Can a deal be done to keep the US in the WHO?
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Welcome to a special edition of the BMJ's Medicine and Science podcast. I'm Cameron Abassi. I'm going to be joined today by Larry Gostin from Georgetown University in the United States to talk about the rather startling executive order from Donald Trump that is withdrawing the USA from the World Health Organization.

I'm now joined by Larry Gostin, Professor of Global Health at Georgetown University. Larry, good to be to join us. Thank you very much, Cameron. I'm a big admirer of yours in the BMJ. Oh, well, that's good to hear. We admire your work as well, Larry. So you have absolute love in here. But I want to know about your reaction to Donald Trump's executive order about WHO and

I don't know what the exact terminology is, but withdrawal from WHO. What is that? What does it mean? I know he's tried it before. Yeah. It might be helpful if I just like backed up and started at the very, very beginning. The United States really helped to form the World Health Organization, who is one of the founding members of

And it was W.H.O. was the first U.N. specialized agency in 1948. And I think the U.S. has been the W.H.O.'s greatest funder and greatest supporter and influencer for over 75 years. So what Trump is doing is is truly historic. Hmm.

When the United States joined WHO in 1948, it did so under a joint resolution of Congress. And that joint resolution said that if we ever withdrew, that we'd need to give one year's notice of the intention to withdraw and pay back all of our current financial obligations.

Trump tried to do that in his first term. He sent a letter to Antonio Guterres, the Secretary General of the UN, giving the one year's notice.

But before the year was out, President Biden came into office and his very first day, he revoked that notice of withdrawal. So here we are back on day one of the Trump administration, and he signed an executive order withdrawing the United States from WHO. My view of that,

is that it's the most cataclysmic decision of a president in my lifetime. It's truly historic. I don't think I'm overstating it because WHO has been the singular global health agency for over 75 years, and it's not perfect by any means, and we can talk about the need for reform, but it's just hard to see a world without WHO and the United States in it

And then we can drill down and I can explain why it's such a flawed strategic decision from the United States' point of view, but also from the world's point of view. Okay, I think we will talk about those things. But first of all, just to be clear, you're saying it's historic. I mean, he has had issued the same executive order previously, but it's historic because this time,

He's not going to get timed out and nobody else is going to reverse it. Yeah, it's pretty likely to happen. But there's still a process, though, isn't there? I mean, apart from the year's notice, there's more process. You know, I believe there should be more process. Oh, OK. But I don't know that Trump believes that. Yeah. I think he just thinks he's got to wait the year and then withdraw us. Yeah. He's already...

he's already in his executive order. He does everything but withdraw immediately.

He immediately cuts funding. He immediately pulls back all US employees and staff at WHO. So for example, it's a lot of senior staff, senior scientists seconded from the CDC at WHO in Geneva, but also in the regions. So he's really already,

And in addition to that, Cameron, he's said that he's revoking the U.S. participation in the amendments to the international health regulations. And he's withdrawing U.S. diplomats from the pandemic agreement. So this is, for all intents and purposes, I think, is a pullout. So it is historic. He

So I believe he needs Congress's approval. He doesn't believe that, and we can talk about that. No. Well, that's a general kind of philosophy of his, isn't it? I mean, if he wants something done, it's going to get done. You know him well. Well, not personally, but... Yeah, but I think we know what his psyche is. So I don't think he's going to seek congressional approval. I don't think that...

I don't really do not believe that Congress would ever give that approval. Okay. Because I think you, you know, the Democrats would be completely opposed to it. And there will be enough, just a few Republicans who are institutionalists. They believe in multilateralism. So I think he's going to just do it on his own. The big question, Cameron, is whether or not

there's a chance for some a deal, some leverage in terms of WHO reform. I think it's a low possibility, but it's one that I'm working on very closely with senior colleagues here in the United States and officials at WHO. Are you able to tell us more about that? Because what I remember just from a couple of days ago when Trump was talking about this

His central argument seemed to be about the funding. You know, we're paying way more than other countries. We being the US, way more than other. We're supporting WHO with far more funding than any other country. And of course, he specifically used the example of China.

