Introduction
Global public health has long been animated by moral purpose and collective ambition. When nations join under the banner of “health for all,” it reflects both humanitarian conviction and political calculation. Yet, the architecture of global health governance often produces outcomes that diverge from its lofty ideals. The World Health Organization (WHO), its treaties, and its many partnerships embody both the promise and the peril of global cooperation: institutions that begin as vehicles for public good can evolve into complex bureaucracies driven by competing incentives.
A useful way to understand this paradox is through the old “Bootleggers and Baptists” framework — coined to explain how moral crusaders (“Baptists”) and opportunists (“Bootleggers”) find common cause in supporting regulation.
In global health, this coalition reappears in modern form: moral entrepreneurs who campaign for universal virtue and institutional purity, joined by actors who benefit materially or reputationally from the resulting rules. But there is a third, often overlooked participant — the bureaucrat. Bureaucrats, whether within WHO secretariats or international treaty bodies, become the custodians of regulation and its moral aura. Over time, their incentives can subtly shift from serving the public interest to preserving and enlarging their institutional mandate.
This essay explores how these three forces — the Baptists, the Bootleggers, and the Bureaucrats — interact within global health governance. It looks at the WHO’s Framework Convention on Tobacco Control (FCTC) as a revealing case, and then considers how similar patterns are emerging in the proposed Pandemic Treaty. The analysis argues that moral certainty, donor dependency, and bureaucratic self-preservation often combine to produce rigid, exclusionary, and sometimes counterproductive global health regimes. The challenge is not to reject global cooperation, but to design it in ways that resist these incentives and remain responsive to evidence and accountability.
Bootleggers and Baptists in Global Health
The “Bootleggers and Baptists” dynamic was first described in the context of US alcohol prohibition: moral reformers (Baptists) called for bans on Sunday liquor sales to protect public virtue, while illegal distillers (Bootleggers) quietly supported the same restrictions because they reduced competition. Together, they sustained a regulation that each group wanted for different reasons.
In global health, the same coalition appears frequently. The “Baptists” are the moral crusaders — public health activists, foundations, and advocacy NGOs that promote regulations framed in universal ethical language: eliminating tobacco, ending obesity, halting pandemics. Their arguments often appeal to collective responsibility and moral urgency. They mobilize attention, generate legitimacy, and supply the moral energy that international institutions depend upon.
The “Bootleggers” are the economic and bureaucratic actors who benefit materially or strategically from these same campaigns. They include pharmaceutical firms that profit from mandated interventions, governments that gain moral prestige through leadership in treaty negotiations, and donor organizations that extend their influence through targeted funding. The alignment between moral appeal and material interest gives regulatory projects their durability — and their opacity.
Unlike national policy debates, global health regulation takes place far from direct democratic oversight. It is negotiated by diplomats and sustained by international bureaucracies that answer only indirectly to voters. This distance allows the Bootlegger–Baptist coalition to operate with less friction. The Baptists supply moral legitimacy; the Bootleggers provide resources and political cover. The resulting regulations are difficult to challenge, even when evidence shifts or unintended consequences emerge.
Bureaucrats and Institutional Incentives
To this familiar duo, we must add a third actor: the Bureaucrat. Bureaucrats in international organizations are neither purely moral crusaders nor profit-seekers. Yet they have distinct incentives shaped by institutional survival. As organizations grow, they develop missions, staff hierarchies, and reputations that require maintenance. They must continually demonstrate relevance to donors and member states, which often means producing visible initiatives, global campaigns, and new regulations.
This tendency creates what might be called mission drift with moral cover. Programs expand beyond their original mandate because new mandates justify funding and prestige. Internal success is measured less by outcomes than by continuity — new conferences held, new frameworks launched, new declarations signed. The appearance of global coordination becomes a goal in itself.
Bureaucracies also develop their own “moral economies.” Staff identify with the institution’s virtue, reinforcing a culture of rectitude and resistance to dissent. Criticism is reinterpreted as opposition to progress. Over time, an organization that began as a forum for evidence-based cooperation can transform into a self-referential moral enterprise, rewarding conformity and punishing deviation.
