Laurie Garrett. Foreign Affairs. Volume 94, Issue 5. Sep/Oct 2015.
In a biological sense, last year’s Ebola epidemic, which struck West Africa, spilled over into the United States and Europe, and has to date led to more than 27,000 infections and more than 11,000 deaths, was a great surprise. Local health and political leaders did not know of the presence of the hemorrhagic fever virus in the 35,000-square-mile Guinea Forest Region, and no human cases had ever been identified in the region prior to the outbreak. Its appearance in the tiny Guinean village of Meliandou in December 2013 went unnoticed, save as a domestic tragedy for the Ouamouno family, who lost their toddler son Emile to a mysterious fever. Practically all the nonbiological aspects of the crisis, however, were entirely unsurprising, as the epidemic itself and the fumbling response to it played out with deeply frustrating predictability. The world has seen these mistakes before.
Humanity’s first known encounter with Ebola occurred in 1976, with an outbreak in the village of Yambuku, Zaire (now the Democratic Republic of the Congo), and surrounding areas. A horrible unknown disease suddenly started causing internal bleeding, high fevers, sometimes hallucinations and deranged behavior, and often death; it was eventually named Ebola after a nearby river. Back then, science lacked today’s tool kit for the rapid identification and genetic analysis of viruses, not to mention meaningful antivirus treatments, biotechnology, sophisticated hazmat suits, and cell phones. Considerable courage, combined with a fair amount of swagger and medical savvy, was the key trait of the couple of dozen foreigners who swooped in to assist the local disease fighters. Most were veterans of battles against other microbes, such as smallpox or yellow fever, but had not previously worked together. Karl Johnson, a virologist at the U.S. Centers for Disease Control and Prevention (CDC), took charge, and the multinational group operated as a team of rivals, jockeying for their respective institutional or national stature in the loosely governed investigation.
Conducting its work under the brutal dictatorship of Mobutu Sese Seko, the group’s every small achievement, from corralling air transport to communicating with the CDC’s headquarters in Atlanta, was a near miracle. But within a few months, the virus was identified, the Belgian Catholic mission hospital at the center of the outbreak was closed, quarantines were enacted, and the epidemic ended. Almost 300 people had died.
The world’s second serious confrontation with Ebola came 19 years later, in 1995, when the disease again broke out in Zaire-this time in Kikwit, a community of nearly half a million people spread out along the edges of a vast rainforest in what amounted to a giant village of mud roads, with no running water, no electricity, no phones, no media of any kind, and only the crudest of medical facilities. I took up temporary residence in Kikwit during the epidemic, reporting on how it played out. There was (and still is) only one paved road out of town, the N1, heading around 300 miles due west to Kinshasa and 550 miles southeast to Mwene-Ditu. At the time, Mobutu held Zaire in his clutches and used its national treasury as his family’s personal account; he would die two years later, and the nation would discover its bank vaults were empty. When the mysterious disease plaguing the community was finally confirmed as Ebola, the despot had his military cut off access to the highway, leaving the people of Kikwit to suffer on their own.
The global response boiled down to the Zairean doctor Jean-Jacques Muyembe-Tamfun and his medical team; three physicians from Médecins Sans Frontières (MSF, or Doctors Without Borders); three World Health Organization (who) officials; and about two dozen clinicians and scientists from the CDC, France’s Institut Pasteur, Belgium’s Institute of Tropical Medicine, South Africa’s National Institute for Virology (now the National Institute for Communicable Diseases), and other Western agencies and academic centers. Supplies and funds were scarce, electricity was available only by using generators, and there were no rapid diagnostic tools, medicines, or vaccines available.
The Kikwit epidemic ended after around nine months, having killed 250 people. Afterward, the leader of the global response, David Heymann, an American employed by the CDC but temporarily working at the who’s headquarters in Geneva, returned to Switzerland with a list of frustrations. Some of his concerns mirrored those of Johnson in fighting Ebola 19 years earlier: there was still no vaccine, no treatment, no field diagnostic tools, limited supplies of protective gear, nearly nonexistent local health-care systems and trained medical personnel, no clear lines of national and global authority for epidemic response, few qualified scientists capable of and interested in being deployed, no international law governing actions inside countries lacking the capacity to stop epidemics on their own, and no money. Heymann had scoured Europe looking for funds to get his team and supplies to Kikwit. The who had not been able to help much, and in the end, the German airline Lufthansa provided free travel and logistical support.
Yet another 19 years on, when I visited Liberia in late 2014, I found that little had improved. Although there had been at least 16 more Ebola outbreaks across the Congo basin and Uganda in the interim, the world had not developed any new technical or medical tools for addressing the virus. Treatment was only incrementally more sophisticated than it had been back in 1995, it was still impossible to rapidly diagnose infections, and there was still no vaccine.
Same Old Story
The 1976 Yambuku outbreak came at a time of tremendous optimism in the fields of global health and Western medicine. The previous decades had seen the development and widespread use of a host of remarkably effective vaccines. They had brought horrors such as diphtheria, measles, pertussis, polio, rubella, and tetanus down to insignificant levels in rich countries, offering the hope that immunization campaigns in poor countries could eliminate the diseases entirely. New antibiotics kept appearing on the market, pushing the prices of older stalwarts, such as penicillin and tetracycline, further down toward affordability in poor countries. The medical establishment in the United States was growing in size and sophistication, producing specialists offering treatments for rare forms of cancer, obscure inherited disorders, and deep psychiatric afflictions. The pharmaceutical industry was at the beginning of an enormous boom. And the who was successfully straddling both sides of the Cold War, garnering support from the Soviet Union and the United States.
But 1976 was also a year of harbingers of bad things to come. There was not just Ebola’s emergence in Yambuku. The United States struggled with two strange new outbreaks of its own, of swine flu and Legionnaires’ disease. In addition, the sexual revolution was spreading across Europe and North America, with increases in unprotected sex leading to a rising incidence of sexually transmitted diseases such as gonorrhea, herpes, and syphilis. Within five years, physicians in the United States would note a set of new, fatal symptoms among hemophiliacs, gay men, and intravenous drug users; the disease would eventually be called acquired immune deficiency syndrome, or AIDS, caused by the human immunodeficiency virus, or HIV.
In what became known as the swine flu fiasco, the Ford administration and the American public health establishment overreacted to the death of a U.S. Army private from the disease. The fatality was isolated, but it led to a panic and a national immunization campaign. Convinced that a massive pandemic was on the way, Congress indemnified the vaccine industry. Immunizations were hastily rushed into production; amid claims of contamination and side effects, years of lawsuits followed. The episode left policymakers skeptical about trusting their health-care professionals and determined never again to indemnify drug makers; manufacturers, in turn, ran for cover, and some drug companies shed their vaccine production lines entirely. An infuriated Congress convened hearings to rake the CDC over the coals, forcing the resignation of the agency’s director.
