GENEVA—Sylvie Briand landed in China looking for answers. Nearly a month had passed since word of a mysterious pneumonia had emerged. It was now late January and the World Health Organization was struggling to learn more about it.
Frustrated with mounting cases and limited information from China, the WHO’s top brass, including Dr. Briand, flew to Beijing to resolve a burning question: How easily did this new disease spread?
They met with President Xi Jinping. They had a phone call with local WHO staff just back from the Wuhan epicenter, quarantined after one developed a cough. Dr. Briand, the agency’s director of global infectious hazard preparedness, drew up a list of questions for Chinese health officials.
By the time the WHO received answers, the Covid-19 pandemic was stumbling into emergency rooms on three continents. Its spread around the world had already begun on Jan. 30 when the WHO declared a global public-health emergency, its one and only level of alert.
The announcement was a dud. Few countries paid enough attention.
Over the next weeks, the WHO warned nations the virus was headed their way. “Now is the moment for all countries to be preparing themselves,” Director-General Tedros Adhanom Ghebreyesus declared on Feb. 4, when the WHO reported more than 20,600 cases in 25 countries.
The WHO’S Tedros Adhanom Ghebreyesus, center, with Michael Ryan, head of the health emergencies program, and Sylvie Briand, director of global infectious hazard preparedness, on Feb. 5.
Photo: Salvatore Di Nolfi/Keystone/Associated PressBut that same day, the WHO also asked nations not to close borders—following its standard protocol, as such restrictions might discourage governments from reporting outbreaks. Within weeks, the virus landed on the agency’s doorstep, turning Geneva into a hot spot. By March, Dr. Briand, a physician, was quarantined in her own apartment, tending to her husband and teenage son, who had become infected at school.
“Very frustrating,” she said. “Everybody realized, we are not talking about theoretical threats.”
The WHO spent years and hundreds of millions of dollars honing a globe-spanning system of defenses against a pandemic it knew would come. But the virus moved faster than the United Nations agency, exposing flaws in its design and operation that bogged down its response when the world needed to take action.
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Sign UpTHE COVID STORM
The Wall Street Journal is examining the causes of the Covid-19 catastrophe and the bungled response that followed. Get alerts for each new installment, along with our daily coronavirus briefing.
The WHO relied on an honor system to stop a viral cataclysm. Its member states had agreed to improve their ability to contain infectious disease epidemics and to report any outbreaks that might spread beyond their borders. International law requires them to do both.
Time and again, countries big and small have failed to do so. The WHO, which isn’t a regulatory agency, lacks the authority to force information from the very governments that finance its programs and elect its leaders. It can’t parachute disease-fighting teams to an outbreak unless a government invites it. And years of painstakingly worded treaties, high-level visits and cutting-edge disease surveillance—all meant to encourage good-faith cooperation—have only bitten around the edges of the problem.
“It doesn’t have a mandate to investigate,” said J. Stephen Morrison, director of the global health policy center at the Center for Strategic and International Studies in Washington. “It can’t demand entry into a country because they think something bad is happening.”
Nearly 200 countries were counting on an agency whose budget—roughly $2.4 billion in 2020—is less than a sixth of the Maryland Department of Health’s. Its donors, largely Western governments, earmark most of that money for causes other than pandemic preparedness.
In 2018 and 2019, about 8% of the WHO’s budget went to activities related to pandemic preparedness. Nearly three times that amount was budgeted for eradicating polio, a top priority for the WHO’s two largest contributors: the U.S. and the Bill & Melinda Gates Foundation. Its headquarters’ staff numbers 2,500, spread across a range of diseases.
Medical staff transfer patients in Wuhan on Jan. 17.
Photo: Getty ImagesTo write its recommendations, the WHO solicits outside experts, which can be a slow process. It took those experts more than four months to agree that widespread mask-wearing helps, and that people who are talking, shouting or singing can expel the virus through tiny particles that linger in the air. In that time, about half a million people died.
The agency’s actions in the Covid-19 pandemic are now a subject of an international review, with nearly all member states calling for an accounting of early missteps.
A review of the WHO’s initial response to the pandemic, based on interviews with current and former WHO staff, public-health experts advising it and officials who work with it, suggests that the agency’s bureaucratic structure, diplomatic protocol and funding were no match for a pandemic as widespread and fast-moving as Covid-19.
