Who's Responsible?

  “Stopping the Ebola outbreak was not about the lack of science,” said Jeff Schlegelmilch,a managing director at the Earth Institute’s National Center for Disaster Preparedness at Columbia University. Schlegelmilch has been working on the Earth Institute’s effort to combat Ebola’s most recent and deadly outbreak, which, thankfully, seems to be finally coming to an end. The week of February 8, the West African countries hit hardest by the epidemic reported 79 cases, down from an average of 500 cases per week in December 2014. The Center for Disease Control report from February 22 shows that there have been 23,694 cases of and 9,589 deaths from Ebola in Sierra Leone, Guinea, and Liberia, the three countries with the most casualties. Now, international health organizations must ask themselves why this has been the worst Ebola outbreak since the disease’s discovery.

Much of the media frenzy surrounding the Ebola epidemic in West Africa has been a product of intense focus on the grotesque symptoms of the disease. The media has also fixated on the chaos that ensued in the most deeply affected countries. Reports have described hospitals overrun with Ebola patients, with other important aspects of medical caregiving such as maternal healthcare and AIDS treatment left unattended, and dead bodies abandoned out of fear of contamination in the streets of Freetown, Liberia. This coverage has unfortunately failed to call attention to the many factors that contributed to Ebola’s rapid spread, including the weak initial response to the disease. While many organizations were quick to react to the outbreak, the premier international health organization, the World Health Organization (WHO), lagged in its response. It has been repeatedly suggested that the WHO is in need of wide-ranging reforms, and its inadequate response to the Ebola epidemic has only made the need for such reform increasingly clear.

The WHO was founded in 1945 by a United Nations conference vote to establish an international health organization. By 1948, enough countries had ratified the WHO’s constitution in order for it to take effect. That same year, the first World Health Assembly was held in Geneva, Switzerland, which is still home to the organization’s headquarters.

Currently, the WHO has 194 member states, making it an international agency with one of the highest memberships; however, the WHO has changed dramatically since it was founded nearly seven decades ago. Originally, the organization was focused on consensus building and limited technical interventions. After the 1970s, the WHO shifted its mission to carry out more comprehensive health care, designing policies and programs not only to treat diseases, but also to address the socioeconomic determinants of health status. This approach to health care, however, covers an incredibly wide range of issues, including programs targeted at specific populations and disease prevention programs that range from heart disease to alcoholism.

As a result of its wide coverage and varied responsibilities, the WHO’s organizational structure is quite decentralized. The World Health Assembly is the governing body of the WHO, and each of the 194 member states gets one vote, regardless of population size or geopolitical influence. The Assembly meets just once yearly, and this is doubtlessly one of the reasons why the WHO is slow to act on health emergencies. During its annual meeting, the Assembly elects a 31 member executive board, which in turn nominates a Director General, the head of the WHO. This nomination process has been criticized for lack of transparency because it is closed to the public. Following a nomination, the Director General must be confirmed by the Assembly, but no nominee has ever been denied the position. The Director General can serve up to three five-year terms and exerts enormous administrative power. Most key decisions—including appointments to other leadership positions and budget proposals—are not subject to review by the Executive Board or the Assembly.

While the Assembly, the Executive Board, and the Director General all work out of the WHO headquarters in Geneva, there are also six regional offices that have their own bureaucratic structures. These bodies include Africa, the Americas, the Eastern Mediterranean, Europe, South-East Asia, and the Western Pacific. Each office has a regional committee which functions much like the Executive Board of the Central Office, electing regional directors to lead for five-year terms. The offices both implement projects directed by Geneva and formulate their own policies within their specific regions. This semi-autonomous structure often causes a disjunction between the regional offices and WHO headquarters that can result in poorly coordinated efforts and responses to health crises.

In hindsight, the WHO’s slow response to Ebola likely made the outbreak worse than it could have been. On March 23, 2014, the WHO was notified of the first Ebola case in West Africa. At this point the appearance of Ebola, while of grave concern, did not warn of the large-scale epidemic that it would become. Prior to this outbreak, the largest Ebola epidemic was in Uganda, when there were 425 cases of the disease reported from October 2000 to January 2001. At the end of last May, the Director General, Dr. Margaret Chan, made her annual address to the WHO Assembly, in which she barely mentioned the growing number of Ebola cases. By June 15, 2014, the number of cases reported in West Africa had reached more than 100. Just one week later, an additional 100 new cases had been documented. This rapid growth continued steadily, while the WHO did not make any announcements that indicated the severity of the outbreak.

On August 8, 2014, 139 days after learning of the first Ebola case in West Africa, the WHO finally declared the epidemic a “public health emergency of international concern.” According to the humanitarian organization Médecins Sans Frontières (MSF), however, this call to arms was not strong enough. On September 2, 2014, MSF International President Dr. Joanne Liu delivered a speech to the United Nations in a special briefing organized by the office of the UN Secretary General and the WHO. “Leaders are failing to come to grips with this transnational threat,” she said. “The WHO announcement on August 8th that epidemic constituted a ‘public health emergency of international concern’ has not led to decisive action, and states have essentially joined a global coalition of inaction.” The two doctors who discovered Ebola decades ago, Jeremy Farrar and Peter Piot, expressed similar concerns in an editorial published in the New England Journal of Medicine. “Ebola has reached the point where it could establish itself as an endemic infection because of a highly inadequate and late global response,” they wrote. As the premier international health organization in the world, the WHO was expected to be a leader in the response to the Ebola crisis, yet initially it failed to do so.