Six months after the death of the army private, 34 hotel guests attending an American Legion convention in Philadelphia died from a mysterious illness (later dubbed Legionnaires’ disease). The inability of the CDC and Pennsylvania health authorities to rapidly determine what had happened further undermined policymakers’ confidence, and when the cause of the disease turned out to be a previously unknown species of bacteria lurking in the air-conditioning system, the public was shocked. If the age of infectious diseases was past, how could a new bacterial ailment appear, go undiagnosed for months, and prove tough to treat with antibiotics?
AIDS would, of course, prove the greatest challenge-to human hubris, the pharmaceutical and research communities, and international global health governance. Shortly after his first visit to Liberia to see the Ebola epidemic firsthand last August, the CDC’s current director, Thomas Frieden, told reporters, “I will say that in the 30 years I’ve been working in public health, the only thing like this has been AIDS. And we have to work now so that this is not the world’s next AIDS.” Frieden was referring not to the disease itself but to the world’s disastrous response to it. For two decades, as the AIDSpandemic unfolded in country after country, governments and general populations almost always proved more interested in attacking the subpopulations at greatest risk for the disease than in fighting the virus itself. Children infected by HIV-contaminated blood transfusions were banned from schools, the homes of hemophiliacs were burned, masses of gay men died with little attention from the heterosexual communities around them, intravenous drug users were denied sterile syringes, female prostitutes were imprisoned or denied access to health care, and many medical and dental providers refused to allow HIV-positive individuals access to care unrelated to their infections.
From the perspective of HIV prevention, in nearly every country in the world, the 1980s and 1990s were long, ugly decades during which the virus spread relentlessly, with AIDS eventually ranking as the third-largest pandemic in world history (after the Black Death and the 1918 influenza pandemic). In comparing Ebola and AIDS, Frieden was not forecasting that Ebola would infect 60 million people, as HIV has; rather, he was indicating that the ignorant, inept, and cruel response to AIDS was being mirrored by events unfolding in West Africa in 2014.
During the 1980s, the who failed to recognize the importance of HIV and AIDS. Inside its Geneva headquarters, some experts exhibited as much prejudice against the populations at great risk for aids-especially homosexuals-as did the general public. For a brief time in the mid-1980s, its Global Program on AIDS (GPA) thrived, led by the epidemiologist Jonathan Mann. But who insiders grumbled and complained about the millions of dollars in AIDS funds Mann was raising and about the dire (and, in retrospect, mostly accurate) forecasts his group was issuing. A common refrain among insider critics was, “Since more people die of diarrhea-or cancer, or hypertension, or malaria, or whatever-than of AIDS, why is it getting so much money and media attention?” Heeding the grousing, the who’s director general, Hiroshi Nakajima, forced Mann’s resignation, slashed the aids budget, and eventually shut down the GPA, essentially walking away from the largest pandemic in modern history.
Since then, the global response to the rise of new pathogens has continued to be limited, uncoordinated, and dysfunctional. From SARS to MERS, H5N1 to H1N1 to H7N9, the story has been similar. Poor nations are unable to detect new diseases quickly and bring them swiftly under control. Rich nations generally show only marginal interest in outbreaks until the microbes seem to directly threaten their citizens, at which point they hysterically overreact. Governments look after their own interests, cover up outbreaks, hoard scarce pharmaceutical supplies, prevent exports of life-saving medicines, shut borders, and bar travel.
The global health infrastructure has shown itself to be weak, fractured, prone to infighting, and more interested in searching for technological silver bullets than engaging in the hard slog of social mobilization and classic local public health work. And through it all, the who has struggled to remain credible, as its financial resources have shrunk, tensions have grown between its Geneva headquarters and its regional offices, and rival multilateral organizations have taken control over much of the global health action and agenda.
“I Thought I Knew Fear”
By now, in mid 2015, the nation of Liberia is returning to its normal, pre-Ebola life. This is in sharp contrast to the horrors of last fall, when every nook and cranny of the country was in the grip of the disease and people were literally dying in the streets of Monrovia for lack of hospital beds and treatment centers. Nearly 500 new cases a week were detected in the country during late September and early October. Toward the end of the year, Liberia seemed to have its epidemic under control, with fewer than five new cases found each day, and it seemed reasonable to think, as Liberian President Ellen Johnson Sirleaf publicly did, that the epidemic might end before Christmas. Sadly, the virus skirted that final elimination, stubbornly spreading inside Monrovia. By mid-March 2015, Liberia once again seemed poised to declare victory, having gone more than 21 days without a new case anywhere in the nation. But on March 27, a 44-year-old woman living in Monrovia died of the disease. Authorities determined that her boyfriend, an Ebola survivor, had the virus in his semen, and a shocked nation learned that Ebola could be transmitted sexually by a man some six months after he was healed. The who officially declared Liberia free of Ebola on May 9, and the country began to focus on economic recovery while remaining on alert for Ebola reentry from neighboring Guinea and Sierra Leone, where control over the disease has proved substantially more elusive. (Ominously, in late June, the cadaver of a 17-year-old Liberian boy tested positive for Ebola, and since then, a handful of other cases have come to light.)
Charts of the rates of infection and fatalities show that Liberia’s plague was on its downward course before the world mobilized to help. With heroic assistance from MSF, the International Committee of the Red Cross, a few other foreign humanitarian and religious organizations, and small teams of foreign scientists and public health experts, Liberia was able to turn the tide of its epidemic largely without the UN Mission for Ebola Emergency Response (unmeer), the U.S. military, or the promised hundreds of millions of dollars’ worth of World Bank and multinational aid. As late as the end of February 2015, after the worst of the crisis had passed, less than half of the finances, personnel, and supplies promised by the global community had actually materialized on the ground. If the aid had arrived earlier, the epidemic would undoubtedly have been contained faster and with fewer fatalities.
There was no good reason to believe that Liberia would be able to acquit itself so well in managing its catastrophe. When the crisis struck, Liberia, one of the poorest nations on earth, barely had a health-care and hospital system or even a method for processing public-sector payrolls. It ranked 175 out of 187 countries in the UN’s Human Development Index, had an official unemployment rate of more than 80 percent, and a total gdp of only $1.95 billion. Less than half of the population was functionally literate, a third of the country’s women had never set foot in a classroom, and fewer than five percent of households could, by African Development Bank standards, be labeled middle class. And in fact, if not for a smattering of dedicated officials and medical personnel, together with the good sense of local villagers, Liberia might still be in crisis.
Miatta Zenabu Gbanya is a perfect example of the expertise that came to Liberia’s rescue. Smart, hard-working, and resilient, Gbanya, a nurse, returned to her Liberian home in mid-2013 after nearly a decade of grueling relief work in such hellholes as Darfur, South Sudan, and contested zones of the Democratic Republic of the Congo. Like most Liberians, Gbanya had toughened up at an early age as a matter of survival through her country’s civil wars, which began in 1989 and spanned the 1990s and beyond, and she had seen rough times since. While she was working in Darfur for a British medical relief group in 2007, for example, members of her team were carjacked by Khartoum-backed Janjaweed militants, and in subsequent months, Gbanya “spent many nights-night after night- laying in fear.” She said, “I thought I knew fear very well.” Until, that is, she faced the Ebola epidemic. “I thought fear in Darfur was the worst feeling,” she told me when I spoke with her recently. “But no-it’s Ebola.”
