The World Health Organization between the United States and China

On April 14, President Trump announced that the United States was temporarily freezing its contributions to the World Health Organization (WHO). On May 29, he declared that the United States was terminating its relationship with the Organization. President Trump’s feud with the WHO was front page news, but it was not the first time that his administration withheld funding, withdrew, or in other ways disengaged with multilateral initiatives and international organizations. In 2017, Trump announced his intention to withdraw the United States from the Paris Agreement on climate change mitigation. In 2018, the Trump administration withdrew the United States from the United Nations Human Rights Council. In 2019, the United States officially quit the United Nations Educational, Scientific and Cultural Organization (UNESCO).

President Trump is hardly the first US President to be displeased with international governmental organizations or to take extreme measures to display his displeasure. Take UNESCO as an example. The United States first withdrew from that organization in 1984, rejoining in 2003 only to stop paying its dues in 2011. Normally, the justification for such punitive measures combines complaints about the incompetence of the organization with complaints about its ‘politicization’ (as displayed by the refusal to abide by the wishes of the United States). Similarly, President Trump in his decision to withdraw from the WHO accused the Organization of incompetence (including the WHO cautioning against travel restrictions in the early phase of the coronavirus pandemic) but emphasized the WHO’s political calculations (here, siding with China).

These similarities notwithstanding, timing still sets President Trump’s decision apart—the decision to withdraw from the UN specialized agency responsible for international public health has been made in a midst of a global pandemic. As such, his decision reflects an extreme anti-multilateral stance at a time when we need international cooperation the most. The global spread of the virus shows how inter-dependent we all are—connected through trade and travel. The solution will also necessarily be at the global level—through science but also coordinated practices and mutual support. US withdrawal will further weaken an international organization that could be our guide in directing and coordinating standards and norms in a midst of this deadly global unknown.

The recklessness displayed by this decision was not the only reason that Trump’s announcement attracted so much media attention, however. This face-off with the WHO was at the same time a face-off with China. In a four-page letter from President Trump to WHO Director-General Dr. Tedros Adhanom Ghebreyesus, ‘China’ or ‘Chinese’ appeared 46 times. ¹ Among the ‘serious concerns’ mentioned in the letter, Trump singled out ‘the World Health Organization’s alarming lack of independence from the People’s Republic of China.’ ² The intention, of course, was to deflect attention away from himself and to blame others—both the WHO and China—for mishandling the pandemic. While there are obvious ironies—that the United States should be alarmed by WHO’s vulnerability to individual member states, for example, or that US withdrawal could itself catapult China into a position of greater influence within the WHO—Trump’s criticism of China in relation to the WHO is itself significant. Trump is reacting here not to China’s position in the world order in general but to China’s position in the institutionalized world order—namely, its standing and influence in international governmental organizations.

The Institutionalized world order matters because, as I argue in my book The World Health Organization between North and South (Chorev, 2012), it changes countries’ conduct. In international organizations, world powers have to include other member states and the international bureaucracies in the conversation. International organizations offer a setting in which member states without financial means may use their votes to shape policies and decisions. In addition, international bureaucracies are strategic actors with their own organizational and normative goals and with some ability to shape or only partly adapt to states’ demands. The result is that institutional settings offer the ability to ‘tame’ or constrain member states.

As for President Trump, one could reasonably suspect that his concern is not the WHO’s delay in declaring the COVID-19 outbreak a Public Health Emergency of International Concern, but, as he claims in the letter, doing so ‘probably for political reasons.’ Trump remarks that, ‘Throughout this crisis, the World Health Organization has been curiously insistent on praising China for its alleged “transparency.”. . . China has been anything but transparent.’ ³ Some of the criticisms made against the WHO and/or China in the letter are valid, and other criticisms are based on false assertions and facts. ⁴ But this simple narrative, painting the WHO as China’s tool, overlooks the political realities of an institutionalized world order.

Here we should also pause for a moment to appreciate the novelty of China’s interest in global health institutions, including the WHO. Understandably, Western governments might be concerned that China’s involvement would come at their expense. Yet, there’s another angle we may want to consider. In recent years, China has been criticized for bypassing multilateral channels in favor of bilateral relations. Especially when it comes to aid, much has been remarked on China’s tendency to go it alone. In that context, is engagement with multilateral organizations a negative or a positive development? It depends on what we think of multilateral organizations. In my work, mentioned above, I find that multilateral organizations do have the capacity to ‘tame’, under certain conditions, the demands and expectations of individual actors. High-income countries have disproportionate influence. But these countries’ influence is constrained by other member states and the bureaucracy itself. To the extent that the United States or other countries believe that China’s influence needs taming, having China channel its funding and programs through the organization rather than only bilaterally might be positive rather than alarming news.

