The Ebola Review, Part II

The G-7 Summit in Germany convening June 7 to June 8 will focus on the epidemic threat agenda, framed both as biosecurity and health system strengthening. Detailed G-7 draft documents are not yet available, so the precise outlines of Germany’s plan aren’t visible. But German Chancellor Angela Merkel left clues in the speech she delivered at the World Health Assembly (WHA68) in Geneva in May. She said: “We need some kind of global disaster response plan. And the World Health Organization must play a key part in this. But first of all we have to ask ourselves what we expect from the World Health Organization, what we think it should achieve and what its member states have to provide.”

Merkel’s appearance at the opening ceremony of the WHA68 was unprecedented — never previously had a political leader, rather than the WHO’s director-general, presented the gathering’s opening remarks. Dressed in her characteristic button-down pant suit the German chancellor voiced support for WHO’s continued existence, noting:

“In my opinion, the WHO is the only international organization that enjoys universal political legitimacy on global health matters. The aim now must therefore be to make its structures more efficient. It is, I am sure, an advantage for the World Health Organization to have 150 country offices and six regional offices in addition to its headquarters — a decentralized structure with strong local links is important. But let’s be honest. Decentralized structures can also impede decision-making and hinder good functioning.”

Merkel continued, describing her vision of a tightly structured three-tiered organization, from countries, to region, to headquarters, each level respecting the hierarchy. The overall WHO structure, Merkel insisted, should be robust, reactive, accountable, transparent, and capable of working well with the rest of the United Nations system. “Notwithstanding its central health policy legitimacy, the WHO cannot be the only organization involved in drawing up a global disaster response plan. We need to ensure that the WHO can work well together with the U.N. system as a whole and with the World Bank,” Merkel concluded.

Among the issues the G-7 is likely to address, according to member experts, are beefing up the nearly moribund Global Outbreak Alert and Response Network (GOARN) within WHO, and clarifying what are now two very separate response streams inside the agency: infectious diseases control and humanitarian crises with health consequences. Leading into the summit the sentiments of G-7 members support the notion that the logical plug-in point for their disease surveillance and epidemiology teams is GOARN. But the network has lost 130 staff in recent rounds of layoffs (ordered by the 2013 World Health Assembly), and was characterized to me by G-7 health experts as “anemic,” “undernourished,” and “emasculated.”

Knowledgeable sources directly engaged in Berlin Summit preparations tell me that the G-7 will call for creation of an emergency workforce that is virtual, rather than a standing army. (Though Merkel refers to them as “the white helmets” other G-7 members recoil at the military-like metaphor.) And though concepts were still gelling at this writing, it appears the G-7 will expect a substantially strengthened GOARN to train and certify health workers — a “virtual response team — that may be called up when needed. Whether they are called White Helmets or something with a less military ring, the will be located in their regular jobs and habitats until called up for service. Some of these doctors, nurses, and other emergency workforce individuals may be located within nongovernmental organizations and humanitarian groups, others may be mobilized by their respective governments. One G-7 member representative described the evolving concept as a partnership with a range of health actors. The experience of the 165 Cuban physicians that worked under the WHO aegis in Sierra Leone, Liberia, and Guinea was cited as the beginning, conceptually, of the health workforce model. The Disaster Assistance Response Team (DART) mechanism used successfully by the U.S. coordinating its diverse array of civilian and military Ebola responders, including the 101st Airborne of the U.S. Army and several NGOs, was also offered as a model.

The G-7 is likely to demand improvements in the language of the International Health Regulations (IHR), which was passed by the World Health Assembly in 2005. As originally passed, the IHR compelled all of the nations of the world to have in place systems of disease surveillance and rapid response for both animal and human disease outbreaks by 2012. But by the deadline fewer than 35 nations, all rich countries, had complied. With substantial financial and expertise assistance from the Obama administration more countries have managed to meet the IHR requirements. But Miatta Gbanya of Liberia’s ministry of health told the WHA68 that, “Only 64 states have met the core requirements, 81 want an extension and about 48, we have no idea.” The Scandinavian states want enforcement in place, even sanctions against nations that fail to meet the core terms of the IHR. But nations large and small plead poverty, inexperience, and lack of technical capacity, begging forgiveness for their failures. And the WHA68 complied with those pleading poverty, voting to extend what was originally a 2012 deadline for compliance to June 2019.