Given her years of relief work, Gbanya was assigned by Sirleaf to head up a new entity called the Health Sector Pool Fund, a health-care-financing scheme that combined resources from about a dozen donors into a single pot of carefully monitored funds for the nation’s desperate government health-care system. Liberia had few doctors, horribly rundown medical facilities, few supplies, and no money. Like its neighbors Guinea and Sierra Leone, moreover, Liberia had seen what institutions it did have collapse during the civil war years, to be replaced by a smattering of disconnected clinics and hospitals funded and operated by foreign missionaries and aid organizations. But Sirleaf felt Liberians should control and provide for their health themselves, and so after coming to power in 2006, her government had negotiated with donors, Gbanya said, and gotten them to agree to pool the funds they spent in the country into a single account. (The U.S. Congress will not permit the pooling of American financial resources, and so U.S. agencies operate in parallel to the fund, with the United States having a seat at the fund’s boardroom table.) By the time Gbanya took the helm in late 2013, the organization was ready to roll.
When she arrived, the Health Sector Pool Fund had about $65 million in the bank, she told me, enough to support the payroll and supplies for only a quarter of the country’s health establishment. Even when this money was combined with support from the U.S. government and the Global Fund to Fight AIDS, Tuberculosis and Malaria, Gbanya said she had no more than a third of the money needed to make full payroll, and she had to root out corruption inside Liberia’s Ministry of Finance to ensure that even those funds were properly allocated. From distant rural clinics to the top tiers of the Ministry of Health, many employees were going unpaid. Remarkably, the unpaid staff kept coming to work, and throughout the system, paid health-care workers shared their salaries with the unpaid, on the assumption that someday their clinical comrades would finally earn enough money to reimburse them.
By the most generous estimates, when Ebola struck, there were fewer than 250 physicians in Liberia, or fewer than two doctors for every 100,000 Liberians; the United States, in contrast, enjoys roughly 245 doctors for every 100,000 Americans. Nurses and midwives were similarly burdened, with three of them per every 10,000 Liberians. And the country had a hospital bed ratio of 0.8 beds per 1,000 Liberians. All of this meant long waits for treatments and exhausting hours of work for health-care providers. “We were dealing with a tough work force that was dissatisfied, from top to bottom,” Gbanya told me. She set to work searching for cost efficiencies, begging donors for more resources, and sniffing out corruption. But as the end of 2013 approached, Gbanya knew that tensions were rising inside the Liberian health-care system, and she simply didn’t have the money to do much about it.
Meanwhile, hundreds of miles away from the Liberian capital of Monrovia, at the edge of a great rainforest where Guinea, Liberia, and Sierra Leone meet, a two-year-old boy named Emile crawled about a water-soaked tree stump with other toddlers and discovered a bunch of little, furry winged creatures. Grabbing at them and poking them with a stick, Emile reportedly played with the nest of lolibelo–the name locals use to describe musk-smelling, dark gray bats with bodies about the size of a child’s open hand. Many months later, a team of German anthropologists and biologists would visit the Guinean village of Meliandou and determine that Emile’s lolibelo were Angolan free-tailed bats or perhaps members of a similar species of mammal found across most of sub-Saharan Africa. Surviving children in the village told visiting scientists and reporters that youngsters had smoked lolibelo out of the tree, filled up sacks with the flying mammals, and eaten them. The men in the village often hunted larger fruit bats with roughly foot-long wingspans, called little collared fruit bats- one of only three bat species thought to carry the Ebola virus.
Whether he caught something from a tiny lolibelo or from a bigger fruit bat, on December 26, 2013, Emile came down with a soaring fever, bloody diarrhea, and nausea, and soon others in the village got sick, too. Emile died on December 28, and over the following six weeks, at least ten other villagers succumbed. Before dying, a Meliandou midwife went to People across the region seek help from her family in the nearby village of Dandou Pombo, passing the whispered that they were strange disease on. She then died in a more afraid of angering hospital in the town of Guéckédou, after their ancestors than they infecting one of her attending traditional healers. That ailing health-care worker were of the disease. went to a government clinic in the town of Macenta; after he died, four members of his family who had prepared his body for burial brought the disease home with them to a fourth area, Guinea’s Farako District. Back in Meliandou, baby Emile’s grandmother died of the disease on January 11, 2014. Relatives from Dawa village attended her funeral, returning home before dying themselves. Soon, a primary chain of transmission was spreading the still-unidentified disease throughout Guinea and into Sierra Leone.
By February, terrified villagers were pouring into medical facilities across the region, including an MSF malaria clinic in Guéckédou, close to the Liberian border, where the 36-year-old Guinean physician Marie-Claire Lamah and her colleagues struggled to figure out what was wrong. “When I arrived the mortality toll was between 80 and 90 percent,” Lamah told Le Nouvel Observateur. Villagers and health-care workers could already see a pattern emerging, with the people who cared for their ailing loved ones and prepared their bodies for burial being the most likely to contract the mysterious disease. But the villagers continued to wash the cadavers, dress them in finery, ritually kiss and caress the deceased to wish them well in the afterlife, and bury the dead, all according to ancient traditions meant to ensure that angry spirits would not return to haunt the families of the dead for failing to provide proper entry for them to heaven. (People across the region later whispered to me that they were more afraid of angering their ancestors than they were of the disease.)
Meanwhile, near Guéckédou, a second line of transmission went untraced by health officials for weeks. It began, according to an investigation by The New York Times, with a woman named Sia Wanda Koniono, who visited the Guéckédou area and died after returning to her home across the border in Sierra Leone, on March 3. Although Guinean authorities knew about Koniono’s death, they apparently made no attempt to notify their Sierra Leonean counterparts. The second line of transmission spread, unobserved, from Koniono’s funeral across a broad swath of Sierra Leone and eventually into Liberia.
At this point, Gbanya knew nothing about Meliandou, the deaths in Guinea, or the strange outbreak that had crossed into Sierra Leone. What she did know was that all the doctors and nurses in Liberia were demanding that she somehow raise enough funds to put everybody on the payroll. Negotiations with health-care workers and their unions broke down when Gbanya tried to explain how the pool fund worked and why she had enough money to pay only a quarter of them. “We had many discussions with health workers,” Gbanya recalled. “But it’s complex. They don’t get it.” So Liberia’s government health work force went on strike. Gbanya pleaded for understanding, and eventually the disgruntled doctors, nurses, midwives, lab technicians, ambulance drivers, hospital managers, and Ministry of Health personnel returned to work, tentatively accepting vague promises of future payment. But it was a challenge. “I’m used to coping,” Gbanya told me last December, shaking her head. “But from the moment of that health-care worker crisis in February, we haven’t stopped. Not for one minute.”
