[Ip-health] Lancet Study: WHO neglects evidence when developing 'evidence-based guidelines'

[Ira Glazer]

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."



< original article: The Lancet DOI:10.1016/S0140-6736(07)60675-8,
'Use of Evidence in WHO recommendations'>