Health is pure science but why objectivity eludes WHO
We certainly need a global body to coordinate responses against health emergencies. However, this sheer need of humanity on this planet should not be milked by the World Organization (WHO) to overshadow constructive criticism and call for reforms.COE-EDP | Updated: 27-06-2020 04:20 IST | Created: 27-06-2020 04:14 IST
Controversies are not new for the World Health Organization (WHO) but too much emphasis on past health events/emergencies often becomes counterproductive. This is for two reasons – firstly, technological advancement has limited the scope of lessons to be learned from deep historical events/emergencies and secondly, new kinds of challenges to public healthcare.
Since its foundation in 1948, the WHO has tasted several appreciations and controversies. However, there has been one consistency – successes are credited to science but failures are often blamed on issues related to social science such as politics, economics, geopolitics, lobbying, and interest groups, etc. The health body claims to have introduced reforms from time to time but they could do little to address the concerns of objectivity which is a top priority for medical sciences. International Health Regulation (IHR)-2005 has been the most comprehensive document for operations of the WHO but even after 15 years, the health body is struggling to achieve objectivity.
"Yes. It's time to stop talking. We are committed to implementing a single program, with a single line of accountability, a single budget, a single set of business processes, a single cadre of staff and a single set of performance benchmarks," said Margaret Chan Director-General (2007-17), WHO in World Health Assembly 2016. After her superannuation, Dr. Tedros Adhanom took over the reins of WHO but the promises of reforms could hardly move beyond 'talking'. Chan, a Chinese national had also faced allegations of over-reaction in the H1N1 Swine Flu pandemic of 2009-10 and negligence on the Ebola crisis in West Africa in the 2014-16 and Zika crisis in the Americas in 2015. It was in her tenure, according to critics, WHO moved from US-centric to Chinese centric to which Dr. Tedros is allegedly a flag bearer. As Tedros was a favorite candidate for China to succeed Chan, he is alleged to prefer Chinese interests over professionalism and scientific approach.
Today, the COVID-19 pandemic is not only a health crisis but has destroyed the whole global economy. It has adversely impacted every single human being and every economy on this planet. It is no longer a matter between the US and China but involves every country of the world to which WHO could not deny its share of responsibilities. This is despite the fact that in its over seven decades of operation, the WHO has both kinds of experiences – successes such as complete eradication of Small Pox and controlling Polio and a long list of failures, to learn with.
The unanimous decision of 194 member countries in the 73rd World Health Assembly on 18-19 May in Geneva to conduct an independent inquiry into the global response of WHO to COVID-19 pandemic is itself an indication towards an urgent need for reforms in the global health body. COVID-19 has posed a 'do or die' situation for WHO. Therefore, the WHO needs to realize that it is not beyond criticism and should prepare to initiate reforms from within to develop a pandemic resilience system and meet the expectations of billions of people on the planet. But, for any such reforms critical review of WHO's health information system is a pre-requisite.
WHO's Health Information System
Health Information System (HIS) is the most crucial aspect of WHO's functioning as it involves data collection, analysis, processing, and dissemination of health information. HIS is, in fact, fundamental to every activity of WHO from advising to member states on health-related issues, preparing response plans to health crises, and policy formulation. The HIF of WHO could be understood as under:
Data Collection (Routine)
Headquartered in Geneva (Switzerland), WHO collects data from its 194 member countries through 149 country offices administered by six regional offices – Africa (Brazzaville – Republic of Congo), Americas (Washington D.C. - USA), South East Asia (New Delhi), Europe (Copenhagen-Denmark), Eastern Mediterranean (Cairo-Egypt) and Western Pacific (Manila – Philippines).
Under the broad guidelines of the IHR 2005, the concerned Country Offices of WHO sign a 4 to 5 years Country Cooperation Strategy (CCS) with member countries which is the basic document for data collection and cooperation between WHO and member countries. In principle, WHO has mechanisms and guidelines for health data collection up to the sub-district/community level which is compiled at the district level but WHO gets country-level data through the health ministries of the national governments.
