The World Health Organization (WHO) sounded its highest alarm on 30 January 2020 — a declaration called a ‘public health emergency of international concern’, or PHEIC, signalling that a pandemic might be imminent. Few countries heeded the WHO’s call for testing, tracing and social distancing to curb the coronavirus. By mid-March, it had spread around the world. Now, health officials and researchers are evaluating why the organization’s warning system failed and how to overhaul it.
Many say the organization should have declared a PHEIC about a week earlier than it did. But the largest failing, researchers agree, is that so many countries ignored it. Two new preliminary investigations — one from the WHO and another from an independent panel responsible for assessing the organization — attempt to unravel why.
“The biggest issue to me is that for six to eight weeks after the PHEIC declaration, countries, except for in Asia, sat on their hands,” says Joanne Liu, a former president of Médecins Sans Frontières (also known as Doctors without Borders), who serves on the independent panel.
World health officials are evaluating potential improvements to the system during the WHO’s executive board meeting, being held 18–26 January. Talks will continue in advance of the annual World Health Assembly in May, when any changes would occur. Some of the proposals include modifying the PHEIC alarm to have colour-coded warning levels, and having countries sign on to a new treaty on preparing for pandemics.
The thorniest problem for the WHO, though, is how to persuade countries to heed its warnings. Liu says: “The real question is, what would it take for people to do something when a declaration happens?”
What’s in a name?
The PHEIC alarm originated in 2005, when the WHO overhauled its decades-old regulations about international health emergencies: 196 countries and territories agreed to alert the organization when outbreaks emerged, and gave it the power to declare a PHEIC. The WHO can sound this alarm if it deems an emergency extraordinary, if the emergency poses a risk to countries outside where it originated and if it requires an international response — meaning, in some cases, that it could have pandemic potential. Since the revision, the WHO has declared a PHEIC six times (see ‘Sound the alarm’).
At each declaration, the WHO advises governments on how to respond to the situation at hand. For example, last January, the WHO director-general Tedros Adhanom Ghebreyesus said of the COVID-19 outbreak, “It is still possible to interrupt virus spread, provided that countries put in place strong measures to detect disease early, isolate and treat cases, trace contacts and promote social-distancing measures.”
Liu admits that the term PHEIC isn’t as sexy as an emotive word, such as ‘pandemic’ or ‘emergency’. But researchers and health officials chose it partly because they wanted to avoid panic while encouraging world leaders to act according to WHO advice to contain a threat, says Gian Luca Burci, an international law specialist at the Graduate Institute of International and Development Studies in Geneva, Switzerland. Burci helped to revise the regulations in 2005.
In hindsight, that reasoning appears to be flawed. Several reports note that politicians and the public mainly ignored the PHEIC declaration and Tedros's corresponding recommendations in January 2020, but started listening when the organization used the unofficial term ‘pandemic’ to describe COVID-19 in March, once it was spreading in multiple continents. Unlike the PHEIC, 'pandemic' is not a defined declaration, and countries haven't agreed to take any actions once it's used.
Despite the disproportionate response to the word pandemic, many scholars argue that changing the name of the WHO’s highest alarm wouldn’t be useful. “I don’t care for the term PHEIC,” says Alexandra Phelan, a global-health lawyer at Georgetown University in Washington DC, “but I worry that if we get too into the words, we miss the point that countries need to act appropriately when there is a declaration.”
Researchers are, however, critical of the process for declaring a PHEIC. On 22 January 2020, Tedros convened a closed-door meeting of virologists, public-health researchers and certain government representatives — as the process dictates. They decided that a PHEIC wasn’t warranted, but a week later, the committee flipped its position, resulting in a delay that might have cost the world time to contain the virus.
Global health scholars debate the timing of PHEICs after every declaration. To improve the system, Phelan and an international consortium of researchers argue, in a white paper published in November, that it should be made more transparent. The reason, they say, is so that scholars can better evaluate how these decisions are made by weighing scientific evidence, as well as social, political and economic concerns.
Still, a one-week lag in declaring a global emergency isn’t even the most concerning action that took place in the early days of the COVID-19 pandemic, critics say. When Tedros declared the PHEIC, he advised governments to move fast with public-health measures including tests and social distancing. He also asked them to resist bans on travel and trade because, historically, they are of limited utility and are potentially harmful.
But governments around the world ignored those calls. For example, the United States did not roll out testing across the country until late February; did not bar large gatherings until March; ditched contact-tracing; and banned some travel from China, where the virus was first discovered.
Praising and shaming
Countries appear to agree that to improve the world’s ability to respond to pandemics, the WHO should be transformed and bolstered. Speaking as a representative of the United States, infectious-disease scientist Anthony Fauci told the WHO this week that the country will reverse its withdrawal from the organization, initiated by former president Donald Trump, and “work constructively with partners to strengthen and importantly reform the WHO”.
One change suggested by a former US government official, speaking with Nature on background because he is advising US President Joe Biden’s administration, is to empower the WHO to act on unofficial data on social media and elsewhere despite questions of accuracy, so that the organization can respond rapidly to emerging diseases without waiting for governments that might withhold information.
The WHO could also be strengthened through a new treaty on pandemics that countries would need to sign onto. On 20 January, Tedros said he would assemble a working group to explore this proposal from the president of the European Council, Charles Michel. Steven Solomon, principal legal officer at the WHO, says a pandemic treaty might be helpful for world leaders who don’t understand the technical details of a PHEIC. Still, the WHO probably wouldn’t have the ability to penalize countries that don’t comply. “There’s no silver bullet here since you’re dealing with a community of nations, all of whom guard their sovereignty very closely,” says Solomon.
The WHO therefore relies on diplomacy, which often boils down to praising or shaming countries. But the WHO’s appetite for criticism is limited by its reliance on donations from its member countries and on countries openly offering access and information — which could be withheld if leaders felt insulted. A case in point is that the WHO spent weeks gently persuading China to permit an international team of scientists to visit Wuhan after the outbreak was reported there. On the financing front, researchers say that a larger, reliable budget for the WHO would give the organization greater autonomy because it wouldn't be dependent on fundraising amid a disaster.
To address communication concerns, Tedros has suggested adding a gradient of warnings to the PHEIC, coded by colour. The colours could separate emergencies that might evolve into a pandemic from those that are serious but won’t affect nations across the globe. Countries with outbreaks — or threatening coronavirus variants — might more willingly share information if there were a low-grade alarm that was less likely to result in disruptions to people's livelihoods or the economy.
Reforms won’t come until the World Health Assembly in May — at the earliest. The possibility of solutions being delayed or forgotten fills Liu with dread, because she recalls dozens of panels assessing failures in the response to the Ebola outbreak in West Africa in 2014–2016. “Less than 10% of the recommendations were followed up on,” she says. “We have an amazing talent to outrage ourselves about a situation, but when it comes time to deliver any change, there is very little traction, and people go back to doing whatever they had done before.”