A Healthy Dose of Realism: Stopping COVID-19 Doesn’t Start with the WHO

May 15, 2020
smallpox-erad

There’s a proven approach to combating the global threat of the novel coronavirus. It was used to eradicate smallpox during the Cold War. Rather than relying on the World Health Organization (WHO), success depends on a “great-power concert.” Today, this means concerted action by the United States and China.

Concerted action is difficult given long-standing tensions between these great powers. In addition to their trade war and military rivalry, the United States and China have traded ugly allegations about COVID-19, including racist rhetoric and conspiracy theories. Working together is particularly contentious during the U.S. presidential campaign. It could involve uncomfortable compromises, such as sidestepping the WHO or turning a blind eye to China’s disastrous cover-up of COVID-19.

Despite these difficulties, concerted action serves the national interests of both China and the United States. It’s also one of the only ways to marshal a global response to this pandemic. In contrast, the WHO lacks the material power required to have much independent effect, even if its funding wasn’t threatened by the Trump administration.

 

 

The campaign against smallpox is instructive in this regard. Conventional wisdom credits the WHO for eradicating smallpox, and yet, contrary to popular belief, WHO leadership opposed this campaign. The eradication of smallpox started and succeeded thanks to the Soviet Union and United States. This political history provides insight into how to combat COVID-19 during the current era of great-power competition.

Ending the ‘Most Dreadful Scourge’

Eradicating smallpox was the greatest public health victory in history. Smallpox had been “the most dreadful scourge of the human species,” as the British physician Edward Jenner wrote in 1801. For millennia, the virus ravaged humanity. It killed everyone from Pharaoh Ramses V and Roman Emperor Marcus Aurelius to untold millions of people in the Americas and Australia after their first contact with infected Europeans. Smallpox nearly defeated the Continental Army during the American Revolution.

More than 1 out of 4 people who caught smallpox died. Many of those who survived were blinded or disfigured for life. COVID-19 is bad. According to key metrics, smallpox was worse.

Jenner discovered a technical solution in 1796: the world’s first vaccine. But public health is inherently political, and it always has been. More than 160 years passed before the political will emerged to eradicate smallpox. That willpower came from the great powers.

In 1953, the first WHO director-general proposed a smallpox eradication campaign, arguing that it would demonstrate “the importance WHO has for every Member State.” The states disagreed. The World Health Assembly — the governing body of the WHO, composed of its member states — rejected this idea as too complicated, even as smallpox killed around 2 million people per year at the time.

In 1959, the Soviet Union made a similar proposal. Announcing this initiative, Deputy Minister of Health Viktor Zhdanov quoted U.S. President Thomas Jefferson, who had praised Jenner for discovering the vaccine. Zhdanov argued that national programs had eliminated smallpox in many countries, but they were still threatened by the virus being imported from regions where it was still endemic. The Soviet Union had suffered several such outbreaks in the 1950s. Zhdanov argued that it was cheaper to fight the disease abroad than guard against it at home.

The Soviet Union had recently returned to the WHO after a boycott (Josef Stalin wasn’t a fan), and it donated 25 million doses of smallpox vaccine to the cause. Eager to appear pleasing, the World Health Assembly voted unanimously in favor of the Soviet proposal. Little action followed. The WHO focused instead on a doomed effort to eradicate malaria (unlike smallpox, malaria is spread by mosquitos and lacked a vaccine).

Had the United States not weighed in, smallpox might still be with us. In 1965, the U.S. Communicable Disease Center (CDC) — now named the Centers for Disease Control and Prevention — was vaccinating against measles in West Africa. The United States wanted political influence in this Francophone region. And measles killed kids. The vaccination program lacked proper equipment and funding, however. Attempting to end it with a bureaucratic head fake, a CDC officer named Donald Henderson proposed drastically expanding the program to include English-speaking countries (Nigeria, Ghana, Liberia, and Sierra Leone), as well as vaccination against smallpox. On the one hand, the CDC worried about smallpox because importations threatened the United States. The last had occurred in New York and Texas. On the other hand, Henderson didn’t expect support. “We proposed what was patently unacceptable,” Henderson later said, according to the book The Invisible Fire. “We would be happy to undertake both smallpox eradication and measles control … we knew this wouldn’t fly.”

At first this proposal didn’t fly. Then the White House intervened. President Lyndon Johnson called for a worldwide war on smallpox in observance of “International Cooperation Year,” marking the 20th anniversary of the United Nations. White House staff latched onto Henderson’s proposal and Johnson agreed, much to the surprise of the CDC.

WHO leadership was also surprised but not happy. The second WHO director-general, Marcolino Candau, feared that smallpox eradication would fail and discredit the WHO. Yet he couldn’t ignore the United States and Soviet Union, the organization’s most powerful member states. So, he tried to derail the campaign by asking for too much. In 1966, Candau asked the World Health Assembly to vote on a special budget for smallpox, on top of the regular budget, and over twice the amount recommended by the Executive Board. This vote was expected to fail. It almost did; the proposal passed by the narrowest margin in WHO history. Unable to stop the campaign but worried it would harm his reputation, Candau insisted that an American lead so that the United States would be blamed when smallpox eradication failed.

It didn’t fail. Henderson was tapped to lead the WHO campaign, supported by an influx of CDC personnel. By 1980, smallpox was officially eradicated from the face of the Earth.

