WHO-sponsored clinical trials for effective treatment of COVID-19 (12).

It is important to note that while the WHO is critically important to global health, they are also a justified target of objective criticism. Despite many achievements, the WHO's track record of responding to public health emergencies is tenuous. For example, the WHO's response to the HIV/AIDS crisis in the 1980s, the 2010 cholera outbreak in Haiti, and the 2013 to 2016 Ebola outbreak in West Africa were criticized because of their slow response (39, 40, 41). However, a series of reforms, including the creation of a contingency fund for emergencies, was undertaken to prepare for future large public health crises (42,43). These reforms have led to an improved response to the recent Ebola outbreak in the Congo in 2018 (44). While this is a positive step in the right direction, it is also worth noting that the WHO was slow to publicly recognize and address the scale of the COVID-19 outbreak in China, which essentially deprived the world of the opportunity to prevent COVID-19 from becoming a pandemic (45). Researchers have estimated that interventions even a week or two earlier may have reduced cases by 50% (46). The WHO also initially refused to endorse mask use despite evidence to the contrary of their potential effectiveness (47, 48, 49).

There are no easy solutions to reform the WHO without full commitment and support from its members. Steps are necessary to make it a more transparent and democratic organization. The current situation is not an accident and is likely the result of years of neglect and perhaps, even malfeasance. It is the unfortunate result of questionable policy and mistrust among the members over the course of many years. The landscape of public health has changed significantly over the decades of the WHO's existence with enormous population growth and huge globalization of trade, travel, information, and disease. Despite the huge increase in scope, the WHO's budget has been reduced or stayed flat over the years (50). The WHO's annual budget to protect the public health of a global population of 8 billion is less than that of some U.S. hospitals (51). The members have been resistant to a higher assessment fee, and membership dues were frozen in 1980 (31,52, 53, 54). The overreliance on voluntary contributions has also created the current environment of large donors dictating the priorities of the WHO agenda. These agendas sometimes cater to special interests and are not actually beneficial to the public (53). For example, critical public health initiatives, such as the marketing of breastmilk substitutes, the ethical criteria of drug marketing, and limiting no more than 10% of sugar in a healthy diet were opposed by the United States (54,55). China refuses to recognize Taiwan as a sovereign nation and has been successful in excluding Taiwan from WHO membership despite the fact that Taiwan meets all requirements to serve as a member (56). Incidentally, Taiwan's experience has been a rare positive example of how governments can control COVID-19 with fewer deaths and number of cases than most countries (57). Being located only 81 miles off the coast of mainland China, Taiwan was expected to be hit hard by COVID-19. However, as of November 15, 2020, they have had only 602 confirmed cases and only 7 deaths, all without the assistance of the WHO (58). Early recognition starting from December 31, 2019, combined with robust comprehensive contact tracing, testing, aggressive social distancing, containment, resource allocation, and regular public service announcements by a prominent epidemiologist led to their success. If the WHO had followed Taiwan's lead as a model, the current pandemic may have been a controlled malady instead of mismanaged event of astronomical proportions. It is also important to note that while the WHO is responsible for coordinating public health activities during a pandemic, they do not have any enforcement authority. A member nation may or may not choose to comply with the plans developed by the WHO during a pandemic. Only a third of countries meet the core capacities of public health required by the IHR. Members are required to notify the WHO of any PHEIC within 24 h. However, China was negligent and waited several weeks to send information about COVID-19 to the WHO (59). To further complicate matters, the IHR does not provide WHO the power to compel member states to report or independently verify the accuracy of data submitted by a member nation. One significant shortcoming of the WHO is that it must obtain approval by the member state to initiate a physical investigation of a public health outbreak. Mandates often do not correspond with available funds. Given the broad scope of global health challenges, the WHO may need to narrow the organizational focus by leaving some of the activities to states or other nongovernmental organizations. In our opinion, the WHO needs to be restructured to make it financially and politically independent to meet its mission. The mistakes in handling the COVID-19 pandemic should be the impetus for a fundamental reset of the long-needed reform within the organization. The IHR treaty needs to be ratified by the member states to establish a new culture and bolster strong leadership, shared values, clarity, accountability, and transparency, along with financial and independent authority of the WHO.

While EDs are playing a pivotal role to detect and isolate COVID-19 cases upon triage, the challenge to conquer the disease is far from over. The COVID-19 pandemic is worsening in the United States and other countries with an unfathomable human toll. According to the World Bank forecasts, the global economy will shrink by 5.2% this year, which is the deepest recession since World War II (60). This is the largest fraction of economies experiencing declines in per capita output since 1870. Moreover, a staggering 83 to 132 million people might face extreme hunger in 2020 (61). The option for suppression of COVID-19 is to reduce the transmission of the virus followed by using proven effective treatments or a vaccine, when available. Stopping an outbreak before its spread is the most effective strategy; however, this is not feasible without global surveillance data. The pandemic has exposed vulnerabilities and structural weaknesses in public health, including the WHO, making it clear that international solidarity and coordination are essential to fight against the disease. The WHO plays an indispensable and irreplaceable role in global health. Leaving the WHO at this critical junction of the pandemic will make the United States and the world less safe with potential harmful repercussions. There is a clear need for reforms to transform the organization into a true advocate of global public health as originally designed. Throughout our history, the United States has always led the world during public health crisis. The United States and the WHO are intertwined natural partners to protect global health security. With U.S. guidance, the WHO can be transformed into an organization that can act independently in the best interest of public health and science. The U.S. failure in controlling COVID-19 was avoidable and we must not make the mistake of withdrawing our support for the WHO in the context of current and future pandemics to protect public health in the United States.

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Acknowledgment

The comments in this article are exclusively from the authors and do not reflect the views or opinions of the Baptist Health System, University of Massachusetts Medical School, University of Pittsburgh, Upstate Medical University, or the Journal of Emergency Medicine.

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