On March 12, 2014, Liberia’s traditional Decoration Day, Gbanya joined thousands of fellow citizens to honor ancestors by festooning their graves with flowers and memorabilia-not realizing the epidemic had now crossed into Liberia, striking Foya, a town of 20,000 people in Lofa County. A week later, Guinea’s top health officials released their first official statement on the mysterious Meliandou outbreak, with the Ministry of Health saying that 35 cases of a hemorrhagic ailment had been confirmed. The statement made no mention of the Koniono case or of evidence that infected individuals were crossing back and forth across the porous borders between Guinea, Liberia, and Sierra Leone, giving rise to the first multinational Ebola epidemic in history. A Health Ministry spokesperson, Sakoba Keita, told local reporters that most of Guinea’s victims had been in contact with dead bodies and suffered “diarrhea and vomiting, with a very high fever. Some cases showed relatively heavy bleeding.” He went on: “We thought it was Lassa fever or another form of cholera but this disease seems to strike like lightning. We are looking at all possibilities, including Ebola.”
Finally, on March 23, the who announced that the cause of the outbreak had been conclusively identified as Ebola by France’s Institut Pasteur. By then, the epidemic had already sickened many people in Guinea’s capital city, Conakry, marking the first time in history that the disease had spread to a metropolitan center with an international airport. On March 24, in Guéckédou, MSF opened the first of what would become several Ebola treatment centers and began calling for international help to find and isolate infected individuals so as to stop the outbreak. Because it had carried out such actions in Kikwit in 1995 and for a dozen other Congo basin Ebola outbreaks since, the organization was able to mobilize quickly. But little help was forthcoming. The who reported that two suspected Ebola patients in Conakry had tested negative for the virus. But the next day, the organization acknowledged that 86 cases of the disease, including 59 deaths, had occurred in Guinea; that labs in Europe had confirmed the presence of the Ebola virus in 13 samples; and that it was investigating rumored cases in Liberia and Sierra Leone. At the same time, the Liberian Ministry of Health confirmed the country’s first Ebola cases. The next day, a who field investigator sent a memo, later obtained by the Associated Press, to the who’s African regional office, in Brazzaville, Congo, calling for urgent help, as “there is evidence of cross-border transmission.” Then, on March 27, the who issued health alerts for all of Guinea, Liberia, and Sierra Leone, as panic took hold in Conakry. On the last day of March, Senegal closed its borders with all three countries, foreign businesses began withdrawing their expatriate employees, commercial air carriers started negotiations that would lead to a cessation of services, and the eu made the first pledge of international funds in response to the Ebola outbreak: $690,000.
By April 1, the number of cases in Guinea had jumped by almost 50 percent, to 122, with 80 deaths. Liberia now had eight confirmed cases. The who mobilized protective equipment for health-care workers in Conakry, but local health-care providers complained that what they really needed was water, electricity, basic medical equipment, and sanitation supplies, none of which were available. Air France began quarantining flights from the region, and a mob attacked an MSF treatment center in Macenta, Guinea, accusing the foreign doctors and nurses of bringing the disease to Africa and forcing MSF to abandon the clinic.
By mid-April, the who’s Global Outbreak Alert and Response Network (GOARN) was overseeing 65 foreign epidemic experts working in Guinea and Liberia, with some 220 cases of Ebola identified and 135 deaths. According to the Associated Press, in a frightening e-mail to the who’s headquarters in Geneva, a field investigator in Guinea called for “a drastic … change [of] course,” warning that health-care workers were “gripped by fear and panic … We need to change strategy urgently.” The who focused the international efforts on educating the Guinean population and rapidly isolating known cases, and by April 27, experts both in Geneva and at the CDC’s headquarters in Atlanta were convinced that the tide had been turned: case loads were falling, and the situation appeared to be under control. The foreigners, with the exception of MSF and the missionary aid group Samaritan’s Purse, began to withdraw.
In Monrovia, Gbanya sighed with relief. She knew that some of the health-care workers fighting the relatively few cases in Lofa County were unpaid, and her pool fund budget had no flexibility to allow for an unexpected catastrophe such as an epidemic. Sirleaf, who told me that by that point she had been assured that the Ebola threat had passed, left the country to attend international finance meetings, and officials inside the Ministry of Health returned to business as usual. Retrospective charts of Ebola cases in the spring of 2014 show a mid-March uptick, followed by a plummet in early April, which the who and the CDC both misinterpreted as the beginning of the end of the outbreak; in fact, it was just a lull. The virus was lurking far from the watchful eyes of health authorities, poised to precipitate the worst Ebola crisis in history.
In Geneva, meanwhile, the who leadership was fixated on the organization’s annual World Health Assembly, coming up in May. The WHA is a one-country, one-vote legislature that governs the who, deciding its budgets and key policy initiatives. WHA gatherings are typically grueling affairs that everybody dreads, with delegates bickering over obscure paragraphs in proposed resolutions at 3 am, as tiny nations such as Kiribati or Paraguay have the same say as behemoths such as China, India, and the organization’s major donors, the eu countries and the United States. Weeks of preparation, including advance private negotiations with key countries, are necessary to make sure anything gets done, and there is even recurrent debate about the fundamental mission and role of the who.
Since its creation as part of the United Nations system in 1948, the who has served as a clearinghouse for technical advice, providing member nations with guidance and expertise on everything from the dangers of smoking and the safety of measles vaccines to health-care-financing mechanisms and the sociopolitical determinants of heart disease. That alone would be more than enough for any entity to handle, but over the years, the WHA has pushed the organization to take on tough policy positions as well. Countries in trouble want the who to mobilize the world’s top technical expertise to vaccinate Syrian refugees, stop cholera in post-earthquake Haiti, erect emergency trauma centers across Typhoon Haiyan-devastated Philippine islands, and so forth. But WHA delegates also insist on introducing countless resolutions on issues such as international recognition of Palestine and Taiwan, the banning of tobacco and fast-food company employees from public health meetings, and sex education, gay rights, and family planning.
Every WHA has had political surprises, and the list of mandates is always far in excess of the budgetary authority conferred to accomplish them. The 2013 WHA, for example, was sidetracked by an unexpected outburst from the delegation from Saudi Arabia, which complained about the patenting by a Dutch scientist of a sample of a new virus (MERS). The assembly descended into a frenzy of oration denouncing the patenting of viruses, even though the issue, however ethically dubious, was entirely irrelevant to the actual course of the virus’ spread inside Saudi Arabia, which the kingdom’s scientists had done little to counter. Meanwhile, assembly delegates declined to raise revenues in order to address a massive budget crisis, accelerating the who’s decline as a player on the global health stage relative to better-funded, more effective, and less politicized institutions, such as the Global Fund; Gavi, the Vaccine Alliance; the U.S. President’s Emergency Plan for AIDS Relief; and the Bill and Melinda Gates Foundation. And they dramatically rearranged the who’s priorities, shifting resources away from combating infectious diseases.
