Introduction

On July 7, 2020, President Trump gave the UN notice that the US would be officially withdrawing from the World Health Organization (WHO). President Trump has been consistently critical of the WHO since April. He announced in early April that the US would be suspending contributions because the WHO had failed to fulfill its basic obligations and because of its pro-China leanings and, at the end of May, Trump declared that the US would be terminating its ties with the WHO because the WHO had not implemented the reforms demanded by the Trump administration. This paper will ascertain the true nature of the problem by deciphering the aforementioned criticisms of the WHO, and consider what approaches should be taken in the US' absence to address the urgent issues facing health cooperation.

Special consideration toward China?

Criticism of the WHO can be broadly classified into two points: the WHO is pro-China, and the WHO did not fulfill its obligations. The criticism that the WHO is China-friendly or not neutral was first triggered by Director-General Tedros' response to China. On January 28, while on a visit to China, Dr. Tedros in a meeting with President Xi Jinping praised China's response and declared that China's robust measures had won the world's admiration. Tedros' lauding of China's response even as infections continued to spread, his postponement of a declaration of a state of emergency at the 1st WHO Expert Committee meeting held on January 22-23, and the WHO's failure to recommend a travel ban were among the reasons the WHO was denounced as being China-friendly.

Dr. Tedros unquestionably demonstrated a degree of extraordinary care in dealing with China. On the other hand, some form of trustworthy evidence is needed to verify whether there was some special consideration accorded China as is rumored. It has been standard WHO practice since 2005 not to recommend travel bans; even as the Ebola hemorrhagic fever ran rampant in 2014, the WHO continued to insist that there was no need to postpone flights bound for West Africa. When SARS struck in 2003, the WHO recommended banning travel to Canada and China, sparking harsh criticism from these countries. Based on this experience, a clause was added in the 2005 revisions to the International Health Regulation stating that WHO recommendations must come with a proviso requiring that disruptions to international traffic be held to a minimum.

Attention must also be paid to the fact that Dr. Tedros' praise of China in a public forum seems very much to have been diplomatic and pro forma in nature. Despite this praise, officials inside the WHO were exasperated at being unable to obtain information they needed from China. This brings to mind the criticism leveled by the then WHO Director-General against China's response to the SARS outbreak that hindered subsequent communication with China, and Dr. Tedros was undoubtedly seeking to maintain open lines of communication with China through praise rather than criticism.

Regardless the reason, more caution would have been needed in handling China with such extraordinary care, as this behavior conveyed to the international community the erroneous message that China had contained the virus. He should have also foreseen what kind of response such special consideration to China would draw from the US in the midst of ongoing US-China confrontation. The effort to eliminate smallpox that was pursued at the height of the Cold War employed a variety of resources, including vaccines, funding and personnel from both the US and the Soviet Union, but the US version of vaccines proved markedly superior. Accordingly, when Soviet vaccines failed quality tests and when an American was appointed director of the eradication team, WHO officials made frequent visits to Moscow and took great care not to offend the Soviets. Given that international health cooperation can never escape the influence of international politics, the Director-General must act with delicacy and tact to avoid sparking a political fight.

Did the WHO fail to fulfill its obligations?

The second criticism of WHO was that it had not fulfilled its basic obligations. The WHO Charter states that the WHO is obliged to establish various health-related standards, to furnish assistance to countries in need, and to coordinate cooperation for such assistance. In responding to infectious diseases, the WHO's obligations are to collect needed information, assess the situation and offer suitable advice. On January 30 the WHO convened a panel of experts that declared "a public health emergency of international concern", on February 3 it issued response guidelines for the international community, and on March 11 it declared the outbreak a pandemic. It conducted a series of daily briefings thereafter and, at the end of May, it launched an initiative to share vaccines, therapeutic agents, and diagnostic tools internationally. The WHO has fulfilled its basic obligations.

This crisis has made clear that what the WHO can do is very limited, rather than that it failed to act or neglected to do what it could.. As mentioned earlier, the WHO, while serving as a rallying point for health cooperation, issuing necessary guidelines to countries and encouraging/coordinating cooperation, lacks any coercive authority, and can only function with the voluntary cooperation of its member states. For example, the International Health Regulation constituting an international treaty that governs responses to infectious diseases requires signatory countries with confirmed public health risks in their own territories that could spread internationally to notify the WHO to that effect within 24 hours. Currently, however, quite a number of countries have not properly fulfilled this obligation. If the WHO had been able to more proactively collect information and to enter countries with suspected outbreaks in order to investigate, things might have turned out a little differently. It does not presently have such authority, and thus has no choice but to rely on information reported voluntarily by outbreak countries. A consequence of such limitations was the extraordinary care the WHO extended to the outbreak country of China.

How should the WHO be enhanced?

