The Guardian – Thousands died in west Africa, but the biggest victim could be the ineffectual World Health Organisation, which acted far too slowly to contain the outbreak
Smiles and banter have returned to Sierra Leone. On its neglected, but beautiful, white sand beaches, boys are playing football again with a new energy. The ban on public gatherings has been lifted. Ebola is a bad memory.
But in Magazine Wharf, a dense shantytown of concrete, wood and rusting corrugated iron tumbling down from Freetown’s biggest market to the sea, and running with pigs and children, all the conditions are there for another epidemic.
It could be Ebola or it could be something else – cholera, Lassa fever, flu. It could be inconvenient, or it could be devastating. But will the world have learned its lessons and respond quicker, more effectively?
A year after the peak of the Ebola epidemic, which killed more than 11,300 people and threw the US and Europe into a panic, it is the global health system that is under scrutiny. In particular, the World Health Organisation (WHO) is in the dock for failing to act soon enough. Big questions are being asked about its competence and its future.
The WHO, founded in 1948 in a postwar world that understood the ravages of disease, pledged to work for “the attainment by all peoples of the highest possible level of health”. Its most celebrated success was the eradication of smallpox in the 1970s. Infectious diseases have been the priority for most of its history. A huge collaborative effort against polio has rid all but two countries of the endemic disease and record numbers of children around the globe are vaccinated against common killers such as diphtheria and rotavirus.
In the 1970s and 80s, the WHO led the global crusade for better understanding and treatment of mental health. At the end of the 90s, it took on the tobacco industry, leading to the groundbreaking WHO framework convention on tobacco control adopted in 2003. Its work has helped bring down child mortality by 53% since 2000, although short of the millennium development goal of two-thirds, and maternal mortality has halved.
But what happened in Sierra Leone and the other small and impoverished west African states of Guinea and Liberia that together bore the brunt of Ebola, has shown up the WHO’s inadequacies – its grindingly slow bureaucracy and its deference to political leaders even in the face of an epidemic that knows no national borders.
The WHO, part of the sprawling UN family of bureaucracies, employs some dedicated and brilliant people, and much of its work setting standards and advising on everything from sugar intake to what drugs each country should stock is vital and sound. And even though there was a moment when some were calling for the WHO to be replaced, probably by a version of the US Centers for Disease Control and Prevention (CDC), most critics now agree that the WHO must be the body to lead in improving health worldwide.
But a close look at what happened when Ebola struck in a remote forested region of west Africa, where boundaries dissolve as traders and extended families travel the rivers and unmarked roads, shows how unprepared the WHO was for a disastrous but all-too-likely scenario – a major disease outbreak with global implications in a desperately poor region with hopelessly inadequate healthcare.
Any virus would thrive in Magazine Wharf. The conditions are perfect: up to a dozen people living in one or two-room dwellings that are cramped together, raw sewage, waste from the market, the slaughtering of goats next to homes and human and animal effluent running down the hill to the sea. There is one toilet for 1,000 people. Fishermen, traders, women and young girls carry impossible loads on their heads thread up and down the steps, weaving around piles of rotting vegetables. There is no barrier to disease spreading through the air or from hand to mouth.
Such urban slums were a nightmare for the public health experts trying to contain Ebola. But it should never have reached Freetown, let alone the US.
The first person to fall ill was a two-year old boy in a remote jungle region of southern Guinea. That was in December 2013. But because of the extreme inadequacies of healthcare and surveillance systems in Guinea, Sierra Leone and Liberia, Ebola was first diagnosed only in March 2014. And then, according to Jose Hulsenbek, the then head of the Médecins Sans Frontières (MSF) mission in Sierra Leone, the government in Freetown did not want to think the unthinkable.
It had happened before. The minister of health, Miatta Kargbo, is said to have taken against MSF when it pushed hard for the government to declare an outbreak of cholera in 2012. Hulsenbek said: “She was very, very negative. She threw that back at us – ‘you guys make panic, you create all kinds of atmosphere, this is not helping’.”
