COVID-19, China, the World Health Organization, and the Limits of International Health Diplomacy

On May 5, 2020, the conservative newspaper the Washington Examiner lambasted China’s behavior in the COVID-19 crisis, claiming that the country “deliberately misled the world so that it could stockpile crucial supplies” while it “let the virus infect the rest of the world.”¹ The Examiner also claimed that China lied about the virus’s capacity for human-to-human transmission. And yet, unlike other conservative media, the Examiner was relatively easy on the World Health Organization (WHO), which, it said, China had manipulated by refusing to let it see early data.

Other voices have been far more critical of the WHO. For example, on April 15, the Libertarian magazine Reason asserted that the WHO “whitewashed the Chinese government’s early handling of the crisis” and did this because of its “overly deferential stance towards China, which is its second-biggest financial contributor.”²

What is the truth about the WHO’s response to the coronavirus crisis in China? The most comprehensive source for the early days of the developing pandemic is the chronology posted on the WHO Web site,³ extracted in the box on page 1150. The chronology raises several questions. The new coronavirus was isolated by Chinese scientists by January 7, so why did China not report this to the WHO until January 12? A high WHO official on January 14 underscored the likelihood of human-to-human spread of the new “pneumonia” analogous to SARS (severe acute respiratory syndrome) and MERS (Middle East respiratory syndrome).³ But why was no confirmatory evidence reported by China until January 23, just after a small WHO team was allowed to visit Wuhan for the first time and more than a week after the Chinese had installed thermometers at airports, train stations, and long-range bus stations?

BOX 1— Chronology of Early COVID-19 Events in China and the World Health Organization’s (WHO’s) Response.

Date	Event
Dec 31, 2019	A “cluster of cases of pneumonia” reported in Wuhan, Hubei Province, China.
Jan 5, 2020	First “Disease Outbreak News” announces 44 reported patients in Wuhan, including 11 who are severely ill with pneumonia of unknown etiology. Many were vendors at the Huanan Seafood Market; Chinese investigators report no evidence of human-to-human transmission.
Jan 12, 2020	Second “Disease Outbreak News” reveals that 1 death had occurred and that of the remaining confirmed 41 patients, most cases were among workers or frequent visitors to the Huanan market. Contact tracing of 763 close contacts of those afflicted, including health care workers of those hospitalized, occurred with no additional cases of infection identified. The Chinese government reports no clear evidence that the virus passed easily from person to person. Chinese authorities also announce that they had isolated the new coronavirus on January 7, 2020 and had shared its genetic sequence on January 12.
Jan 13, 2020	A confirmed case is reported in Thailand, a traveler from Wuhan, China.
Jan 14, 2020	The WHO’s technical lead for the response notes in a press briefing that there may have been limited human-to-human transmission of the coronavirus (in the 41 confirmed cases), mainly through family members, and that there is a risk of a possible wider outbreak.
Jan 20–22, 2020	WHO officials from its Western Pacific Regional Office in Manila, Philippines, and its country office in Beijing, China, make a brief field visit to Wuhan. The team issues a statement of evidence of human-to-human transmission in Wuhan. The situation report noted 32 new cases in a single day, including 1 in Taiwan. Seven additional provinces in China and 2 municipalities now also report cases, and 16 cases are reported among health care workers in Wuhan.
Jan 22–23, 2020	The situation report specifically noted that Chinese national authorities on January 14 installed 35 infrared thermometers in “airports, railway stations, long-distance bus stations, and ferry terminals.” More cases are reported in the United States, Thailand, Japan, and Korea, now with “solid evidence of human-to-human transmission.” WHO director general Dr. Tedros Adhanom Ghebreyesus convenes an EC “to assess whether the outbreak constituted a public health emergency of international concern.” The 15 members of the EC split down the middle, failing to reach a consensus.
Jan 28, 2020	The WHO director general leads a senior delegation to Beijing to meet with Chinese leaders, including President Xi Jinping, who agrees that an international team of experts should soon be allowed to visit to help bring the outbreak under control. The number of people confirmed with the virus totals more than 4500 globally, with the vast majority in China.
Jan 30, 2020	The EC reconvened and reached consensus that the outbreak should be declared a PHEIC. Total confirmed cases worldwide reached 7818, with 82 cases in 18 other countries.
Jan 31, 2020	The Situation Report presents a detailed account of the EC’s deliberations, with warm praise for China, and “welcomed the leadership and political commitment of the very highest levels of Chinese government, their commitment to transparency, and the efforts made to investigate and contain the current outbreak.”
Feb 16–24, 2020	The WHO–China Joint Mission, which included 25 experts from Canada, Germany, Japan, Nigeria, Republic of Korea, Russia, Singapore, and the US (CDC, NIH), spends time in Beijing and travels to Wuhan and 2 other cities and issues a final report that includes more lavish praise for China. The report states that a cumulative total of 75 465 COVID-19 cases were reported in China by February 20.

