The Ebola Review, Part I

The G-7 nations will commence their annual summit on June 7 in Germany, and the host, Chancellor Angela Merkel, has put the Ebola epidemic and it implications for global biosecurity at the top of the agenda. Yes, the Islamic State, climate change, economic issues, FIFA, and tens of thousands of immigrants and refugees washing up on the shores of Europe and Asia will be addressed as well, but the concern over the World Health Organization’s (WHO’s) performance and the more than 11,000 Ebola deaths is taking center stage at this year’s summit.

Among the litany of mistakes that critics have charged the WHO with during its handling of the Ebola outbreak in 2014 are two top misjudgments. First, the agency’s leaders in both Geneva and the WHO’s Regional Office for Africa, in Brazzaville, Republic of Congo, concluded in late March 2014 that the Ebola outbreak in Guinea was winding down and that most of the infected individuals had been identified and were being monitored, so it was safe to withdraw international experts from the region. They were wrong. At that point the virus had already spread across Guinea’s borders into Sierra Leone and Liberia and was claiming lives in Guinea’s capital, Conakry, spawning the first urbanized Ebola outbreak in history.

The second error was Director-General Margaret Chan’s decision to delay the formal declaration of a “public health emergency of international concern” until Aug. 8, 2014, by which time the virus was claiming lives in the cities of Conakry, Freetown, and Monrovia and had spread to Nigeria. Moreover, two volunteer health workers had, by that time, already become infected and were being hospitalized in the United States, while ailing Spanish missionaries were undergoing treatment in Madrid.

An independent panel of experts whom the WHO convened this March to assess the agency’s performance was led by former Oxfam CEO Barbara Stocking. The panel released its preliminary report this May on the eve of the annual gathering of the World Health Assembly. Its assessment was scathing: Stocking told reporters that among the panel members there was a “strong, if not complete, consensus that WHO does not have a robust emergency operations capacity or culture.”

She went on to say that the WHO did not seek appropriate and timely support from the United Nations or other humanitarian actors, delaying mobilization of a full-on global response to the outbreak. “At an earlier stage, these resources could have been made available and known systems put in place. These might have averted the crisis that led to the need to establish the United Nations Mission for Ebola Emergency Response,” Stocking insisted.

The G-7 member-state delegations that attended the 68th annual gathering of the member nations of the World Health Assembly (WHA68) in Geneva in late May — especially Germany, the United Kingdom, and the United States — tugged and pushed at the 194-nation assembly, prodding for resolutions that might make the WHO a stronger, better-financed, and tougher disease-fighting agency, rather than the failure the West African Ebola epidemic revealed the U.N. agency to be.

I have attended several of the gatherings of the World Health Assembly over the years and have always found the gatherings frustrating for their lack of meaningful action, tedious amid endless speeches of repetitive content, and exhausting, with the most decisive meetings occurring in backrooms late at night. At the WHA68, the phrase I most commonly heard in the hallways, Palais des Nations cafes, and even openly, from the floor of assembly proceedings, was “fit for purpose,” a reference to the WHO. The “purpose” is containing and preventing pandemics, and “fit” alludes to the WHO’s genuine capabilities. Some used the phrase with an optimistic tone, expressing hope that the changes ordered at the Geneva gathering, at the June G-7 summit in Germany, by the WHO’s Ebola Interim Assessment Panel, and by a special committee created by U.N. Secretary-General Ban Ki-moon (the High-Level Panel on Global Response to Health Crises) will render the WHO an institution capable of fulfilling its most sacred duty — protecting humanity from infectious diseases. But others grumbled the phrase along with “defining moment” and “existential turning point” to say that the WHO is unredeemable and will never be “fit for purpose.”

Within the optimistic crowd, which includes the German, South African, and U.S. delegations, along with the Bill & Melinda Gates Foundation, there is the conviction that because the WHO is essential, its survival and improvement are “givens” that will be met through fine-tuning the global health engine, improving its legal instruments, and fueling smart operations with sufficient financing. It is this contingent that drafted the Ebola-related resolutions passed at the WHA68, pushed for stronger International Health Regulations language, created the concept of a $100 million emergency contingency fund, and is pushing a worldwide health-systems strengthening agenda.