This is a periodic system for the data collection on a variety of health-related issues including birth, death, morbidity, communicable diseases, and non-communicable diseases which help the WHO in designing short-term, mid-term, and long terms responses and policies. In pursuance to its objectives, the global health body uses the data to advise member countries on public healthcare policies and response plans and also to alert/ aware of the whole world about the potential health crises.
Data Collection (Health Emergencies)
- Each State Party (country) shall designate or establish a National IHR Focal Point and the authorities responsible within its respective jurisdiction for the implementation of health measures under these regulations.
- National IHR Focal Points shall be accessible at all times with the WHO IHR Contact Points for sending health-related urgent communications on surveillance and reporting, points of entry (ports, airports and ground crossings), hospitals, public health services, and other government departments.
- WHO shall designate IHR Contact Points which shall be accessible at all times for communications with National IHR Focal Points.
- The member countries shall assess the health information/ events on a regular basis. In case of any health information to the level of 'public health emergency of international concern' (PHEIC), the concerned country shall inform the WHO within 24 hours. The country shall continue providing further details.
- If the PHEIC involves nuclear disaster, WHO shall 'immediately' notify the International Atomic Energy Agency (IAEA).
- Unexpected/Unusual Public Health Event: Even if a country does not have any credible/ relevant information/ origin/ source of any health crisis which could be of PHEIC level, it shall inform the WHO within 24 hours (Article 7).
- After receiving the PHEIC level health information, with or without details (unexpected events), DG-WHO will constitute the 'emergency committee' of health experts which may seek details from the concerned country for verification (Article 10) to which the country should reply within 24 hours.
- If satisfied, the WHO shall declare PHEIC at the earliest.
- A country may reject the offer of collaboration by WHO but it cannot prevent WHO to pass available information of PHEIC to other countries (Article 10.4). The WHO shall disseminate the PHEIC information 'as soon as possible' by the 'most efficient means available' (Article 11.1).
From the above analysis, it looks like the WHO has a robust system of data collection and response plans on health emergencies but the collapse of this system before COVID-19 indicates major loopholes that are gradually coming out in the form of allegations through media reports.
Health Information Systems in Member Countries
However, the word internet has not used in the IHR 2005 but it mandates every member country to 'develop, strengthen and maintain' within five years, extendable to four years in two shifts, capacities to 'detect, assess, notify and report' health events/ emergencies. These capacities are related to surveillance, notification, verification, response, collaboration, and activities related to entry points such as ports, airports, and ground crossings.
WHO is also required to assist countries in developing such capacities thereafter they will submit annual reports on compliance (Article 5: Surveillance). In addition, the countries are also required to develop an efficient health response system and provide the information to the public through district and national level dashboards. These dashboards should include all kinds of health-related information including morbidity, mortality, birth and available healthcare infrastructure, etc. The IHR also mandates member countries to record the reason for every death in their jurisdiction.
Monitoring of Capacities in member Countries
The Global Health Observatory is a monitoring mechanism of WHO through which it monitors national level HIS and health response capacities of member countries under 13 IHR capacities and 24 indicators. They include surveillance, risk communication, food safety, laboratory, points of entry, and chemical events among others.
As per the data available till 17 April 2020, about 30 countries had not submitted their annual reports for the year 2019. In the previous year (2018) five countries including two from Europe - Poland and Greece - had not submitted reports till 9 September 2019. WHO has developed e-SPAR, a kind of electronic dashboard to display the State Party Annual Report of every country in a highly analytical format.
Data Collection Tools
SCORE (Survey, Count, Optimize, Review, Enable) is a technical package being developed by the WHO with five essential interventions and key elements for strengthening country health data systems and capacities for universal health coverage and the health-related Sustainable Development Goals (SDGs).
Routine Health Information System (RHIS) or Health Management Information System (HMIS) are initiatives of WHO for collection, presentation, and utilization of routine health data in healthcare policy formulation. However, despite these tools, the WHO is primarily dependent on its member countries for health-related data.
