WHO cares? A reply to Calvert and Arbuthnott

WHO cares? Well, yes, WHO – the World Health Organisation – does actually care. It cares a lot about a lot of things – all of which are beneficial to my, yours, everyone’s health on the planet. But that isn’t generally where I start a conversation with someone largely ignorant of what WHO is and what it does. Typically, it starts with a bit of something that they might have picked up on the internet about how WHO is corrupt, useless, and/or a puppet of the Gates Foundation, the pharmaceutical industry, or China. It’s a shame that people are so ignorant of, and thus so quick to denigrate, an international organisation that does so much good. As someone who has researched and taught students about WHO for many years, and who also happens to lead a course on global health, the media and what Carl Bergstrom would call ‘bullshit’, I feel moderately qualified to review the recent Insight Investigation on WHO by a couple of The Sunday Times journalists Jonathan Calvert and George Arbuthnot (C&A). It’s called China, the WHO and the powergrab that fuelled a pandemic, but don’t let that arbitrary constellation of words confuse you.

First off, let me state, for the record, that I am not an apologist for the Chinese government. It’s heinous and has, over the years, committed all manner of crimes against humanity. In that respect, I put it in the same category as the United States, the United Kingdom, Brazil, the Philippines, etc. Take your pick of any number of WHO’s member states and you will have yourself a gaggle of political entities led by corrupt, entitled and just plain awful people. It’s also worth considering that, more likely than not, none of them will like being constrained by the norms of international organisation, and all of them will be seeking power and influence wherever they can get it, particularly at WHO. So when you read from the authors of this Sunday Times ‘investigation’ theatrical flourishes such as: “What followed was a concerted campaign over many years [by China] to seize power within the organisation [WHO]”, it’s worth acknowledging that all member states will be trying to seek power and influence to some degree or another.

But hang on a second. C&A are claiming something more of China’s machinations: it has, apparently, initiated a “concerted campaign” and sought to “seize” power ‘within’ WHO. Really? That’s some claim. No doubt these journalists will have some convincing evidence to substantiate what, on the face of it, sounds pretty ridiculous.

Turns out they don’t. Three hundred and twenty seven words in and you begin to suspect that C&A’s article may just be a whole lot of words interspersed with very little evidence. But it’s early days and I’m sure evidence is on its way. What we do have is a reference to Taiwan. Or, rather, the email that Taiwan CDC sent to WHO that was brandished last year as evidence that WHO knew but did not act on information received about the pneumonia-like outbreak in Wuhan in late December 2019. Here’s the passage in the C&A article:

“So when the first alert of a mysterious respiratory illness in China, exactly as Tedros had described, was reported by health monitors in Taiwan at the end of December 2019, the health agency should have been prepared and ready for action”.

The Taiwan email was a storm in a teacup back in April 2020. Taiwan is a trigger word in the Covid-19/WHO conspiracy narrative. All a journalist has to do is mention the word ‘Taiwan’ and juxtapose it with the word ‘controversy’ and people will automatically go ‘ooh, I wonder what that’s about’? And you’re off – job done, reader distracted, mud raked.

It doesn’t really matter that WHO has responded to the Taiwanese claims by pointing out that it received similar information about the Wuhan cases from multiple sources at the same time as it received notification from Taiwan CDC. Nor that there was no mention of human-to-human transmission (H2HT) in the email. If Taiwan CDC was concerned about the possibility of H2HT, why didn’t it mention it explicitly in their communication? But none of this matters: the function of the ‘Taiwan email’ is not to inform but to sow doubt.

It also distracts attention away from the main point of C&A’s claim – namely that WHO was not prepared or ready for action. Well, was it? Up to a point, it was! WHO’s country offices monitor and collate health information from formal and informal channels all the time. WHO also makes use of its Epidemic Intelligence from Open Sources (EIOS) platform, and it has a Global Outbreak Alert and Response Network (GOARN) of national and international public health actors. So when Wuhan’s Municipal Health Commission reported cases of pneumonia of unknown origin to local hospitals on 30th December 2019, WHO was not just aware of the outbreak but by the 3rd January was also notifying its GOARN partners. WHO country offices, EIOS and GOARN represent a pretty remarkable system of disease surveillance, for which we should be very grateful. But, as the Independent Panel for Pandemic Preparedness & Response’s final report concludes, “the alert system does not operate with sufficient speed when faced with a fast-moving respiratory pathogen” (IPPPR, 2021 p26). The reasons for that are detailed in the report. Curiously enough, the ‘fact’ that China has seized power over WHO was not one the writers of the report thought to mention.

The bulk of C&A’s ‘investigation’ is unsubstantiated narrative. Take a look at the following two paragraphs and see how – in the absence of any evidence – my text in red could just as easily be true:

“In fact the WHO would receive considerable criticism for failing to help stop the spread of the Sars-CoV-2 virus in the opening weeks of the Covid-19 pandemic [in fact WHO received plenty of praise for helping to slow the of spread the virus]. Not only did the organisation fail to act [Not only did the organisation act] but it also promulgated misinformation [expert information] about the virus originating from China and even discouraged [encouraged] other nations from taking steps that might have contained the spread. For all his foresight, Tedros would be accused of being ineffective when the big test came [Tedros was praised for doing a good job].