The local WHO officials quickly became part of the problem. Margaret Chan, the organisation’s director general, has always maintained that the WHO is a technical body there to give help and advice when asked. But representatives in Sierra Leone and the other affected countries did not feel it was their job to tell ministers of health what to do. Quite the reverse. People who attended meetings on the Ebola threat said the WHO staff always agreed with the minister that it was a local difficulty. Ebola had been contained elsewhere and would be in Sierra Leone.
“I do feel that WHO’s role is to help us convince the government of these things and that didn’t happen,” said Hulsenbek. “Once it became very clear at the end of May that the government couldn’t ignore what was going on any more, there was still this tendency for WHO and the government both to say ‘we’ll get it under control’.” It took three more months for the full scale of the crisis to be admitted.
There were weaknesses at country level and in the Afro regional headquarters in Congo-Brazzaville. The WHO has a three-tier structure. Each country representative reports to a regional office. Above that is Chan in Geneva. But the Afro director is directly elected by Africa’s ministers of health, who partly fund the office, and is therefore dependent on them.
“What should be WHO’s strongest regional office because of the enormity of the health challenges is actually the weakest technically, and full of political appointees,” said Peter Piot, the head of the London School of Hygiene and Tropical Medicine and one of the discovers of the Ebola virus in 1976. Jeremy Farrar, the head of the Wellcome Trust, agreed. “There are longstanding issues around capacity, its location – it’s in Brazzaville, a tricky place to attract the world’s best – riven by politics, corruption and endemic weak leadership.”
The WHO offices in Freetown are colonial in style, occupying an enviable hill site with sea views. In the reception area is a hierarchy of photographs: the largest is of Sierra Leone’s president, Ernest Bai Koroma, followed by those of the WHO’s director general, Margaret Chan, and the newly appointed Africa region director, Matshidiso Moeti. Below them, slightly smaller again, are the portraits of the country directors from the 1960s on. The last is of Jacob Mufunda, who took up his post in 2013. They look like government ministers rather than the representatives of an international organisation.
The organisation’s capacity to deal with infectious diseases in the region had got worse in the wake of the flu pandemic of 2009, with a cut in the regional technical team from 10 to three. The WHO had been accused of crying wolf when the flu turned out to be less severe than expected. And the focus had turned to the growing problems of non-communicable diseases (NCDs) – lifestyle-related heart attacks, strokes, cancers and diabetes – in response to the demands of the member states that make up its executive board.
One insider said: “The WHO has consistently been told that the burden of disease has shifted to NCDs. Resources have been shifted to cover this. If that is what governments want, that is what they get.”
Money is an issue. Over the past 50 years, core funding – the mandatory contributions from all member states that it can use for whatever it thinks fit – has eroded. Its approved programme budget for 2014-15, as of April, was $3.98bn, of which just 23% was directly funded contributions from member states. The rest is from voluntary contributionstied to specific projects.
So funding was tight, and there were competing emergencies in the Central African Republic and South Sudan. And still a sense, in the spring at least, that this could be controlled like previous outbreaks.
“We had controlled outbreaks in DRC, in Angola, Uganda, in Congo many times,” said Zabulon Yoti, an Ebola expert from Uganda based at the Brazzaville office. We use a small core group, which is WHO, CDC, MSF and the local Red Cross that usually supports the country.”
The Geneva secretariat of the WHO’s global outbreak and response network (GOARN) was alerted. This called on experts from the US and elsewhere, who flew to Guinea. They quickly realised it was longer lasting and more complicated than a few isolated cases. But it was in a rural area, as before, and they felt sure it could be contained. They were wrong. Villagers were simply not reporting outbreaks any more. By May, it had been diagnosed in all three countries. By late summer, it had reached the slums.
“It became out of control because it reached congested slum areas as well,” said Yoti, who moved to the frontlines at Keilahun in Sierra Leone in June, and on to Freetown in August. “This was the period where we said no, no – we have never seen [anything like] this. So this is when the shouting was made, but our efforts had gone in, our sweat had poured on this, we had done our best: we emptied our coffers, we left our own offices, we came and sat in the villages, worked with the chiefs, [but] the spread was just too fast. This was unprecedented. This was unusual. I’m not sure if this happened again we would still be prepared.”