But the ability to restrict member states’ influence does not mean that political calculations are not part of the multilateral game. Has the WHO capitulated to China? It is too soon to tell. Take, for example, Trump’s complaint that the WHO opposed travel bans from China. This is not an indication of the WHO’s submission to China in particular. WHO’s position on travel bans in the context of COVID-19 has been the same as in previous pandemics, including Ebola. In response to the outbreak of Ebola virus disease, the WHO announced that ‘travel bans are detrimental and ineffective’, ⁵ and that trade restrictions ‘would have a negative impact on the response and on the lives and livelihoods of people in the region’. ⁶ There are complex political and public health reasons for the WHO to be wary of travel and trade restrictions. The WHO relies on countries for information on potential public health emergencies; if such reporting would automatically lead to travel and trade restrictions, countries would be more reluctant to report. ⁷ Still, to the extent that WHO’s opposition to travel and trade restrictions reflects capitulation to countries’ interests, then it reflects WHO’s vulnerability not to China in particular but to all member states—including Guinea, Liberia, and Sierra Leone.

And we should not miss the irony in the United States fearing China’s dominance in the WHO, because US actions since at least the 1980s have contributed to the increasing vulnerability of the WHO to individual countries. The WHO is dependent on all member states but the organizational structure of UN specialized agencies—including a one-country-one-vote rule and mandatory contributions calculated based on a country’s wealth and population—means that while some countries only have the power of their vote (and the vote of their allies), others may also have the power of their purse. As long as the WHO budget relied mostly on mandatory contributions, it was more difficult to directly use contributions to put pressure on the WHO. Over the years, however, the United States and other Western countries were able to lower assessed contributions and force the WHO to depend on voluntary funds, which are often earmarked. For the biennium 2018–2019 (not including the 4th quarter), assessed contributions made only 17% of the total budget. With the exception of less than 3% of the total budget, the rest was ‘specified’ (that is, earmarked). ⁸

The same institutional and financial arrangements that benefit a hegemon may hasten a hegemon’s decline. Yet we should not exaggerate China’s status at the WHO. China’s financial contributions to the WHO are still quite minimal. As of 2018, China’s mandatory contributions were the third highest among all member states, behind only Japan and the United States. However, the United States contributed 22% of the total assessed contributions, while China contributed only 7.9%. ⁹ More significantly, China offered only $6 million as voluntary contributions, compared with $280 million by the United States. ¹⁰ On the other hand, and possibly reflecting things to come, China contributed $50 million to the WHO’s COVID-19 Response Fund. The United States contributed $30 million. ¹¹ Financial indicators aside, other measures do hint at China’s diplomatic achievements. Dr. Margaret Chan, who was the WHO Director-General from 2007 to 2017, is originally from Hong Kong, and China reportedly supported the election of the current Director-General Dr. Tedros Adhanom Ghebreyesus. ¹² (It is believed that the Obama Administration supported him but that the Trump Administration did not. ¹³ ) The issue here is not the potential loyalty of those who got elected toward member states who had supported their nomination. Rather, it shows China’s ability to lead or, at minimum, be part of, an influential coalition of member states.

What then are the geopolitical implications of the United States withdrawing from the WHO? Arguably, threats to withdraw and actual withdrawal could strengthen US influence—by forcing the WHO and its member states to find ways to pacify the United States. And while President Trump’s actions could weaken US influence at the WHO by simply not having American delegates present when decisions are made, decisions are often reversable and could be changed once the United States is back. But some changes are less reversible—for example, if programs and priorities are reduced or terminated due to lack of funding. US absence may also give opportunity for others, including China, to step in and in the process change the rules of the game. Yet the fate of the WHO, like other international organizations, is ultimately tied to broader matters, such as the future political trajectories and economic developments in China and the United States. This takes us back to COVID-19. A larger question, then, is how COVID-19 might change the ongoing international power game. Four months into the pandemic, we already know that COVID-19 is going to have lasting impact on economic opportunities and employment, on political trends and the future of populism, and, hopefully, on social justice as well. Countries’ influence at the WHO is an outcome of financial, diplomatic, and other strategic actions, but their influence also reflects broader geopolitical events and economic shifts. These are shaped by, but reflect much more than, Trump’s latest provocations.