If the World Health Organization (WHO) is to better protect humanity from major epidemics, it will have to change fundamentally. That is the conclusion of an independent panel charged with assessing WHO's handling of the Ebola outbreak in West Africa, which has killed more than 11,000 people. The report, issued today, is highly critical of some aspects of WHO’s response and makes wide-ranging recommendations on reforming the organization’s structure and decision-making processes, including the proposal to establish a new Centre for Emergency Preparedness and Response within WHO.
But the report also concludes that WHO needs more power, more money, and more support from member states to fulfill its role. "I think this is a frank and important report," says Preben Aavitsland, an epidemiologist at epidemi in Kristiansand, Norway, who helped craft the International Health Regulations (IHR), a 2005 treaty that lays down what powers WHO has in an international health crisis. "The authors are not afraid of making bold proposals.“
Founded in 1948 as an agency of the United Nations, WHO aims for “the attainment by all peoples of the highest possible level of health.” But there is wide agreement that it bungled its response to the Ebola outbreak last year. In March, an independent six-member panel led by Dame Barbara Stocking, the former chief executive of Oxfam in the United Kingdom, was appointed to look at what went wrong and what should be changed. Panel members interviewed WHO sources and outside experts, met with representatives of numerous relief organizations, and flew to the affected countries in West Africa.
In the report, the panel faults WHO for several problems, most notably for “significant und unjustifiable delays” in declaring the outbreak a public health emergency of international concern (PHEIC). WHO didn't label the epidemic a PHEIC—a formal acknowledgement of its threat to global health—until 8 August, more than 4 months after the outbreak was detected. By then, almost 2000 cases had been reported.
The report acknowledges that assessing the situation early in the outbreak was complicated by several factors. Patients were hiding or being hidden by family members, for instance, and there was a collective denial about the extent of the outbreak in the affected countries. Still, WHO should have realized that the situation was spiraling out of control sooner, the report says.
"In the early stages of the Ebola crisis, messages were sent by experienced staff at headquarters and the Regional Office for Africa, including after deployments in the field, about the seriousness of the crisis. Either these did not reach senior leaders or senior leaders did not recognize their significance,“ the panel writes. Part of the problem was WHO's organizational culture, which does not support "open and critical dialogue between senior leaders and staff or that permits risk-taking or critical approaches to decision-making.“ Fears about challenging the three African governments and implications for trade and economy kept WHO from declaring a PHEIC earlier, the authors charge.
Instead of the current system, in which an outbreak either is a PHEIC or it isn't, the report suggests establishing “a new intermediate stage of alert.” But that would only complicate things more, Aavitsland says. “I think it is better to lower the threshold for declaring a PHEIC. The intention was never to make the threshold so high that this was seen as a global crisis."
The report also concludes that rather than establish a new organization to deal with global health crises, WHO should be made "fit for purpose.“ To that end it suggests increasing WHO funding by 5% and immediately establishing a new WHO Centre for Health Emergency Preparedness and Response that could both combat an outbreak and provide humanitarian assistance, two tasks that are currently separated within WHO. The center should be overseen by an independent board, the authors write, and headed by "a strong leader and a strategic thinker, with political, diplomatic, crisis coordination, organizational and managerial skills.“
The new center is the most far-reaching proposal, says Aavitsland, who thinks it's a good idea. But it may not go down well with WHO management, he adds, because it would effectively create a state within a state.
The increased funding is also unlikely to materialize, says John-Arne Røttingen, head of infectious disease control at the Norwegian Institute of Public Health in Oslo. Just a few weeks ago, at the World Health Assembly (WHA), plans to increase the "assessed contributions"—essentially countries' member fees—were rejected, he notes. "We just tested the appetite of member states to invest, so I had hoped [the panel] would come up with stronger wording,“ Røttingen says. (The panel writes it was "extremely disappointed“ by the WHA decision and "requests that Member States reconsider this decision“ at the next assembly.)
The report also criticizes WHO for taking too long to coordinate the response to the outbreak and for failing to mobilize community leaders, particularly women, early on. It took too long to prioritize culturally sensitive messages to ensure support from the stricken populations, the report says.
The authors reserve some of their most damning language for the way WHO handled communications, however. "The Panel is clear that WHO failed to engage proactively with high-level media and was unable to gain command over the narrative of the outbreak. This weakness had repercussions for many areas of the response; a better approach to communications could have improved confidence in WHO and reduced levels of fear and panic.“
The report has some positive words for WHO as well. Some had worried that the agency’s role in researching and developing Ebola therapies and vaccines might distract it from combating the virus on the ground. Instead, "WHO should be commended for this work, as it stepped up to fill a void at a critical stage of the outbreak,“ the authors write. "WHO will need to be involved in research and development work for future emergencies.“ Still, Røttingen says he had hoped for more concrete proposals and some mention of the responsibilities of countries to support research and development of neglected diseases.
The report also takes aim at the United Nations. While U.N. leadership was necessary to galvanize a response, the resulting U.N. Mission for Ebola Emergency Response (UNMEER) was not very successful, they write. “What you don’t need is a new U.N. mission being established right in the middle of the crisis,” Stocking said at a press conference on Tuesday. During the Ebola outbreak, a coordinating center established by several countries in the Guinean capital, Conakry, was closed, after which it took months for a new U.N. center in Ghana to get going, she says. “That really doesn’t make any sense,” Stocking said.
WHO member states get their share of criticism as well. For instance, more than 40 countries implemented measures that interfered with international traffic—such as Ebola tests or compulsory quarantines—that were not recommended by WHO, a clear breach of the IHR. "As a result, the countries affected faced not only severe political, economic and social consequences but also barriers to receiving necessary personnel and supplies.“
To avoid such overreactions in the future, the authors propose establishing mechanisms that allow WHO to sanction countries for inappropriate precautions. They also want to give countries an incentive to notify WHO of possible health threats—as opposed to denying them or downplaying their importance—for instance through an insurance scheme that allows countries to access emergency funds after a WHO risk assessment.
The basic problem is that member states have been reluctant to really embrace the meaning of the IHR, Aavitsland says. "They in fact give up some power from their state to WHO, to the global community, when a public health emergency of international concern is declared. But they are unwilling to do so,“ he says. The only recourse WHO currently has against countries that don't play by the rules is naming and shaming them—and that does not work well, he says.
In fact, a 2011 review of the IHR, which Aavitsland helped produce, made some of the same points. But that report was never acted on. "It was simply acknowledged and the recommendations were not really discussed in detail,“ Aavitsland says. It was a mistake with far-ranging consequences, as the new report notes. Had the recommendations been implemented, "the global community would have been in a far better position to face the Ebola crisis,“ the authors write. They express their hope that this time action will follow words. "The world simply cannot afford another period of inaction until the next health crisis.“
That is the biggest danger, says Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota, Twin Cities. "The good news is that this is a report that can move us to the next level. But it will mean little if it does not translate into action.“ The next 30 to 60 days will show the real weight of the report, he predicts.
Stocking acknowledged that getting the report implemented will be a tough act. "The more public pressure we get on this, the better it will be,“ she said at today's press conference.
In a first response, WHO welcomed the report and noted that a committee to review the IHR will be convened by director-general Margaret Chan. There, "member states can discuss the recommendations of the panel, including the idea of establishing an intermediate level of alert to sound an alarm earlier than a full Public Health Emergency of International Concern," WHO wrote in a statement sent to journalists.
*Update, 7 July, 1:15 p.m.: This story has been expanded from its original version to include quotes from Rottingen, Stocking, and Osterholm.