In this sense, bureaucratic dynamics subtly reinforce the Bootlegger–Baptist alliance. The moral zeal of the Baptists legitimizes bureaucratic expansion; the resources of the Bootleggers sustain it. The result is a global health regime that is rhetorically altruistic but institutionally self-interested — what might be called bureaucratic virtue capture.
Case Study: Tobacco Control and the FCTC
The Framework Convention on Tobacco Control (FCTC), adopted in 2003, remains the WHO’s most celebrated treaty. It was heralded as a triumph of moral clarity — the first international agreement to target a specific industry deemed inherently harmful. Yet, two decades later, the FCTC also illustrates how the Bootlegger–Baptist–Bureaucrat dynamic operates.
Moral Zeal and Institutional Identity
The moral framing of tobacco control was absolute: tobacco kills, and therefore any product or company associated with it is beyond legitimate dialogue. This Manichean narrative energized advocacy groups and governments alike. For the WHO, it provided a defining moral cause — a crusade that could rally public opinion and reaffirm the organization’s relevance after decades of criticism. The FCTC secretariat, established within the WHO, became a hub of moral entrepreneurship, shaping global norms and advising governments on compliance.
This moral clarity, however, created rigidity. Article 5.3 of the Convention — which prohibits engagement with the tobacco industry — was designed to prevent conflicts of interest but ended up preventing dialogue even with innovators or scientists outside the mainstream. As new nicotine products emerged, promising to reduce harm relative to cigarettes, FCTC institutions often dismissed or excluded the evidence. The treaty’s moral vocabulary left little room for pragmatic nuance.
Bootleggers in the Shadows
Meanwhile, new economic beneficiaries emerged. Pharmaceutical companies producing nicotine replacement therapies gained from policies discouraging alternative nicotine delivery systems. Advocacy groups and consultancies dependent on FCTC grants and conferences became part of the permanent ecosystem. Governments, too, used the moral capital of tobacco control to signal virtue on the international stage, often while collecting lucrative tobacco taxes at home.
In this sense, the Bootleggers were not only industry actors but also parts of the public-health establishment itself — those whose budgets, reputations, and influence grew with the perpetuation of the fight. The irony was that a treaty meant to constrain corporate influence ended up reproducing similar incentive structures within the global health bureaucracy.
Bureaucratic Drift and Donor Dependence
The WHO’s broader financial structure reinforced this drift. Over 80 percent of its budget now comes from voluntary, earmarked contributions rather than assessed member dues. Donors, both governmental and philanthropic, direct funds toward preferred programs — often those that promise visibility and moral clarity. Tobacco control, like pandemic preparedness or vaccine campaigns, fits that bill.
For WHO bureaucrats, success is measured not by reduced disease burden but by maintained funding and institutional visibility. Conferences, reports, and treaties become proof of relevance. The FCTC thus functions as both a moral symbol and a bureaucratic anchor — an enduring source of legitimacy and donor attraction.
Donors, Visibility, and the Expanding Mandate of the WHO
The same dynamics that shaped the FCTC permeate the WHO’s broader operations. The organization’s dual dependence on moral narrative and donor funding creates a cycle of institutional behavior that rewards expansion and penalizes humility.
High-profile crises — pandemics, obesity, climate-related health risks — provide opportunities for visibility. Each crisis invites new frameworks, task forces, and funds. Over time, the WHO’s agenda expands from its original technical focus on disease control to encompass social determinants, behavioral regulation, and even political activism. Each expansion justifies the organization’s growth and sustains its relevance in global discourse.
But as the agenda widens, priorities blur. Limited core funding means the WHO must continuously court donors whose preferences may not align with the health needs of poorer nations. The beneficiaries of these arrangements — the Bootleggers — include foundations that influence the WHO’s priorities, industries aligned with favored interventions, and governments seeking global moral standing.
Meanwhile, the Bureaucrats — WHO staff, treaty secretariats, and affiliated NGOs — operate within an ecosystem that rewards symbolic action over measurable outcomes. Success becomes synonymous with global mobilization rather than on-the-ground effectiveness. And the Baptists — advocacy groups and public figures — provide the rhetorical shield, casting any challenge to the institution’s orthodoxy as an attack on public health itself.
