Battered with criticism, what's next for WHO?

MANILA — The World Health Organization is coordinating one of the largest global responses to a disease outbreak in its history, with over 4.5 million confirmed cases of the coronavirus across 188 countries. But instead of a pat on the back, the organization has received questions and criticism, the most severe coming from its biggest donor, the United States.

U.S. President Donald Trump has ordered an American review of the WHO’s response to the pandemic, accusing the organization of failing to provide timely and accurate information on COVID-19, and being too “China centric”. He ordered a funding freeze, and U.S. officials have been fighting the Chinese over a conflict resolution at the U.N. Security Council that references WHO.

Many global leaders have questions for the U.N. health agency, mostly centered at how the world ended up with the COVID-19 pandemic, and want an independent review of the response to the outbreak.

In a recent radio interview, Australian Prime Minister Scott Morrison called for a “proper, transparent, independent review as to what happened, where did it happen, how did it start?”

“I've written to all the G-20 leaders and asked for this to be done at the World Health Assembly, which is on the 18th of May,” he said, adding that Australia will be supporting motions put forward by the European Union as a “first step” in the process.

Why a review?

The call for an independent review is shared by many global health experts. David Fidler and Thomas Bollyky of the Council on Foreign Relations in April called for the U.N. secretary-general to launch an interim review of the response to help WHO and its member states start understanding what happened.

“Countries are weaponizing this pandemic as a way to either go after China, or to scapegoat WHO as a way to attack China, or from Taiwan's point of view, its political interest,” Fidler told Devex.

“And they're doing that for reasons that I don't think really have much to do with global health. And so until those three countries back off this issue, WHO is and will continue to be in hot water,” he said.

The independence of the review is critical, Fidler and other health experts told Devex. Many of them believe that WHO is caught in the middle of a geopolitical warfare between the U.S., China, and Taiwan. An independent review can help validate WHO’s narrative of what it has done to date, or identify areas where it has fallen short of its international obligations.

An independent review can also shed light on how countries responded to the pandemic, according to Ilona Kickbusch, director of the Global Health Programme at the Graduate Institute of International and Development Studies in Geneva who was part of the independent expert panel in 2015 that assessed WHO’s response to the Ebola outbreak in West Africa. She said that review also looked into how countries responded to the crisis — something not as discussed in calls for a review of the response to COVID-19.

“We need to find out a lot of things. But there is the second question: WHO called a PHEIC on the 30th of January. And then when did member states react?” Kickbusch asked, referring to WHO’s declaration of a public health emergency of international concern.

“We find that many of the Western countries reacted very late. They did not take action until March, whereas countries that were in Asia that have gone through the SARS pandemic ...  reacted very quickly.”

Kickbusch said it was a huge undertaking to set up an independent, credible review of the response, which needs to be thought out carefully. But it should be conducted for purposes of learning.

“We need a culture that is a culture of learning and not a culture of blame,” she said. “It's no use throwing blame about. We're all dependent on each other and we need to find a system that works because we're going to have the next pandemic. Full-stop.”

The EU-led resolution being put forward to the WHA stresses the importance of a comprehensive and coordinated U.N. response to the pandemic, an EU spokesperson for foreign affairs and security policy told Devex. But it also calls for an independent review on lessons from the international response to the COVID-19 pandemic, “to strengthen future global health security preparedness,” the spokesperson said.

Reforms, again?

Member states are already floating ideas to reform WHO. Australia’s Morrison has mentioned giving WHO powers to send investigators — similar to weapons inspectors — to a country during a disease outbreak. U.S. officials have also discussed the idea of a body separate from WHO solely responsible for pandemics.

Experts anticipate heated debates over these ideas, if and when they are tabled for discussion, as they involve questions on state sovereignty and the painstaking process of building another organization from scratch.

Reforms are nothing new to the organization. The review of the West Africa Ebola outbreak recommended reforms, which led to the creation of WHO’s health emergencies program. When Tedros Adhanom Ghebreyesus became director-general in mid-2017, he also led an organizational-wide restructuring and initiated a transformation agenda.

At an institution such as WHO, where every country can feel like a supervisor, staff are used to calls for reforms, although it can get tiring and raise questions whether what they are doing still fits in the “so-called newer WHO,” said Keiji Fukuda, director and professor at the University of Hong Kong’s School of Public Health.

Calls for reform of the organization should first answer a critical question — what kind of WHO do countries want? An independent organization that tells countries what to do, or a consensus-building secretariat, which is what WHO is in reality, asked Fukuda, who was WHO assistant director-general for health security during Margaret Chan’s 2006-2017 years at the helm.

“The difficulty that I have with a lot of calls for reform is that it suggests that the actual issue is in WHO, that that is what has to be reformed, when in fact many of the fundamental issues are with the countries themselves. And that is the unstated part of the reality. And this is the part which you know, countries really don't like to focus attention on, but in fact they are a big part of the problem,” he said.