Like other UN organizations, the WHO is large and slow moving due to its immense bureaucratic structure, and this makes rapid responses to diseases like Ebola almost impossible. The WHO Assembly does not come together often enough to discuss pressing global health issues, as it is only required to meet once a year. Furthermore, Director General Dr. Chan has expressed support for a more democratic decision making process, a move that may reduce the WHO’s ability to act swiftly, especially in sending funds and personnel to address emergency outbreaks. Nils Daulaire, a former American representative on the Executive Board, said in a New York Times article, “[Chan] has very assiduously promoted the idea that it is member states of WHO that are the owners and decision makers in a fundamental way.” In this vein, the headquarters in Geneva delegated most of the WHO’s responsibility to the Africa regional office in its early response to Ebola. Dr. Chan and other leaders at the WHO headquarters sent aid and experts, but left the coordination of the on-the-ground response to the regional office.

Another issue that has become more evident during the fight against Ebola is the WHO’s budgetary woes. Currently, the WHO is $102 million short of its funding goal to combat the epidemic until June 2015. In fact, the WHO’s funding troubles started long before the recent Ebola outbreak. One source of the problem is the WHO’s budgetary structure, which has two separate branches. One share of the budget is comprised of the mandatory contributions from each member state, called “assessed contributions,” and the allocation of these funds is left to the discretion of the Director General. The other share of the budget consists of voluntary contributions from individual governments, non-governmental foundations, and other organisations. Unlike the assessed contributions, voluntary contributions are earmarked for specific programs, with donors determining their funding priorities. Thus even though the WHO may receive huge sums of money in donations, it is often unable to divert these funds to projects based upon current needs or emergencies. Furthermore, while the assessed contributions have remained unchanged for decades, the WHO’s ever-expanding scope has necessitated a greater reliance on voluntary contributions, causing increased inflexibility in the budget.

The size of the WHO budget has also been reduced in recent years, prompting cuts to departments and funds that would have been incredibly helpful in addressing the Ebola epidemic. The African Regional Office’s budget for epidemic preparedness and response was more than halved over five years, decreasing from $26 million in 2010-11 to $11 million for 2014-15. Nine of twelve emergency response personnel for the African office were laid off. The WHO was forced to let go of their team of cultural anthropologists, which likely impeded the effectiveness of the on-the-ground Ebola response. But even as the WHO’s budget has declined, the amount of money invested worldwide in all health-related activities is estimated to have risen from $5.6 billion in 1990 to $26.8 billion in 2010. In the context of the Ebola epidemic, Schlegelmilch believes that the WHO’s smaller budget had far reaching consequences. “It was the lack of people, the lack of access, the lack of managing politics, that were direct results of the cuts that were made,” he said.

The WHO’s funding shortfall is by no means an indicator of diminished interest in addressing global health problems. Rather it is that the WHO, which was one of the only organizations of its kind when it was established in 1948, is today part of a vast community of global health organizations. Now, the World Bank, the Bill and Melinda Gates Foundation, Oxfam International, and MSF are some of the larger players in the global health arena. Recently, many international health organizations that are better funded and less bureaucratic than the WHO have proved instrumental in combating West Africa’s Ebola epidemic.

While necessary for an effective response to the Ebola epidemic, working effectively with smaller organizations can be a challenge for a large organization like the WHO. Anne Lui, a Program Manager for Health Systems Development at the Earth Institute, observed that the WHO was hesitant to partner with smaller organizations treating Ebola patients in Guinea. “The international pressure probably did cause a little bit of skepticism in terms of who was coming in,” she said. The WHO’s hesitancy to work with outside organizations is not entirely self-serving: “They also feel like they have a responsibility in-country,” Lui said. “There are all of these organizations coming in; who are the right ones to work with?” In fact, the WHO’s delayed cooperation may have been an attempt to filter out the organizations that were not effective or helpful to their efforts. Although the WHO has good intentions, it needs to change in order to improve its performance. This fact has been recognized within the organization, and in January 2015, Dr. Chan proposed the most sweeping set of reforms in WHO history. The planned changes would allow the WHO to execute more effective on-the-ground response to health crises as they arise. The changes would also establish a $100 million emergency fund, and a team of doctors, nurses, and other medical personnel, to be deployed in case of a crisis. The WHO Executive Board has unanimously approved of these reforms. In order to take full effect, however, the WHO assembly will have to vote on the reform measures during its annual meeting this coming May. While many agree that these reforms are necessary, whether they will actually be implemented is uncertain, as the WHO has been in a similar position before and still failed to enact change. After the 2009 swine flu epidemic, which revealed many of the same weaknesses in the WHO, structural reforms were proposed and yet none were put into place.

This does not mean that the WHO cannot be an incredibly effective organization. In 1958, the WHO began a worldwide initiative to eradicate smallpox, which proved successful in 1977. But today, now that the global health sphere is saturated with a variety of organizations, the WHO needs to rebrand itself. Lui and Schlegelmilch both agree that the WHO has an opportunity to remodel itself as an international coordinator, synchronizing the efforts of organizations with the same goals. As Lui notes from her experience working in Guinea, this is a role that the WHO has started to take on during the Ebola epidemic. “When I first went there in October, they were the office that hosted all the meetings for the partner [organizations], so that’s a step,” she said. But the WHO needs to take even larger steps if it wants to stay relevant and continue to effectively act on its mission to improve health worldwide. As Schlegelmilch says, “If WHO doesn’t have that coordination capability and it doesn’t invest in disaster logistics, then the science is just a series of publications.”•