The World Bank Has the Money to Fight Ebola but Won’t Use It

The Ebola epidemic in the Democratic Republic of the Congo is now officially a global emergency. The director-general of the World Health Organization declared it one yesterday, after a team of scientific advisors decided that recent developments in Congo constituted a “public health emergency of international concern,” under the agency’s International Health Regulations. It was the fourth time the advisors reviewed the outbreak, which has raged for nearly a year; on three prior occasions the group concluded no emergency declaration was warranted. Now, apparently, it is.

The declaration begs two obvious questions: Why now? And what will now be done differently—or should be?

The epidemic, which began on Aug. 1, 2018, has now sickened over 2,500 people, killing more than 1,700 of them. Given living conditions in the affected region, it is entirely possible that the toll is much higher, because some of those ailing never seek formal care and all of the dead are not tallied. Originally focused on one small town in the North Kivu province of Congo, the epidemic now spans an area stretching approximately 300 miles in two provinces (North Kivu and Ituri), with spillovers reported in the major metropolis of Goma, and across the border in Uganda. To date, the spillovers have been isolated incidents, with no evidence of local person-to-person spread, but the West African outbreak of 2014 has erased any sense of hubris in the halls of the WHO about the ease of national containment of the virus.

In a press conference on Wednesday announcing the emergency, WHO Director-General Tedros Adhanom Ghebreyesus added that “the security problem is serious,” after two Congolese Ebola workers were assassinated in their homes last week and a WHO Cameroonian epidemiologist was murdered in April, in addition to more than 190 attacks since January on health care workers and their facilities amid warfare in the region. Ebola teams have reported being shot at in restaurants and in their vehicles, assaulted with machetes, stabbed, and showered with rocks, sometimes by orchestrated Mai-Mai militia efforts, and at other times by local people caught up in disinformation and conspiracy theories spread by the rival groups, claiming that the foreigners are causing or lying about the disease.

The Ebola epidemic and incredibly tense military situation in eastern Congo have undermined normal childhood vaccination efforts, spawning a measles epidemic that has sickened more than 115,000 people and killed some 2,000 children this year. The Congolese Ministry of Health, WHO, and other U.N. agencies and nongovermental organizations are trying to immunize more than 100,000 children against measles across Congo, according to UNICEF, but suspicions surrounding the Ebola crisis, coupled with warfare, are hampering those efforts, as well.

For example, earlier this month, hundreds of thousands of people—mostly women and children—fled villages in Ituri province following military attacks that featured demolition of their homes. Congolese President Félix Tshisekedi has labeled the most recent attacks “attempted genocide” carried out by one local ethnic group against another, executed with knives, machetes, guns, and arson. Warfare has escalated since 2017 in a long-standing power struggle that has been underwritten by regional powers, chiefly the governments of Rwanda and Uganda.

The most recent tide of refugees—thousands of whom have poured across the border into Uganda—has added to some 200,000 others forcibly displaced from their homes in Ituri over the past year and a half. Most of those people now live in close quarters in informal encampments under conditions that are ripe for the spread of measles, cholera, and other diseases. The catastrophic scale of health and epidemic need in Congo is, according to Sarah Terlouw of the International Rescue Committee, overwhelmed by the decades-long, now-escalating warfare, creating “so much displacement and a staggering amount of need across” Congo.

Neighboring North Kivu has become a hotbed for the Allied Democratic Forces, a rebel group founded in Uganda that now operates in Beni, where Ebola health care workers have come under lethal attacks. So many organized military forces are operating in the two provinces that the safe movement of health workers is extremely difficult.

If measles is any indicator of Ebola contagion risk, the Congolese measles epidemic has already spilled over into Rwanda and Uganda, prompting further mobilization of scarce resources and personnel for mass immunization efforts. In Ituri, according to Moussa Ousman of Doctors Without Borders, “it has not yet been possible to vaccinate against measles because of the ongoing Ebola outbreak, and the fear of Ebola further spreading,” coupled with the desperate conditions.

Despite this explosive constellation of dangers in the region, the scientific advisors summoned by WHO to decide whether or not to issue a global emergency declaration on three prior occasions said no. One factor contributing to the change may have been this month’s visit to the region by Rory Stewart, a popular British Conservative Party politician and the head of Britain’s foreign aid agency, the Department for International Development. Stewart livetweeted and broadcast over BBC the horrors he observed: “I would politely,” he said, “encourage them to declare this is a global health emergency, and partly because it will make it easier to raise the extra cash.” He backed up that statement by committing $63 million to the WHO effort.

“We shouldn’t link the PHEIC [public health emergency of international concern] with intent to mobilize resources,” urged Tedros, the WHO director-general, in his press briefing. “Financing should be available” regardless of an emergency declaration, as a matter of outbreak prevention, he said, “to fix the roof before the rain comes.”