At the opposite pole are countries that demonstrate little interest in the WHO’s reform, preferring an entirely new focus and even shrugging at the possibility that the U.N. agency will wither on the vine. The U.K. delegation (often along with Australia and Canada) professes little faith in reform, admonishes the WHO for its failures, and declines all calls for increased funding, instead demanding accountability for finances already spent. (Privately, however, the United Kingdom has committed $10 million to the contingency fund, and India has contributed $1 million, leaving the fund $89 million shy of its target.) Libya and Thailand voiced far more concern about the World Trade Organization’s patent protection regimes, drug and vaccine pricing, and access to generic formulations than the nuts and bolts of epidemic responses. They repeatedly demanded insertion of language in every WHA68 infectious diseases resolution that would compel the WHO to battle the innovative pharmaceutical industry and support compulsory licensing for vaccines, antimicrobials, potential Ebola drugs, and every other potential medical intervention. Libya’s hastily drafted vaccine resolution calls on the WHO to supplement all immunization efforts with transparent demands for pricing information, cost controls, and construction of regional vaccine production facilities operating under compulsory licensing provisions (which void patents) when necessary. The resolutions for vaccines and the calls for new antimicrobials to fight drug-resistant bacteria saw their votes delayed by splits so severe that Chan concluded one such session by castigating “those countries that want to work together to go outside and try to find a solution,” or to table resolutions, leaving the battles to the WHO’s Executive Board.

As Stocking put it, this is a defining moment for the WHO — in many ways an existential one. As Ebola spread across West Africa in 2014, every major Western and African news organization decried the lack of appropriate, swift action, and dozens of top medical and scientific journals published detailed accounts of failures and missteps, primarily made by the WHO. With its credibility on the line and major donors threatening to withdraw support for the agency, the WHO’s Executive Board convened in January 2015 and issued a blistering denunciation of the organization’s Ebola performance. In quick succession a number of special panels and U.N. reviews of the WHO commenced, culminating in Merkel’s that philanthropist Bill Gates set up a group of experts tasked with drafting a WHO reform agenda for the G-7 leaders.

As at least three panels of experts convene to critique the WHO’s woeful performance in the West African Ebola epidemic and, hopefully, to review the allegedly egregious activities of the U.N. Mission for Ebola Emergency Response (UNMEER), the World Bank, and several NGOs, as well as review the fact that a host of would-be donors has yet to produce promised outbreak-support funds, it would be wise to first ask what the 194-member states of the World Health Assembly actually want and what they are actually willing to pay for.

Back in January, the members of the WHO’s Executive Board met to assess the agency’s Ebola performance, finding a long list of failures and calling for massive reform of every tier of global health. It called for serious improvements in individual countries’ own medical systems and changes in the entire chain of response from local clinics up to the WHO’s headquarters in Geneva. The Executive Board concluded that any package of meaningful reforms would be costly, and it called upon the world’s countries to conjure the necessary financial support to strengthen their own disease-fighting systems and put additional muscle behind the WHO.

Four months later at the WHA68, the EMRO (Middle East) nations and the 47 AFRO (African) states made it clear that they were willing to pay larger assessments annually to the WHO and called upon other countries to join them in pledging more money. For decades the agency’s core budget has been frozen below $1 billion as member states have proved unwilling to provide more financing, yet have consistently demanded that the WHO perform an ever-broader range of functions. The result of this imbalance is that, over time, the WHO has developed a dwindling inflation-adjusted core budget, one for which an expanded percentage of support is provided on a voluntary basis. But typically these donations are targeted to specific programs of interest to their respective donors and are not funds to be used at the WHO’s discretion. Since 2010, these extra-budgetary contributions have exceeded assessment-based support handsomely. For its core work the agency has had less money every year, while support for activities favored by the richest donors has steadily increased. When the World Health Assembly convenes, its members are arguing about that dwindling core budget and often voicing resentment over the influence that a handful of rich donors (the U.S. government and Gates, especially) have. It’s a blatant contradiction: The nations of the world want to control the WHO, but won’t pony up funding for its activities.

According to the financial report and audited financial statements for the year ending in December 2014 (WHO report A68/57), released at WHA68, the assessment-based core budget totaled $956 million, versus voluntary contributions to the WHO of $3.46 billion. And the two major voluntary contributors have been the U.S. government and the Bill & Melinda Gates Foundation — the world’s richest country and, essentially, it wealthiest private individual.

Although both U.S. President Barack Obama’s administration and Gates continue to back Chan’s leadership and the WHO, their criticisms and concerns have grown louder, even jumping to on-the-record comments. Reportedly Gates was especially vocal and critical in early May during the meeting of the G-7 independent expert group (IEG) on emergency preparedness. Convened by Merkel prior to WHA68, the IEG is charged with drafting a plan of action for the G-7 countries and a road map for global responses to future epidemics and pandemics. Its members represent a range of scientific, medical, pharmaceutical, public health, and humanitarian expertise.