According to G-7 insiders, the Berlin summit will commit resources toward bringing nations into IHR compliance. And the rich nations will put “millions of dollars” into GOARN, creating a muscular, robust disease surveillance and response institution that nests inside the WHO, but outside of its current hierarchy, answering only to the director-general. The GOARN will have a series of trigger points to operate from, both in response to outbreaks and major humanitarian disasters with health repercussions. The triggers, which the G-7 reportedly wants written into an updated IHR, will give GOARN flexibility to take a range of actions, rather than WHO’s current all-or-nothing limitations that WHO Director-General Margaret Chan has blamed for her failure to declare a Public Health Emergency of International Concern for Ebola until Aug. 8, 2014, despite widespread viral carnage that by then had been spreading for months.

In January, the WHO executive board issued a blistering report that labeled all tiers of Ebola response in 2014, from local country efforts all of the way up to Geneva “complete failure[s],” and called for radical change. Noting that Ebola had never previously crossed national borders during outbreaks, the executive board called upon countries to strengthen eight key facets of their disease surveillance and response capabilities.

And the executive board spared nothing in its criticisms of operations at WHO-AFRO, the regional office for Africa based in Brazzaville, or Geneva headquarters. The board also called for a complete shake-up in all aspects of the African regional operations, and gave Chan a tough list of nine directives for improvement.

The G-7 is not expected to explicitly endorse each of the January executive board recommendations, but seems poised — according to multiple inside sources — to embrace the overall intentions and criticisms. It will not, however, be satisfied with merely a fine-tuned WHO. It will demand that a semi-independent GOARN operates with its own budget authority, and exercises direct power over outbreak and humanitarian health responses.

Of course the GOARN was “emasculated,” its budget slashed, and staff laid off just prior to the Ebola outbreak by the 194 member states of the World Health Assembly. The countries voted to shift the WHO’s resources away from infectious, toward noncommunicable disease issues, leaving the agency bereft of expertise to handle Ebola. It’s tempting to agree with the G-7 assumption that a beefed-up GOARN would be the key to proper handling of future outbreaks. But Chan and the WHO had powerful tools at their disposal last year, despite the weakened GOARN — tools they chose not to use until the outbreak had reached catastrophic proportions. Chief among them was the IHR, which Chan delayed implementing until Aug. 8, 2014, after hundreds of deaths had occurred in four countries. Beefing up GOARN won’t be enough to protect the world from epidemics if the leadership of WHO fails to exercise its options in a timely, smart manner.

After months of delay in WHO action, U.N. Secretary-General Ban Ki-Moon lost confidence in the agency and created a novel superstructure for Ebola control that answered directly to him. There was a tendency in media coverage and perhaps the United Nations to view the United Nations Mission for Ebola Emergency Response (UNMEER) structure as something of a savior. Despite U.N. oversight of funds used in the Ebola fight, a tremendous amount of money remains unaccounted for. In addition to the estimated $19 million was spend and $3.3 went missing that , the enormous UNMEER mobilization appears to have been spectacularly expensive, accounting for far more expenditure than WHO’s interventions. The primary criticism of UNMEER is that it was carried out as a humanitarian famine mobilization, transporting vast quantities of food, rather than medical supplies, and pushing logistics operations of little value to a medical crisis. In short, it acted in the Ebola outbreak as it would in an earthquake, refugee disaster, or famine.

Individual countries also merit criticism, experts say. Gbanya, the Liberian delegation member, pointedly noted at the WHA68 that there were “failures” of country responses early in the epidemic. “The epidemic started in Guinea in December — which did not report it to WHO until March 21. That was a defective response [by Guinea].”