But last week, the WHO was leading the epidemic response with a $54 million shortfall, robbing other agency programs to cover its Ebola costs. In contrast to the $3.6 billion that eventually came forward from donors to combat the disease in West Africa in 2014 and 2015, the agency has, since February, received only about half of what it needs from donors.

Though the U.S. government is, so far, the largest donor for the overall response, having put more than $98 million into the fight since last summer, most of that money has been spent on U.S. operations outside the epidemic zone, in neighboring countries and in faraway Kinshasa, Congo’s capital. Under rules made by the administration of U.S. President Donald Trump, U.S. personnel cannot operate in the eastern Congo for security reasons, no money—even humanitarian aid—can currently be given to the Congolese government because it is labeled an enabler of human trafficking, and little has gone directly to WHO.

The World Bank has, to date, given $20 million to the response: just $6.5 million of that to WHO, according to its director-general. In response to the emergency declaration the bank tweeted that it “remains committed to doing everything we can to support the govt & people of” Congo.

But the World Bank’s sentiments have not been mirrored by its actions. Indeed, the bank has behaved reprehensibly.

In 2014, in response to the tremendous financial shortfalls that delayed national and global responses to the West African Ebola epidemic, then World Bank President Jim Yong Kim publicly and repeatedly vowed that “never again” would an epidemic be allowed to unfold for reason of lack of funds. He created a unique, and rather complicated, set of insurance and hedge funds inside the International Bank for Reconstruction and Development (IBRD) to be used to combat outbreaks.

Dubbed the Pandemic Emergency Financing Facility, or PEF, the idea was to amass billions of dollars in insurance, bonds, and hedge funds that could be activated, based on unstated triggers, for use in fighting outbreaks. Investors were encouraged to put money into the various disease-specific funds, hedging against outbreaks. After five outbreak-free years the investors would realize gains on their gambits.

“We are moving away from the cycle of panic and neglect that has characterized so much of our approach to pandemics,” Kim said at the formal 2017 launch of the PEF. “This creates an entirely new market for pandemic risk insurance.”

Beyond the small sum of $20 million given two months ago, the PEF has not been activated for the Ebola epidemic. To date, the World Bank has released $60 million in development funds, which do not come from the PEF, to the Congolese government for its Ebola efforts, and just $20 million from the PEF to WHO and UNICEF.

The WHO has now declared a global emergency, but apparently it will not have any impact on the World Bank’s decision to release money. 

According to the French foreign-aid agency GHA France, those managing the PEF insisted this week that “activation criterion of the insurance window are not linked to decision about IHR procedures concerning PHEIC,” meaning that WHO may declare a global emergency, but it will not have any impact on the World Bank’s decision to release money.

According to PEF documents, up to $200 million to combat Ebola should be released when, “upon an activation of pre-agreed parametric trigger (based on public and observable data), the private sector will make agreed-upon payouts to the IBRD.” The key objective of the PEF is “providing financial support to PEF Eligible Countries and Responding Agencies to help prevent a high-severity infectious disease outbreak from becoming a pandemic.”

In April the World Bank’s former chief economist, Lawrence Summers, denounced the PEF, labeling it “an embarrassing mistake” and a symptom of “financial goofiness” within the World Bank. The PEF was designed, Summers said in a speech to the Center for Global Development, by “goofy governments who wanted to have an initiative for the G-7,” a group of “World Bank officials who didn’t understand the first thing about finance,” and “bureaucrats at the bank who were looking to make their careers by having had a major innovation.”

Back in 2017 when Kim announced creation of the PEF, I repeatedly asked World Bank officials about those “pre-agreed parametric triggers”—what would constitute a trigger for release of funds, and who would decide? I never received answers.

As Summers argues, the market—those investors and bond holders—will always be averse to such a trigger declaration because it removes their profits. In other words, thousands of people might die in the Ebola epidemic, but never formally trigger release of $200 million before the PEF five-year payout period for investors.

Trump-appointed World Bank President David Malpass has not publicly commented about the PEF, so it is not clear how he will react to the deadly consequences of what Summers has called “financial goofiness.”

Investors and bond holders will always be averse to such a trigger declaration because it removes their profits.

The warring factions that are raping, pillaging, and killing local civilians and attacking the Ebola responders have financial backing from a variety of sources, including regional governments. When the United Nations Security Council convenes on July 31 to review the Ebola crisis, it should specifically name and blame those armies and governments.

Until then, international recriminations should focus on the World Bank. It is appalling that the bank has failed the people of Ituri and North Kivu, and placed the people of neighboring South Sudan, Uganda, Rwanda, and Burundi in harm’s way.

It must be held accountable for its unconscionable refusal to release the PEF funds that are, by design, specifically meant to address precisely the sort of situation now unfolding in the Democratic Republic of the Congo.