As humans, we commonly consider ourselves, our beliefs, and our work of particular importance. It is not surprising, then, that when we form institutions, those within them seek to promote the institution’s relevance, expand their work, and centralize decision-making within their own ‘particularly important’ group. Few want to divest power and resources, let alone put themselves and their colleagues out of a job. This fatal flaw infects all bureaucracies, from local to national and regional to international.

It is unsurprising, then, that the World Health Organization (WHO), an international health bureaucracy of over 9,000 staff, a quarter of them in Geneva, should suffer the same problems. The WHO was originally intended primarily to transfer capacity to struggling states emerging from colonialism and address their higher burdens of disease but lower administrative and financial capabilities. This prioritized fundamentals like sanitation, good nutrition, and competent health services that had brought long life to people in wealthier countries. Its focus now is more on stocking shelves with manufactured commodities. Its budget, staffing, and remit expand as actual country need and infectious disease mortality decline over the years.

While major gaps in underlying health equality remain, and were recently exacerbated by the WHO’s Covid-19 policies, the world is a very different place from 1948 when it was formed. Rather than acknowledging progress, however, we are told we are simply in an ‘inter-pandemic period,’ and the WHO and its partners should be given ever more responsibility and resources to save us from the next hypothetical outbreak (like Disease-X). Increasingly dependent on ‘specified’ funding from national and private interests heavily invested in profitable biotech fixes rather than the underlying drivers of good health, the WHO looks more and more like other public-private partnerships that channel taxpayer money to the priorities of private industry.

What should be the use-by date of an international institution? In the WHO’s case, either health is getting better as countries build capacity and it should be downsizing. Or health is getting worse, in which case the model has failed and we need something more fit for purpose.

The Trump administration’s actions are an opportunity to rebase international health cooperation on widely recognized standards of ethics and human rights. Countries and populations should be back in control, and those seeking profit from illness should have no role in decision-making. The WHO, at nearly 80 years old, comes from a bygone era, and is increasingly estranged from its world. We can do better. Fundamental change in the way we manage international health cooperation will be painful but ultimately healthy.