The result is a complex moral economy where virtue and self-interest coexist, sometimes indistinguishably.
The Pandemic Treaty: A New Stage for Old Dynamics
The proposed WHO Pandemic Treaty offers a contemporary laboratory for this recurring pattern. Born of the trauma of Covid-19, the treaty is being negotiated in an atmosphere of urgency and moral imperative. Its stated goals — preventing future pandemics, ensuring equitable access to vaccines, and strengthening surveillance — are unimpeachable. Yet beneath these goals lie familiar incentives.
The Baptists in this context are those who frame the treaty as a moral necessity — a test of global solidarity. The Bootleggers include governments seeking to expand influence through treaty mechanisms, pharmaceutical companies anticipating new market guarantees, and consulting groups positioning themselves as indispensable partners in preparedness. The Bureaucrats, once again, stand to gain institutional permanence.
For the WHO, a successful treaty would anchor its centrality in global governance for decades. It would expand its legal authority and moral prestige. But as with past initiatives, the question is whether the pursuit of institutional relevance will overshadow the pursuit of effective policy.
Experience suggests risks ahead. Treaty negotiations dominated by moral urgency tend to privilege symbolic commitments over practical accountability. Expanding surveillance powers and emergency authorities may erode national autonomy without ensuring better outcomes. The treaty could replicate the FCTC’s exclusionary tendencies — marginalizing dissenting scientists or alternative approaches in favor of a consensus that flatters donors and protects institutional orthodoxy.
Moreover, the pandemic experience revealed the dangers of conflating moral rectitude with scientific certainty. Institutions that equate compliance with virtue risk repeating past mistakes — discouraging debate, silencing qualified critics, and equating skepticism with heresy. When bureaucracies adopt the posture of moral authority, their errors become harder to correct.
Reforming Global Health Governance
Recognizing these dynamics does not mean rejecting international cooperation. It means designing institutions that can balance moral conviction with institutional humility, and donor generosity with democratic accountability.
Several principles emerge from this analysis:
- Transparency in incentives and funding. The WHO and its treaty bodies should disclose not only financial contributions but also the conditions attached to them. Earmarked funding should be limited relative to core, unearmarked contributions to reduce donor capture.
- Regular mission review and sunset clauses. Every major program or treaty secretariat should face periodic review against measurable outcomes. If objectives are achieved or obsolete, mandates should be wound down rather than perpetuated.
- Pluralism in consultation. Institutions should include structured space for minority views, dissenting experts, and nontraditional evidence — especially where new technologies challenge orthodoxies. Dialogue, not exclusion, should be the norm.
- Restraint in moral rhetoric. Moral urgency can motivate action, but when it becomes the sole currency of legitimacy, it suppresses nuance. Global health organizations should return to empirical grounding rather than moral grandstanding.
- National accountability. International treaties should enhance, not erode, national sovereignty. Member states must remain the ultimate arbiters of policy within their borders, with international agreements serving as coordination tools, not instruments of compulsion.
Conclusion: A Cautious Path Forward
Global health cooperation remains indispensable. No nation can manage pandemics or illicit global trade in harmful products alone. But cooperation must not become a moralized bureaucracy detached from results.
The Bootleggers, Baptists, and Bureaucrats of global health each serve a role — but their interaction can produce dysfunction when moral certainty, material interest, and institutional survival align too neatly. The FCTC demonstrated how virtue can harden into dogma, how donor-driven programs can entrench bureaucracy, and how noble causes can become instruments of self-preservation. The pandemic treaty risks repeating these errors under new banners.
The lesson is not cynicism but vigilance. Effective global health governance requires mechanisms that check virtue with evidence, constrain expansion with accountability, and remind bureaucracies that their legitimacy derives from results, not rhetoric. Institutions should serve the public good — not their own survival.
If future global health treaties can internalize this lesson, they may finally reconcile moral ambition with practical wisdom.