In particular, The Wall Street Journal found:
* China appears to have violated international law requiring governments to swiftly inform the WHO and keep it in the loop about an alarming infectious-disease cluster. Those laws were written so that governments could break them with impunity—there are no clear consequences for violations.
* The WHO lost a critical week waiting for an advisory panel to recommend a global public-health emergency, because some of its members were overly hopeful that the new disease wasn’t easily transmissible from one person to another.
* The institution overestimated how prepared some wealthy countries were, while focusing on developing countries, where much of its ordinary assistance is directed.
“Retrospectively, it’s always easy to reinterpret the facts,” said Dr. Briand. “I was in the middle of the storm myself….It was like driving at 400 kilometers per hour. You don’t see the landscape when you are at this speed.”
The U.S. intends to withdraw from the organization next year. President Trump has said the agency responded too slowly to the pandemic and wasn’t tough enough on China. Democratic presidential candidate Joe Biden has pledged to keep the U.S. in the WHO.
Public-health leaders say the WHO plays a critical role in global health, leading responses to epidemics and setting health policies and standards for the world. It coordinates a multinational effort every year to pick the exact strains that go into the seasonal flu vaccine, and has provided public guidance and advice on Covid-19 when many governments were silent.
“We sounded the alarm early and we sounded it often,” Dr. Tedros repeated during thrice-weekly news conferences.
It is up against a particularly contagious pathogen that has flummoxed some of the world’s best-resourced health agencies. Many institutions were slow to realize that the new coronavirus was spreading before its victims showed symptoms, helping it slip through fever checkpoints at the borders the WHO encouraged to stay open.
Frightening news
The world’s public-health agency was born weak, created in 1948 over U.S. and U.K. reluctance. For decades, it was legally barred from responding to diseases that it learned about from the news. Countries were required to report outbreaks of only four diseases to the WHO: yellow fever, plague, cholera and smallpox, which was eradicated in 1980.
A measles vaccination campaign led by the WHO in India, 1974.
Photo: nik wheeler/Sygma/Getty ImagesIn early 2003, the WHO confronted some frightening news. A strange new pneumonia was spreading from China to other countries.
The WHO immediately issued global alerts and the agency’s chief, Gro Harlem Brundtland, publicly scolded China for not reporting the new disease, called severe acute respiratory syndrome, before it jumped borders.
SARS convinced governments to retool the WHO. The next year, delegates arrived in the Geneva palace where the League of Nations once met to resolve a centuries-old paradox: Countries don’t report outbreaks, because they fear—correctly—their neighbors will respond by blocking travel and trade.
As months rolled on, it became clear that governments were reluctant to allow the U.N. to scold, shame or investigate them. An early draft included blunt language allowing the WHO to call out countries that don’t share information on a potential outbreak, said Gian Luca Burci, then a WHO senior legal officer: “Everybody pushed back. No sovereign country wants to have this.”
China wanted an exemption from immediately reporting SARS outbreaks. The U.S. argued it couldn’t compel its 50 states to cooperate with the treaty. Iran blocked American proposals to make the WHO focus on bioterrorism. Cuba had an hourslong list of objections.
Around 3:15 a.m. on the last day, exhausted delegates ran out of time. The treaty they approved, called the International Health Regulations, imagined that each country would quickly and honestly report, then contain, any alarming outbreaks. In return, the treaty discouraged restrictions on travel and trade. There would be no consequences for reporting an outbreak—yet no way to punish a country for hiding one.
The treaty’s key chokepoint: Before declaring a “public health emergency of international concern,” or PHEIC, the WHO’s director-general would consult a multinational emergency committee and give the country in question a chance to argue against such a declaration. Delegates agreed this could give some future virus a head start but decided it was more important to discourage the WHO from making any unilateral announcements that could hurt their economies.
WHO instructors train new health workers in Liberia during the Ebola epidemic in 2014.
Photo: John Moore/Getty ImagesOver the next few years, emergency committees struggled over how to determine whether an outbreak was a PHEIC. It took months to declare emergencies for two deadly Ebola epidemics. Yet the WHO declared one when a few hundred polio cases imperiled an eradication push.
Early warning
Just before dawn on Dec. 31, reports started streaming in on a multimillion-dollar early-warning system, which scans the internet for keywords. The reports were translations of health notices from officials in the city of Wuhan to hospitals that had been leaked to Chinese media.
