First, Do No Harm? The World Health Organization in the MENA Region

In June 2022, Richard Horton, the editor in chief of The Lancet, one of the world’s most well-regarded health and medical journals, published a short piece calling for the cessation of the World Health Organization’s (WHO) “erasure” of Palestinians. Horton condemned the WHO for choosing to exclude residents of the occupied Palestinian territories from its 2022 World Health Statistics report, accusing the organization of “statistical genocide.” This criticism was echoed by a group of researchers who likened the decision to a “weapon of war,” and was again repeated by a member of the Lancet Palestine Health Alliance Steering Group, who described the omission as “disturbing” and called on the WHO to “live up to its values [and] produce statistics for all peoples.”

Based on this assessment by such renowned experts, one may be tempted to conclude that the WHO is simply one of the many global organizations that overlook, obscure, or even justify Israel’s occupation of Palestine. However, the WHO does consider occupied Palestinian territory as its own entity within the Eastern Mediterranean region, and meticulously compiles data on Palestinian health access on a monthly basis, including data on the number of medical permits applied for and either approved or denied by Israel. It also publishes regular reports and infographics on Israeli attacks on Palestinian health facilities and personnel. In fact, the WHO is among the few global health organizations that dares to wade into this complex situation and to explain its health effects on real people.

The WHO at times provides much-needed resources and services, while at others fails to address governments’ health policy failures or even plays a part in normalizing cooperation with regimes that commit human rights abuses and war crimes.

How, then, can the WHO stand accused of the “statistical genocide” of Palestinians while at the same time playing an important role in documenting numerous health-related human rights violations inflicted on the very same population? This single case displays some of the many competing interests that inevitably come into play in an organization as large as the WHO, which is dependent on its nearly 200 member states for financial support, but which is also tasked with serving the world’s most marginalized people—people whose marginalization often comes at the hands of the WHO’s own member states. In the Middle East and North Africa this juxtaposition plays out in often contradictory ways, with the WHO at times providing much-needed resources and services, while at others failing to address governments’ health policy failures or even playing a part in normalizing cooperation with regimes that commit human rights abuses and war crimes.

What is the World Health Organization?

Like many of today’s largest multilateral organizations, the WHO was founded in the aftermath of the atrocities of World War II. One of the priorities within the effort to build the United Nations was the establishment of an international health organization. The WHO’s constitution was signed in 1946 and ratified in 1948, establishing the organization as one of the largest and most influential specialized agencies of the UN.

Today, the WHO is comprised of 194 member states across six regions: Africa, the Americas, the Eastern Mediterranean, Europe, Southeast Asia, and the Western Pacific. Its headquarters are located in Geneva, and it also maintains six regional and 150 country-specific offices. Diverse leadership roles within the organization focus on issues such as universal health coverage, antimicrobial resistance, and emergency responses to health crises. As of 2021, Germany is one of the WHO’s top funders, followed by the United States, the Bill and Melinda Gates Foundation, the United Kingdom, Gavi (the Vaccine Alliance), and a number of other wealthy countries and well-known organizations.

The WHO’s portfolio is significant, covering a panoply of current and future health issues that do not always enjoy consensus among many of the organization’s member states. For example, the WHO heavily promotes the concept of universal health coverage, which is not available in the United States, or in many of the world’s low-resource nations. The organization also advocates for policies that impact the social determinants of health, including clean air and water, road safety, healthy eating, and sustainable climate policy, all of which are highly debated issues in many countries around the world. The WHO is also a major player in responding to health emergencies such as infectious disease outbreaks—though it was highly criticized for its response to the COVID-19 pandemic. But despite its broad mandate and many initiatives, when it comes to global, regional, and local health policy, the organization is primarily an advisory body, one that makes recommendations and guidelines and both promotes and advocates for issues deemed most impactful to health, but one that cannot mandate change.

The WHO in the Eastern Mediterranean Region

The WHO’s activities in the MENA region fall within its Eastern Mediterranean regional office, which covers 21 member states and the occupied Palestinian territories. Aside from the Arab states, the Eastern Mediterranean office includes nations like Afghanistan, Iran, and Pakistan. The current regional director is Dr. Ahmed al-Mandhari from Oman, who launched the region’s Vision 2023 agenda in 2018, which identified the region’s main priorities: expanding universal healthcare, addressing health emergencies, promoting healthier populations, and making transformative changes to the WHO.

