After Slow Ebola Response, WHO Seeks to Avoid Repeat

After Slow Ebola Response, WHO Seeks to Avoid Repeat

Health Body to Consider Rapid-Response Teams, Other Changes

By Betsy McKay in Atlanta and Peter Wonacott in Freetown, Sierra Leone

From the Wall Street Journal

The tepid initial response to West Africa’s Ebola outbreak exposed holes in the global health system so gaping it has prompted the World Health Organization to consider steps to prevent a repeat, including emergency-response teams and a fund for public-health crises.

In a special session next month in Geneva, the WHO’s executive board is expected to consider those and other recommendations by its member countries—including a proposal that it commission an outside review of its Ebola response—according to a document reviewed by The Wall Street Journal.

The plan comes as global health officials are struggling with a knotty question: how the WHO could have moved at a slow pace initially despite lessons learned more than a decade ago from another deadly outbreak, of SARS.

That virus killed hundreds after surfacing in China in 2002. But the WHO acted more quickly and decisively back then, international public-health specialists generally agree. And the global health system put measures in place afterward that were supposed to help it respond even more quickly to such outbreaks.

Many aspects of Ebola’s spread trace to crippling local lapses, such as strikes by body collectors who left diseased corpses on the streets. And known diseases like Ebola tend to cause less alarm than diseases like SARS that are new and airborne. Ebola, which spreads through bodily fluids, has been causing human outbreaks since 1976.

But some global health officials say an overly cautious WHO bureaucracy was another factor in Ebola’s unchecked spread early on. Among other contributing problems at the United Nations agency, they say, were its lack of authority over its regional network and budget cutbacks.

WHO Director-General Margaret Chan says the agency, “like the rest of the world,” was slow to respond to the outbreak. “With the benefit of hindsight, WHO could have mounted a more robust response,” she says in an email relayed by a spokesman.

The Ebola epidemic, which has killed over 7,800 people so far, is part of a new reality: Contagions in countries with rickety health systems can threaten those with the most-advanced medical care, though developed countries have prevented major Ebola outbreaks thus far.

Next month’s WHO special session will seek to face that reality by forming better defenses against deadly pathogens.

At the Jan. 25 meeting, the WHO says, its executive board—health officials from 34 countries—will debate changes to how it responds to outbreaks. It will determine which to put forward for approval by the WHO’s decision-making body, the World Health Assembly. The assembly, which meets in May, comprises delegations from the WHO’s 194 member countries.

Recommendations it is expected to consider include forming a highly trained rapid-response team to deploy upon an outbreak—part of a “global health emergency workforce”—according to a draft resolution the Journal reviewed.

Other recommendations include a review prepared by a panel of outside independent experts, a special WHO fund for public-health emergencies and requiring that WHO representatives in countries have strong backgrounds in outbreak response, the draft shows.

Dr. Chan says she welcomes the recommendations. A review of the WHO’s actions during a 2009 flu pandemic showed the world was ill-prepared for a global health emergency and was lucky that virus wasn’t more severe, she says.

“We were not so lucky this time and if we don’t fix the system we may be very unlucky the next time,” she says. “And there will be another international public health emergency.”

Peter Piot, director of the London School of Hygiene & Tropical Medicine and a founder of the Joint U.N. Program on HIV/AIDS, says the WHO should be allowed to intervene in countries, possibly autonomously, with a well-funded, dedicated group of germ detectives. “These epidemics,” says Dr. Piot, who helped discover the Ebola virus, “must be looked at as what economists call a public good.”

Those who battle against global epidemics face unprecedented challenges. The list of infectious-disease threats ranges from Ebola and SARS to Middle East Respiratory Syndrome, a mysterious new virus that has killed at least 343 people since 2012. And international travel and increasing urbanization let viruses spread more quickly.

Ebola cast a particularly harsh light on the global health system’s ability to handle such outbreaks.

The crisis started with striking similarities to the SARS outbreak. In 2002, a deadly flulike respiratory disease—severe acute respiratory syndrome—started spreading quietly in China. Beijing at first played down the danger and insisted it had matters under control.

But once SARS appeared outside China, the WHO acted decisively, calling for health authorities around the world to join forces to stop it. The organization issued an emergency travel advisory, warning the public of symptoms.

Perhaps most crucially, WHO officials compelled Beijing to come clean about the number of infections health authorities had concealed. In one dramatic news conference, the Chinese government admitted the true number was almost 10 times what it originally reported. The health minister and Beijing mayor were ousted.

 “If you think of SARS,” Dr. Piot says, “the WHO did a good job” in warning the world early about the disease and calling Beijing’s bluff, even though doing so was politically difficult.

Since then, governments and private donors have invested billions of dollars in new disease-surveillance systems, diagnostic testing, drugs and vaccines, and preparedness training. The World Health Assembly adopted new international health regulations in 2005 that require WHO countries—including those now hardest-hit by Ebola—to report cases or outbreaks of disease that pose an international risk.

But global health authorities are often still slow to recognize outbreaks, because many lack the capacity to monitor for unusual disease clusters. And when the response does come, it can be disjointed.