In addition to the office to office communication and publications designed for routine health information, WHO has following internet-enabled AI (Artificial Intelligence) based interactive platforms for speedy dissemination of information related to health events/emergencies.
- Public Health Emergency Dashboard: This dashboard displays information related to health emergencies/ disease outbreaks on a geospatial map of the world. It claims to refresh its data every 15 minutes with a proclamation 'data is accurate at the time of refreshing'. This dashboard has three external links as well – Disease Outbreak News, WHO publications, and Useful Links. WHO has put a disclaimer that the data displayed on this dashboard are provided by member countries but the scope of WHO's response is beyond those pieces of information. The pre-existing Real-Time Alert has been merged with this dashboard.
- Recently, the WHO launched two more geospatial dashboards – COVID-19 Dashboard and COVID-19 News Map. The COVID-19 News Map is reportedly based on data provided by the publically available website. These two dashboards are now providing the most updated and verified data on COVID-19. Besides, there are dedicated pages for each health event/ emergency on the WHO website. These dashboards are new additions to the WHO's information but were added much later than Worldometer, Gisanddata, and other privately operated dashboards.
- Disease Outbreak News: This page claims to provide the most up to date information on health emergencies and WHO's response plans.
- Health Emergency Highlights: This is a system of disseminating health emergency highlights through email to subscribers and also displaying it on the website.
- Myth Busters: This a response system of WHO to counter the infodemic of COVID-19. Through this page WHO provides verified scientific information in a highly creative manner to counter fake news on COVID-19.
- Fake News Alert: This is also a new addition to WHO's information system through which it contradicts misinformation and disinformation being spread on behalf of WHO.
- Research and Development Dashboard on COVID-19: This dashboard acts as a one-stop window to provide information about scientific researches and updates on COVID-19 throughout the world.
- Newsroom: Newsroom includes different tools of information dissemination through media persons.
What Ails WHO?
As evident from the above analysis, WHO has a comprehensive system for data collection, information dissemination, and response planning on paper. It is also backed by the latest information technologies. However, the system could not meet the expectations whenever it encountered a PHEIC - Ebola, Zika, Swine Flu, and COVID-19. These failures of WHO could be looked into the following structural and operational lacunae:
- Loopholes in Data Collection: WHO is completely dependent on member countries for data collection. The member countries often have economic and political concerns on disease outbreaks which contribute to further spreading of the disease.
- Lack of Integrated Information Dissemination: Various modes of data collection and platforms of information dissemination in WHO work separately. WHO itself has displayed disclaimers which indicate towards lack of integration in its information dissemination.
- Lack of Accountability: Accountability is the first and foremost requirement to fix the responsibility for failures. However, WHO lacks a robust system to fix accountability. Nobody was held accountable for over 10,000 deaths caused due to the Ebola crisis, inaction on Zika crisis, and over-reaction on H1N1 during the tenure of Margaret Chan. There is hardly any effort from within to fix accountability for the alleged failures of WHO in handling the COVID-19 pandemic.
- Centralization of Powers: The powers related to the proclamation of PHEIC are centralized in the Director-General. He is the sole authority to finalize the expert members for committees including the 'emergency committee', convene meetings, and take a final decision on proclamation of PHEIC or pandemic. He also decides the information/ health emergency alerts to be disseminated to the member nations. This was due to the centralization of powers, Dr. Tedros allegedly made WHO to 'parrot' the lines of China or something more than that. According to critics, Tedros showered praise on China and give it time to serve its economic interests while killing precious time for the rest of member countries and humanity.
- Committee Designed Organization: WHO is a committee designed organization. There are committees for everything – emergency committee, review committee, and committees for almost all the diseases. These committees work under the office of Director-General which is again centralization of powers. The members of the committee are medical professionals but often accused of geopolitical considerations and having links with pharma companies to serve their vested financial interests. Emergency Committee which has powers to proclaim PHEIC has been the most controversial in recent years. The proceedings of the committee are largely secret but only decisions are made public.
- Corruption: Corruption is also one of the major issues in WHO. In 2019, the auditors pointed towards corruption in about US$192 million travel expenses in 2018.
