key: cord-319998-dkk2motm
authors: Ho, Jing-Mao; Li, Yao-Tai; Whitworth, Katherine
title: Unequal discourses: Problems of the current model of world health development
date: 2020-09-09
journal: World Dev
DOI: 10.1016/j.worlddev.2020.105176
sha: 
doc_id: 319998
cord_uid: dkk2motm

The COVID-19 pandemic has exposed institutional deficiencies in world health development. This viewpoint paper examines the allegations about the partiality and political bias of the World Health Organization’s (WHO) response to world health emergencies. We draw on quantitative and qualitative analysis of the WHO’s Director-General’s speeches pertaining to the COVID-19 and EVD outbreaks. We find that the WHO’s discourse on COVID-19 praised the Chinese government’s role in the containment. By contrast, the WHO’s discourse on the African countries fighting to contain Ebola centered on the unpreparedness of these countries. We argue that the WHO’s unbalanced emphasis on different practices and “traits” of member states paints a partial picture of global health emergencies, thus it fails to uphold its founding principles of egalitarianism and impartiality. Finally, we put forward suggestions about a more equal and fairer model of world health development.

The World Health Organization (WHO) has been regarded as playing an important role in advancing global health development (Brown, Cueto, & Fee, 2006; Magnusson, 2007; Ruger & Yach, 2009) , however it is no stranger to calls for institutional reform. Following the WHO's handling of the 2014 outbreak of Ebola Virus Disease (EVD) in West Africa numerous requests for its overhaul or even dissolution were made (Checchi et al., 2016; Kamradt-Scott, 2016; Negin & Dhillon, 2016) . Institutional deficiencies identified in the WHO, include amongst others (Wenham, 2017) , that the functioning of the WHO is subject to international power struggles. The current model of global health development has been criticized for its imperialist tendency (Levich, 2015) and the dominant role of state actors (Adams, Behague, Caduff, Löwy, & Ortega, 2019; McInnes et al., 2020) . Indeed, the governing body of the WHO is made up of member states, while civil societies, such as professional associations, academic groups, and non-profit organizations, only play a very limited role (Checchi et al., 2016) . This institutional structure opens the door for political manipulation, making the WHO vulnerable to the power game of international politics (Kamradt-Scott, 2016) . Consequently, global health development is contingent upon power relations among the WHO's member states. Sovereignty and national interests, for example, can confound attempts at transnational coordination, rulemaking, and adjudication (Frenk & Moon, 2013) . Certain health programs or initiatives may be underfunded and underdeveloped because the countries affected lack the political or financial clout to mobilize support (Adams et al., 2019; Nunes, 2016) . Thus, inequalities in global health development are perpetuated and exacerbated. A variety of proposals to address these deficiencies were unveiled by special commissions and panels. Ideas in the proposals included splitting the WHO, revising its constitution, and establishing a new world organization that engages non-state actors (for a summary, see Mackey, 2016) . After reviewing these suggestions, the WHO decided not to make major, structural changes (Mackey, 2016) .

Unfortunately, the COVID-19 pandemic has again exposed the WHO's institutional deficiencies. In early December 2019, a ''cluster of pneumonia cases" was identified in Wuhan, China, but official, public messages about this novel coronavirus were not released until 31 December 2019. Despite the absence of independent scientific research, on 14 January 2020, the WHO announced that China had not found ''clear evidence of human-to-human transmission" of COVID-19. The Director-General of the WHO, Tedros Adhanom Ghebreyesus, also asserted there was no need to ''unnecessarily interfere with international travel and trade" nor implement travel bans on people from China. Even as evidence https://doi.org/10.1016/j.worlddev.2020.105176 0305-750X/Ó 2020 Elsevier Ltd. All rights reserved. mounted that COVID-19 was highly contagious, the WHO delayed declaring a global pandemic until 11 March 2020. Ghebreyesus, for example, in late February claimed that COVID-19 is not a pandemic and is not spreading in an uncontained way. To date, COVID-19 has resulted in nearly 26 million confirmed cases across the world, and more than 860 thousand deaths worldwide. The WHO has been widely criticized for not acting impartially, for failing to coordinate an immediate international response, and for being too slow to sound the alarm. It is again facing demands for reform.

We were particularly interested in these allegations of partiality and political bias because the WHO, as an independent international health agency, is expected to be immune from political pressure or intervention from any country and should present factbased evidence in an impartial way. Impartiality (and the perception of it) can be achieved by maintaining consistency in decision making processes and offering balanced factual information regardless of who the stakeholders are. Therefore, we decided to analyze the WHO's Director-General's speeches pertaining to COVID-19 (60 documents from January to April 2020) and EVD (17 documents from August 2014 to September 2015), to test the credibility of the above assertions. We found the WHO constructed markedly different narratives of the countries identified as the source of these pathogens and appears to have engaged in a selective presentation of information.

After quantitatively and qualitatively analyzing the WHO's official discourses on both COVID-19 and EVD, we found the official WHO narrative disproportionately focused on a single member state (China) (see Fig. 1 ) or group of member states (Guinea, Sierra Leone, and Liberia) (see Fig. 2 ).

One may argue that frequent mentions of these states should be expected as ''factual background" considering the first cases of each pathogen originated there. However, examining the WHO's discourses carefully, we find that mentions of China in connection with COVID-19 often highlighted China's positive contributions to controlling the pandemic. Our results show that out of 46 nonneutral references to China, not one was negative. 1 By contrast, mentions of Guinea, Sierra Leone and Libera were more varied. Out of 17 non-neutral documents, 7 of them contained negative references to the affected African nations highlighting poverty, poor facilities, political instability, and cultural traditions that facilitated the spread of EVD. 7 were neutral and described facts such as infection rates and deaths, while only 3 of them were positive commending efforts to conduct contact tracing.