A year later, as staffers prepared for the 2014 WHA, they were still grappling with the consequences of the previous one, trying to fight a raging Ebola epidemic in West Africa with a meager budget and scarce personnel. More than 130 people had lost their jobs in GOARN, leaving the who with a skeleton crew of fewer than 35 outbreak fighters and clerical support personnel. In Saudi Arabia, meanwhile, MERS was spreading out of control inside the country’s largest public hospital, its animal origins remained unclear, no point-of-care diagnostics existed to quickly determine whom the virus had infected, and there were no cures or vaccines available. And the virulent H7N9 bird flu was moving rapidly across mainland China, Hong Kong, and Taiwan.
Further compounding the organization’s problems were two internal policy matters. Margaret Chan, the who’s director general, had recently won reelection, and to many observers, she seemed to defer too much to national governments’ wishes and agendas, even when they were in conflict with the organization’s primary mission. During Chan’s tenure, which began in 2006, the who’s regional offices had gained power and autonomy at the expense of the organization’s central headquarters. This was fine for those parts of the world with strong regional healthcare institutions, such as the Americas. But it was a disaster for a continent such as Africa, whose regional who office had scant resources and a poor reputation. Throughout the spring of 2014, as MSF was trying to draw attention to the worsening situation, reports from the who office in Brazzaville were downright cheery. On April 25, for example, the office reported that “overall, the epidemiological situation in Guinea has improved significantly over the last few weeks.” A few weeks later, the office issued a similar assessment: “The overall Ebola outbreak in Guinea continues to improve.” These rosy views were echoed by Guinean President Alpha Condé, who, during a visit to Geneva in early May, vaguely commented to reporters that “there haven’t been any new cases.” Owing in part to such reassurances, who and CDC officials in Geneva and Washington concluded that the West African Ebola epidemic was coming to an end.
Unfortunately, it wasn’t.
Out of Control
MSF officials were convinced that the decline in reported cases was a product not of a fading epidemic but of a reluctance by local villagers to engage with foreigners or national institutions. After the MSF clinic in Macenta was attacked by a mob on April 4, MSF officials tried in vain to get the who to change its mind about withdrawing. When the 2014 WHA convened in Geneva in late May, the Ebola epidemic garnered only a smattering of references in speeches. It was not on the agenda, and no resolutions were passed concerning it. As the delegates conversed, however, the virus was continuing to spread across Guinea, Liberia, and Sierra Leone, undetected by authorities for precisely the reasons MSF had identified: locals were not reporting their illnesses, and families were burying their dead in secret.
According to internal who documents obtained and published by the Associated Press, a June 2 meeting of GOARN team members in Geneva revealed a radically increased sense of urgency; one scientist on the team noted that the West African countries were “overwhelmed with outbreaks” and that “outbreak vigilance [was] down to a minimum.” Two days later, a who scientist suggested internally that it was time to declare a public health emergency under the International Health Regulations, an international legal framework that provides guidelines to prevent the spread of infectious diseases. But in response, Sylvie Briand, the head of the Pandemic and Epidemic Diseases Department at the who, said that the invocation of the IHR should be considered only as “a last resort.” And a June 10 memo prepared for Chan by senior who officials warned that invoking the ihr “could be seen as a hostile act in the current context and may hamper collaboration between who and the affected countries.” In contrast, in mid-June, the leaders of MSF declared the Ebola situation “out of control” and begged the world to pay heed. According to a report that MSF later published, some who officials responded to those entreaties by accusing MSF of exaggerating the risk and encouraging panic.
In Liberia, Luke Bawo was heading up a small team in the Ministry of Health tracking Ebola. “We thought we were down to zero back in April-we couldn’t find any cases-but then the epidemic surged and overwhelmed us,” he told me.
There was a lull, 21 days with no cases. Everybody let their guard down. Then a Ugandan physician at Redemption Hospital [in Monrovia] got infected, and the minister of health called me and said, “We need your help to manage data.” I had no idea what I was getting into. I read and studied about Ebola, and I thought in 40 days it will go away. But that did not happen with Ebola here-not like [in the past] in Uganda. And then this Liberian guy [Patrick Sawyer] exported the virus to Nigeria, and that woke the whole world up. Since then, I have been working seven days a week, no holidays. I start calling all the counties at 8 pm, until 10, maybe midnight. Catch a couple hours of sleep. And then up at 5 am to prepare the [daily] situation report and have it ready to present at 9 am. It’s never-ending.
Sirleaf took charge of her country’s response to the epidemic in early June; she began, she told me, by begging for the CDC and the who to return. But the CDC’s leadership was preoccupied with a succession of scandals back home involving inappropriately handled samples of dangerous pathogens; Congress was investigating, and in July, the CDC temporarily shut down some of the labs where work on the Ebola virus could have been carried out. Then came the long European summer holidays and the monsoons in West Africa.
With the rains came tremendous logistical challenges, as the countries in question have few paved roads outside of their capital cities. On average, Monrovia gets 202 inches of rainfall annually, most of it pouring down between June and October. (In contrast, moist Bangkok averages 55 inches, and Seattle, 33.) Many of Liberia’s poor roads are transformed by rain into seas of mud, bringing transport to a near standstill. Scattered reports from the hinterlands came into Monrovia indicating that Ebola was spreading out of control, and by mid-July, its presence in the capital itself was undeniable as patients turned up in local hospitals and beloved doctors and nurses perished. Their losses, in a country of so few skilled health-care workers, “felt like a stab in our hearts,” Gbanya told me. “July, August, September-hoo! We lost the best we had. We spent a lot of nights crying and a lot of mornings saying, ‘We must go ahead.’ Even at the ministry, there were days when we were just too worried. There were dead bodies everywhere! Our phones never stopped ringing. Ambulances all night! For eight months, none of us has slept.”
Ministry of Health Ebola meetings, usually attended by the president herself, became deeply emotional. “There were days we used to sit around the table and couldn’t find a way out,” Gbanya said. At one such meeting, on July 22, a young man shouted at Sirleaf, accusing her of running a government that had denied hospital care to his dying relative. The next day, the man returned and set off a firebomb inside the conference room, destroying computers that stored valuable information and sending terrified staff scrambling. It would be one of many violent episodes in Monrovia-and Conakry and Freetown-spawned by fear and rage among populations unable to comprehend why their governments could not stop the plague.