Eradicating smallpox cost less than $3 billion in today’s dollars. Poor countries with endemic disease paid most of the bill. The United States and Soviet Union provided most of the vaccine and global leadership. The positive returns on this investment — lives spared, agony avoided, costs saved — are huge. Working through the WHO proved helpful in the end. But this remarkable achievement wouldn’t have been possible without at least tacit coordination between the United States and Soviet Union.

A Cure for What Ails Us

What can smallpox eradication teach us about the fight against COVID-19? For one thing, focusing on the WHO is a distraction. Fervor over the WHO — including criticism and deflection from President Donald Trump — is misplaced. The WHO simply isn’t the most significant actor or factor in pandemic response.

That’s because the WHO is too weak to do anything more than what powerful states tell it to do. The bureaucracy may drag its feet, as happened with smallpox. But now, as then, the WHO will come to heel. For better or worse, its actions reflect the balance of power in the world.

Said another way: Don’t hate the player, hate the game.

Weak players can be subbed out. If the WHO hadn’t come around on smallpox in 1966, then the United States and Soviet Union could have chosen another forum. The CDC was already working through a different, regional organization of former French colonies for its measles program in West Africa, L’Organisation de Coordination et de Coopération pour la Lutte contre les Grandes Endémies. More recently, the U.S. President’s Emergency Plan for AIDS Relief circumvented the WHO in 2003. Even the United Nations substituted the WHO with the U.N. Mission for Ebola Emergency Response in 2014.

Is it smart to substitute for the WHO on COVID-19? Probably not, unless the White House also plans to spend far more on global health security in the process. Slashing the WHO without a muscular alternative in place is certainly counterproductive and contrary to America’s strategic interests.

But neither is it correct to suggest that the WHO is irreplaceable. The same goes for its leadership. The current WHO director-general, Tedros Adhanom Ghebreyesus, is under fire for praising China’s “commitment to transparency” despite its cover-up of COVID-19. Must he fall on his sword? Again, probably not, unless doing so serves the greater good.

Rather than burn valuable time attacking or defending the WHO, it’s better to focus on more significant actors. These are nation-states. During the Cold War, the most powerful states were the United States and the Soviet Union. Although the world is no longer bipolar, the balance of power now rests with the United States and China.

The United States and China are indispensable nations in part because they account for most cases of COVID-19. Unfortunately, other countries are catching up. But given inadequate testing in the United States, underreporting in China, and mismanagement by both, they still rank among the world’s largest hot spots.

The burden of smallpox was different in the 1960s. The United States and Soviet Union had already eliminated that virus at home before they embarked on global eradication. Their shared fear was imported infections, which threatened their respective domestic populations. Today, the fact that the countries with a high incidence of COVID-19 include those most capable of doing something about it is an important coincidence. Improving the global response aligns with their national interests.

These interests have little to do with idealistic notions of altruism or universal human rights to health. They have everything to do with national self-interest in survival and, similarly, the power needed to survive. These aren’t our better angels. Nevertheless, they give the United States and China reason to work in concert on health security driven by realpolitik.

Granted, the United States and China also have reason to fear each other. Suspicion and security competition are par for the course and will continue. But now they face a common threat. Contagion abroad threatens their health security at home. Bloodletting and beggar-thy-neighbor policies will backfire with this communicable disease. The uncertain and unintended consequences of allowing COVID-19 to fester threaten the relative power of both Washington and Beijing.

If COVID-19 goes unchecked, both stand to lose.

One may lose more than the other, but neither knows which that would be. Both have reason to worry about their standing relative to other countries as well. Russia is still out there, for instance, both on China’s border and inside American cyberspace. Both China’s rise and American hegemony are threatened by the blood and treasure lost to this pandemic. Both have a significant stake in returning to the status quo ante. Their vital interests align.

Both China and the United States can help themselves by working in concert on COVID-19. Targets of opportunity include international travel and trade, infection control, and medical treatment. Washington and Beijing can coordinate policies to increase production of medical supplies and reduce the risk of a global economic depression. This doesn’t require resolving their trade war, just as eradicating smallpox didn’t require ending the Cold War. It doesn’t even require good faith; the Soviet Union helped eradicate smallpox at the same time it stockpiled the virus as a biological weapon. Bad actors sometimes do good. Despite bad behavior, the United States can also work with China to help control the spread of COVID-19 by coordinating when, where, and how to lift restrictions on international travel.

Concerted action on vaccines, therapeutic drugs, and diagnostics is warranted as well. Research and development for public health is political. Those countries that are powerful enough or lucky enough to produce COVID-19 vaccines and antivirals will probably help themselves first, even if the need elsewhere is greater. Nevertheless, a great-power concert can expedite mass production and worldwide distribution when vaccines and other drugs are available. The same goes for reliable testing equipment and reagents. While global access won’t be equitable, coordination between Washington and Beijing can help avoid some of the worst possible outcomes.

A great-power concert won’t save the world. It will help nation-states — particularly the United States and China — help themselves in the midst of great-power competition. It will also accomplish more than damning the WHO or expecting miracles from international institutions. As with the eradication of smallpox, the WHO and the rest of the world will follow when the great powers choose to lead.

 

 

Frank L. Smith III is director of the Cyber & Innovation Policy Institute at the U.S. Naval War College. His research examines the relationship between technology and international security, particularly cybersecurity and biosecurity. He has a Ph.D. in political science and a B.S. in biological chemistry, both from the University of Chicago. His views do not reflect the official policy or position of the Department of the Navy, the Department of Defense, or the United States government.

 

Image: CDC

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