President Trump is threatening to permanently cut funding for the World Health Organization (WHO) within 30 days unless the organization commits to reform, substantially escalating a battle with the global health body amid the novel coronavirus pandemic.

In a harshly worded letter to WHO Director-General Tedros Adhanom Ghebreyesus released late Monday, Trump demanded the WHO implement “major substantive improvements,” while portraying the organization as too friendly toward China and blaming it for a lagged response to the deadly virus.

Trump said he would permanently freeze funding to the WHO and “reconsider” U.S. membership in the organization if it did not commit to reforms within a month. A WHO spokesperson said the organization had received the letter and is “considering” its contents.

The move followed Trump’s decision last month to temporarily suspend millions in U.S. funding to the WHO pending a review of the body’s handling of the pandemic. That prompted warnings from health experts about the adverse impact of cutting funding during an outbreak.

Permanently severing ties would have a debilitating effect, said Lawrence Gostin, a global health law professor at Georgetown University who has served on various WHO expert advisory committees.

A permanent suspension of funds would be even more damaging, Gostin said, because the United States is the largest contributor to the WHO, sending roughly $400 million to the organization each year.

“[Trump is] making an existential threat to the World Health Organization because the U.S. was the country that helped found the WHO, is the most responsible for it. It’s been its historically largest supporter and its most powerful country,” said Gostin. “To withdraw U.S. funding permanently and withdraw U.S. membership would literally disable the World Health Organization.”

The president has faced pressure from conservatives to come down harder on the WHO and China for their handling of the outbreak early on. Critics have accused the WHO of being too trusting of information from China and overlooking warning signs about the virus.

Still, some who support Trump’s criticism of the WHO say that setting a 30-day timeline is unrealistic, given that the reforms the administration seeks will need buy-in from other member states.

“I think it would benefit the administration to show a little patience and work with other members on specific reforms and make sure that this independent, impartial review process is implemented by individuals who have the expertise and have the strength of will to resist the types of pressures that will inevitably be placed upon them by China to downplay its role in the COVID-19 disaster,” said Brett Schaefer, an expert in international regulatory affairs at the conservative Heritage Foundation.

Trump’s four-page letter to Tedros offered few specifics about the reforms his administration is seeking of the global body.

“It is clear the repeated missteps by you and your organization in responding to the pandemic have been extremely costly for the world,” Trump wrote. “The only way forward for the World Health Organization is if it can actually demonstrate independence from China.”

Asked Tuesday what reforms he would like to see, Trump declined to go into detail.

“They have to clean up their act, they have to do a better job, they have to be much more fair to other countries including the United States, or we’re not going to be involved with them anymore,” the president told reporters at the White House. “We’ll do it a separate way.”

Trump’s letter rehashed his previous criticisms of the global body’s handling of the coronavirus, at one point alleging the WHO “consistently ignored credible reports of the virus spreading in Wuhan in early December 2019 or even earlier, including reports from the Lancet medical journal.”

The Lancet disputed Trump’s claim as factually inaccurate, saying its first such reports were published in January.

“The allegations leveled against WHO in President Trump’s letter are serious and damaging to efforts to strengthen international cooperation to control this pandemic,” The Lancet said in a statement Tuesday. “It is essential that any review of the global response is based on a factually accurate account of what took place in December and January.”

An effort by Trump to permanently suspend funding to the WHO would likely spur a fight with Congress, which sets appropriations and allocates funding for global health programs.

“We don’t know how this is going to play out because it’s not the U.S. president but the U.S. Congress that will decide whether to fund the WHO or not,” said Yanzhong Huang, a senior fellow for global health at the Council on Foreign Relations. 

However, Schaefer argued that the Trump administration has broad discretion over how to spend funds that have been allocated by Congress for global health issues. The administration signaled it would use funds promised to WHO when the temporary suspension was announced last month to address the coronavirus outbreak in other ways.

Trump has sought to blame the WHO in recent weeks as his administration’s response to the virus has come under growing scrutiny. Trump’s decision last month to temporarily suspend funds to the WHO followed mounting criticism of the WHO from congressional Republicans. Reports emerged late last week, subsequently confirmed by Trump, that his administration was considering restoring partial funding.

Trump’s new threat to permanently suspend funding came amid a virtual World Health Assembly meeting when international partners discussed the coronavirus response. Trump declined to make a statement during the meeting, saying the WHO had done a “sad job in the last period of time.”

Health and Human Services Secretary Alex Azar in his own remarks at the meeting insisted the WHO must become more transparent and accountable, describing a failure by the body “to obtain the information that the world needed” that “cost many lives.”

Before the letter was released Monday, Tedros said he would back an independent review of the global response to the coronavirus as the U.S. and other Western countries increase pressure on China to be more transparent about the origins of the virus. Chinese President Xi Jinping also said in a video address that Beijing supported a comprehensive investigation.

There has been broad support for reform of the WHO in the years following the 2014 Ebola outbreak in West Africa.

“There are some steps being undertaken to address certain issues but we haven’t seen any fundamental reform measures,” said Huang, who pointed to the need for changes to how the WHO delineates its functions and its management of international health issues. 

But experts criticized the president’s approach to pressing for reform by threatening to withhold funding. 

Gostin said Trump’s criticisms of the WHO were misplaced, arguing that the organization has no power to force China to provide truthful information or give access to international health officials.

“I do think the WHO needs to be reformed but those reforms need to come from a unified front,” Gostin said. “We are doing the exact opposite of what we would need to do to make the WHO strong.”

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