Nothing To See Here
On July 20, an American financial consultant to the Liberian government, Patrick Sawyer, flew from Monrovia to Lagos, unintentionally taking Ebola to Nigeria. In response, Sirleaf ordered most of the country’s borders sealed and banned its diplomats from traveling abroad. The Sawyer case elevated the Ebola crisis on the international agenda, prompting some major airlines to cancel flights to Guinea, Liberia, and Sierra Leone and leading a number of countries, including France, Germany, and the United States, to issue travel warnings advising their citizens to stay away. The Ebola-hit countries descended into a period of almost complete economic and political isolation from the rest of the world, one that continues today.
Still, the who declined to declare an emergency. An expert panel of advisers told the Geneva headquarters in July that it would be wrong to divert scarce medical resources in the three impoverished countries to the Ebola crisis. “If you want to blame somebody for this epidemic, blame me. It was my mistake,” the statistician and doctor Hans Rosling later told me, speaking so earnestly that his voice broke. A leading analyst of global health trends at Sweden’s Karolinska Institute and a member of the expert panel, Rosling argued in July that a diversion of scarce national health talent in the three nations to address the “small problem” of Ebola would doom a far larger number of people in the countries to die of the greater threats of malaria, pregnancy complications, diarrheal diseases, and bacterial infections. Rosling was persuasive–although hardly alone in making an argument that echoed claims made by the who in the 1980s regarding the relative importance of AIDS versus other diseases. (Unlike others who offered the same advice, Rosling later recognized his terrible mistake as the number of Ebola cases skyrocketed throughout the summer and volunteered to do penance, working beside Bawo, the Liberian Health Ministry official, for three months, counting Liberia’s sick and dead.)
By the first week of August, overstuffed hospitals were turning away patients and corpses were being left unattended on the streets of Monrovia. On August 6, Sirleaf declared a national state of emergency, calling on her people to fast and pray from 6 am to 6 pm for three days: “Relying on his divine guidance for our survival as a nation,” she said, “I call on all Liberians to observe three days of national fast and prayer to seek God’s face, to have mercy on us and forgive our sins and heal our land.” Given the dire situation, Sirleaf decided not to attend U.S. President Barack Obama’s U.S.-Africa Leaders Summit later that month in Washington, sending in her place Liberian Vice President Joseph Boakai and relying to some extent on the U.S. ambassador to Liberia, Deborah Malac, to be an advocate for her views. Malac told me that she tried to raise alarms within the Obama administration and Congress about the crisis. But despite her efforts, the subject took a back seat to economic development during the summit-this despite the fact that two American aid workers had contracted the disease in Liberia and were undergoing experimental treatments in the United States, causing considerable American media hysteria.
It was not until August 8 that the who declared the Ebola situation a “public health emergency of international concern,” an official designation previously invoked in 2009 in reference to the H1N1 swine flu. But by then, Rosling’s fears had ironically been borne out: routine health care had collapsed in all three affected countries, and even minor medical complications, in childbirth, car accidents, and simple falls, were proving lethal.
By that point, the epidemic was of such staggering proportions, and the panic it was producing so great, that Guinea, Liberia, and Sierra Leone seemed on the edge of collapse. Riots broke out, bodies were hidden, health-care workers were attacked, and food supplies dwindled. In an interview with National Public Radio, Lindis Hurum, MSF’s emergency coordinator in Liberia, said, “We’ve reached our limit … We certainly have the motivation, but I don’t have enough people to deal with this.”
UN Secretary-General Ban Ki-moon, seeming to have lost faith in the who, appointed David Nabarro as the UN’s special envoy on Ebola and sent him to assess the situation in the Ebola-stricken region. Nabarro later told me it was one of the gravest situations he had ever witnessed. He set to work mobilizing resources and institutions to stop the epidemic. He initially reckoned that a successful effort would cost at least $600 million.
Frieden, the CDC’s director, also visited the region, in late August, telling Obama on his return that the epidemic was even worse than he’d feared. On September 1, Sirleaf went on CNN, pleading for help: “Our health delivery system is under stress … It could easily become a global crisis … We need that hope; we need that assistance. We need for the Liberians to know that this war can be won.” The next day, Liberian health-care workers went on strike again, this time arguing that physicians, nurses, ambulance drivers, and other health-care employees should be receiving extra hazard and overtime pay. Msf’s international president, Joanne Liu, spoke at a un briefing that day and placed the situation in stark relief. “To curb the epidemic, it is imperative that states immediately deploy civilian and military assets with expertise in biohazard containment,” she said. “We cannot cut off the affected countries and hope this epidemic will simply burn out. To put out this fire, we must run into the burning building.”
Gbanya turned to her donors, she told me, and begged them to increase their support for the Health Sector Pool Fund, pleading in vain with the World Bank and the who. There were murmurs that Monrovia’s large soccer stadium ought to simply be filled with cots and all those suspected of being infected with Ebola loaded inside. Distraught Ministry of Health staff members worked relentlessly, took catnaps in their offices, and attended funerals. “I was so sad; everybody was so sad,” Gbanya recalled. “We just cried and cried every day and then tried to go on working. Just cry, and push on, cry, and push on.” Soon, the very people leading Liberia’s Ebola fight were suffering losses in their own families and among their staffs, and a sort of mass-scale traumatic shock hit the nation’s leadership.
In the middle of all of this, Sirleaf summoned Gbanya and told her that the whole country was listening to the striking workers’ complaints about corruption and conspiracies, and so she needed to explain to the public just how the pool fund worked. After hearing an hour of details about its operations and shortfall, Gbanya recalls, the president shook her head sadly and said that the situation was too complex and depressing for people to accept. So Sirleaf dropped the idea of mass public education about the fund and instead went to hospitals and Ebola treatment centers herself and begged medical workers to stay on the job for the good of the nation.
Not In My Backyard
On September 16, Obama announced his decision to deploy around 3,000 U.S. military personnel to West Africa to fight the epidemic and committed $750 million to the effort. On a visit to the CDC’s headquarters, Obama pledged a series of additional commitments from Washington, pointedly adding, “But this is a global threat, and it demands a truly global response. International organizations just have to move faster than they have up until this point. More nations need to contribute experienced personnel, supplies, and funding that’s needed, and they need to deliver on what they pledge quickly. Charities and individual philanthropists have given generously, and they can make a big difference.”
It was the middle of September when the world finally began to reckon with the reality of what was happening in West Africa. The un Security Council declared Ebola an international threat, the General Assembly echoed the cry the next day, and the CDC released a forecast predicting exponential growth to more than a million cases by February absent major international intervention. The World Bank and the White House pressured countries around the world to pony up resources; the un estimated the costs of stopping the epidemic at just under $1 billion and created a new Ebola task force, unmeer; and according to a report in The New York Times, the World Bank’s president, Jim Yong Kim, chastised Chan for the who’s failed response during a meeting of international health officials at the bank’s headquarters. (Through a who spokesperson, Chan declined a request to be interviewed for this article.)