Sierra Leone has depended on mass quarantines, placing entire towns and even regions of the country under lockdown for protracted periods. The strategy has been criticized by neighbor states as ineffective and in violation of human rights. Nevertheless, the mass quarantine approach has garnered both political and financial backing from the U.K.’s foreign assistance agency.

Responders in Guinea during the March and April outbreak in that country incorrectly assumed a single line of transmission, stemming directly from the December Meliandou index case, represented the totality of the outbreak. After contact tracing that chain of transmission, the government of Guinea, the U.S. Centers for Disease Control and Prevention (CDC), and WHO declared the epidemic was under control and withdrew most foreign responders and scientists from the country. But they were wrong, both about having successively identified the full chain of the primary transmission, and in missing a second line of transmission entirely.

Ebola had by then reached Conakry, establishing the first urbanized epidemic of the disease in history. It is extremely difficult to understand how and why the U.S. CDC and the WHO reached the conclusion that the prospect of urban Ebola in a large city with an international airport posed no larger risk. Moreover, Guinea health authorities were aware that a second line of transmission existed, and the index case had crossed into Sierra Leone. Guinea failed to inform Sierra Leone, allowing the epidemic to cross into the neighboring nation. Recently released e-mail communications between WHO-AFRO, WHO headquarters, and its teams in the field reveal a dramatic failure to implement the IHR. Though no language in the IHR stipulates that economic considerations should carry equal weight with health and medical ones, Geneva clearly chose to respect the Guinean government’s economic worries.

Finally, the performance of WHO-AFRO was nothing short of abysmal. On Feb. 1, Matshidiso Moeti took over the WHO’s Africa Regional Office. Born in South Africa, the physician grew up in Botswana and cut her teeth on public health working with AIDS patients and the national HIV response. In a wide-ranging private conversation, Moeti assured me that she plans major shake-ups that will affect all of the 2,500 country-based employees and 200 staff in the headquarters of WHO-AFRO.

“Our challenge: There is big skepticism about WHO-AFRO, and many demands, expectations — all with the same resources. We have to make changes, and earn back the trust,” Moeti said. “We have to prove ourselves. We can’t float on nice speeches.” The staff throughout WHO-AFRO displays enormous ignorance, she said, includes genuine thieves, and “a large element just bumbling along, being inefficient.”

Perhaps the most complicated problem Moeti faces involves the African Union’s announced scheme to create its own centers for disease control, based in Addis Ababa. The African member states have no faith in WHO-AFRO, and plan to shift most infectious disease surveillance and response to the planned center. “We need to think it through,” Moeti concluded.

Thinking things through carefully is obviously the key to transforming the WHO into an institution that is fit for the purpose of epidemic control — or, perhaps, to concluding that the Geneva agency cannot carry out the task, forcing creation of a novel institution. Given how full the G-7 plate is, and the leaders’ brief two-day summit, it’s hard to believe considerations can be sufficiently weighed to provide an optimistic beginning to true WHO reform. But I’ve been wrong before. In 2000 the then G-8 met in Okinawa, and Prime Minister Yoshiro Mori pushed for creation of an international response to infectious disease threats, particularly HIV/AIDS, tuberculosis and malaria. I thought the summit’s was overly vague, and nothing but hot air would come of it. But I couldn’t have been more off base, as the outcome was creation of the multibillion-dollar Global Fund to Fight AIDS, Tuberculosis and Malaria in 2002. As of December 2014, the programs supported by the fund “have 7.3 million people on antiretroviral therapy for AIDS, have tested and treated 12.3 million people for TB, and have distributed 450 million insecticide-treated nets to protect families against .”

Please, G-7: Prove my skeptical soul wrong, and make biosecurity a reality for all people, living in rich and poor nations, alike.

Read “The Ebola Review, Part I: The G-7 is gathering to tackle the world’s biggest problems. It’s starting with Ebola — and what the World Health Organization did wrong.”

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