When the World Health Assembly (WHA) convened in Geneva on May 18, few of the delegates had knowledge of the substance of the IEG’s officially secret recommendations to the G-7. Nor were they aware of the intentions of the High-Level Panel on Global Response to Health Crises, appointed on April 2 by Secretary-General Ban — a group reportedly inclined to conclude that the WHO is incapable of leading serious epidemic responses. When the world’s health delegates took their seats inside the Palais des Nations, it was to devote several days to debating the merits of a stack of resolutions proposed by the WHO’s leadership.

This year the WHO’s leadership had hoped to finally break the WHA’s financial tradition of refusing to entertain assessment increases. At the opening of WHA68, the proposed program budget for the 2016-2017 biennium (WHO report A68/55) called for an overall two-year budget of $4.38 billion, an 8 percent increase ($236 million) over the 2016 to 2017 period. Most of the enhanced budget (or $47 million) would have been derived from a modest 5 percent increase in assessments, and the remainder would have represented a 3 percent allowable funding ceiling applicable to the core budget, to be raised by the director-general. Additionally, the $100 million contingency fund would have allowed Chan (and future WHO leaders) discretionary spending in crises.

But WHA68 prohibited an assessment increase. The net approved two-year budget (for 2016 and 2017) of $4.38 billion is 8 percent aspiration: The countries simply gave the director-general permission to somehow find $236 million more than is in her current budget, raising the official budgetary ceiling. But the cash is a dream: It is not in the pipeline. And the genuine core budgets for 2016 and 2017 are the same as those for 2014 and 2015, despite a voted increase in mandates for the WHO’s performance and epidemic response capabilities.

Before WHA68 convened on May 18, the WHO’s leadership, commonly referred to as the Secretariat, prepared a series of draft resolutions aimed at giving the Geneva-based entity more power and expertise in epidemics through a combination of beefing up its epidemic response office and putting more legal teeth into the International Health Regulations. A WHO auditing report reckoned that the operational cost of implementing Secretariat-proposed changes in the International Health Regulations and Ebola-related reforms would be $4.3 million, an unfunded gap in the agency’s budget.

In her opening remarks to WHA68, Chan acknowledged: “The Ebola outbreak shook this organization to its core.… This was a defining moment for the work of WHO and an historic political moment for world leaders to give WHO new relevance and empower it to lead in global health. I urge you to make this happen. I will do my part.”

Merkel opened WHA68, promising that the upcoming June G-7 summit would stress health security, support for a reformed WHO, global health, and climate change. For days following Merkel’s opening remarks, the German delegation consistently took the lead in supporting WHO reform proposals and financing, even when compelled to note that it was differing with European Union positions. At one point a delegation member declared that the assembly “would have difficulties [explaining] why we should deny WHO to accept potential funding for priorities set in the assembly.” He also said, as a Devex article reported, that if the assembly refused the budget, it should explain what the WHO “should not be doing in the near future.”

From my perch in the press gallery, the frustration of many delegates, particularly the Germans, was obvious. Following the WHA’s decision to deny the WHO its assessment increase, the German delegation said the group of nations “has indeed eroded the work of the Secretariat. At present, WHO does not have the capacity to deal with epidemic responses. To make WHO fit for purpose for emergency response requires increased funding and political support.”

In the round, domed Palais des Nations, the delegations sat in concentric rings of alphabetically organized seats, with the “A” countries closest to the chairman’s dais and the “Z” countries farthest out. Although delegations always strive to use polite language, the tone and carefully selected language typically indicate how heated the backroom private negotiations have been. At WHA68, several countries were clearly exasperated by the contradiction between needs for no increase in the price of WHA membership and demands for an ever-higher-performing WHO.

Sweden said the WHO should “re-emerge from the crisis stronger, better, and fit for purpose,” so the Scandinavian country would back the budget increase if the WHO could show “in a clear way” how the budgeted funding would be spent. France was similarly inclined to back a budget increase, provided the WHO offered a clear strategy for reform: “We must be coherent with the need of the organization, with the challenges the organization is facing, and with what we asked for of WHO. We must give WHO the means to do it.”

Lebanon gave the WHO stronger, nearly unequivocal support, with its delegate insisting, “We believe the responsible position is increased support for WHO. Both the Middle East and Africa are willing to increase assessments and create a core fund for emergency response. Fighting outbreaks is the primary purpose of WHO.”

But Latvia, leading the holdouts for stricter reform and speaking on behalf of the European Union, said that rather than committing new funds to the health agency, “we want more analysis of WHO management. There needs to be cultural and management change in emergency responses. The lack of a serious command structure is the largest gap” in Ebola response, not funds. Spain concurred, with its delegate saying, “We do not want to see a budget increase. Rather, we would like to amend the budget to state that there must be support [in it] for emergency response. Hold total assessment at $956 million.”