In many ways, these priorities echo the WHO’s broader goals of increasing health coverage and improving population health regardless of geographic location. However, characteristics particular to the region, which affect just how this work can be done, are noted throughout the Vision 2023 plan. Strengths of the Eastern Mediterranean region include community-centered values and a large population of young and ambitious people. However, the region also faces many challenges that complicate the WHO’s mandate.

Strengths of the Eastern Mediterranean region include community-centered values and a large population of young and ambitious people. However, the region also faces many challenges that complicate the WHO’s mandate.

The Eastern Mediterranean region is socioeconomically diverse, and includes some of the world’s richest countries, like the Gulf Arab states, along with its poorest, like Yemen. This situation results in significant disparities in the social determinants of health, even those as basic as sanitation and access to clean water. Poverty rates across the region are high, and have been further exacerbated by multiple protracted conflicts. Preventive care is not prioritized in most MENA states, and unhealthy behaviors like smoking and excessive consumption of sugar remain common. Such poor conditions have effects that ripple throughout these countries’ health systems, leading to the exodus of health professionals, resource-poor health facilities, and a lack of specialized resources for women, children, refugees, people with disabilities, the elderly, nomadic groups, and others. These factors present significant obstacles for the WHO’s work in the region, especially considering the lack of standardization and cooperation between individual countries’ ministries of health, which produces a patchwork of health systems of varying and inconsistent quality.

Challenges facing the WHO became increasingly apparent during the COVID-19 pandemic. During countries’ initial lockdowns, when fear of the unknown nature of the virus led to high rates of compliance, optimism surged, as did coordinated international efforts. The WHO partnered with Saudi Arabia, for example, to airlift medical equipment and supplies throughout the MENA region—including to Yemen—and the kingdom even donated medical supplies to Wuhan, China in early March 2020. It was initially thought that the region’s experience with Middle East respiratory syndrome (MERS), which hit Saudi Arabia especially hard in 2012, would make it uniquely well-equipped to manage the new virus. But the MENA region’s lack of transparent, well-resourced, and accountable health systems quickly faced difficulty implementing the WHO’s recommendations, especially given the organization’s focus on isolation and quarantine, which is hard to manage in a region with a high number of refugees and conflict-afflicted populations whose members are often closely clustered together, and with large, multigenerational households where at least one family member is likely to regularly travel outside the home for school or work.

The WHO’s Successes and Failures Across the Middle East

As with any entity of its size and longevity, the WHO has a mixed track record consisting of both great successes and notable failures. The WHO is perhaps most respected for its child vaccination campaigns, which have contributed to the eradication of smallpox and the near eradication of polio. Even in war-torn Syria, the WHO was able to mobilize personnel and resources to successfully tackle multiple polio outbreaks before the disease could spread beyond the country’s borders. And the organization has long been an advocate for the health of refugees and internally displaced people—groups that are disproportionately represented in the MENA region—and established a health and migration program in 2020 specifically to address this issue. The WHO has also worked to increase health promotion throughout the region, especially when it comes to pervasive issues such as smoking. For example, the WHO supported Morocco in 2020 when it launched a tobacco free initiative, producing informational materials and assisting with their dissemination. Other countries with high smoking rates, such as Saudi Arabia and the UAE, have also joined in such efforts.

The WHO is present in nearly all of the world’s conflict settings, including in Palestine, and focuses not just on trauma-related care as many nongovernmental organizations do, but also on other aspects of health that are often forgotten in such settings, including housing, preventive health, and women and children’s health. The organization is highly visible in countries like Syria, Libya, and Yemen, where it works with local partners to publish health-related data that is difficult to collect. The WHO was also highly involved in tracking and combatting MERS when it first emerged in 2012, collaborating with local health providers and scientists to better understand the virus and how to control its spread. Individual MENA countries also work with the WHO to reach their health goals. For example, Egypt, which once had the world’s highest prevalence of Hepatitis C, heeded a call by the WHO in 2016 to tackle the disease. The government worked with the WHO to develop mass screening and treatment campaigns on an unprecedented scale, and it now claims to be on the path to fully eradicating the disease within the decade.

