WHO and the Ebola Crisis

It was 38 years ago, in 1976, that scientists first identified the virus. It had been found in a small village in northern Zaire (as the Democratic Republic of the Congo was called in those days) along the banks of the Ebola River. Initially called Ebola hemorrhagic fever and now known simply as Ebola virus disease (EVD), it has erupted two dozen times since then. Most of the outbreaks have been small and quick, but they killed more than half of those inflicted. The current West African outbreak, which has struck urban areas with mobile populations, has already killed more people than all previous outbreaks combined. Moreover, the number of cases is growing exponentially, with reported cases doubling every three weeks. Computer simulations done by the U.S. Centers for Disease Control and Prevention (CDC) suggest that by late January 2015 (four months from this writing), the number of Ebola patients could be anywhere from 0 to 1.4 million, depending on many shifting variables, including the effectiveness of the international response. The medical systems of the countries involved are breaking down, and the epidemic is currently outpacing international efforts to contain it. In addition, the World Bank reports that the epidemic could have a catastrophic economic impact on the countries involved, owing less to the disease than to “aversion behavior” as others seek to isolate whole countries. The suspension of commercial flights to the afflicted area has even made it difficult for volunteers and supplies to reach victims.

The current Ebola outbreak, which primarily effects Liberia, Sierra Leone and Guinea, began in December 2013, but it was identified only in March 2014 and declared a health emergency in August. On Sept. 18, 2014, the U.N. Security Council unanimously declared it a threat to international peace and security and urged member states to rally their resources to combat it. Dr. David Nabarro, the recently appointed U.N. system coordinator for Ebola, estimated that the existing level of effort needed to be increased twentyfold. (Keep in mind, too, that this is happening at a time when wars in Iraq, Syria, South Sudan and the Central African Republic are generating their own health crises.)

Within the United Nations system, the agency most concerned with the crisis is the World Health Organization (WHO). Its performance, however, has come under criticism for its slow response. The problem is largely due to WHO’s eroding position within the international health system and, to some extent, to its complex bureaucratic structure.

WHO was established in 1948. Its founding treaty gave it a complex, federated bureaucracy because it was required to absorb existing regional entities, such as the Pan-American Health Organization (PAHO). Still, for decades, it was one of the most successful U.N. agencies. WHO acted as a coordinating body and a technical consultancy, advising member states on the best practices for combatting disease. WHO oversaw the eradication of smallpox, and it organized global immunization campaigns against measles, polio, and yellow fever. Then, in the 1990s, it was struck by a set of adverse trends. Some member states and special interests objected to its “overly political” studies that, for example, linked disease to poverty or examined the health impact of pharmaceutical patents. At the same time, private philanthropic institutions and governments began promoting their own disease-specific programs focused on AIDS, malaria, or tuberculosis. WHO became one voice among many on international health issues. (The U.N.’s creation of a new specialized program, UNAIDS, contributed to this trend as well.) Moreover, some of these rivals, such as the Bill and Melinda Gates Foundation, were much better funded. Health-related aid quadrupled in the two decades after 1990, but WHO’s governing body, the World Health Assembly (WHA), froze members’ dues that year and has not changed them in the quarter century since, which means that WHO’s official source of funding declined dramatically in real terms. To pay its staff and keep its offices open, the agency sought voluntary contributions from private and public sources. Such voluntary contributions came to account for 80 percent of its budget. These funds are often tied to the donors’ priorities, which makes it difficult to address global health trends in a cohesive, comprehensive manner. Far from providing direction, leadership, and coordination, the various entities in WHO’s federated structure were competing with each other for grants and catering to donors’ goals.