Note. CDC = Centers for Disease Control and Prevention; EC = Emergency Committee; NIH = National Institutes of Health; PHEIC = public health emergency of international concern.

The WHO director general Dr. Tedros Adhanom Ghebreyesus tried but failed to get a mandate to declare a public health emergency of international concern when the Emergency Committee he convened under the International Health Regulations deadlocked on January 22 to 23, yet he personally found the evidence compelling enough to arrange a visit with Chinese leaders in Beijing on January 28. Tedros was able to get a mandate for a public health emergency of international concern on January 30, but by then there were 7818 confirmed COVID-19 cases—the vast majority in China, with 82 additional cases in 18 other countries. On January 30 the WHO director general praised China lavishly, and only afterward did the WHO get approval for a mission to China February 16 through 24.

If these events can be seen as a chronicle of failings, was the WHO at fault? What options did it really have? Even if the WHO’s leadership suspected that China was withholding or misrepresenting data, what course of action could it have taken? The organization has limited financial and staff capacity as it strives to stretch its tight budget so it can address a very wide range of global health challenges. The WHO’s annual budget, based on member states’ dues plus voluntary contributions, is a little more than 2 billion dollars per annum, which is about one third of the Centers for Disease Control and Prevention’s annual budget and less than the annual budgets of many hospitals in Western Europe and the United States. If the world’s nations want the WHO to perform watchdog functions with an adequate staff, these nations have to contribute far more robustly to operating expenses than they seem willing to do.

The WHO’s range of action in response to suspected epidemic and pandemic outbreaks is also very tightly bound by the carefully negotiated and precisely stipulated International Health Regulations adopted in 2005 by 196 nations. According to the International Health Regulations, signatory states are supposed to maintain “core capacities” for surveillance but many do not, meaning that they are unable to investigate and track suspected outbreaks. They are also supposed to report to the WHO any such developments, but many states—even those with the capacity—do not comply, certainly not fully and transparently. Yet the same International Health Regulations were negotiated in a way that granted no real power to the WHO to force states to comply with the supposed international rules. Unlike the World Trade Organization, the WHO has no authority to sanction or otherwise pressure its member states. As Lancet editor Richard Horton has said, “The WHO has been drained of its power and resources. Its coordinating authority and capacity are weak. Its ability to direct an international response to a life-threatening epidemic is non-existent.”⁴

What alternative does the WHO have but to use delicate diplomacy to ensure the transmission of data and the cooperation of member states? If the WHO had an adequate budget and authority to force China to yield data, then it could force other powerful countries to do the same. The International Health Regulations would need to be renegotiated and affirmed to make sure this new reality could happen. But will they be? Perhaps we should accept the reality, as Lawrence Gostin has stated, that the world has the WHO it deserves.⁵

So, what is the truth about the WHO’s response and China’s behavior regarding the coronavirus crisis in China? The truth is that neither an ineffective WHO nor China alone can be singled out as solely responsible for our currently disastrous pandemic. The world collectively has failed to build an institution that can protect us against global health threats. Hopefully, COVID-19 will stimulate the profound reform of the WHO that many have advocated for years.⁶