Which a lot of his thinking is kind of preoccupied with China and China's place and the USA's place. And if you look at it, I mean, if you were to say, well, give him the benefit of the doubt, there is quite a big difference there between...

the numbers he quoted about what the US was paying WHO for how much it was funding WHO and how much China was funding WHO. Now, the first thing to ask about that is, so now the New York Times fact-checked him after his inauguration speech and not much was factually correct in that. Were those statements factually correct? It depends on how you slice it. I mean, he was using per capita numbers.

and China has a huge population. But let me talk a little bit about China, talk a little bit about funding and Trump's view of that. There have been successive US administrations that have wanted reform of WHO in terms of transparency, financial oversight, accountability. Those things are...

I mean, I think WHO has done a lot to address those, but those things are not unreasonable. But Trump, first of all, says that China has had an undue influence on WHO. And, you know, I've worked with WHO very closely for, you know, close to 40 years.

And I can say quite unequivocally that the United States has had far more influence over WHO than China ever has. But the irony is, is if we leave, we see leadership and influence to China. So I think he's flawed on that. Yeah, it becomes, sorry, it becomes self-fulfilling. But also, I suppose his reference point is,

You mentioned the pandemic is the events around the origins of the... Yeah. Yeah, of SARS-CoV-2. Yeah, and I'm glad you asked about that because...

You know, was China a malign actor during COVID-19? I believe absolutely so. I don't think they accurately reported human-to-human transmission at the beginning. They have blocked independent investigations of the origins of SARS-CoV-2. But it's hard to say that that's WHO's fault.

WHO has no power to force China or any country to do what they want to do. They don't have power to force them to accept independent scientists into their own jurisdiction. And I know Tedros really well. And, you know, Tedros being the head of WHO. The head of WHO, yeah. I think a really excellent director general. So, you know, he...

He's told me repeatedly, and I know this to be true, I've talked to senior staff, that he believes that you play hardball with China behind the scenes and you are not dismissive of them publicly. And he's, Tedros is a diplomat. He was the foreign minister of Ethiopia

I can't fault that. I would have done it differently if I were him. I probably would have said China has reported this, but we can independently verify it and we don't believe it to be true. But I understand what he did.

But I think to lay the blame on WHO for what happened during COVID is wrong. And of course, WHO got it wrong in terms of aerosolized spread, masking. But so did the US CDC, NIH, British health authorities. And the White House was spewing false claims about COVID treatment. So nobody has a great record there. Well, Trump himself, I mean, was active. Yeah, of course.

trying to be polite. Yeah, Trump in particular. So on the funding, would I like to see the United States reduce its funding to WHO? No, absolutely not. WHO operates on a shoestring. It needs to have more financing to be more economically resilient, not less resilient.

But I would like to see China, Russia, the Gulf states, the UK, France, Germany pay more. And so I think he's right that there is a mismatch. The United States pays more than other countries do. I think we should use leverage and cooperation at WHO to make that happen.

So the answer is, don't reduce U.S. funding because that's just a rounding error in the U.S. budget. So what you mean by that is a very small amount of money when it comes to the U.S. budget. Very, very small amount of U.S. funding. But I do think Trump is right that other countries, particularly China, ought to step up and end WHO and finance it properly. Yeah, so you're saying WHO is in a position of underfunding.

So the answer isn't to cut that funding further, it's to raise other people's funding so it becomes more adequately funded as an organisation, other countries' funding. The question then is, you said earlier that there are benefits to the US. I mean, there are benefits.

You argue there are benefits to the US, there are benefits to the world of USA being involved with WHO as it is now. So first of all, what are the benefits for the US? I think they're enormous.

