Can the Global Public Health System Learn From Its Ebola Mistakes?
With the crisis gone, the time for soul-searching has begun. But real reforms are what’s needed.
The worst of the Ebola crisis in West Africa has passed. This week the three countries where the epidemic was the worst recorded no new cases of the disease for the first time since the outbreak began in March 2014. In a few months, the World Health Organization will officially declare it over in Sierra Leone and Guinea, as it already has for Liberia. But the repercussions of the epidemic, criticisms of the WHO’s handling of the situation, and calls for radical change in the global health landscape are beginning to pour forth and will continue for months to come. Sadly, it appears likely that no coherent scheme for saving lives in the next epidemic will emerge. Rather, the din of pontificating and criticism will resound in a sort of global anarchy. Little will actually change.
Every crisis begets soul-searching, and the global public health world is as prone to self-analysis as any other professional arena. But what really matters isn’t the process of airing discontents and offering suggestions for improvement. More important is what comes next.
Famously, in the United States, the bipartisan 9/11 Commission dedicated months to analyzing what went wrong when Washington failed to recognize and prepare for the al Qaeda terrorist threat. The commission’s final report was praised by leaders of both political parties, across the spectrum of American media, and throughout law enforcement and intelligence communities. Its roadmap for reforms of the American intelligence and emergency response apparatus garnered huzzahs from nearly all opinion leaders in the country, as well as those of allied nations.
Ten years later, the leadership of the 9/11 Commission reconvened to assess progress, concluding: “[Some] major 9/11 Commission recommendations remain unfulfilled, leaving the U.S. not as safe as we could or should be. These unfulfilled recommendations require urgent attention…. Today, our country is undoubtedly safer and more secure than it was a decade ago. We have damaged our enemy, but the ideology of violent Islamist extremism is alive and attracting new adherents, including right here in our own country. With important 9/11 Commission recommendations outlined in this report still unfulfilled, we fail to achieve the security we could or should have.”
The Ebola crisis of 2014 was a 9/11 moment for the global health leadership, particularly the WHO. And it merits review on the order of that executed by the 9/11 Commission. But instead of a single commission, the performance of the World Health Organization and other global agencies has been scrutinized by multiple panels, commissions, academic centers, and the office of the secretary-general of the United Nations, with recommendations and reports likely to continue flooding forth well into 2016. The World Bank, the U.S. Centers for Disease Control and Prevention (CDC), and the WHO have been changing and reforming their internal operations in the months since the Ebola crisis, rendering some of the critiques moot even before they are publicly released. And there are differences among the various official and academic postmortems regarding assignment of blame and suggested reforms. But from this cacophony of self-reflection comes a serious danger: As the horror of last year’s Ebola sufferers dying in the streets of Conakry, Freetown, and Monrovia recedes from public memory, there is genuine danger that financial commitments from the G-7 nations, disease surveillance promises made by 194 nations, and essential improvements needed in the global governance of outbreaks will all simply fade off into the sunset of forgotten urgency.
We have to get this right. There are outbreaks of infectious diseases somewhere in the world nearly every day, a few of which each year threaten to claim significant numbers of human lives and cross national borders. Someday a contagious, virulent form of influenza will emerge and spread around the world with devastating impact. We must be prepared.
In January of next year, the Executive Board of the WHO will convene in Geneva to assess, among other things, the agency’s post-Ebola transformation, including steps taken to implement reforms the board suggested while the epidemic was still raging in January. Also on the agenda will be critiques and recommendations for change issued by the Stocking Commission, an outside expert panel assembled in January by WHO Director-General Margaret Chan. Before the January board meeting, at least three other major reports will be released: A panel of academic and think-tank experts from around the world, working under the Harvard School of Public Health and the London School of Hygiene and Tropical Medicine, will publish its conclusions in early November. (I am a member of that panel.) The Institute of Medicine in Washington, D.C., will soon release its assessment. And in December, a special panel convened by U.N. Secretary-General Ban Ki-moon will announce its performance review and suggested reforms.