“The South China Seafood Market in our city has seen patients with pneumonia of unknown cause one after another,” read one.
“Whether or not it is SARS has not yet been clarified, and citizens need not panic,” read another.
A short notice in Chinese soon followed on the website of the Wuhan Municipal Health Commission, reporting 27 cases. “The investigation so far has found no obvious person-to-person transmission,” read the notice, which has since been deleted. Another sentence suggested the opposite: “Avoid closed public places and crowded places with poor air circulation.”
The WHO’s electronic system receives hundreds of notices daily. Still, “every time we see a cluster of unexplained pneumonia, especially in China, it always catches our attention,” Dr. Briand said. Anything beyond five cases was cause for alarm.
Following protocol, the WHO formally requested verification from Chinese health officials. By now it was Jan. 1.
On Jan. 3, representatives of China’s National Health Commission arrived at the WHO office in Beijing. The NHC acknowledged a cluster of pneumonia cases, but didn’t confirm that the new pathogen was a coronavirus, a fact Chinese officials already knew. That same day, the NHC issued an internal notice ordering laboratories to hand over or destroy testing samples and forbade anyone from publishing unauthorized research on the virus.
China’s failure to notify the WHO of the cluster of illnesses is a violation of the International Health Regulations, said Lawrence Gostin, professor of global health law at Georgetown University who has advised the WHO on international health regulation matters. “Once a government knows that there is a novel virus that fits within the criteria, which China did, it’s obliged to report rapidly,” he said.
China also flouted the IHR by not disclosing all key information it had to the WHO, said David Fidler, an expert on global health and international law at the Council on Foreign Relations. The regulations call for member states to provide the WHO with “timely, accurate and sufficiently detailed public health information available to it on the notified event.”
When asked for comment, the National Health Commission pointed to a Chinese government white paper that said China reported the new virus “in an open, transparent, and responsible manner and in accordance with the law.”
The WHO said it’s up to member states to decide whether a country has complied with international health law, and that the coming review will address those issues.
In Geneva, the WHO’s emergency response team had been meeting since Jan. 1, searching for evidence the disease was spreading between people, infecting more than those who had been at the seafood market where the early cases originated. The agency’s infectious disease experts were convinced it was.
The WHO’s Maria van Kerkhove on Jan. 29.
Photo: Martial Trezzini/Keystone/Associated Press“Whenever you hear of a cluster of atypical pneumonia you think respiratory and you think human-to-human transmission,” Maria van Kerkhove, a specialist in Middle East respiratory syndrome and now the WHO’s technical lead for the Covid-19 response, said in a May briefing. “It’s not if—it’s just what is the extent?”
While Chinese scientists had sequenced the genome and posted it publicly, the government was less forthcoming about how patients might be catching the virus. WHO scientists pored over data they did get, and consulted with experts from national health agencies, including the CDC, which has 33 staff detailed to the WHO.
Then a 61-year-old woman was hospitalized in Thailand on Jan. 13. She had been in Wuhan, but not at the seafood market. That was strong evidence that the virus was spreading from human to human.
The next day, Dr. van Kerkhove told reporters: “It’s certainly possible that there is limited human-to-human transmission.” MERS and SARS, both coronaviruses, were transmissible among people in close quarters. Epidemiological investigations were under way, she said.
Emergency declaration
Six days later, China acknowledged that there was human-to-human transmission. Dr. Tedros convened an emergency committee to determine whether to declare a global public-health emergency.
On Jan. 22, a committee of 15 scientists haggled for hours over Chinese data and a handful of cases in other countries. Clearly, the virus was spreading between people in China, though there was no evidence of that in other countries. The question now: Was it mainly spreading from very sick people in hospitals and homes—or more widely?
The committee met over two days, but was split. They mostly agreed on one point: The information from China “was a little too imprecise to very clearly state that it was time” to recommend an emergency declaration, the committee chair, Didier Houssin, said in a news briefing after the meeting ended.
Meanwhile, a team of five WHO staff had just toured Wuhan. Case counts would likely increase, potentially into thousands, reported the team, which had begun to understand a crucial phenomenon: Many cases were mild. They asked if China needed the WHO’s help. Then one member developed a cough, and the team was quarantined.
With so many unanswered questions, Dr. Tedros decided to go to China with a small entourage. They rushed on a weekend to get visas and catch a flight to Beijing.
