WHO’s coronavirus response and alert system on outbreaks need to be reassessed, says IOAC report
Experts have called for an independent assessment of the World Health Organization's (WHO) performance during the ongoing coronavirus pandemic “at an appropriate time” in an interim report by the Independent Oversight and Advisory Committee (IOAC) for the WHO Health Emergencies Programme. The report cautions that conducting such a review during the heat of the response, even in a limited manner, could disrupt WHO’s ability to respond effectively.
“The IOAC reiterates that global health is a shared responsibility and member states must play their part. It may be useful, at an appropriate time, to independently assess the Organization’s performance during this response and identify lessons for the future. The scope of such an assessment should be determined by member states, and should cover both member states’ and WHO secretariat’s actions in response to the Covid-19 pandemic,” says the 11-page report on WHO’s response to Covid-19, January-April, 2020.
“The IOAC reiterates that WHO secretariat’s actions are grounded in its duties and responsibilities under the International Health Regulations (IHR, 2005) and recommends that reviewing WHO’s performance must be considered in light of the suitability of the IHR, and member states’ adherence to the IHR in their own responses to the crisis,” says the IOAC, emphasizing that this is not a comprehensive assessment of the WHO’s response. The report acknowledges that initial information on case fatality rate, severity, and transmissibility furnished by China in early January reflected an incomplete picture of the virus. These were updated by the WHO secretariat following a country office mission to Wuhan from January 20-21, it says.
“An imperfect and evolving understanding is not unusual during the early phase of a novel disease emergence. Many uncertainties still remain about Covid-19, including the actual number of infections around the world, the mortality rate, its animal reservoir population and emergence, transmission patterns, the full range of complications, seasonality, immunity, and mutation of the virus,” says the report. The review raises the question as to whether the WHO's warning system for alerting the world to outbreaks is adequate. The report says that on January 30, at the second emergency committee meeting, the WHO declared the coronavirus outbreak public health emergency of international concern (PHEIC).
The Organization also issued a statement reconfirming human-to-human transmission and further international exportation of cases and recommending comprehensive strategies for country preparedness. “The urgency with which member states took action based on the PHEIC varied both in terms of the timing and the comprehensiveness of public health measures in response to Covid-19. This raises questions about whether member states view a PHEIC declaration as a sufficiently clear trigger. The IOAC notes that the design of the PHEIC is very broad, covering everything from a limited regional outbreak such as Ebola in West Africa to a large global pandemic that touches every country,” says the review.
Following the present crisis, the report says it may be useful to review and update the IHR to reflect lessons from the pandemic. “The IOAC encourages member states to consider whether: a stepped level of alerts and galvanization of response measures should be added to the IHR; to enhance the openness and transparency of the emergency committee process, and to review whether the IHR-nominated focal points in governments can adequately raise the alarm to ministers within their governments when a PHEIC is declared,” it recommends.
The report says that the pandemic has called into question whether the existing roles and responsibilities that the IHR assigns to the WHO secretariat and member states are widely understood, fit for purpose, and still appropriate for a pandemic. “The WHO Secretariat’s response to Covid-19 was faster than for either the MERS or SARS epidemics, but this did not prompt similarly rapid action by all member states. This may indicate a gap between the current IHR and member state expectations of the WHO secretariat’s role. The IOAC, therefore, recommends that the IHR should be reviewed by member states in the light of the Covid-19 pandemic to ensure that the attribution of authority and roles outlined under the Regulations are in alignment with member states’ understanding and expectations,” it says.
The WHO activated its incident management system to coordinate the Covid-19 outbreak response on January 1, 2020. The report observes that WHO’s incident management support team is overstretched due to the huge demand generated by the pandemic. It says one needs to evaluate whether this team is an adequately resourced and staffed command structure to handle the immediate public health response, produce and communicate sound scientific guidance, develop recommendations for the multiple consequences of the public health measures, support country preparedness, and if it equipped with the strategic capacity to manage the challenges of a pandemic of this scale, complexity and impact.