The first small U.S. Army team arrived in Liberia on September 17 to assess the situation; hundreds more U.S. military personnel would arrive in October, and a field hospital dedicated to the care of healthcare workers themselves would open in early November. In Sierra Leone, the British military mobilized, deploying at about the same time as the U.S. Army did in Liberia. Both built elite-care Ebola treatment facilities. But the U.S. Army’s facilities went operational only after Liberia’s epidemic had started winding down, and most received no patients. The Sierra Leone epidemic, in contrast, lagged months behind Liberia’s, and British forces saw many Ebola patients, including at least one from their own ranks. Unmeer, meanwhile, put its first official boots on the ground in the region on September 29, coordinating humanitarian activities akin to those executed by un agencies during famines and after natural disasters.
While all of this was happening, however, attention in the West shifted away from Africa and toward the enemy within. On September 24, a Liberian man named Thomas Duncan came down with Ebola while visiting his fiancée in Dallas, Texas, and soon two of Duncan’s attending nurses were infected. (Duncan died on October 8; both nurses were eventually cured.) A nurse in Spain, meanwhile, contracted the disease from a patient who had been brought home from Africa for treatment, showing that both the United States and Europe were potentially at risk. The reaction was swift and hysterical, with a host of prominent Americans issuing calls to ban travelers from the three Ebola-afflicted countries and self-proclaimed experts warning about the possibility that the virus might be able to spread through the air. Ebola coverage became a staple of cable television and talk radio and even figured prominently in the U.S. midterm elections (as a telling sign of the global chaos supposedly sparked by Obama’s foreign policy failures).
African observers hardly knew what to think. “We were saddened by the reaction in America,” Sirleaf later told me. “We understand the fear. We live with fear. But the risk was minimal [for Americans].” To put the world reaction in perspective, on September 28, when the Liberian epidemic was at what later proved to be its peak, Twitter users were posting Ebola-related messages at the rate of about a few dozen per minute. In the days after Duncan was officially diagnosed, on September 30, the rate rose to around 6,300 messages per minute.
Ironically, it was during just this period that Liberia’s epidemic started to abate. Many factors played a role in defeating it, including a remarkable U.S. mobilization; great improvements in laboratory testing and diagnostic speed; the construction of Ebola treatment units, which allowed infected individuals to be isolated; and the virtual elimination of unsafe burials and the imposition of mandatory cremations. But officials in the Sirleaf government repeatedly acknowledged actions taken by the Liberian citizenry at large. “We need to give credit to the public for what has been done,” one of Sirleaf’s political advisers, Emmanuel Dolo, told me. “And we have to say that we cannot let that go.”
For example, rural communities realized that Ebola was coming from outsiders, especially villagers returning from Monrovia and other big cities. So without any push from the government, communities took matters into their own hands, setting up temporary isolation places (usually designated houses or sheds), in which they ordered visitors and returnees from the cities to be quarantined. After months of struggling with traditional burial practices, rural residents began bringing their dead to authorities. And the Liberian Ministry of Health deployed an army of thousands of contact tracers-young men and women hired temporarily to track down all known associates of confirmed Ebola patients and fatalities. In local villages, I found village chiefs taking control: ordering families to bring out their sick and dead, commanding safe burials, and searching for ways to feed quarantined households.
When I visited the Liberian town of Jene-Wonde, nestled along the border with Sierra Leone, the chief was ordering young men to dig a well and build a fence to enclose a newly refurbished clinic, made of wattle and thatch. Chebe Sano, a middle-aged woman with a quiet, commanding presence, was the chief of the roughly 700 residents and led the creation of a three-room Ebola community care center, designed to house a dozen people in quarantine. Sano didn’t wait for the Liberian government or a group of nonexistent doctors to take action. She knew that her people’s plague could be stopped only if the infected were separated from the rest of the population. With advice from a handful of the CDC’s Epidemic Intelligence Service officers, Sano simply took tough quarantine steps that eventually stopped Jene-Wonde’s horror.
“It is the communities in Liberia that turned this around. The thing that kept us going,” Gbanya explained to the wha in Geneva in May 2015, “is we knew, we need to do the best we can to save Mama Liberia.” But she admonished the delegates from 194 nations to maintain international vigilance. “It’s not over until it’s over in our sister countries, Guinea and Sierra Leone,” she said. “When a disease hits your neighbor’s front door, be aware that it can come to your backdoor.”
Who Needs The Who?
The who performed so poorly during the crisis that there is a question of whether the world actually needs it. The answer is yes, it does-but in a revised form, with a clearer mandate, better funding, more competent staff, and less politicization. The agency should be clearly at the apex of the global health architecture, not jockeying for command of epidemic response with other organizations, as happened last year. But with power comes responsibility, and the who needs to merit its position, not simply assume it. If the who is going to remain the world’s central authority on global health issues-which it should, because there needs to be one, and it has the most legitimate claim to perform such a role-it needs to concentrate on its core competencies and be freed from the vast array of unrealistic, unprioritized, and highly politicized mandates that its member states have imposed. Rather than wasting resources duplicating the responsibilities and expertise of other agencies, it should scale back to providing technical expertise and advice in areas such as tuberculosis, malaria, HIV/AIDS, and child immunizations. And although the World Bank offers financial backing and advice on many programs having to do with health, its own expertise is primarily about money: it should not be competing with the who on providing guidance for handling outbreaks of infectious diseases but rather be helping finance the measures a competent who argues are necessary. Ban, the UN secretary-general, should convene private meetings with the leaders of the World Bank, the who, and several dozen other relevant agencies and institutions to develop plans for a more coherent and efficient response to future epidemics.
This year’s WHA was obsessed with trying to learn lessons from the crisis and featured a great deal of questioning of the who’s basic credibility, given the organization’s inadequate response. It may not represent an existential crisis, but as the former Oxfam chief executive Barbara Stocking told the gathering, it is surely the who’s “defining moment.” Stocking is chair of the Ebola Interim Assessment Panel, which Chan created to offer an objective appraisal of the organization’s response to the outbreak. If the director general had hoped for a mild rebuke, she must have been sorely disappointed. In July, the panel published its final report; it was devastating.
The Ebola outbreak revealed, Stocking’s panel concluded, that the who was incapable of responding to emergencies in a timely fashion and lacked the credibility to enforce the ihr, its own instrument. The who’s leadership was alarmingly slow to respond to the unfolding crisis, the panel reported, because the organization “does not have a culture of rapid decision-making and tends to adopt a reactive, rather than a proactive, approach to emergencies.” The panel lamented that senior who officials failed to adequately react to warnings of the outbreak’s growing seriousness that they received from within the organization and from outside sources, especially MSF. “Who must re-establish its pre-eminence as the guardian of global public health; this will require significant changes throughout who,” the panel’s report stated. It went on to recommend 21 major reforms, affecting nearly every aspect of the organization, including strengthening GOARN, significantly increasing funding to improve the ability of member countries to respond to disease emergencies, and placing all of the who’s disparate emergency-response units into a single chain of command.
