WHO Declarations of Public Health Emergencies Need to Better Use Expert Advice

Global coordination of responses to pandemics has improved dramatically, it's now time to also modernize the expert advisory processes that inform those responses

One of the most important powers of the World Health Organization is its ability to declare a “public health emergency of international concern,” in the event of an emerging pandemic such as COVID-19. Such power of declaration carries with it enormous implications for national, international and diplomatic responses as well as the public health and economic consequences that follow.

The international community has made notable progress in coordinating global public health governance in recent decades. However, the expert advisory mechanisms which inform global public health governance have not kept pace. In this post, the first in a series, I document some of the shortfalls in the WHO emergency declaration process, setting the stage for discussing possible reforms.

International governance of public health risks, notably pandemics, has a long history. Europe experienced repeated waves of cholera pandemic in the first half of the 19th century. The first International Sanitary Conference was held in 1851 in Paris, “to protect States against the international spread of infectious diseases in a way that minimized interference with international trade and travel.” It was the first of 14 such conferences held over the subsequent century, seeking to harmonize international responses to cholera, yellow fever and plague pandemics.

Pandemics, and cholera in particular, were a driving force behind the formalizing of various institutional innovations of the 19th century, including the emerging relationships of science and politics. As Valkeska Huber wrote in 2006 of the 19th century battle against disease, “In the fight against cholera politicians had to rely on scientific expertise and prescriptions.”

The 2003 SARS outbreak accelerated reform in international public health governance, culminating in a new body of International Health Regulations, which came into force in 2005. That reform effort carried forward the same goals that had been expressed almost a century-and-a-half earlier: ‘‘ensuring maximum security against the international spread of diseases, involving minimum interference with world traffic and trade, should remain the basic principle of the revised [International Health Regulations].’’

Among the reforms of IHR (2005) is a requirement that nations “notify WHO of events that may constitute public health emergencies of international concern.” Such information underpins the ability of WHO to declare a “public health emergency of international concern” (a PHEIC, the definition of which is guided by a formal “decision instrument” - hereafter “public health emergency”) .

Since 2005, WHO has declared six public health emergencies, including SARS-CoV-2 earlier this year. According to Clare Wenham and colleagues the declaration of a PHEIC “highlights the severity and seriousness of an outbreak, and acts as a clarion call to galvanise high-level political, financial, and technical support from Member States, and NGOs.” Thus, WHO’s decision whether or not to declare a public health emergency and the process leading to that decision are central features to international pandemic response.

The Director-General of the WHO is empowered under the IHR (2005) to declare a public health emergency. That decision is informed by the WHO “Emergency Committee,” another innovation of the IHR (2005). David Fidler has argued that “The radical nature of the PHEIC power—and the public health, political, and economic implications of its exercise—has made this authority prominent and controversial in global health governance.”

The “IHR Emergency Committee for COVID-19” met for the first time 22 and 23 January 2020. In that meeting it declined to issue a public health emergency, with its minutes noting:

“the Committee expressed divergent views on whether this event constitutes a PHEIC or not. At that time, the advice was that the event did not constitute a PHEIC, but the Committee members agreed on the urgency of the situation and suggested that the Committee should continue its meeting on the next day, when it reached the same conclusion.”

The committee met again one week later, and then recommended the WHO Director-General that a public health emergency should be declared. That same day, 30 January 2020, WHO Director-General Tedros Adhanom Ghebreyesus declared a PHIEC for SARS-Cov-2.

The process leading to the public health emergency declaration for COVID-19 has, according to Wenham and colleagues, “highlighted multiple legal ambiguities in the IHR text and practice.” Among these: it is not known if the Emergency Committee holds formal votes or has applies consistent criteria to developing its recommendation.

Also of significant concern is the degree to which national political interests may have influenced Emergency Committee deliberations on SARS-CoV-2. According to the WHO guidelines for its advisory committees, members “may not request or receive instructions from any government or authority external to the Organization.” But how realistic is such a prohibition?

Consider that of the 19 members of the WHO IHR Emergency Committee currently listed on its website, at least half are employed by national governments. Wenham and colleagues suggest that “it appears Member State representatives may have pushed against declaring a PHEIC.”

Questions raised by the actions of the Emergency Committee in the case of SARS-CoV-2 are not unique. In the case of the Ebola outbreak in the Democratic Republic of the Congo in 2019, David Fidler writes that the Emergency Committee “demonstrated an astonishing lack of fidelity to the text of the IHR… the committee rejected widely held interpretations of the definition [of a PHEIC], ignored the actual text, and inserted language that the IHR does not contain” and ultimately “an abuse of its role under the IHR.” Fidler cautioned that these failures were perhaps unique to this one case. The further questions raised by the Emergency Committee actions in the case of SARS-CoV-2 suggests more fundamental problems.

The lack of transparency in WHO Emergency Committee deliberations and decision making, and the lack of clear criteria consistently applied to emergency declaration decisions indicate a need for reform of the advisory mechanism informing WHO declarations of public health emergencies.

The good news is that in parallel to the notable progress in recent decades made in the governance of international public health, so too has progress been made in understanding and implementing effective mechanisms of science advice. The challenge now, as in many contexts, is to integrate the best practices in public health governance with the governance of expertise. That is the subject to which I’ll turn next.

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