PHA-Exchange> WHO criticized for neglecting evidence

[claudio at hcmc.netnam.vn]

 from Vern Weitzel <vern at coombs.anu.edu.au> -----

http://www.miamiherald.com/852/story/99331.html

WHO criticized for neglecting evidence
By MARIA CHENG
AP Medical Writer

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 
U.N. 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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