What many cannot understand is how anyone at the WHO could ever have thought Sierra Leone, bottom of the world poverty league table and still recovering from a civil war, was capable of controlling Ebola. In 2005, 195 WHO members states had agreed to a set of international health regulations. Every country would strengthen its surveillance capacity and its ability to respond. Few have complied; impoverished and fragile states have never even begun. Sierra Leone had few doctors and nurses, let alone epidemiologists, and was unable to deal with everyday healthcare needs, such as childbirth and malaria, let alone an exceptionally dangerous virus.
But some in Geneva were more concerned about the potential devastation to west African economies that declaring an international emergency would cause – which did indeed prove the case. On 10 June, Sylvie Briand, the head of the pandemic and epidemic diseases department, her boss, Keiji Fukuda, and others sent a memo to Chan, noting that cases might soon occur in Mali, Ivory Coast and Guinea-Bissau. But they went on to say that even convening an emergency committee to discuss the issue “could be seen as a hostile act”.
MSF’s international president, Joanne Liu, met Chan in July when, she said, “we were really getting upset”. The first Americans had been infected – two volunteers working in Monrovia, Kent Brantly and Nancy Writebol. The world was starting to realise that something deadly was happening in west Africa.
Liu said she told Chan: “You are the only person I know who has the legitimate authority to call it. I said you need to step up to the plate.” But Chan said she did not believe it was out of control. There was a meeting planned of the three country presidents. Liu said: “I said to her you should get on a plane and go. She did. I think it had not sunk in until it was right in her face.”
On 8 August, with the three countries imploding, Chan finally made the declaration. That same month, Jacob Mufunda, the WHO country representative in Sierra Leone, was moved – and is now the country representative in Zambia. Kargbo was sacked from the ministry of health. The WHO representatives in Guinea and Liberia have also been moved, while at the Afro regional office, the term of the director Luis Sambo has ended. A draft internal document leaked last October was blunt about the “politically motivated appointments” made in Brazzaville. Hopes for change are riding on Matshidiso Moeti from Botswana, who has taken Sambo’s place.
It will take more than a few redeployments. The WHO’s inadequacies have been noted before, but proposals for reform have been left on the sidelines. A prescient report by Charles Clift at Chatham House, published before the Ebola outbreak hit the headlines, said “numerous external reports going back more than 20 years have identified key problems arising from the WHO’s unique configuration of six regional offices, with directors elected by member states, and its extensive network of about 150 country offices”. But the WHO’s governance structure meant there was a strong interest in maintaining the status quo.
An independent report commissioned by Chan to assess what went wrong within the WHO over Ebola, led by Barbara Stocking, the former head of Oxfam and now the principal of Murray Edwards College, Cambridge, said the outbreak might have looked very different if the political will and resources to ensure countries complied with the regulations had been there.
Her report was highly critical. It said the “independent and courageous decision-making” by the director general and secretariat necessary to declare a public health emergency “was absent in the early months of the Ebola crisis”. Messages between WHO staff on the Ebola frontline and those in Geneva either “did not reach senior leaders or senior leaders did not recognise their significance. The WHO does not have an organisational culture that supports open and critical dialogue between senior leaders and staff or that permits risk-taking or critical approaches to decision-making”.
Stocking also condemned the funding of the WHO by member states, which has not been increased for some years, in spite of a request by Chan. The money available to monitor countries’ implementations of the international health regulations “is now very inadequate”, the report said.
The WHO is under scrutiny as never before. Two important reviews into the way the world responds to global health threats are under way – by the Institute of Medicine in the US, and byHarvard and the London School of Hygiene and Tropical Medicine. Both are expected to feed into the deliberations of a high-level panelconvened by the UN secretary-general, Ban Ki-moon, which will report in December.
Chan, meanwhile, is trying to bring about the revolution needed to ensure the WHO is fit to fight the next pandemic. In May, she told the World Health Assembly in Geneva: “I am committed to building an organisation with the culture, systems and resources to lead the response to outbreaks and other health emergencies. ” She was creating, she said, “a single new programme for health emergencies, uniting all our outbreak and emergency resources”. It would have benchmarks for what must be done within 24, 48 and 72 hours of an outbreak – rather than over the course of months.
