Recommendations given by the World Health Organization (WHO) carry substantial weight. During the Covid-19 pandemic, the WHO partnered with the world’s largest tech companies to restrict information and scientific debate to billions. YouTube explicitly banned all content contradicting the WHO’s recommendations, whilst the WHO actively vilified those questioning its recommendations. A concerning outcome of this suppression of open discussion in international public health has been an apparent loss of evidence base in subsequent WHO recommendations, particularly in response to pandemics.
When the WHO endorsed the unprecedented measures taken by the Chinese authorities in response to the outbreak of SARS-CoV-2, this was a watershed moment in WHO pandemic policy. Traditionally, these recommendations were relatively cautious, grounded in a recognition of health as not “merely the absence of disease.” WHO recommendations during health emergencies often focused primarily on avoiding harm by unilateral border closures. Although the organisation still upheld its traditional advice against trade and travel restrictions for a few weeks, this also changed after countries imposed restrictions irrespective of the WHO’s caution. With the WHO giving ambiguous advice, governments around the world followed each other unreflectively, imposing lockdowns that turned a respiratory disease into a global socioeconomic crisis, plunging millions into poverty.
The lockdowns and mandates of the Covid-19 era can be regarded as the largest natural experiment in public health. With governments imposing dozens of measures simultaneously, attributing effects to specific measures is tricky, and it is no wonder that the academic debate on what worked and what didn’t is far from being settled. The fact that Sweden had one of the lowest excess mortality rates worldwide despite having some of the least aggressive restrictions certainly calls into question the unprecedented lockdowns, extended school closures, and mask mandates. Or at least in a rational world, it would. Nonetheless, these measures are becoming the new go-to response to future pandemics, now promoted by the WHO itself. This is confirmed by a systematic comparison of the WHO’s pre- and post- Covid pandemic response recommendations.
As part of the REPPARE project at the University of Leeds, we searched all WHO publications between January 2017 and April 2025 for recommendations on non-pharmaceutical interventions during pandemics. We excluded temporary guidance during specific events like Covid, focusing on standing recommendations that will influence future health emergencies. The results show a normalisation of measures that the WHO formerly advised against and were first applied at scale during Covid.
As example, in 2018, the ‘Managing Epidemics’ handbook stated that:
“…many traditional containment measures are no longer efficient. They should therefore be re-examined in the light of people’s expectations of more freedom, including freedom of movement. Measures such as quarantine, for example, once regarded as a matter of fact, would be unacceptable to many populations today.”
A new edition, revised in 2023, states:
“…many traditional containment measures are challenging to put in place and sustain. Measures such as quarantine can be at odds with people’s expectations of more freedom, including freedom of movement. Digital technologies for contact tracing became common in response to Covid-19. These, however, come with privacy, security and ethical concerns. Containment measures should be re-examined in partnership with the communities they impact.”
Containment is “challenging” rather than “no longer efficient,” while quarantine is no longer “unacceptable.” The same 2018 document also referred to the use of face masks by sick people as an “extreme measure,” while the update recommends their use even for seasonal flu. A literal adherence to WHO’s ongoing Covid-19 guidelines would today require everyone aged 6 or older to wear a mask in all indoor spaces where a distance of 1 meter to others cannot be upheld. People aged 60 or older, or those with underlying comorbidities, are recommended to wear a mask everywhere, irrespective of evidence of lack of effect.
The “WHO benchmarks for strengthening health emergency capacities,” a tool to monitor country progress towards fulfilling the core capacity requirements of the International Health Regulations (mainly ramping up surveillance), now also include public health and social measures (PHSM), including contact tracing, mask wearing, physical distancing, restricting mass gatherings, and school and business closures. To meet the benchmarks, States must establish quarantine units for human and animal infectious diseases, and perform simulation exercises to prove they work.
Recommendations for contact tracing, border screening, and quarantine all stand in stark contrast with the guidance WHO released in late 2019 on pandemic influenza, where contact tracing, quarantine of exposed individuals, and entry and exit screening at borders were all “not recommended in any circumstances.” This approach was based on their limited effectiveness and collateral damage. In contrast, the document recommended only the voluntary isolation of sick individuals.
Five years later, the WHO’s review of learnings from Covid-19 noted that states “should ensure that pandemic plans explicitly account for the unique challenges faced by vulnerable populations when navigating travel restrictions; complying with lockdown, isolation, and quarantine measures; and accessing health and social services.” This illustrates the subtle normalisation of Covid-19-era policies. Earlier pandemic plans never foresaw the prolonged lockdowns and restriction of 2020 to 2022, as it was assumed they were not effective but would be dangerous to health (and economies) overall. Now they just accept that it will be done and to consider limiting the harm.
