This week US President Donald Trump made good on his threat to withdraw the United States from the World Health Organisation (WHO) by sending a formal letter of withdrawal to the UN Secretary-General.
In so doing, the president has initiated the Congressionally-mandated 12-month countdown to withdrawal that will take effect in July 2021. That is, unless it is over-turned, as presumptive Democratic nominee Joe Biden has immediately pledged to do if elected.
But if the United States’ exit goes ahead, it will be a hit to global health cooperation and place lives at risk in the US and beyond.
Questions persist about the president’s legal authority to unilaterally withdraw the United States from the WHO. But under the conditions imposed by the US Congress in 1948, the president must first ensure payment of any outstanding dues before the withdrawal can take effect.
According to some estimates, the US government currently owes US$58 million to the WHO in unpaid dues, as well as a further $110 million to the Pan-American Health Organisation, the branch of the WHO covering North and South America.
According to the American Medical Association, American lives will be placed at “grave risk” if Trump’s withdrawal from the WHO is not reversed. Digging a little deeper, it’s not hard to see why.
Twice a year, for example, the WHO Global Influenza Surveillance and Response System (GISRS) provides WHO member states with vital information on the dominant influenza strains circulating around the world. This data is then used to develop life-saving influenza vaccines. If enacted, the United States’ withdrawal will mean it’s officially excluded from this global network, placing the country at a distinct disadvantage ahead of every flu season.
The implications could be profound, given that in 2018-2019, 34,200 Americans died of seasonal influenza-related illness despite having access to vaccines developed using GISRS data.
Likewise, important international discussions about vaccine research and development on diseases that threaten American lives will likely now occur without US scientists being involved. International guidelines on best medical practice will continue to be produced by the WHO but without US input.
The US has benefited for decades from obtaining advance warning about disease outbreaks in other parts of the world through the WHO’s Event Information System, but this will no longer be possible. The US would be effectively cut off from such alerts, forced to rely on foreign media or public WHO announcements.
Aside from the notable health consequences, withdrawing from the WHO will mean the country no longer has a seat at the negotiating table on what future reforms are needed to make the WHO a more effective global health agency. This is something many of Trump’s advisers and supporters had wanted to see happen, but the president’s actions will relegate the United States to the sidelines.
The United States has traditionally remained one of the most generous contributors to WHO-led global health initiatives, providing almost twice as much as most other donors. Because of US withdrawal, the future viability of polio eradication, tuberculosis control, and access to HIV/AIDS treatment initiatives, just to name a few, are now all at risk.
US withdrawal is likely to have a significant impact on public health in the region. The Pan-American Health Organisation (PAHO) is on the verge of insolvency as a result of unpaid dues. The US is currently the primary debtor, owing 67% of the unpaid fees.
Even before the COVID-19 pandemic, PAHO provided vital technical assistance and expertise unavailable throughout many Latin American countries. In the event PAHO is allowed to go bankrupt, the impact on regional health programs such as maternal and child health, not to mention the pandemic response, will likely contribute to considerable loss of life.
For the World Health Organisation, the departure of the United States will be a significant blow. For many years the level and extent of technical cooperation between the global health agency and the US Government has contributed to making the world safer and healthier. Such collaboration is now under threat.
As with the EU’s approach to negotiations on the United Kingdom’s “Brexit”, the WHO’s remaining member states now have to make an example of the United States, ensuring that it is excluded from multiple WHO initiatives. If they do not, it risks more countries threatening to withdraw. The future of global public health is at stake, and the actions of one country cannot be allowed to undermine decades of multilateral efforts to improve the health and well-being of all peoples of the world.
In the event the United States does withdraw from the WHO it will sit in a unique category: that of a global health pariah.
America First is increasingly looking like the new reality will be America Alone.
This article is supported by the Judith Neilson Institute for Journalism and Ideas.
The deployment of three US nuclear-powered aircraft carriers to the South China Sea have further tested strained relations between China and the United States.
The US naval exercises represent an enormous aggregation of firepower. Adding to tensions, the US deployment coincides with Chinese war games in the same vicinity.
These waters are becoming congested naval space.
This is the first time since 2017 that America has deployed three carrier battle groups into contested waters of the South China Sea and its environs. You would have to go back a further ten years for another such display of raw American naval power in the Asia-Pacific.
In 2017, the US sent a three-carrier force into the region to exert pressure on nuclear-armed North Korea to cease provocative missile tests and the further development of its nuclear capability.
On this occasion, it is China that is being reminded of American capacity to assert itself in what has become known as the Indo-Pacific. This describes a vast swathe that laps at China’s borders from India in the west to Japan in the north-east.
Washington seems bent on conveying a message. However, it is not clear that China is in a mood to heed such messages in an atmosphere of escalating rhetoric.