I mean, I think, let me just jump to the, well, I'll mention a few. I had an op-ed in the Washington Post yesterday that gave five reasons, and I won't go through all of those five, but among them is WHO's polio eradication initiative.

um uh if it weren't for a who coordinated effort um we would have hundreds of thousands of polio cases around the world as it is it's only in two countries africa afghanistan and pakistan the united states is not welcome in those countries but who vaccinators and others are they can help

reduce the risk. WHO was also in Gaza when polio struck out and they did a massive childhood vaccination. US couldn't have done that. With childhood vaccinations in the United States dropping, particularly with Robert F. Kennedy Jr. likely to be the Secretary for Health and Human Services,

you know, our kids are not protected. And so we do need high immunization rates. I gave polio as an example, but the expanded child immunization program of WHO also provides this kind of global herd immunity against these childhood diseases. So that's the point is the global work of WHO that US is then benefiting from. It's the argument, you know, that was very clear in the pandemic that, you know,

These illnesses, these communicable diseases, they're not restricted by borders. Yeah, they're not. You know, and one of the things I mentioned on PBS TV yesterday was, you know, Trump may think that he can kind of close the border, the southern border, against immigrants, but you can't close America's border against a pathogen. America is kind of one of the world's greatest...

destinations and transportation hubs. Novel viruses can get to the US shores within 24 to 48 hours. That's the world we live in. And there's GORON, which is kind of a rapid detection and response, WHO system that kind of gives an early warning system and tries to stop outbreaks before they leave.

countries and get to the United States. So those are all really important ones, but I have the most important. Yeah. So, I mean, so global herd immunity, what are the other issues that you raised? Yeah. I mean, I think, and yeah, and childhood immunization, polio, and early outbreak response was assured. Okay.

The one I think is the most important is scientific exchange. I've worked very closely with U.S. leaders on this. I've worked at WHO. I'm on the IHR Review Committee, the International Health Research

Regulations Review Committee, AWHO. And the US, along with its partners like the UK, France, Germany, during the pandemic treaty negotiations and the international health regulation negotiations, they pushed for one thing beyond anything. And that was free, open, and rapid scientific exchange. It's really important to the United States

to be involved in the vast network of WHO laboratories, scientists, and public health agencies that do surveillance and collect and share really vital data. These data are needed by the CDC to monitor circulating viruses. They're needed by NIH.

to decide what priorities to invest in for research. And above all, they're needed by US-based pharmaceutical industry. They need pathogen samples, genomic sequencing data, and other information in order to innovate. And the United States is used to being in the front of the line for life-saving medical technologies, vaccines, treatments, diagnostics.

And we were with Operation Warp Speed during COVID-19. I think the American public might get a rude awakening if we became near the back of the line because we weren't able to rapidly gain access to data, rapidly innovate and bring these technologies to the market. And with H5N1 circulating in the United States,

Is the clearest example of that which I can explain if you'd like to go there now. Yeah, well, why don't you yeah, just talk about that Okay, I mean as all of your listeners will know and readers there's a major outbreak of avian influenza h5n1 in dairy cows in the United States and

Many of us believe that's only a mutation or two away from perhaps spilling over to more efficient human-to-human transmission. The WHO runs what's called GISRIS, the Global Influenza Surveillance and Response Program. That monitors

seasonal and novel influenza around the world. And so we will want to know if there are any dangerous variants, mutations, how the virus is behaving worldwide to get vaccines. But even in the most mundane way, every single year, US residents roll up their sleeves and get an updated COVID vaccine and an updated influenza vaccine.

We get that update through WHO laboratories and stales and gistrous. And so that would be a huge self-inflicted wound to the United States. Okay, and I'm sure there are more reasons, Larry. Let's talk a little bit about how the world benefits from the USA's involvement in WHO. In a nutshell, what are the reasons?

well first and foremost is funding yeah and and we fund who but let's not forget also that in addition to um uh kind of literally um canceling out all u.s funding of who which is you know roughly you know 20 of its budget hollow out the agency in addition to that

Trump ordered in the same executive order a 90-day moratorium on all U.S. international assistance for health. And he's threatened PEPFAR, the Global Fund, the GAPI Alliance. So what's at stake is not just WHO's vibrancy and ability to act,

It's also the major global health programs in the world for AIDS, TB, malaria, just to name a few. There's gonna be massive cuts and new regulations for sexual and reproductive health, which are necessary for the fight for STDs, HIV, and the like. So all in all, the turning off a spigot of funding,

participation at WHO and more globally will be an enormous vacuum. And I recently returned from Berlin, and I can tell you that European Union leaders, German leaders, French leaders, UK leaders who were at my meeting,