These factors came to a head in March, when a laboratory identified the deadliest strain of Ebola—Ebola Zaire—as the cause of a mysterious three-month old outbreak in Guinea.

Past Ebola outbreaks had surfaced in rural pockets of Central Africa, but not in West Africa. And while the WHO’s health security chief, Keiji Fukuda, in April called the early cases “one of the most challenging Ebola outbreaks that we have ever faced,” others played down the initial outbreak.

In West Africa, deferential WHO officials initially ceded control of the Ebola response to local governments, which were overwhelmed and short of resources, say people familiar with the response. WHO staff in West Africa reported that the situation was under control, and officials in Geneva didn’t actively seek other sources of information, these people say.

In May, many experts, including some Ebola veterans outside the WHO, say they thought the outbreak was winding down. Instead, the virus was spreading virulently. The outbreak soon became the largest in history, and the WHO and aid organizations were overwhelmed by the number of patients.

It wasn’t until July that the WHO mounted a global-scale emergency response to Ebola. By then, the virus had spilled across borders with Liberia and Sierra Leone. In September, the U.N. formed a new unit to lead management of the epidemic.

Cases are surging in Sierra Leone, where more than 2,200 illnesses have been reported since the beginning of December, including more than 1,200 deaths. The government this month asked citizens to avoid public gatherings during the festive season.

Some health experts worry the epidemic may never be fully contained in West Africa.

“It was a perfect storm for an epidemic,” says Amanda McClelland, a senior officer with the International Federation of Red Cross and Red Crescent Societies who in September opened the group’s first Ebola clinic in Kenema, Sierra Leone.

Under the WHO’s epidemic response, she adds, “there were more technical advisers than boots on the ground and more meetings than I could handle.”

In Kenema, the WHO demonstrated the muscle it can bring. At the Kenema Government Hospital, 37 nurses and doctors died as Ebola ravaged the city. Experts working for the WHO helped set up infection-control points and isolation wards. Christian Pratt, the senior doctor there, credits the WHO for saving his hospital and God for saving him. “At least someone should be left behind to tell the story,” he says.

“This epidemic is a real wake-up call for all of us,” says Daniel Kertesz, a Canadian doctor and one of a few WHO officials who replaced existing country chiefs in West Africa to accelerate the WHO’s response.

While many global health officials say the WHO’s slowness to recognize the threat of Ebola was a structural problem, others say differences in leadership style may have helped set the agency’s response to Ebola apart from SARS.

The WHO’s chief during SARS, Gro Harlem Brundtland, moved quickly to alert the world to the disease. She worried less about alienating member states politically than about “getting stuff done,” says Nils Daulaire, U.S. representative to the WHO’s executive board from 2010 until earlier this year.

Dr. Chan, elected director-general in 2006, prefers building consensus with WHO’s member countries over public action or confrontation, say those who have worked with her.

Dr. Chan says that while she believes consensus-building is the best approach, she also confronts governments when necessary. “But when it comes to confrontation, I prefer to do that behind closed doors.”

Dr. Chan says requirements under the 2005 international health regulations, which went into force in 2007, make outbreak response today different from during SARS. She says she can’t issue a travel advisory without consulting an emergency committee of experts, for example.

Her focus on consensus has led to some changes that could improve disease response, Dr. Daulaire says. They include building closer ties with the WHO’s powerful regional offices, which are the front line in crises but whose directors are elected regionally rather than appointed by Geneva.

Regionally appointed WHO officials can be a problem because they have little incentive to rock the boat with national health authorities who put them in their posts, says Dr. Daulaire. “This is not an emergency-response-friendly kind of system.”

He says Dr. Chan has also tried to gain greater authority for Geneva over the spending of voluntary contributions from governments, foundations and others, which make up 77% of the 2014-15 budget. Many are currently earmarked for specific health issues, an increasing problem as the agency’s budget has been cut.

Budget cuts went “well beyond the fat,” Dr. Daulaire says. The WHO’s budget shrank at least 12% since 2010 as donors cut back in the global financial crisis. Big donors include the governments of the U.S. and the U.K., and the Bill & Melinda Gates Foundation. The WHO underwent layoffs; veteran disease trackers left, only to be called back to battle Ebola.

Dr. Chan says: “Predictable funding and better clarity on roles and responsibilities” within the WHO “are essential for an effective outbreak response.”

If the WHO adopts some of the proposals it is expected to discuss in January, it may better be able to rapidly deploy a global coterie of specialized and seasoned units.

One such unit is the People’s Liberation Army 302 Military Hospital, which in September began training local medical personnel in Freetown, Sierra Leone, to tackle Ebola. The unit had several staff infected by SARS in China. At a Freetown clinic run by the unit, there are contamination-control points, separate wards to isolate suspect and confirmed cases, and a clear neutral zone for other patients.

“This is international methodology,” says George Gao, a member of the Chinese hospital team and deputy director of China’s Centers for Disease Control and Prevention. “But after SARS it was much clearer to us why we were doing this.”