While most attention will be paid to the World Health Organization’s performance, many other entities merit scrutiny for their actions (or lack thereof) during the Ebola crisis, including the World Bank, the governments of the countries hit by the crisis, the World Health Assembly, a long list of nongovernmental organizations and humanitarian groups, the African Union, and international organizations representing key trade groups that boycotted the Ebola-affected nations. The bilateral government responses from the militaries and agencies of the governments of the United States, Britain, and France will also come under scrutiny.
This panoply of reviews and assessments need to be coordinated. A summit should be convened, ideally by a respected third party outside of the U.N., allowing all of the panels and commissions to compare their diagnoses of global health governance problems and suggested solutions. In the absence of such a synthesized approach, the relevant agencies themselves will sift through the reports, cherry-picking ideas they find suitable or palatable or easiest to implement. As the 9/11 Commission found 10 years after its original report, agencies and institutions like the CIA, Congress, and the FBI cherry-picked through the commission’s report and implemented the recommendations they agreed with, ignoring the others. The result was incomplete reforms.
Of all the entities involved in the Ebola response, the one that has already adapted the most in response to criticism is the WHO. Its Africa regional headquarters is under new leadership and is cleaning up its highly criticized shop. And in Geneva the leadership has set up expert panels to examine ways to create a large force of emergency health workers that can be mobilized in a catastrophe, and the director-general is tightening chains of command for disaster responses. But future epidemics will require rejection of the business-as-usual behaviors at dozens of other organizations, ranging from the International Federation of Red Cross and Red Crescent Societies to the U.S. Department of Defense. Without the sort of leverage a full summit can provide, it is unlikely that the range of parties pivotal to epidemic preparedness and response will absorb and respond to the panels’ critiques and recommendations. And in the absence of a summit, differences in the recommendations among the plethora of reports cannot be thrashed out.
This isn’t a hypothetical problem. It’s already happening. For the last six months, the African Union has been trying to create an African version of the U.S. Centers for Disease Control. On its face, the project, based in the headquarters of the African Union in Addis Ababa, seems to be a wonderful step forward on the road to adequate disease surveillance and control for the continent. But such a move would mean building a Biosafety Level 4 (BSL-4) laboratory in the Ethiopian capital, wherein dangerous viruses like Ebola could be scrutinized and housed. The Ethiopian government has long sought funding and technical support for the construction of a BSL-4 lab, but donors have declined due to the government’s dubious human rights record, violations of domestic civil liberties, and military tensions in the Horn of Africa. It’s hard to imagine how an African CDC can function without the laboratory capacity to diagnose and study dangerous new viruses, but should a BSL-4 lab be housed in Addis Ababa?
On a similar biosecurity note, the Chinese government this summer announced its planned withdrawal of Ebola responders that built and operated virus laboratories in Sierra Leone and Guinea. This has opened the question of where, exactly, the Ebola samples collected throughout the epidemic ought to be stored: Should they remain in the impoverished countries, given their recent histories of civil war and oppressive military activities? If the samples are removed from the countries, where should they go, and how can any decision be balanced against likely political outcry from the governments, neighboring African nations, and the world community as a whole? When Indonesia declared “viral sovereignty” over samples of H5N1 influenza, or bird flu, a decade ago, refusing to share the viruses with non-Indonesians and demanding financial control of medical products derived from study of the microbes, the WHO brokered a special flu virus agreement. Who should now decide the fate of Ebola viruses stored in freezers in Liberia? How will profits be shared from products created based on viruses found in Sierra Leone? Many such questions need serious policy resolution, reflecting agreement about the larger reforms and visions for the future roles of key players in world responses to outbreaks, especially the WHO.
The WHO desperately needs more money — financing is at least $1.5 billion below its essential needs level. African nations with equal urgency need funding and technical support to fulfill the dream of continent-wide rapid surveillance and control of emerging microbes. But the whole world needs coherent, rational changes in the landscape of epidemic recognition and mobilized global responses. We must learn from the Ebola mistakes. And that means putting wise heads together to agree on courses of action, governance, and funding support.
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