With treatment centers overflowing, and alarmingly little being done to stop Ebola from sweeping through West African villages and towns,Joanne Liu, president of Doctors Without Borders, said she knew that the epidemic had spun out of control.
The only person she could think of with the authority to intensify the global effort was Margaret Chan, director-general of the World Health Organization, which has a long history of fighting outbreaks. If the WHO, the main United Nations health agency, could not quickly muster an army of experts and health workers to combat an outbreak overtaking some of the world’s poorest countries, then what entity in the world would do it?
“I wish I could do that,” Dr. Chan said, recounting their conversation at the WHO’s headquarters in Geneva this summer, months after the outbreak burgeoned in a Guinean rain forest and spilled into packed capital cities. The WHO simply did not have the manpower or ability to flood the Ebola zone with help, Dr. Chan said. It was a fantasy, she argued, to think of the WHO as a first responder ready to lead the fight against deadly outbreaks around the world.
The Ebola epidemic has exposed gaping holes in the ability to tackle outbreaks in an increasingly interconnected world, where diseases can quickly spread from remote villages to cities housing millions of people.
The WHO — the U.N. agency assigned in its constitution to direct international health efforts, tackle epidemics and help in emergencies — has been badly weakened by budget cuts in recent years that have hobbled its ability to respond in parts of the world that need it most. Its outbreak and emergency response units have been slashed, veterans who led previous fights against Ebola and other diseases have left, and scores of positions have been eliminated — precisely the kind of people and efforts that might have helped blunt the West Africa outbreak before it ballooned into the worst Ebola epidemic ever recorded.
Unlike the SARS crisis of 2003, which struck countries in Asia and elsewhere that had strong governments and ample money to spring to action, the Ebola outbreak has waylaid nations that often lack basic health care, much less the ability to mount big campaigns to stamp out epidemics.
The disease spread for months before being detected because much of the work of spotting outbreaks was left to desperately poor countries ill prepared for the task. Once the WHO learned of the outbreak, its efforts to help track and contain it were limited, according to some doctors who participated, contributing to a sense that the problem was not as bad as it actually was. Then, as the extent of the epidemic became obvious, critics say the agency was slow to declare its severity, come up with plans and marshal the people and supplies needed to help defeat the disease and treat its victims.
“There’s no doubt we’ve not been as quick and as powerful as we might have been,” said Marie-Paule Kieny, a WHO assistant director-general.
Another WHO leader agreed. “Of course, in retrospect I really wish that we had jumped much higher much earlier,” said Keiji Fukuda, assistant director-general in charge of outbreak response. “Of course, I wish we’d poured in more and more earlier.” But Dr. Fukuda added, “If this outbreak had been a typical outbreak, nobody would be saying we did too little, too late.”
After, the global financial crisis struck. The WHO had to cut nearly a billion dollars from its proposed two-year budget, which today stands at $3.98 billion. (By contrast, the 2013 budget of the U.S. Centers for Disease Control and Prevention was about $6 billion.) The cuts forced difficult choices. More emphasis was placed on efforts such as fighting chronic global ailments, including heart disease and diabetes. The whims of donors also greatly influenced the WHO’s agenda, with gifts, often to advance individual causes, far surpassing dues from member nations, which account for only 20 percent of its budget.
At the agency’s Geneva headquarters, outbreak and emergency response, which was never especially well-funded, suffered particularly deep losses, leaving offices that look, one consultant said, like a ghost town. The WHO’s epidemic and pandemic response department — including a network of anthropologists to help overcome cultural differences during outbreaks — was dissolved, its duties split among other departments. Some of the main outbreak pioneers moved on.
“That shaping of the budget did affect the area of responding to big outbreaks and pandemics,” said Dr. Fukuda, who estimated that he now had 35 percent fewer staff members than during the H1N1 flu pandemic in 2009 — more than double the cuts for the organization as a whole. “You have to wonder are we making the right strategic choices?” he said. “Are we ready for what’s coming down the pike?”
The outbreak began close to the borders of three neighboring countries — Guinea, Sierra Leone and Liberia — and spread surprisingly fast.
Stopping previous Ebola outbreaks had required meticulous tracking: monitoring people who had close contact with infected individuals, and isolating them if they developed symptoms. Previously, “if we missed a case,” said Simon Mardel, a British emergency doctor deployed by the WHO to help with the effort, “it was like a failure.”
This time, the number of contacts being followed was disastrously low from the beginning, only 8 percent in the epicenter of Guéckédou, Guinea, in early April, according to another doctor sent by the WHO. That meant the disease was silently spreading. Dr. Mardel said he thought the more experienced WHO leaders who had left the agency “would have been very vocal, and they would have sought to put it right quickly, as a matter of urgency.” A single person who traveled and became sick could touch off a conflagration.
It was not that responders were not trying. Victims’ contacts were spread across a wide area, hours away on bad roads. The payment of local workers had somehow been overlooked, so they stopped doing vital, risky jobs. Essential protective equipment was not delivered to many who needed it. Bottles of bleach were given out without buckets. The WHO lacked relationships with some long-standing organizations with large networks of health workers in the region.
“There never were the resources to put those things in place in many parts of the world,” said Scott F. Dowell, a specialist formerly with the CDC.
Since then, the WHO has engaged more than 400 people to work on the outbreak, including employees of other agencies in its network, and in August, the agency declared the epidemic an international emergency, hoping to stop it from crossing more borders. Dr. Chan has met with presidents in the region, and last week the WHO announced what it called a road map for a “massively scaled” international response.”
The current outbreak has killed more than 1,900 people and spread to the point that the WHO warns that more than 20,000 people could become infected. Some feel that the entire model the world uses to fight outbreaks needs to be rethought, so that an agency such as the WHO takes command.
But Dr. Chan said governments have the primary responsibility “to take care of their people,” calling the WHO a technical agency that provides advice and support. Still, she noted that her organization, like many governments and agencies, was not prepared for the epidemic to become worse than all other Ebola outbreaks combined.
“Hindsight is always better,” Dr. Chan said. “All the agencies I talked to — including the governments — all of us underestimated this unprecedented, unusual outbreak.”united nations - Europe - West Africa - Africa - Western Europe - Switzerland - Geneva - World Health Organization - Guinea - Margaret Chan - Keiji Fukuda