The world paid a heavy price for the WHO’s inaction [the world benefited from the work of the WHO]. As Tedros predicted [the threat of a pandemic was well understood by many, including Tedros], the virus has killed more than four million people, and there will be many more. The body that is charged with looking after the world’s health seriously malfunctioned [functioned very well] in those opening weeks, when humanity most needed it to come to the rescue”.

It’s also worth pointing out that it’s not WHO’s job to “come to the rescue”. That’s not what WHO does. WHO advises its member states what to do based on public health knowledge and expertise AND in accordance with the International Health Regulations (IHR). Its staff no doubt pull their hair out with frustration (despair even) when member states then repeatedly and consistently ignore the advice they’re given. If you want to understand the relationship between WHO and its member states, I do recommend you read the IHR. It’s not a long document. Failing that, read Kamradt-Scott’s analysis of WHO’s response to Ebola and the nature of the principal-agent relationship between WHO and its member states.

Wading through C&A’s ‘investigation’, you’ll eventually come to a section sub-headed ‘Beijing’s Man’ (0/10 for imagination). First, we have some sinister hints that China appointed Tedros to lead WHO and now instructs Tedros what to do (no evidence provided); then we jump to the infamous Robert Mugabe appointment as a Goodwill Ambassador (an admittedly inexplicable, tragi-comic appointment that Tedros swiftly revoked) which C&A claim was also at the behest of China (no evidence provided); and then we’re back to Covid and WHO/China misinformation about H2HT mixed in with a bit of tut-tutting about WHO’s position on travel bans (which its member states ignored), all of which was done to aid China’s economy (no evidence provided). It’s pure conspiracy.

Here again, I would encourage you to read the IHR:

“The purpose and scope of the IHR (2005) are “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.””

IHR (2005), Forward.

Here’s that last phrase again: “And which avoid unnecessary interference with international traffic and trade“. The regulations are explicitly designed to protect the economic interests of all economies, not just China’s. There’s more detail on the health measures that countries can implement to curb the spread of disease in article 43 of the IHR. Here’s a sentence from that article:

“Such measures shall not be more restrictive of international traffic and not more invasive or intrusive to persons than reasonably available alternatives that would achieve the appropriate level of health protection”.

IHR (2005) Article 43 (1b)

When WHO issues advice on international travel, it’s issued in accordance with the IHR (which, to repeat, all member states of WHO have signed – meaning that they have an international legal responsibility to respect it). The advice is also based on evidence of the limited utility of travel bans in curbing the spread of disease. I know it sounds counter-intuitive but please read the literature on this.

A review of the literature just a month or two into the pandemic found “limited evidence about the effectiveness of travel bans to minimize global EID spread” (which is, of course, also a call for more research – we need to know much more about this issue), while an early modelling study of the spread of Covid out of Wuhan found that “additional travel limitations (up to 90% of traffic) have only a modest effect unless paired with public health interventions and behavioral changes that can facilitate a considerable reduction in disease transmissibility”. Writing in Science, Jason Meier and colleagues cautioned:

“Rather than implementing coercive travel restrictions, governments should follow WHO recommendations in realizing transparent governance, expanding testing capacity, and implementing social distancing to protect public health”.

Meier, J (2020) Travel restrictions violate international law. Science, 24th March

So far, then, C&A have rolled out two hoary examples to ‘support’ their ‘investigation’ of WHO – the Taiwan CDC email and travel ‘bans’. Here’s another one: Brundtland’s response to SARS. This narrative typically portrays Brundtland as the no-nonsense, take-no-shit, let’s-show-China-who’s boss Director General of WHO (Brundtland was DG from 1998 to 2003). It’s used as an exemplary position to take by Directors Generals of WHO towards recalcitrant member states, and is contrasted with all actions by any subsequent DG who takes a different stance. In brief: Brundtland was strong and stood up to China, while Lee, Chan and Tedros were or are China stooges.

An argument could be made that when the IHR were revised in 2005, member states did indeed recall Brundtland’s assertive attitude towards China. The problem is, they didn’t like it! As Catherine Worsnop pointed out in Stephen Buranyi’s ‘long read’ analysis published in the Guardian in April 2020: “WHO members were happy with the actions that were taken during SARS, but there was definitely a sense afterward of ‘What if that was us in China’s spot?’” One might conclude that Brundtland was out of line, diplomatically speaking. Suppose China had called her bluff. How would SARS have evolved then?