Not all of the WHO’s actions in the region, however, have been as well received. For example, the fact that Syria was appointed to the organization’s executive board came as a shock to many given that Syrian President Bashar al-Assad’s regime is notorious for having targeted healthcare facilities and personnel across Syria during the Syrian Civil War, destroying dozens of facilities and killing hundreds of health workers, largely through airstrikes. Paradoxically, the WHO was one of the primary organizations tracking and reporting these attacks.

The fact that Syria was appointed to the organization’s executive board came as a shock to many given that Syrian President Bashar al-Assad’s regime is notorious for having targeted healthcare facilities and personnel across Syria.

Members of the organization’s board are appointed for three years and help plan and implement WHO policy. The White Helmets, a Syrian civil defense group that often works to dig people out of buildings destroyed by Syrian bombs, said that this selection “rewards the Assad regime despite its systematic destruction of hospitals and health centers, in addition to a long list of other war crimes.” Meanwhile, Physicians for Human Rights and the Syrian American Medical Society wrote a joint letter to WHO Director-General Tedros Ghebreyesus criticizing the appointment. Even though WHO leadership was not involved in the selection process—the nations of the Eastern Mediterranean region itself voted for Syria to be appointed—the organization’s response to criticism was disappointing, as it simply stated, “We are neither equipped nor mandated to find political solutions.”

Indeed, the WHO more than any other organization should recognize that health is political, especially when one considers that policy choices often lead directly to worse health outcomes among diverse populations. The WHO’s work with conflict-afflicted and vulnerable populations should make this obvious. However, as an organization made up of member states, the WHO often makes pragmatic compromises in order to maintain support, some of which seem to directly counter its goal of improving health for all. For example, the WHO recently partnered with Qatar and FIFA in an initiative meant to “make the FIFA World Cup Qatar 2022 a role model for healthy sporting events.” Objectives include offering healthy foods inside stadiums and limiting areas for tobacco use. However, the press release announcing the agreement said nothing about the health of the 30,000 migrant workers building the stadiums and other infrastructure necessary for the events. Although workers’ conditions have improved and Qatar has made significant changes, many foreign workers are living in meager housing, have had their travel documents confiscated, and are working in harsh conditions, including extreme heat. According to the International Labor Organization, in 2021 alone at least 50 workers died, 500 were seriously injured, and 37,600 were mildly injured.

The Future of the WHO

Ultimately, the unique role of the WHO is essential, especially in an increasingly interconnected world. The organization has undoubtedly contributed to an overall healthier global population in the more than 70 years since its inception, and its size and scope are unparalleled. Regardless, just as there have been calls to reform the United Nations, advocacy to improve the WHO has existed for decades. Some recommendations are large and structural, including those made by US government officials, such as modernization, stronger international laws and norms, sustained financing, and increased transparency and accountability. Other suggestions are more targeted, including increasing membership dues to better fund the organization. As has been made clear by the WHO’s muddled response to the COVID-19 pandemic, reform is indeed long overdue. But genuine reform will be most meaningful if it comes from within, rather than merely being dictated by the world’s most powerful nations, many of which already play an outsized role in global health governance.

However, much like the United Nations, the WHO is a product of social, political, and economic factors, motivations, and obstacles that exist within and between its member states. It will therefore always be both buoyed and limited by these many competing entities. In the MENA region, where governance is already brittle and adherence to international norms is less than optimal, the WHO’s work is made all the more difficult. Because its work is not a matter of political grandstanding, but rather of intricate international coordination—a vaccination campaign, for example, requires the buy-in of multiple stakeholders, from manufacturers and health providers to government entities—the organization must be permitted to function in a way that allows it to pursue its ultimate goal, which is improving health and well-being, despite potentially hostile objections from member states.

Although the WHO certainly does good work in countries across the globe, when it excludes Palestine from a statistical report, or accedes to a process that allows the Syrian regime to regain international legitimacy, or works hand-in-hand with governments that have been credibly accused of human rights violations, the line between pragmatism and cynicism is blurred. As the COVID-19 pandemic has demonstrated, the world desperately needs a strong, fully-functioning global health body, and for now at least, the WHO is that body. But the WHO is not a government, and it cannot replace a well-coordinated and well-planned state response. Regardless, it is vital that the WHO work to uphold its founding principles to promote “complete physical, mental, and social well-being” for all, regardless of attempts by member states to limit its efficacy, and despite the challenge of both known and unknown future threats to global health.