How, then, should these various problems be rectified? As a matter of urgency, one practical prescription would be to enlarge the WHO's authorized scope of action by revising the International Health Regulation. The International Health Regulation has been amended from time to time in response to changes in the international environment. The 1981 revisions excluded smallpox, whose eradication had been declared the year before, while the 2005 revisions expanded the Regulation's coverage from infectious diseases to "public health emergencies of international concern" in light of the September 11 terrorist attacks and the possibility of terrorist attacks employing biological weapons. These same revisions also enabled the WHO to make inquiries with countries to request verification of information obtained through various unofficial channels. Flexibly modifying rules in line with changes in the international environment is an essential process. What has surfaced now as perhaps the top issue to be addressed is revising the WHO's authority regarding initial responses to infectious diseases. As noted above, outbreak countries with confirmed public health risks within their territories that could spread internationally are required on their own initiative to report this to the WHO, but at present there are numerous countries around the world unable to fulfill this obligation properly. It may be necessary to revise the WHO's authority regarding initial responses by, for instance, enabling the WHO to make use of all information available to discover such risks early on and take the necessary steps in response.

Additionally, more detailed standards are needed on assessing situations and providing advice to individual countries. Six phases have been established for influenza outbreaks, but only two standards exist for other infectious diseases: whether or not they constitute a public health emergency of international concern. More detailed classifications of situations should be established, and more concrete advisory standards regarding travel, border control, surveillance, etc., should be developed for individual phases.

Collaboration for making improvements

None of the aforementioned problems can be resolved without active involvement and solidarity among members of the international community, and international cooperation is certainly essential in that sense. It is the WHO member states that will prepare and implement specific roadmaps for reform, and that will undertake the diplomatic efforts to garner sufficient votes in favor of the revisions. There are some hopeful signs in this regard. In April, the G7 health ministers began discussions on WHO reform intended to address the aforementioned issues, and France and Germany recently led efforts to draft a concrete reform proposal. Among the measures contained within the reform proposal are strengthening the framework for securing reliable funding for the WHO, expanding the initial response obligations of outbreak countries and the WHO's initial response authority, and creating an independent expert committee to evaluate WHO's operations in emergencies. As the November meeting of the World Health Assembly approaches, it is likely that countries will increasingly reach out and engage in diplomatic efforts to ensure support for this reform proposal from the US, China and others.

There are now several other reasons that international cooperation is deemed necessary. One is that the novel coronavirus is having such an extensive impact, not only harming people's health but actually disrupting the global economy, leading to concerns that the coronavirus will exacerbate poverty and social unrest, and even bring about changes in the international order. Individual countries are limited in their ability to respond to these issues, necessitating collaboration among countries in undertaking preventive measures and countermeasures. Cooperation is also necessary to contain the rise of China. The US' absence is apt to give China greater leeway in playing a more prominent role in international health cooperation. China has long sought to expand its influence in this area. Unlike the expensive pharmaceuticals produced by the developed countries, Chinese-made pharmaceuticals are readily accessible to developing countries, and China will be able to take on an even greater role if it succeeds in developing a vaccine and supplying it to developing countries. At the same time, China will not necessarily emphasize the norms of respecting human rights and ensuring transparency that have been stressed in health cooperation heretofore. Active involvement is needed from Japan, Canada and other liberal democracies in Europe, Oceania and elsewhere in maintaining and strengthening the norms that constitute the core elements of governance. If Japan and these countries can team up to support health cooperation - with the inclusion of the US if a Biden administration comes into office - then solidarity could perhaps be accelerated. This is because many Democratic members of the US Congress want to see the US more engaged in health cooperation and WHO reform.

Expectations of Japan's role are particularly high. Japan has maintained fairly good relations with both the US and China on the urgent issue of finding ways to contain the coronavirus, and it is thus expected to do its part in urging the two countries to cooperate. It has committed itself to participating in the COVAX Facility, and much will be expected of Japan's initiatives for establishing fair access to vaccines.

Furthermore, Japan has a not insignificant role to play with respect to medium- to long-term preparations for the next pandemic. Even before the ongoing pandemic, Japan was putting to good use its advanced technological capabilities and its experiences in achieving universal healthcare, making the healthcare/medical field a key for its international cooperation. More specifically, it has worked to ensure that everyone can enjoy basic healthcare/medical services when needed at an affordable cost (universal health coverage), and it has provided assistance to buttress healthcare systems in Africa and Asia. It has also striven to make available artificial dialysis technology and Japan-made medical equipment and to popularize the idea of maternal and child health handbooks. Pushing for broader-ranging health cooperation to help strengthen developing countries' capability to deal with infectious diseases will not only positively impact public health ahead of the next infectious disease but will also likely enhance international trust in Japan.

The future will undoubtedly require that infectious disease countermeasures become viewed from the perspective of security in the broad sense. Infectious diseases are intricately intertwined with changes in the global environment, as previously noted, and the spread of infections could have an enormous and extensive impact on everything from the global economy and day-to-day life to national security. For that reason, a robust system to combat infectious diseases must be put in place from the standpoint of peacetime security. In specific terms, infectious disease monitoring systems should be constructed, response capabilities enhanced and joint vaccine development promoted within existing frameworks such as the Japan-US alliance, the Free and Open Indo-Pacific Strategy and the Japan-China-ROK health ministers' conference. As envisioned by the US when the WHO was established, health cooperation is an area in which it is relatively easy to reach consensuses between states, and it is thus a potential platform for cooperation. To make this possibility a reality, and to help contain the ongoing pandemic and prepare against the next infectious disease, leaders of the world will need to demonstrate enthusiasm and political will.