There's no political appetite for those countries to step in and rescue WHO now because they're undergoing their own problems in every country. Okay, so being clear, there will be a major impact if this goes through, which looks like what's going to stop it. So then the questions are, is there a way to potentially stop this from going through? And then secondly, you know,

You're not making WHO sound like an attractive proposition when you say other countries, we understand, you know, other countries are in financial difficulties themselves. But is that a value judgment on WHO and how might WHO be better placed to attract that funding? Yeah, what a great point.

you know i have to admit that um who's reputation is tarnished and it has been since covert 19. so i think it's a combination of both um not stepping up for who um in this new global environment of populism and nationalism um it's also because these countries who are the normal candidates to

are themselves suffering. German government failed, French government failed. It's under some austerity measures.

and the likes. - Yeah. - Yeah. - Yeah. - So these are a combination of factors. WHO, I do think needs reform. I think that countries that do value it like the UK, France, many of the Western European countries do value WHO.

I think they might be persuaded to step up, but particularly so if the Trump administration saw this as an opportunity for leverage over WHO to actually exact those reforms. So I'm, you know, with other really seasoned people in the United States,

really talking to senior administration officials in the Trump administration and also at the highest level of leadership at WHO, let's stand back from the brink. Let's do the adult thing. We don't want to tear WHO down. We don't want to tear the global health safety net down. We want to make it

stronger, more agile. We want to make it more resilient. We want to make it more accountable and transparent. There's a deal to be done there. And we also want other countries to pay their fair share. Okay. So what you're saying is there is a clear argument for reform of WHO.

But the answer, that doesn't begin with withdrawing funding. No. I think that isn't where we need to be. It's kind of the opposite. You don't change things by leaving. Okay. I'm interested that you're saying you're having these conversations. When I first read the responses to Trump's announcement, I think I saw you talking about legal action, Larry. Yes, I did. What might that be? And is that a genuine prospect?

Yes, we're meeting with senior legal team this week to plan a strategy. And we have a public interest law firm that's the smartest, most influential in America and has brought many cases before the Supreme Court. They're very interested.

There are basically two problems we have. The first, of course, is

standing, you know, will this personally affect the economics of any given individual? At the moment, that might be me because I'm the director of the W.H.O. Collaborating Center. Okay. You know, the other the other aspect is, you know, very conservative Supreme Court sees, you know, the Trump presidency as in imperial terms. They just

Yeah. From committing crimes for God's sake. Yeah. Well, I mean, he, I mean, he shifted the balance of that Supreme court with his appointments. We all know that. Yeah, we do. Yeah.

And it's now a super conservative majority. So your point is even if you get it to the Supreme Court, we might lose. It's a bit of a bleak prospect in terms of whatever action you're thinking of taking. Okay, in that case, Larry, thank you for your time. My final question to you then is you said you're having conversations with people in the Trump administration.

At this stage, what kind of response are you getting? Are there reasons to perhaps not be hopeful, but see a way forward? Well, not hopeful. You know, there is particularly the hardliners in Congress and also in the administration just have this real hostility to international organizations,

to multilateralism, to international norms like the IHR and the pandemic agreement. And their mind is pretty much made up. There are a few thoughtful institutionalists that are willing to listen. I have to say that me and people like me now

don't have a lot of influence in the Trump administration the way we did with Biden or Obama. This is very, very different. But we're hoping to be an intermediary. At the same time, WHO can't be defensive. I do believe they need to engage. I mean, just to give you an example, you know, Marco Rubio, the new Secretary of State, I don't agree with much that Rubio says, but he's

an intelligent, thoughtful person that does understand the importance of U.S. alliances and international cooperation. I think there should be really serious conversations between him and Tedros, the head of WHO, at that kind of a senior level. So WHO needs to engage. They need to be willing to make even deeper reforms than they have before.

And the United States needs to step back from the brink and say, okay, you know, we're supposed to be America first, but America first is not America alone. Because America alone in global health is simply a recipe for making us fragile, vulnerable, and weak. And I hope that

you know people that care about the united states even if they don't particularly care about the world which i really hope they do um should think twice about what really is in our national security interests larry i think that's a perfect note to end it on uh thank you for making the time to talk with us today thank you very much for having me i really appreciate it