from The Internationalist and International Institutions and Global Governance Program

Ebola Reveals Gaps in Global Epidemic Response

Health workers screen patients for the Ebola virus at a local government hospital in Kenema, Sierra Leone, on June 30, 2014.

September 10, 2014

Health workers screen patients for the Ebola virus at a local government hospital in Kenema, Sierra Leone, on June 30, 2014.
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Coauthored with Daniel Chardell, research associate in the International Institutions and Global Governance program.

Jan Eliasson, deputy secretary-general of the United Nations (UN), calls the Ebola outbreak ravaging West Africa a “test of multilateralism.” If so, the world is failing.

The epidemic has already infected a reported 4,300 people in Guinea, Liberia, and Sierra Leone, claiming 2,300 lives. Fragile health-care systems in these countries are collapsing. Poorly equipped treatment centers are overflowing. Riots are erupting as soldiers enforce quarantine zones at gunpoint. Scores of doctors and nurses, who lack proper protective gear, are contracting the virus from infected patients. Others are walking off the job, intensifying the region’s severe shortage of health workers. Meanwhile, border closures are causing food shortages and price spikes, leading the UN’s Food and Agriculture Organization to warn of “grave food security concerns.”

Unlike prior Ebola outbreaks, which have occurred in remote regions and been quickly contained, new infections are rising “exponentially,” according to the World Health Organization (WHO). Cases are expected to reach at least 20,000 over the next six to nine months. The root cause of this epidemic is the institutional weakness of the affected states, all three of which have experienced civil war in the recent past and struggle to provide basic public services to their populations even under the best of circumstances. Before the outbreak, Liberia had one doctor and thirty nurses per 100,000 inhabitants, according to estimates.

These rudimentary health systems have been absolutely overwhelmed by the deadliest Ebola outbreak in history. Low levels of confidence in public institutions—a common feature of post-conflict environments—have made populations wary of cooperating with government officials throughout the crisis. This pervasive distrust has facilitated the spread of the vicious disease and exacerbated existing social tensions. Complicating matters further, Ebola was previously unknown in West Africa, so local health workers were woefully unprepared to recognize the virus, isolate infected individuals, and monitor their contacts.

But the severity of the epidemic and the disastrously slow response also reflect glaring gaps in the international system—namely, multilateral institutions that are ill-equipped to respond to global health crises. The WHO, in principle charged with coordinating global responses to international public health emergencies, has drawn heavy criticismfor its belated recognition of the epidemic’s severity and waiting until August 8 to declare the outbreak a public health emergency of international concern (PHEIC).

WHO director-general Margaret Chan, who had received high marks for her earlier performance as director of health in Hong Kong during the SARS outbreak and subsequent crises, has come under unaccustomed criticism. As the emergency developed, she has appeared testy and defensive at times. In a September 4 interview with the New York Times, Chan resisted the very notion of WHO responsibility to combat the outbreak, asserting: “First and foremost, people need to understand WHO. WHO is the UN specialized agency in health. And we are not the first responder. You know, the government has first priority to take care of their people and provide health care. WHO is a technical agency.” Similarly, David Nabarro, whom UN secretary-general Ban Ki-moon appointed to coordinate the UN response to the epidemic, insists that primary responsibility rests with the afflicted West African countries themselves. What they need above all, he said, is money.

With thousands dead in West Africa and tens of thousands more likely to become ill in the coming months, the WHO’s insistence that it is primarily a technical agency is both exasperating and inadequate. As our CFR colleague Laurie Garrett has written:

Chan has been at great pains in her media blitz this week to say that the UN and WHO are not in charge—the respective governments are in command of the Ebola crisis. […] Unanswered is the obvious question: What does the world community do if a weak government fails to act, or makes wrong choices? If Ebola spreads to other countries this conundrum will arise again, and the global community will be left with its own question: “Who’s in charge?”

But in another sense, making WHO a scapegoat is deeply unfair, for the failure in West Africa has been a collective one. The agency’s lackluster performance reflects a huge mismatch between the high expectations placed upon it and the narrow mandate and modest resources at its disposal. Hamstrung by years of budget cuts to its outbreak and emergency response units, for instance, the agency learned of the outbreak only in March, nearly four months after the virus claimed its first victim in Guinea.

Faced with a lethargic WHO and ineffectual West African governments, the medical humanitarian organization Médecins Sans Frontières (MSF, or Doctors without Borders) has attempted to fill the void. MSF has been on the ground treating the ill from the outset, all the while vociferously warning that the global response to the Ebola outbreak was inadequate. “Leaders are failing to come to grips with this transnational threat,” cautioned MSF international president Joanne Liu at a UN briefing earlier this month. “We are in uncharted waters.”

MSF should be lauded for its indispensable work in the field. But the world cannot expect NGOs to address transnational health threats on their own. Nor should we rely on hopes that experimental drugs and vaccines will miraculously relieve us of the burden of action.

Though far from over, the crisis has demonstrated how ill-equipped the multilateral system is to cope with global public health emergencies, particularly in the world’s weak and failing states. In an increasingly globalized world, it is illusory and hazardous to imagine that fragile states can cope with such emergencies on their own, cordoned off from the rest of the world.

If UN member states are serious about confronting global health crises, they must rethink the role of the WHO, empowering it to lead the response to transnational health threats.

The world needs a multilateral framework that can provide both rapid responses to emergencies and long-term capacity-building that targets the underlying deficiencies in infrastructure, expertise, and funding in these weak states. Without that, they will remain the weak links in global public health.

Two components of that framework are clear.

To start, UN member states should establish a contingency fund available to the WHO that is dedicated exclusively to financing outbreak containment measures in countries that are unable to do so. These measures would include mass deployment of health workers, medicines, food and water, and protective equipment. The idea is not new. In a 2011 report [PDF] on strengthening global responses to pandemics and public health emergencies, the WHO itself recommended that member states develop a “Global Health Emergency Workforce” and a $100 million contingency fund to “support surge capacity” in the case of a PHEIC, such as the current Ebola outbreak. However, as Georgetown professor Lawrence Gostin recently wrote [PDF], these recommendations never secured support from wealthy donor nations.

Second, in global development initiatives, public and private donors should place greater emphasis on building health care infrastructure in weak states, especially those emerging from conflict. Again, this is not a novel concept—scholars have been writing about the importance of incorporating health into post-conflict reconstruction efforts for years. Such infrastructure could have been critical in staving off the rapid spread of Ebola in Liberia and Sierra Leone, for example.

Unfortunately, for the thousands of Ebola victims, it is too late for these measures to help them. But they may help prevent a future outbreak of the same magnitude—or ensure that, if one does occur, the world is better equipped to respond.

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