Then came the crash of 2008, and the voluntary contributions began to shrivel up. Then came the euro crisis of 2010. The Geneva-based agency receives its funding in U.S. dollars but makes its payroll and many other payments in Swiss francs. With the onset of the euro crisis, people fleeing the euro for Swiss francs drove the value of the franc up by 32 percent, reducing the value of dollar-denominated revenues. In 2011 WHO was forced to lay off 20 percent of its staff. In the same year, an independent study proposed the creation of a $100 million fund that WHO could use in the event of a public-health emergency, but no action was taken. Instead, WHO’s epidemic-response department saw its budget cut three times in the next three years. In 2012 alone, the WHA slashed funding for crises and epidemics by 50 percent. WHO hoped to balance these cuts by issuing guidelines on how countries could respond to their own epidemics. This is, indeed, a key part of WHO’s role, but many countries, especially in Africa, were not in a position to implement them.*

As Laurie Garrett, a global-health specialist at the Council on Foreign Relations, describes the current situation: “In reality, the WHO begs airlines for tickets in coach, pleads with drug companies and protective gear manufacturers for free handouts, and has only the expertise on hand that governments are prepared to payroll and donate, such as scientists from the U.S. Centers for Disease Control and Prevention (CDC).” WHO was hardly in a strong position to address the most recent Ebola outbreak.

The market, of course, has not resolved the Ebola issue, either. Up to now, outbreaks have been too brief, too small-scale, and too concentrated in poor countries to generate the sort of profit potential that would interest the private sector. Thus, while some preliminary testing has been done, there is no approved remedy or vaccine for Ebola 38 years after the disease’s discovery.** (The entire inventory of the unapproved experimental drug ZMapp consisted of about half a dozen doses.)*** The disaster-oriented philanthropic response to the current epidemic has also been weak. Philanthropy generally has its strongest response in the immediate recovery phase of a sudden, dramatic, catastrophic event, such as an earthquake or hurricane. Epidemics are not well suited to that form of behavior. Epidemics begin quietly, build slowly in their initial stages, and have no easily identifiable transition to recovery. Although epidemics are easiest to address in their earliest phases, when the cases are still few in number, such situations do not generate public attention.

After a slow start, however, WHO has been getting its act together. In late August the agency released its “Ebola Response Roadmap,” a plan for stopping the Ebola epidemic within nine months. It established the Ebola Crisis Center, in New York, in September. Also that month the Security Council created the United Nations Mission for Ebola Emergency Response (UNMEER), its first health-related overseas mission. Given the reluctance of commercial carriers to fly to Ebola-stricken countries, arrangements were made to fly people and supplies in through Ghana and UNMEER was set up there. Now, the remaining question is whether member states can mobilize enough funds and personnel in time. A clinic with 80 Ebola patients requires 200–250 health-care providers, equipped with full-body protective gear, plus logistics personnel.

Addressing the Ebola situation in early September, Dr. Scott F. Dowell, a past director of the Division of Global Disease Detection and Emergency Response at CDC, told the New York Times: “There’s confusion and chaos. It argues for a system that’s organized as much as possible ahead of time so people know their roles.” There is an agency in position to perform that role, WHO. It only requires the international community to fund it and staff it adequately.

*The countries afflicted by the current outbreak are desperately poor and never had robust public-health systems. Moreover, Liberia and Sierra Leone were ravaged by civil war in the 1990s and 2000s. This is a problem for WHO, which, in theory, focuses on coordination and relies on member countries to do the work in the field.

**The traditional method for “treating” Ebola is to isolate victims from society in order to check the spread of the disease and then to wait to see if they live or die. The chances of survival can be increased significantly by treating symptoms and by replenishing lost fluids. (Ebola victims lose fluids through hemorrhaging, diarrhea, and vomiting.) One factor hindering treatment is local suspicion of government, in general, and of health-care workers, in particular. Many people in West Africa hear rumors that Ebola volunteers are there to spread the disease and see people taken to hospitals never to return alive. Thus untold numbers of victims are kept at home and hidden from the authorities, undermining efforts to stop the spread of disease.

***The media devoted much attention to two U.S. medical volunteers in Liberia who survived after being treated with the experimental drug ZMapp, but others treated with it have died. Moreover, the two Americans were also treated with “convalescent serum,” that is, transfusions of blood from an Ebola victim who had survived and thus had built up natural antibodies to the disease. A third American, treated with blood from one of the first two, also recovered. WHO recommends treatment with convalescent serum.

For further reading: “WHO: Past, Present, and Future,” a special issue of Public Health 128:2 (February 2014).

A version of this post appeared in UNA-Westchester Global Connection (October 2014).