“The IOAC recommends that member states and the WHO secretariat revisit the size and surge capacity of the WHO Health Emergencies Programme (WHE Programme) to ensure sufficient capacity, resilience and flexibility within and beyond the incident management system to respond adequately to such multidimensional and large-scale emergencies, alongside the increasing number of graded emergencies that it routinely manages,” suggest experts.
While recognizing the fact that the WHO has published over 50 technical guidance documents, providing advice on the Covid-19 response, it acknowledges there is a delay between messaging at press briefings and putting out corresponding guidance, which has given rise to uncertainty. This includes some key response elements such as the testing strategy, mask usage and managing personal protective equipment shortages, and the long-term virus suppression strategy.
The IOAC observes that there is a tension between “rapid communication and timely provision of guidance,” between WHO’s aspirations to lead technical guidance, and the limits imposed by its workforce capacity to do so in the heat of a crisis. The IOAC, therefore, recommends that the WHE Programme make more robust use of WHO collaborating centers around the world, expert networks, such as technical advisory bodies, and public health institutes. These bodies can support WHO in generating technical recommendations, validated by WHO, and thus supplement WHO’s capacity in fast-moving crises, it adds.
The experts also suggest member states might need to reassess the WHO's role in providing travel advice to countries. The IHR include specific measures to be taken at ports, airports, and ground crossings to limit the spread of health risks to neighboring countries while minimizing interference with world travel and trade. The WHO issued its first travel advice on January 10, drawing the attention of member states to IHR provisions. Subsequent recommendations regarding travel under the IHR were issued based on updated guidance. However, over 100 state parties reported to WHO that they were taking additional measures, given that each country had different goals depending on the phase of the epidemic, the country’s socio-demographic composition, and its health system capacity. “The IOAC notes it may be opportune for member states to reassess WHO secretariat’s role in providing travel advice during a pandemic,” suggests the team.
The report is critical of the rising politicization of pandemic response, which it says is a “material impediment” to defeating the virus, even as it aggravates other health, social and economic impacts. The WHO cannot succeed without unified global political support during the next phases of the pandemic, it emphasizes. The IOAC also condemns the threats targeted against the WHO Director-General and staff members, which, it says, have followed criticism of the Organization in the media.
“No single member state can hope to defeat this virus solely with the tools that exist within their own borders. Yet there has been a palpable lack of global solidarity and common purpose. That is a recipe for extending and worsening the global outbreak, leaving all countries less secure,” say experts. “The world is at a critical juncture in this unprecedented crisis and will not defeat this virus without greater global solidarity and stronger multilateral cooperation, and the execution of the forward-looking strategy required for the upcoming months of the pandemic,” they emphasize in the report. Meanwhile, the WHO said on Monday, May 18 that an independent review of the global coronavirus response would begin as soon as possible. WHO Director-General Tedros Adhanom Ghebreyesus made the promise during a virtual meeting of the WHO’s decision-making body, the World Health Assembly.
“The IOAC published its first report on the pandemic, with several recommendations for both the secretariat and member states. In that spirit, we welcome the proposed resolution before this Assembly, which calls for a step-wise process of impartial, independent, and comprehensive evaluation. To be truly comprehensive, such an evaluation must encompass the entirety of the response by all actors, in good faith,” said Dr Ghebreyesus while addressing the World Health Assembly on May 18. “So, I will initiate an independent evaluation at the earliest appropriate moment to review experience gained and lessons learned, and to make recommendations to improve national and global pandemic preparedness and response,” he said.
US President Donald Trump has repeatedly questioned the WHO’s performance during the pandemic. Trump halted the US contributions to the WHO last month, claiming that the organization had mishandled the coronavirus outbreak as it emerged in China. On May 18, Trump also sent a letter to Dr Ghebreyesus, stating that the US would permanently end all funding to the organization if it did not commit to significant improvements within the next 30 days.