The who’s executive board, meanwhile, had delivered its own harsh critique of the agency back in January. There is a “clear gap in the who’s mission and structure,” it stated, with “no clear lines of decision-making or dedicated funding in place [leading to] a slow, uncoordinated response to the Ebola outbreak.” Not only did the who fail to implement the IHR in a timely fashion, the executive board concluded, but it also did too little to prevent nations from taking steps in violation of the IHR that isolated and stigmatized the affected countries. At the height of the crisis, most other African countries banned people from and trade with Guinea, Liberia, and Sierra Leone; Australia and Canada declined all visa requests from the region; all but two commercial air carriers and all airfreight services ceased flights to the area; and insurance companies declined to pay for air rescue services. All such actions were in violation of the IHR, yet the who appeared powerless and inept in response, unable to enforce its own regulations.
The executive board’s and the assessment panel’s reports both insist that epidemic prevention should be the core function of the who: if the agency cannot credibly lead in a disease crisis, it might not merit donor support. But as MSF’s Liu said on the sidelines of an Ebola meeting in Dakar in June, “The reality today is if Ebola were to hit on the scale it did in August and September, we would hardly do much better than we did the last time around.”
In response to the assessment panel’s report, the who issued a statement claiming that it was “already moving forward on some of the panel’s recommendations.” A few days later, I spoke with Bruce Aylward, a who assistant director general who was deeply involved in the Ebola response and who distinguished himself as one of the first members of the senior leadership to realize that the organization’s response was lagging. Aylward acknowledged the validity of many of the complaints lodged by the executive board and the assessment panel but argued that many of the who’s critics fail to appreciate just how difficult a position the who is in and underestimate how much the organization relies on buy-in and consensus from its member states. “I think the issue is, what is the purpose [of the who]? And are the member states in agreement on that purpose? Where do they want the organization to land?” he said. “We’re in an extremely dangerous position, being pressured to make incremental changes until member states are assuaged, but not so much change that the organization, internally, revolts.” But he conceded that the who “has got to evolve, to be more than a mere technical organization. It must be a health emergency manager.”
That idea is now the subject of heated debate among global health experts and policymakers. Some argue that the who cannot credibly fulfill its role as an emergency manager. But no one has identified an alternative agency that could realistically take on the job. The only way the who can hope to do so is by enlarging GOARN and expanding its mandate, allowing it to operate as a semiautonomous unit that controls its own budget, overseen by an independent governing board and protected by a firewall separating its science-based decisions from the vagaries of international politics.
Another important step the who should take is to plan for a competent, quickly deployable, international volunteer medical corps. Composed of doctors, nurses, lab technicians, epidemiologists, and other professionals necessary for handling a humanitarian crisis, such a corps should be voluntary and multinational, with thousands of trained and registered people ready to be summoned into service on short notice when the next emergency arises. When crises are so obviously recurring and predictable, there is simply no reason that each one should be met with a similarly ad hoc, uncoordinated, amateurish response, sluggish when it matters most and panicked when problems have already escalated.
Even were such a corps to exist, however, it would still need to get to the crisis quickly, something that is a much greater problem than most people realize. As soon as the Ebola epidemic was confirmed, the only air travel of any kind between the affected countries was provided by the un Humanitarian Assistance Service, which was available only to UN agencies and authorized others. Under the 1944 Convention on International Civil Aviation, sovereign states may close their airspace due to adverse conditions such as bad weather or conflict, and airlines may cancel flights for their own marketing or risk-assessment rationales. The convention offers no means for a sovereign state to compel airlines to service it, nor for an airline to override an airspace closure. The International Civil Aviation Organization should revisit these issues, paying special attention to encouraging airlines to maintain reasonable services to countries facing health crises.
As a result of these difficulties with air travel, it was hard for people and supplies to get to the epidemic and practically impossible to coordinate responses across all three countries. Medical volunteers from the developed world who tried to help out, meanwhile, found themselves discriminated against by airlines or subject to mandatory quarantines when they tried to come home, which was not only unfair but also a clear deterrent to such help, rather than the facilitation and support of it that the situation required.
The who and the U.S. State Department, accordingly, should figure out how to ensure that such problems do not arise in future crises. Among other things, this will mean scrutinizing the air transport agreements the CDC has with commercial carriers for the emergency transport of personnel, supplies, and dangerous microbe samples. The world cannot rely on standard market operations to proceed as usual during a crisis, and so authorities need to lock in appropriate arrangements beforehand.
Another area requiring advance attention is the availability and use of experimental medicines, vaccines, and rapid diagnostic tools. All three were lacking during the recent crisis, even though promising drugs, immunizations, and point-of-care instant diagnostics are in various stages of development. The who’s innovation team has been bogged down for months in ethics debates and arguments over how vaccine trials might be properly executed, and with the epidemic waning, it is possible that nothing will actually get into field trials in time to be tested against actually existing Ebola. Together with the pharmaceutical, scientific, medical ethics, and biotechnology communities, the who should create policy templates for future rapid action-now, before the next crisis hits, rather than being forced to deal with such matters in the heat of the moment.
In the end, the world must come to grips with the fact that future epidemics are not just likely but also inevitable and prepare to deal with them more effectively. As Nabarro, the UN’s special envoy on Ebola, recently put it to me, “There will be more: one, because people are moving around more; two, because the contact between humans and the wild is on the increase; and maybe because of climate change. The worry we always have is that there will be a really infectious and beastly bug that comes along.”
Some major authorities have argued that the real problem is less epidemic response than the availability of basic public health programs-that the Ebola crisis would never have developed to catastrophic proportions if Guinea, Liberia, and Sierra Leone had universally accessible health-care systems. This is simply not true. Good health care should indeed be considered a basic human right, but even if it were available everywhere, outbreaks of strange new diseases and viruses would still occur-just look at SARS in Toronto and Singapore in 2003, mrsa and other drug-resistant bacterial diseases in hospitals across the United States today, and MERS in Saudi Arabia, to name a few.
On the other hand, there is simply no question that the problems Gbanya and her colleagues have had to grapple with go well beyond crisis response. The health-care systems of Guinea, Liberia, and Sierra Leone were in terrible shape before the Ebola epidemic struck, and they will be in worse shape after the epidemic has passed, having lost a significant number of health-care professionals to the disease. Across Liberia now stand empty Ebola treatment units that are little more than tented wooden platforms wrapped in plastic sheets. With the return of the rainy season this summer, those expensive emergency isolation facilities will be washed away, leaving no permanent improvement in local medical systems.
“A weak health system was struggling before Ebola,” Gbanya told me. “After Ebola, health-care service delivery will be difficult. And the costs will be three times as high. Why? Because of all the protective equipment, all the training, the emergency-response system. At this stage, we have the opportunity to think what sort of investment can equal medium-term improvement in Liberia. We’re not going to have a country anymore if we keep getting Ebola.” And so it comes back to money. The world will get what it pays for-and right now, that is not very much.