- Links with Pharma Lobbies: WHO adopts a highly clinical approach to health events and emergencies in cases of both communicable and non-communicable diseases. This provides an easy market and route to pharma companies in the WHO systems. The outgoing DG Margaret Chan and some scientists were accused of conniving with pharma companies during the swine-flu crisis.
- Bureaucratism: The response of WHO on COVID-19 has been a classic case of red-tapism. China's Taiwan (Taiwan is yet to be recognized as an independent country by the UN and WHO) was providing all the information on the COVID-19 outbreak but WHO did not pay heed to that information. Neither DG office nor expert members of WHO's Emergency Committee ever tried to crosscheck the information of Taiwan. Emergency Committee may have asked the Chinese authorities to clarify media reports regarding Taiwan's warnings but nothing was done on the inputs of Taiwan and subsequent media reports. Those defending WHO argue that Taiwan is not a member country but what prevented WHO to declare COVID-19 a pandemic on the basis of cases in Japan and other neighboring countries under 'unusual public health event' (Article 7, IHR 2005), is still a mystery.
- Non-Implementation of IHR 2005: IHR 2005 has not been implemented in its letter and spirit. If all the clauses of the IHR are implemented, several issues of data collection and information dissemination could be resolved.
- Arbitrary Allocation of services to Regional Offices: WHO is the only organization in the world which does not include Pakistan and Afghanistan in South Asia. This is probably the only UN body that has clubbed these two countries with the Middle East under the Eastern Mediterranean Regional Office. But this is not the standalone case, South East Asia Regional Office (SEARO) serves North Korea but South Korea is served by the Western Pacific.
- Inadequate Emphasis on Preventative Healthcare: However, the world is now moving towards preventive healthcare and more close to nature but WHO is not doing adequate efforts to publicize preventive healthcare for healthy life particularly in case of non-communicable diseases. It's highly dependent on the consumables of pharma companies.
- Economic and Political pressures: It seems WHO is easily buckled under the political and economic pressures of member countries. Though China is a dominant economy, countries like Guinea, Liberia, and Sierra Leone had pressurized WHO in the past to not declare PHEIC on the Ebola outbreak due to their economic interests. These geopolitical issues often dominate over professionalism in WHO.
Conclusion and Agenda for Discussion
Pandemics are linked with climate change and global warming. According to a study, there were 12,012 disease outbreaks between 1980 to 2013 infecting about 44 million people. As the UNEP has warned about more pandemics in the future due to changes in temperature, humidity, and seasonality, the world needs to prepare for pandemic resilience systems based on increased surveillance that could provide real-time information.
In addition to the decentralization of powers, WHO also needs a real-time integrated health management information system including its response to health emergencies. The human interference in WHO's health response system should be minimized with the use of AI-based technologies. In light of the assurance of increased funding by China, Dr. Tedros may ignore the defunding threats of the USA president Donald Trump but, if it happens, WHO, as a global health body, will be the biggest loser. For WHO, it's not a selection between the highest funder USA and dominant funder China but maintaining objectivity and credibility. Being a dominant global pharma supplier, China may have increased its status but as a global health body WHO needs to address concerns of every member country.
There is an urgent need for reforms in WHO both at structural and operational levels. The piecemeal efforts and bureaucratic approach will no longer be effective in preparing response plans for PHEIC. WHO needs to be more scientific and objective in its approach and decision making. The world deserves a synchronized, holistic, and credible health information and response system under a global health body that could provide real-time healthcare alerts in case of health emergencies, besides making sustained efforts for eradication of non-communication diseases in a time-bound manner. Besides, the officials in WHO should also be trained to handle politico-economic pressures as it is practically difficult for a global health body to ignore human interests in dealing with scientific problems like public healthcare.
VisionRI's Centre of Excellence on Emerging Development Perspectives (COE-EDP) aims to keep track of the transition trajectory of global development and works towards conceptualization, development, and mainstreaming of innovative developmental approaches, frameworks, and practices.
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