In a response to the American naval exercises, Beijing’s official English-language mouthpiece, The Global Times, accused Washington of “attempting to show off its military capability, threaten China and enforce its hegemonic policies”.
The newspaper quoted Beijing “analysts” as saying:
The South China Sea is fully within the grasp of the People’s Liberation Army, and any US aircraft carrier movements in the region is solely at the pleasure of the PLA.
This is not true, of course. But the fact such sentiments are emanating from Beijing’s security establishment is confronting, to say the least. When it comes to big-power rivalry, talk might be cheap, but words matter.
In China’s armoury, propaganda is a weapon of influence.
Perhaps the most interesting component of the Global Times assault on US regional “hegemonistic” ambitions is its characterisation of American meddling as that of a “non-regional country that lies tens of thousands of miles away”.
Leaving aside the usual propaganda from Beijing, these sorts of observations represent a continuing escalation in Chinese rhetoric and cannot simply be dismissed as more of the same.
China’s own characterisation of the South China Sea as a “Chinese lake”, in defiance of multiple territorial claims and counter-claims from its neighbours, represents a noose around the region’s neck.
This begs the question whether a regional arms race is under way and likely to intensify. Australia’s own announcement of increased defence expenditures on such items as long-range anti-ship missiles attests to concerns about China’s growing assertiveness.
Canberra’s commitment to lift defence spending above the 2% of GDP benchmark and equip itself with greater offensive capabilities represents a direct response to a perceived China threat.
In that regard, Prime Minister Scott Morrison’s 2020 Defence Strategic Update, in which he described the Indo-Pacific as the “epicentre of rising strategic competition”, crosses a red line in Australian strategic thinking.
Morrison added “the risk of miscalculation and even conflict is heightening”.
This is indisputable.
As a snapshot of the region, the 11-member Association of Southeast Asian Nations (ASEAN) increased military spending between 2009 and 2018 by 33% in real terms, according to the authoritative Stockholm International Peace and Research Institute (SIPRI).
This was significantly more than growth in spending in other regions. It’s directly attributable to concerns about a deteriorating security environment. Australia’s planned acquisition of long-range anti-ship missiles is part of a wider regional trend.
More weapons with greater range increase the risk of an incident. This may come about by accident but be built up into something much bigger – a shooting war or, more likely, a nasty memory that will haunt international relations for many years and lead to yet more militarisation.
The Stockholm International Peace Research Institute estimates China’s defence budget in 2020 stands at US$261 billion. This compares with the US defence budget in 2019 of US$717 billion.
In percentage terms, increases in China’s spending outstripped that of its significant neighbours. This includes India, Japan, South Korea and Australia.
A lot more spending is on the way. By 2035, half the world’s submarine fleet will be deployed in the Indo-Pacific, according to Australia’s 2016 Defence White Paper.
At the same time, China is pressing ahead with its own aircraft carrier fleet. It has two: one purchased off the shelf from Ukraine; the other built in China. The keel has been laid for a third at a Shanghai shipyard.
This is serious stuff. China is a nuclear state.
All this needs to be kept in mind as ill-tempered exchanges between Washington and Beijing over China’s responsibility for a global health pandemic, trade tensions, human rights abuses, bullying of Hong Kong, border skirmishes with India and increased pressure on Taiwan weigh on an increasingly strained relationship.
Arguably, tensions between the US and China are worse now than in 1989, when a crackdown on pro-democracy protesters ruptured relations. The difference between then and now is that China has a vastly larger economy and is an emerging superpower with a military to match its ambitions.
In 1989, China’s economy on a purchasing power parity basis was a fraction of the size it is today. Its contribution to world trade had not yet become supercharged.
What also is noteworthy is that, unlike 1989, China’s armed forces are no longer almost exclusively land-based. Chinese naval capabilities have progressed in leaps and bounds, along with its electronic warfare capabilities.
Hanging over a potentially worsening security environment, certainly an ill-tempered relationship between Beijing and the West, is widespread uneasiness over a deterioration in American global leadership.
In a presidential election year in which a wounded president is fighting for his political survival, risks of a miscalculation are real.
In other words, the security and political environment is treacherous at a moment when China itself feels under siege. As a consequence, China is lashing out at its perceived detractors, real or imagined.
This includes Australia, which has found itself under an almost daily barrage of Chinese invective following Morrison’s clumsy attempts to spearhead an independent inquiry into China’s responsibility for the coronavirus pandemic.
Typical of this sort of invective is the following, courtesy of the Global Times:
Australia is only a follower of the US, and its capability in the South China Sea will be limited.