“So when calls for reform suggests that by restructuring or by changing some kind of operational aspect of WHO is a fundamental reform, I don't believe it,” he added.

But if countries want a better performing WHO, they can do two things: Provide the agency an adequate budget and act upon the decisions they adopt at the WHA, Fukuda said. That includes following commitments to the International Health Regulations — the international, legally binding instrument agreed to by all 194 WHO member states to monitor and control the international spread of diseases. Under the IHR, countries are required to immediately report to WHO any unusual or unexplained health events.

However, Flavia Bustreo, vice chair at Fondation Botnar, told Devex that countries often tend to underreport.

“The willingness to be transparent and share [information] is the primary responsibility of member states. But our experience has shown that every country, when it is the first one to … be surprised with a new pathogen, or an old pathogen that is very, very dangerous like in the case of Ebola, every country at the beginning minimizes,” said Bustreo, formerly WHO assistant director-general for family, women’s, and children’s health.

Bustreo said any discussions for reform should include fixing the organization’s financial woes, ensuring it has sufficient resources to deploy in an emergency situation. This could provide the organization some operational capacity, which she said a number of Europeans were looking for when COVID-19 hit the region.

She also encouraged discussions on giving WHO the ability to rapidly send independent medical teams in countries to investigate, noting some non-health focused multilateral organizations have that capability.

Time to revisit the IHR?

One of the biggest issues confronting WHO is how it dealt with Chinese authorities, and the information China has provided on COVID-19.

“Even before Trump began picking on WHO ... this rhetoric doesn't sound like what we normally see from WHO. It seems over the top. It seems almost obsequious,” CFR’s Fidler said.

“Again, I don't know what happened. I don't believe that Tedros is corrupt or the Chinese have him in their pocket, but something unusual happened here and we don't know the full story behind that. And I think that's what some people want to know more about,” he said.

Bustreo agreed. “Just praising governments because they are responding and not highlighting their shortcomings … rings hollow to the people that are suffering,” she said.

This is the first time since World War II that European countries are experiencing this kind of health crisis, she added, and “having an organization that is reactive this way was problematic."

Some have compared Tedros’ approach with that of former WHO director-general Gro Harlem Brundtland, who during the SARS outbreak of 2003 publicly called out the Chinese government for not sharing information. Unlike WHO’s calls for countries to keep their borders open in the early phases of the COVID-19 pandemic, Brundtland recommended some travel restrictions.

David Heymann, professor of infectious disease epidemiology at the London School of Hygiene and Tropical Medicine, said it was clear to countries why WHO was calling for postponement of travel at that time, and Brundtland didn’t suffer “any serious repercussions” for her approach with China.

Countries will need to decide whether that’s the kind of leadership they want at WHO.

“They elect their director-general … and if they elected this director-general, then they need to continue to work with this director-general as far as I can see. And they need to work with him to make sure that they're happy with the way he's performing,” he said. Heymann was assistant director-general for health security and environment at WHO under Brundtland.

Fidler says it is not right to compare the approach of the two directors-general, arguing that Tedros is leading WHO in a very different political era.

“China's now a great power with global ambitions … Politics is back with a vengeance,” he said.

But knowing when China learned of the disease, if it informed WHO immediately, and if WHO took all the necessary actions according to the IHR are questions everyone wants answers to, and should be clarified in a review, said Kickbusch.

Global health law expert Lawrence Gostin of Georgetown University told Devex that WHO could have said: “Here are the data we're getting from China about cases, deaths, and community transmission and lack of community transmission. But we have no independent means to verify those data. Or it could have been more insistent, to really push for access [for] WHO experts on the ground, with freedom to independently verify facts and talk to independent scientists, journalists, and civil society.”

But he said WHO lacks the political support to “speak truth to power,” adding that a reform of the IHR was needed to give WHO more power to evaluate independent sources of information.

Under the IHR, WHO has the authority to consider unofficial reports of public health events, and use that to obtain verification from countries. WHO made that move in 2019, when it considered unofficial reports of Ebola in Tanzania and asked the government to share more information. But the IHR can’t impose penalties to countries that fail to comply with its provisions.

Heymann said the IHR is being “constantly reviewed,” giving an example of a series of meetings at WHO looking at the merits of providing countries travel recommendations under IHR in an era where countries can make their own risk assessments and obtain information from multiple sources.

Could that help WHO move away from criticisms it has received in relation to its travel recommendations, such as in the current pandemic? Heymann, who is also the chairman of an external advisory group to the WHO’s emergency program, noted that WHO is made of 194 member countries, including the United States, that agreed to the provisions of the IHR.

“If they don't agree with it anymore, then they should convene another group to try to make the revisions that they feel are necessary.”

Lisa Cornish contributed reporting to this article.