Russia simply insisted that the WHO should manage its resources more effectively. Iraq suggested that epidemic funding and the contingency fund should be considered elements of development, applied in direct support of countries’ health systems. And the grim delegates of Thailand and Venezuela argued that the global economic woes made any contemplation of assessment increases inconceivable. “A gloomy economic situation in most countries does not allow such increase. A 5 percent increase in assessed contributions is next to impossible,” insisted Thailand. WHO’s budget should show zero growth, Venezuela said, “until the global economy has reached greater stability.”

However, as the assembly continued for a further week, none of this financial hesitancy prevented WHA68 from piling more duties onto WHO’s plate, including creating systems for tracking patents and prices of drugs and vaccines, expanding support at the country level for health systems and universal health coverage, tracking antimicrobial resistance, conquering polio, and much more.

The Israeli health minister summarized the untenable financial situation clearly, asking, “Do we want a WHO that is small and efficient or one that is big enough to do everything? We have to be frank with ourselves. Either, as Germany said, we need a bigger budget, or prepare yourselves for the next epidemic. We have to add a chapter to the International Health Regulations in order to give the WHO power to react next time. Stand behind the director-general.… She led us from one crisis to crisis to another. Give her more [financial] support.”

After long days of debate and backroom chatter, I reached a point of deep cynicism at WHA68, unable to see any way out of its institutional inanity. The key message is that there is no key message. No consistency exists in visions of an improved, fit-for-purpose WHO.

Examples I heard voiced from the floor of the WHA68 include:

• Claus Sorensen, ECHO (the European Commission’s Humanitarian Aid and Civil Protection department): “I’m fishing for an effective organization inside [the WHO] that has capacity of giving us forward warning, capable of supporting health clusters in all different catastrophes. The responsibility for health crises must stay inside WHO, but that requires changes. There must be sufficient command-and-control capacity, surge capacity.”
• Tim Evans, World Bank: “The Liberian medical school had 20 faculty — now 10, post-Ebola. Harvard has more than 10,000 medical faculty. We have to recognize that this is a development crisis.… WHO must be WHO, first and foremost, and we must have a strong WHO.”
• Save the Children’s Simon Wright and the Iraqi delegation in agreement: “We need WHO to play the role of a coordinator.”
• Barbara Stocking, United Kingdom: “We have two systems working, but not speaking to each other. One is public health; the other is a whole-of-U.N. emergency structure. The U.N. needs to learn more about public health, and WHO needs to learn more about humanitarian responses.”
• Mexico: “The key error was the non-activation of the United Nations Health Cluster [in the Ebola crisis] — that was a key error. We need different systems of alert, with tiers. The largest gap at WHO is the absence of a command structure.”
• Lebanon: “We need to overcome the bureaucracy of the WHO. WHO’s response [to Ebola] was imprudent and lengthy, lacking political and financial support.”
• Denmark: “There must be deep, substantial, and structural change in all layers [at the WHO].”
• Jamaica: “WHO needs to rebuild the trust of the member states.”
• Saudi Arabia: “We need a robust and sustained response capacity at WHO.”
• Norway: “This is a defining moment for WHO. The states will look elsewhere if WHO fails to reform.”
• Iran: “We need a strong global health system with the capacity to detect infectious diseases. An emergency health workforce must work with domestic military forces.”
• United States: “UNMEER has not been the best model. We need an all-hazards mandate, unified command and control in WHO.”
• Cuba: “We need a greater synergy between WHO and the rest of the U.N., with WHO leading the health sector.”
• Switzerland: “A change of WHO culture is necessary for emergency responses. You can’t manage a crisis the same way you set norms and standards. We need a stronger WHO that is not duplicative of other U.N. agencies.”
• Germany: “We need a detailed analysis of mistakes made — it’s the only way WHO can regain its credibility. We need a better-understood role for WHO.”
• Sudan (which has twice faced Ebola outbreaks): “We think fighting epidemics should mean supporting countries like Sudan. Preparedness is the key.”
• Brazil: “WHO should be at the center of global health emergencies. But it must strengthen its leadership and continue in its role-setting norms and standards.”

The World Bank has expressed interest in taking over several emergency-response features and not only commanding financing. The bank’s often repeated interest is widely viewed as usurping the WHO’s authority, and I found little interest at WHA68 in, as one African delegate put it to me, “letting a bunch of economists run the next epidemic.”

Read “The Ebola Review, Part II: 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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