The bloody Tiananmen crackdown in 1989 on pro-democracy protesters might be regarded as the low point in Beijing’s post-Mao Zedong relationship with the West, but it could be argued there is now a more worrying set of circumstances.
No country in the Indo-Pacific, with the possible exception of North Korea, can feel comfortable about China’s growing assertiveness. So it is tempting to say something will most likely give.
To beat the coronavirus pandemic, countries need to collaborate. We need the best possible science to develop vaccines and drugs, and to test, track and contain the virus. If we’ve learned anything from the rapid global spread of this virus, it’s that we’re all in this together.
It was therefore shocking to hear, on June 29, that the US government has bought more than 500,000 treatment courses of the antiviral drug remdesivir, representing manufacturer Gilead’s entire production capacity for the next three months and effectively excluding other countries from accessing this drug.
The purchase raises concerns, not only about access to remdesivir in other countries, but more broadly about how to prevent profiteering from the COVID-19 pandemic.
Gilead announced its global price for remdesivir on June 29 as US$390 per vial. The Guardian has reported the cost to the US government will be US$3,200 for a six-day treatment. In contrast, production costs for remdesivir are estimated at 93 US cents for one day’s treatment, or less than US$6 for an entire course.
It was hardly a secret that Gilead was seeking to profit from its product. Earlier this year, it applied for seven years of “orphan drug exclusivity” for remdesivir – a status that extends a drug’s period of patent protection, and is meant to act as a regulatory incentive to develop drugs for rare diseases. If only COVID-19 were rare!
The US Food and Drug Administration granted the exclusivity 12 days after the World Health Organisation declared COVID-19 a pandemic. The move was met with strong criticism and Gilead has since rescinded the orphan drug status.
US consumer group Public Citizen estimates taxpayers in the US, Europe and Asia have contributed US$70.5 million in development costs for remdesivir. The list of US government grants is impressive and begs the question of whether remdesivir should be in the public domain. Instead, Gilead maintains a monopoly on sales, holding patents in many countries, the latest of which lasts until 2036.
Remdesivir’s revenue this year could be US$2.3 billion, which would make the drug a blockbuster.
We might criticise Gilead, but this is how commercial drug companies function – in non-pandemic times, at least. But it does call into question pharma’s lofty promises of ensuring “equitable global access” to COVID-19 treatments.
Gilead and the billion-dollar odyssey
If remdesivir doesn’t work, the US purchase would be a waste of money. The first report of benefit was a small follow-up study of 53 patients with no comparison group. This was followed by a more rigorous randomised controlled trial from China, published in the Lancet, in which remdesivir did not outperform placebo. However, fewer patients were recruited than anticipated.
A third, mainly publicly funded trial by the US National Institute of Allergy and Infectious Diseases found patients given remdesivir recovered four days earlier, on average, than those not treated with the drug. But it also found no statistically significant difference in death rate between the two groups.
That study was also stopped early, which can lead to exaggerated estimates of treatment benefits. A British Medical Journal editorial highlighted the study’s financial links to Gilead as another source of bias.
More trials are ongoing, but until more evidence becomes available we really don’t know whether remdesivir significantly helps COVID-19 patients. If it does, it would be needed not only in the US but globally. Now Gilead’s supply is confined to the US, what can other countries do?
As a stopgap measure, Gilead has donated a stockpile of remdesivir to Australia, but it’s unclear whether this is a one-time-only act of generosity, or indeed why Gilead would donate its products to a wealthy country like Australia.
Gilead has voluntary licence agreements with manufacturers in Egypt, India and Pakistan to supply remdesivir to 127 lower-income countries. Under these agreements, Gilead allows generic manufacturers to produce remdesivir with specified conditions, such as limits on where it can be sold. A company in Bangladesh, where Gilead holds no patents, also produces generic remdesivir.
Where Gilead holds patents, countries could nevertheless gain access to generic remdesivir by issuing a compulsory licence. This is a recognised measure under both international trade law and the patent laws of many countries, including Australia. A compulsory licence grants the right to produce and sell a patented drug without the permission of the patent holder, both domestically and to other countries that have also issued a compulsory licence.
The remdesivir saga highlights the need for greater international solidarity and a more public health-oriented approach to the development of new treatments. On June 1, 2020, the World Health Organisation addressed this by launching the COVID-19 Technology Access Pool (C-TAP), which offers a way to share knowledge and intellectual property in response to COVID-19.
Countries and charities spending billions of dollars on developing new vaccines and drugs should require that technologies developed with public funds are shared with C-TAP.
Unfortunately, Australia has not yet pledged its support to C-TAP. Perhaps the recent experience with remdesivir will help the government realise that an open and collaborative approach is a much-needed alternative to one country hoarding the world’s supply of an overpriced and largely unproven drug.