This is not how C&A describe the consequence of Brundtland’s ‘brave’ stance vis a vis China. Instead, it becomes an opportunity for them to imagine a cabal of member states (led by China of course) that attempted to “limit the authority of its director-general”. Note that the “senior source at the WHO” is anonymous – so they could in fact just be WHO’s head of catering for all we know – and not quoted directly.

Fast forward fourteen years to the present. China is now a superpower, wielding significant economic and political power. Trump (you will recall) was about to pull the plug on US funding to WHO. And, perhaps more significantly, WHO had to navigate not just a pandemic but an infodemic, fuelled by real-time social media. Given all that, does anyone seriously imagine that the head of a relatively small international organisation would play hard ball with China? It would have been suicidal for WHO. And here’s another hypothetical scenario: suppose the outbreak had emerged in the U.S? Would you expect Tedros to throw diplomatic caution to the wind and start berating the Trump administration? Do you imagine that either nation – China or the U.S – would have said, “Oh, ok then, sorry – here’s all the information you need. I don’t know what we were thinking”? The idea that Tedros would (or should) have ‘done a Brundtland’ is simply divorced from political reality. And I’m really glad he didn’t.

I am not defending China’s recalcitrance, by the way. It would have been much better if that country’s government had cooperated from the outset and done what it was supposed to do in accordance with the IHR. But I agree with Lancet Editor Richard Horton’s conclusion:

“At moments of geopolitical stress, it is surely better to intensify, not weaken, personal and institutional relationships. It is surely better to build better understanding between peoples. The present wave of anti-China sentiment has now evolved into an unpleasant, even racist, sinophobia, which threatens international peace and security.”

Horton (2020) This wave of anti-China feeling masks the west’s own Covid-19 failures, Guardian.

Meanwhile, WHO continues to be blamed for what is essentially a member state’s reluctance to share important information at various points in the story and initial refusal to grant access to scientific observers. The result of two reports (one for the WHO, another from the US) on the origins of Covid-19 remain inconclusive, with “all of the hypotheses regarding to the origins of the virus…still on the table” (Mike Ryan, WHO, reported in the Guardian 25th August 2021).

It’s important to remember that, in the words of Mike Ryan again: “WHO does not possess the mandate to enter uninvited into any nation state and must show due diplomatic respect to the process of engaging with governments” (WHO press conference, 15th February, 2020). For sure, there are risks: if you engage in it you can be perceived to be ‘in bed with the enemy’ and no doubt Tedros will reflect on the language he used to describe the level of China’s cooperation. But if you don’t engage in diplomacy, then you close down a necessary mode of communication between key players in the game. In a pandemic, we definitely don’t want to do that.

C&A, of course, have a much simpler explanation (no evidence provided) of China-WHO relations: “a backroom deal negotiated between the WHO and China” whereby Tedros’ team “struck an agreement in secret with China that emasculated the inquiry” which constituted a “shameful charade” according to another unnamed source. This, again, is (laughable) conspiracy.

When I teach my global health course ‘Wicked problems in Global Health’, I spend a lot of time talking to students about the importance of using authoritative sources. It’s basically the first skill in the art of intellectual self-defence. There are three sources I recommend you read if you want to understand the role of WHO and its response thus far to Covid-19. The first, as noted above, is the IHR. The second is the final report of the Independent Panel for Pandemic Preparedness and Response (IPPPR) COVID-19: Make it the Last Pandemic, and the third is the companion report How an outbreak became a pandemic: The defining moments of the COVID-19 pandemic. Read these documents and you will have as good an understanding of what went on as anyone you’re likely to meet. The only reason why I would recommend you read the C&A article is so you can see an example of conspiratorial, irresponsible journalism at its very best. At least the authors are good at something.

Sure, you can read C&A’s ‘investigation’ and come away from that ‘analysis’ thinking that WHO “had failed in its single most important job — to swiftly sound the alarm”. But that’s a grossly unfair conclusion to reach. There is a clear timeline of events described in the two IPPPR reports. You can also take a look at WHO’s own interactive timeline. You might think that the 30th January was too late for WHO to be declaring a PHEIC. Hindsight is a wonderful thing, and the IPPPR report concludes that, yes, the alert system is too slow. But note the operative word system. The WHO is part of that system but so too are its member states, as is the international legal instrument (the IHR) that both WHO and all member states have signed. There were deficiencies across the system and not just with the WHO (of which, a small part was internal governance). At the time, with the information available, and with the legal and governance mechanisms at its disposal, WHO probably responded as quickly as it could: the first case of the virus outside of China was the 13th January; H2HT was only publicly confirmed on the 19th; the Emergency Committee 1st met on the 22-23rd but was undecided about the need to declare a PHEIC; and a PHEIC was declared a week later. As it turns out, that was just not quick enough.

There’s much more I could write about the C&A ‘investigation’ but I think you get the general gist of what I think about it. C&A note that, when asked for a follow-up interview, “a WHO spokesperson said this newspaper’s article rehashed old events and contained “falsehoods and baseless claims””. That seems like a fair and accurate assessment to me.

Andrew

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