WORLD / Health
WHO criticized for neglecting evidence
(Agencies)
Updated: 2007-05-08 16:49
LONDON - When developing "evidence-based" guidelines, the World Health
Organization routinely forgets one key ingredient: evidence. That is the
verdict from a study published in The Lancet online Tuesday.
The medical journal's criticism of WHO could shock many in the global
health community, as one of WHO's main jobs is to produce guidelines on
everything from fighting the spread of bird flu and malaria control to
enacting anti-tobacco legislation.
"This is a pretty seismic event," Lancet editor Dr. Richard Horton, who
was not involved in the research for the article. "It undermines the very
purpose of WHO."
The study was conducted by Dr. Andrew Oxman and Dr. Atle Fretheim, of the
Norwegian Knowledge Centre for Health Services, and Dr. John Lavis at
McMaster University in Canada. They interviewed senior WHO officials and
analyzed various guidelines to determine how they were produced. What
they found was a distinctly non-transparent process.
"It's difficult to judge how much confidence you can have in WHO
guidelines if you're not told how they were developed," Oxman said. "In
that case, you're left with blind trust."
WHO issues about 200 sets of recommendations every year, acting as a
public health arbiter to the global community by sifting through
competing scientific theories and studies to put forth the best policies.
WHO's Director of Research Policy Dr. Tikki Pang said that some of his
WHO colleagues were shocked by The Lancet's study, but he acknowledged
the criticism had merit, and explained that time pressures and a lack of
both information and money sometimes compromised WHO work.
"We know our credibility is at stake," Pang said, "and we are now going
to get our act together."
WHO officials also noted that, in many cases, evidence simply did not
exist. Data from developing countries are patchy at best, and in an
outbreak, information changes as the crisis unfolds.
To address the problem, they said, WHO is trying to develop new ways to
collect information in poor regions, and has proposed establishing a
committee to oversee the issuance of all health guidelines.
The Lancet study -- conducted in 2003-04 through analyzing WHO guidelines
and questioning WHO officials -- also found that the officials themselves
were concerned about the agency's methods.
One unnamed WHO director was quoted in the study as saying: "I would have
liked to have had more evidence to base recommendations on." Another
said: "We never had the evidence base well-documented."
Pang said that, while some guidelines might be suspect and based on just
a few expert opinions, others were developed under rigorous study and so
were more reliable.
For example, WHO's recent advice on treating bird flu patients was
developed under tight scrutiny.
Oxman also noted that WHO had its own quality-control process. When its
1999 guidelines for treating high blood pressure were criticized for,
among other things, recommending expensive drugs over cheaper options
without proven benefit, the agency issued its "guidelines for writing
guidelines," which led to a revision of its advice on hypertension.
"People are well-intended at WHO," Oxman said. "The problem is that good
intentions and plausible theories aren't sufficient."
It remains to be seen how WHO's 193 member countries will react to The
Lancet study, released just before WHO's governing body -- the World
Health Assembly -- meets next week at UN headquarters in Geneva to decide
future health strategies.
"If countries do not have confidence in the technical competence of WHO,
then its very existence is called into question," said Horton, the
journal's editor. "This study shows that there is a systemic problem
within the organization, that it refuses to put science first."
WHO Director-General Dr. Margaret Chan, who took over the position this
year, will be under pressure to respond to the study's criticism.
"We need a strong WHO," which in recent years "has seen its independence
eroded and its trust diminished," Horton said. "Now is a fabulous
opportunity for WHO to reinvent itself as the technical agency it was
always meant to be."
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