As justification for the policy change, the WHO published a report on the role of social protection in mitigating the burden of Covid-19 PHSM, passingly reiterating the message that they were overall “effective in curbing the outbreak.” This claim rests on scant evidence. A cited Royal Society report relies almost exclusively on short-term studies of limited quality, and further presents Hong Kong, New Zealand, and South Korea as exemplary cases that contained the spread of Covid-19 for 18 months.
However, very few other countries achieved the same, and eventually the virus also spread to these locations. Meanwhile, the Nordic countries achieved equally low excess mortality with less aggressive PHSM. This could be argued to contradict the WHO’s claims on PHSM, as it suggests that such harmful measures and their economic costs provide little or no benefit. A recent extensive analysis in the Journal of the Royal Statistical Society appears to confirm this lack of benefit on Covid-19 outcomes.
Another key reference is a WHO-commissioned systematic review of systematic reviews, which actually found quite little conclusive evidence regarding the effectiveness of specific measures, best illustrated by its conclusion: “There is low-certainty evidence that multicomponent interventions may reduce the transmission of Covid-19 in different settings.” This is not the type of strong backing one would expect for far-reaching intrusions into social and economic life.
Where strong social safety nets existed, they undoubtedly softened the short-term economic harm for many who lost jobs or had their businesses closed. However, only a minority of those whose livelihoods were affected by lockdowns could rely on such support. In most countries, the large majority work in the informal sector. Where poverty is already the norm, lockdowns cannot be mitigated but will exacerbate existing inequality. Whereas in wealthy countries, social safety nets funded by debt will need to be paid for by the children whose schools were closed. To this will be added further costs of the ‘next pandemic,’ if the WHO’s new approach is followed.
In October, the WHO published a ”Decision Navigator” for future public health emergencies. Unlike the documents identified in our article, the Navigator does not give recommendations on specific measures, but lays out a framework for decision-making. This insists actions should be guided by evidence and take into account equity and other ethical considerations. It highlights balancing feasibility, acceptability, unintended negative consequences, and mitigation measures, explicitly listing many collateral effects of Covid-19 PHSM that the WHO ignored.
Unfortunately, the WHO decision tool is also yet another piece of PHSM normalisation. To respond to a health emergency, policy makers are pointed to a menu of PHSM that includes, among other things, stay-at-home orders, curfews, or a maximum distance people can be away from their home. To learn whether these interventions, or more benign ones like Plexiglas barriers, should be considered in a health emergency, the document points to the WHO’s PHSM Knowledge Hub, a website that includes a “Recommendation Finder” as well as a “Bibliographic Library,” a repository of academic literature on PHSM. These are still a work-in-progress. For example, filtering for influenza in the Recommendation Finder currently yields no results.
Meanwhile, the new WHO Pandemic Hub in Berlin is currently developing a “Pandemic Simulator.” Screenshots of the prototype indicate that it will allow policy makers to model how the epidemiological situation changes in reaction to lockdown. It is yet to be seen whether the weighing of costs and benefits, ethical, and epidemiological considerations proposed in the Decision Navigator will be more influential in the next pandemic, or the simplistic logic of the Pandemic Simulator.
The WHO’s post- Covid recommendations are thus not without contradictions, and it would be an exaggeration to claim that WHO unequivocally supports lockdowns as a necessary approach to all health emergencies. Nonetheless, some of the measures taken against SARS-CoV-2, contrary to earlier advice, are now expected despite lack of evidence for change. The implication is that human rights restrictions and actions that harm general health and well-being have become acceptable options for future health crises. In the light of limited evidence for the effectiveness of PHSM, perhaps Hippocrates, “First do no harm,” would mandate more caution.
Many countries will update and rewrite their pandemic plans in the coming years. Much of this will be based on advice from the WHO, as most countries still assume it meticulously weighs evidence and maintains a broad view of health, physical, mental, and social, consistent with its constitution. The WHO itself also has its hands tied to a large extent. Once independent, it now struggles under a funding model within which almost 80% of support is for activities that are specified by the funder. While not the WHO’s fault, this almost by definition pushes it into prioritizing what major funders want, which may differ from what public health science demands. While countries are under no obligation to follow WHO guidance, it can be difficult to follow directions that differ from the world’s leading health body, especially when that body works with the media to restrict alternate views.
Pandemics will happen. The world will benefit from an international health organization that can help coordinate rational and proportionate responses, whilst also assisting in managing the vast panoply of other, greater public health priorities. The WHO risks making the latter worse by abandoning a robust evidence-based approach on the former. The populations the WHO was set up to protect deserve a return to evidence-based public health and not simply the normalization of failures of the past.
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