Primary Health Care conference at Kazakhstan 1978
© Pan-American Health OrganizationBlack and white wide-angle shot of cavernous building with people seated at large table facing banks of stadium seats. Delegates at the International Conference on Primary Health Care held in Alma Ata, Kazakhstan in 1978.
"Power tends to corrupt and absolute power corrupts absolutely...", observed the English historian, Lord Acton, writing to a friend in 1857. This widely-quoted aphorism should lead us to reflect on the absolute powers that the World Health Organization is currently seeking for its director-general (DG). The organization has abandoned the broad, interdisciplinary vision of health based on primary care and public engagement that characterized its original mission and was expressed in the Alma-Ata Declaration of 1978. What we now see is a top-down, command-and-control approach, based on a narrow scientific base and the preferences, or prejudices, of a few major donors. This model has palpably failed to deliver in times of crisis. If the response is to strengthen the powers of command, can the organization be trusted to use these wisely, responsibly and effectively?

Much public attention to date has been distracted by the proposal for a new international treaty but the more serious issues can actually be found in the proposed amendments to the international health regulations. Both are being rushed towards a deadline of May 2024, for adoption at the World Health Assembly. This is exceptional speed for such documents and creates significant obstacles to civil society participation in the process. The treaty, however, will require a two-thirds majority in the assembly. It must then be ratified by each member state through its established procedures, which should create further opportunities for scrutiny. The changes to regulations only require a simple majority and become effective more or less immediately. It is these changes that represent a significant shift of power from nation-states to the person of the director-general, without any provision for a transparent appointment process or for that person to be accountable to any representative body or international legal tribunal. They are a recipe for autocracy.

Currently, the WHO can issue recommendations to members when a Public Health Emergency of International Concern (PHEIC) is declared. The amendments have the effect of changing recommendations to directions or commands. The definition of a PHEIC is loosened so that the DG can declare one in response to a potential, rather than an actual, threat and regardless of the views of the state from which the threat is thought to arise. Once this declaration is made, the new text moves away from the present language, based on the Universal Declaration of Human Rights, to subordinate rights to the discretion of the DG, who acquires the power to close borders, require vaccine passports, mandate vaccinations, impose quarantines and censor media critical of these interventions. The DG is to be the sole source of pandemic truth. While overriding the traditional jurisprudence of human rights, these also trespass on the sovereignty of nation-states to make their own judgments about what is best for their citizens. In the COVID pandemic, for example, Sweden could have been directed to comply with WHO instructions rather than following the different views taken by its own public health experts.

WHO was founded in 1948 to promote a broad vision of health, in a context of human rights and community engagement, with a horizontal, 'whole of society', approach. It played a valuable role in co-ordinating national efforts, sharing knowledge and best practice, and supporting national health ministries in countries with weak or resource-poor infrastructures. Many African countries, for example, looked first to WHO for pandemic flu planning rather than developing their own documents.

However, it has increasingly been colonized by a much narrower vision, which identifies public health with biomedical science. The response to epidemics is to be found in vaccines rather than communities. If the community does not accept the vaccine, they must be made to do so. The failure of this approach was well-documented in West Africa in the 2013 Ebola outbreak. WHO, and other international organizations, tried to impose interventions and failed. The outbreak only came under control when local communities were engaged, as anthropologists and sociologists had been urging from the start. Seizing dead bodies from villagers did not work: negotiating alternative arrangements for the transfer of the spiritual powers associated with these corpses had an immediate impact on transmission. By the time the vaccines arrived, the outbreak was in its final stages. Any historian of infectious disease would recognize the pattern, documented by Thomas McKeown more than 50 years ago.

WHO has, though, fallen under the spell of narrow biomedical thinking, not least because it has come to depend so much on donations from companies and foundations rather than national government subscriptions. This is not the sort of silly conspiracy theory that claims Bill Gates wants to use vaccines to microchip everyone on the planet. But it is not a matter of controversy that the Gates Foundation's disbursements reflect the founder's technophilia and belief that all human problems will be solved by technology. This presumption is not widely shared outside Silicon Valley, where others acknowledge that technology needs to be acceptable to users, if it is to be taken up and its benefits are to be realized. The dreams of tech entrepreneurs tend to founder on the reality of the wild environment. Compelling obedience to their visions should never be a policy option.

Similarly, pharmaceutical, medical device and IT companies are in the business of selling their products. There is nothing wrong with this, provided that we understand the consequences. We can address the diseases of poverty by making people less poor - or by giving them a pill for the diseases. WHO's original mission was to speak for the poor not for those who stand to gain from medications, vaccines, or electronic apps for surveillance and control of the movement of citizens. Nation states must be free to choose their path and to hear advocates of alternatives.

In the hands of a saintly DG, some of these new powers might be a reasonable response to some of the institutional weaknesses revealed by the Covid pandemic. However, we do not design systems of governance on the assumption that they will always be staffed by saints. DGs are humans, like the rest of us. Thomas Hobbes's vision of a benevolent dictator to whom citizens surrendered power in exchange for protection fell apart in the political realities of 17th- and 18th-century Europe. This is no time to re-enact it. Even military doctrine has moved away from pure command and control as the effectiveness of the Ukrainian military effort against an old-style Russian army has demonstrated.

Governments should not be signing up to the IHR amendments without a proper debate in civil society, informed by the social, political and socio-legal sciences of regulation and governance. Absolute power should not be given away in the moment of panic provoked by the pandemics of fear and action.