Turning to our qualitative analysis, similar to Salzberger et al's (2020) findings, we find that the WHO emphasized China's successful containment of COVID-19. For example, on January 30, 2020, the Director-General claimed in his speech:

As you know, I was in China just a few days ago, where I met with President Xi Jinping. I left in absolutely no doubt about China's commitment to transparency, and to protecting the world's people (emphasis added).

The WHO repeatedly expressed its gratitude toward China's efforts of containing the spread. For example, at the Munich Security Conference, Ghebreyesus claimed that ''the steps China has taken to contain the outbreak at its source appear to have bought the world time" (February 15, 2020). Bruce Aylward, who led a WHO expert mission to China in February, defended WHO's narra-tives and said that China had ''worked very hard, very early on" to identify and detect early cases (April 8, 2020). However, the WHO's descriptions could be seen as inconsistent with the findings of previous research that suggest the Chinese regime tends to withhold information about public health issues and could pose a threat to global health governance (Brown & Ladwig, 2020; Chan et al., 2009; Goldizen, 2016) .

In contrast to the praise of China's efforts of containing COVID-19, the WHO's narrative of the West African nations affected by EVD highlighted their poverty, political instability, and cultural traditions. For example, in 2014, the then Director-General of the WHO, Margaret Chan, in her address to the Regional Committee for Africa, said ''[b]ecause Ebola has historically been confined to poor African nations. The R&D incentive is virtually nonexistent. . .Ebola, make Africa's neglected health systems and impoverished populations highly visible" (emphasis added). In another official speech on August 12, 2014, Chan highlighted the affected African countries' inability to fight Ebola by claiming ''Guinea, Liberia, and Sierra Leone have only recently returned to political stability following years of civil war and conflict, which left health systems largely destroyed or severely disabled. The outbreak . . . threatens to push these countries backwards (emphasis added).

In addition to describing the affected African countries as incapable of dealing with the epidemic, the WHO claimed that the EVD ''virus exploited West Africa's deep-seated cultural traditions and some of them were the most dangerous because they proved highly resistant to change" (emphasis added) (March 10, 2015). More specifically, Chan argued in the same speech:

In Liberia and Sierra Leone, where burial rites are reinforced by a number of secret societies, some mourners bathe in or anoint others with rinse water from the washing of corpses. . ..To this day, communities in Guinea and Sierra Leone continue to hide patients in homes, conduct secret unsafe burials at night, and refuse to cooperate with contact tracing teams (emphasis added).

The WHO seemed to attribute the failure of West Africa's EVD containment to intrinsic problems with those affected countries by arguing that ''[d]eep poverty, a disruptive political history, and centuries-old cultural beliefs and traditions created immense barriers to rapid containment" (November 2, 2015). Such language may serve to reinforce the impoverished image of the affected African countries amidst Ebola (Jones, 2011; Kapiriri & Ross, 2020) .

Here it is not our intention to say that the WHO's praise of China undermines its impartiality (e.g., Gilsinan, 2020) , nor do we wish to say that the WHO's acknowledgement of resourcebased and practice-based challenges faced by clinicians in West African nations is unfounded. Rather, we wish to highlight that the WHO's positive narrative of China's role in the current pandemic and the negative narrative of the capacity of West African nations to contain EVD created a partial (in both senses of the term) picture of the respective health crises. The praise of China may divert attention away from less favorable facts, including its role as the source of the pandemic and its initial attempts to restrict information about and reporting on the virus. Similarly, the WHO's focus on the vulnerabilities of west African countries may draw attention and agency away from the work health practitioners did on decontamination, giving the dead dignified but safe burials, and contact tracing. These unbalanced accounts of nation states can open the WHO up to allegations of the selective, or biased presentation of information. These partial narratives may deepen pre-existing misperceptions and prejudices related to unequal global development held by the general public and international community (Kapiriri & Ross, 2020; Leach et al., 2010) . 1 We acknowledge that the analysis of media portrayal may produce different results, but this is not the focus of this study.

The dramatic differences in the WHO's discourses on COVID-19 and EVD remind us that the world is not only divided by health disparities but also by the power plays of international politics. The WHO's unbalanced emphasis on different practices and ''traits" of member states allows us to see that it is not immune to taking on the biases found in international politics and as a consequence has failed to uphold the principles of egalitarianism and neutrality in global health governance upon which it is founded. If the WHO is to guarantee ''the happiness, harmonious relations and security of all peoples," international politics should not be a hinderance to the efforts to succeed in achieving that purpose (Benatar, 2016) . Thus it is again clear that institutional reform is needed to bring about a more equal and transparent system of global health development (Lee & Kamradt-Scott, 2014; Ruger, 2006) .

We acknowledge that any international body responsible for health governance must recognize and address the inequalities in financial capacity and health outcomes found between the global North and South. However, it should not perpetuate such a divide ontologically through its narratives (Sastry & Lovari, 2017) . As the world's authority of health information sources, the WHO ought to prioritize the presentation of scientific facts rather than political rhetoric. Factual information about a new disease or virus matters not only to public understanding but also to public health and policymaking.

One way to avoid the dissemination of partial narratives would be increasing the space for and visibility of other actors and their narratives within and outside the organization. Instead of over- whelmingly only focusing on its member state governments, the WHO can and should pay more attention to both local and international NGOs that are usually in the front line dealing with public health emergencies, and their initiatives for and contributions to global health. Concrete starting points in this vein might be to revisit the text of the WHO's Framework of Engagement with Non-State Actors and its membership criteria. Our suggestions may be easier said than done, but should serve as a steppingstone along the way to a more sustainable and successful model of world health development. 

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

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