The plan is to include a global health emergency workforce made up of volunteers ready to drop everything and come when the WHO calls. GOARN, the WHO-supported network with about 2,000 experts on tap that has sent specialists into 17 Ebola outbreaks, said that was what it already did. Ray Arthur, who chairs its steering committee, said: “From our perspective, WHO already has this workforce and it has been successful in the last 15 years. There were teams in the field less than a week after it was known there was Ebola in Guinea.”
It became a bigger problem, he said, because of “the lack of international commitment to bringing transmission to an end – that includes WHO”. There were also problems with the Guinea government. Arthur said: “Everybody wanted the problem to go away. It wasn’t as aggressively pursued as it should have been.”
David Heymann, the head of the centre on global health security at the Chatham House thinktank,said: “It’s the leadership that’s the issue in WHO. If the leadership is strong and rapid, then things can happen. If it’s not, they don’t happen.”
There may be a struggle over who controls the emergency workforce Chan is proposing. Should it be embedded inside the WHO? Influential critics say not. Farrar and others put forward a plan for a semi-autonomous body with its own leader reporting directly to the DG. They say: “What are the alternatives? It just remains a cluster division – whatever they currently call it – of WHO. As soon as we forget about Ebola, the individuals within it will just be redeployed – that happens. The staff after the [flu] pandemic were cut by 30% in the epidemic preparedness. The good ones will leave first and you will be left with the less good ones.”
We have been here before. The WHO’s inadequate and reluctant response to the Aids epidemic led to the launch in 1996 of UNAIDS, a separate agency under the UN umbrella, led by Piot. It was not the finest hour for the WHO, which still had an HIV department. The launch of two major semi-independent campaigning organisations, Roll Back Malaria and Stop TB, were also seen as manoeuvres to bypass the bureaucracy of the WHO, although it has since been praised for working with them.
The US showed the most disquiet over the WHO’s handling of the outbreak and has already moved to set up an African version of its CDC in Addis Ababa in conjunction with the African Union. Farrar said: “I think if there isn’t action, Obama won’t come out and say we’re taking over the epidemic responses for the world. It will just happen quietly and you can see some of that happening already with the African CDC.”
The WHO is, meanwhile, in danger of being outflanked by other innovative new arrivals on the global health scene. Over 20 years, the number of serious players in global health has grown enormously, from the World Bank to the Gates Foundation, the CDC and many others.
In Sierra Leone, the new country representative is Anders Nordström, a former acting director general of the WHO, who as yet does not have his photograph on the wall. He is a high-level appointee to an office seen as a backwater before Ebola. He wanted to return to the field after years on high-level boards, he said, but is also keen on overseeing restructuring in Sierra Leone and bringing reform to west Africa. He talked of “trying to make WHO be what WHO should be”, supported by Chan and Moeti, the Afro regional director.
He identified six core areas, the first of which is as “a trusted leader”, which will be “essential with the NCD agenda we have in front of us”. Nordström, from Sweden, thinks the WHO should be leading the crusade against inactivity and bad food that is fuelling obesity and diseases such as diabetes and cancer.
The second area is setting standards and guidelines – as the WHO has on tobacco and sugar. Third is providing policy advice on health systems and staff. Fourth is research – one area where the WHO did really well in the Ebola outbreak, as the backer of the successful efforts to find a vaccine. Fifth is technical advice – and he believes that WHO should be advising governments but not running treatment centres as MSF does. Nordström says: “WHO should not procure drugs. WHO should not do logistics. WHO should not provide services.” The sixth core area is monitoring health around the world to be able to speak out about what is going on.
This is, according to Stocking, a defining moment for the WHO. Few want to see it replaced. Liu said: “Although MSF was very critical of the WHO, we do acknowledge the necessity to have such an entity. The reality is [that] we are dreaming of a stronger WHO.” The WHO ought to be a superhero, she said, standing up for the right to good health and speaking the truth to the powerful. That requires bold and brave leadership.
Chan seems set on reform of the WHO, but her term ends in less than two years. It will be up to the member states to choose her successor. How many will want a leader who is prepared to tell them truths that matter to the health of all of us but that they may not want to hear?