On Jan. 28, Dr. Tedros and the WHO team arrived for their meeting with Mr. Xi. Dr. Briand was overtaken by the enormous room and the formality and protocol.
Leaning across three wooden coffee tables, Dr. Tedros pressed for cooperation. In the absence of information, countries might react out of fear and restrict travel to China, he repeated several times throughout the trip.
Mr. Xi agreed to allow a WHO-led international team of experts to visit. It took until mid-February to make arrangements and get the team there.
Dr. Tedros and Xi Jinping at the Great Hall of the People in Beijing, Jan. 28.
Photo: Naohiko Hatta/Press PoolChina also agreed to provide more data, and Dr. Tedros departed, leaving Dr. Briand behind with a list of mysteries to solve. How contagious was the virus? How much were children or pregnant women at risk? How were cases linked? This was vital information needed to assess the global risk, Dr. Briand said.
Back in Geneva, Dr. Tedros reconvened the emergency committee. By now it was clear there was human-to-human transmission in other countries. When it met on Jan. 30, the committee got the information the WHO had been seeking. This time the committee recommended and Dr. Tedros declared a global public-health emergency.
The emergency was the sixth the WHO had ever declared. The announcement was the biggest cannon in its arsenal.
In the weeks to come, Germany’s Angela Merkel remained focused on repairing a faltering border-control agreement with Turkey.
President Trump and New York Gov. Andrew Cuomo both assured constituents their health systems would perform well.
The U.K.’s chief medical officer described the WHO’s advice as largely directed at poor and middle-income countries.
As for keeping borders open, by then many governments had already closed them to visitors from China.
The WHO shifted focus to the developing world, where it believed Covid-19 would exact the heaviest toll. To its surprise, cases shot up just across the border, in northern Italy.
A WHO doctor visits a lab in Ghana where samples of Covid-19 are tested.
Photo: Nana Kofi Acquah/Blink Media/WHOHospitals there overflowed with desperately ill patients. Soon, the virus tore through a nursing home in Kirkland, Wash., and ravaged New York City.
To date there have been 24 million cases world-wide, nearly a quarter of those in the U.S. More than 822,000 people have died.
Lessons learned
If there were one thing the WHO might have done differently, it would be to offer wealthier countries the type of assistance with public-health interventions that the WHO provides the developing world, Michael Ryan, head of the WHO’s health emergencies program, said in a media briefing last month.
An intensive care unit at a Wuhan hospital, Feb. 6.
Photo: /Associated PressGoing forward, an independent committee will review parts of the International Health Regulations, Dr. Tedros said Thursday. The committee will advise him on whether changes “may be necessary to ensure this powerful tool of international law is as effective as possible,” he said.
“The pandemic has been an acid test for many countries and organizations as well as for the International Health Regulations,” he said.
Many global-health experts, including Dr. Tedros, say the WHO’s warning system of declaring a global public-health emergency needs to change. Some want to see a warning system more like a traffic light—with color-coded alarms for outbreaks, based on how worried the public should be. A flare-up of polio or Ebola isn’t the same as a rapidly spreading new respiratory virus. One afflicts a region; Covid-19 swept the world.
Emergency committees need clearer criteria for declaring a global public-health emergency and should publicly explain their thinking, according to a recent study in the BMJ Global Health, which found past decisions inconsistent.
The WHO should have more powers to intervene in countries to head off a health crisis, said Jimmy Kolker, a former U.S. ambassador and former assistant secretary for global affairs at the U.S. Department of Health and Human Services. He also said that the WHO’s health emergencies unit should report to the director-general and not member states, and its budget should be protected so it doesn’t have to compete with other programs for money.
Implementing many of those ideas would require herding diplomats back for another monthslong slog of treaty revisions. If and when such talks begin, new governments will likely be in place, and political priorities will float elsewhere, said Adam Kamradt-Scott, a global health security scholar at the University of Sydney who sat through the last round.
“Unfortunately, I’m very cynical about this,” he said. “We are living through cycles of panic and neglect. We’ve been through all of this before.”
—Illustration by Jessica Kuronen/WSJ
Write to Betsy McKay at betsy.mckay@wsj.com and Drew Hinshaw at drew.hinshaw@wsj.com
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Appeared in the August 29, 2020, print edition as 'The WHO’s Flawed Design Was No Match for Covid.'
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