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 Lugli, an Italian nurse, was among the first responders from medical
charity Medecins Sans Frontieres (MSF) to reach the remote forests
of Guinea in March where the hemorrhagic fever - one of the most
lethal diseases known to man - was detected.
When the epidemic spread to the capital Conakry, Lugli set up a
second Ebola clinic there. He encountered a foreign medic and a
logistician sent by the U.N. health agency but saw no sign of a WHO
official in charge of handling the escalating outbreak.
"In all the meetings I attended, even in Conakry, I never saw a
representative of the WHO," said Lugli, deputy director of
operations for MSF Switzerland. "The coordination role that WHO
should be playing, we just didn't see it. I didn't see it the first
three weeks and we didn't see it afterwards."
The worst outbreak of Ebola on record has killed more than 3,400
people in four West African countries and spread to the United
States, where the first case was confirmed in Dallas this week.
After a dire warning from the U.S. Centers for Disease Prevention
and Control (CDC) that the virus could infect up to 1.4 million
people, many health professionals and politicians are asking how the
crisis got so badly out of hand. In the past 40 years, Ebola had
killed just 1,500 people in sporadic outbreaks in Africa.
Some aid workers and U.N. officials blame a lack of WHO leadership
in the emergency response, particularly in the early stages when it
would have been easier to contain. On several occasions, WHO
officials played down the outbreak, they say.
MSF International President Joanne Liu, who warned that her
organization could not cope with the rising number of Ebola victims,
has accused the WHO of failing its mandate to help member states
cope with health emergencies.
Stung by the criticism, WHO officials say the organization was
overstretched by a series of health care crises. They blame weak
health care systems and uncooperative populations in poor African
nations still reeling from civil war in the 1990s for allowing the
outbreak to explode.
Senior WHO staff, including Director General Margaret Chan, said the
organization's role was not to run Ebola clinics or campaigns but
advise states how to do so.
Yet after a direct appeal from the leaders of Guinea, Liberia and
Sierra Leone - the worst affected countries - for the United Nations
to do more on Ebola, Secretary-General Ban Ki-moon stepped in to
create a special U.N. mission last week, effectively stripping WHO
of its coordination role.
"I hope the Ebola crisis will become a turning point for WHO, a
needed wake-up call," said Lawrence Gostin, global health law
professor at Georgetown University. "The WHO's budget and capacity
to respond are in tatters, and it has become mostly a technical
organization."
"The WHO's narrow view of its role is in stark contrast to its
constitutional mission as the global health leader."
POLITICIZED
Insiders say the WHO is amongst the most politicized of U.N.
agencies, with governments holding sway over its regional
operations. The director of its regional African bureau (AFRO) based
in Brazzaville, Congo, is appointed by governments and has access to
locally raised funds, allowing autonomy from Geneva.
"Neither donors nor WHO headquarters has a true hold on it," said
one diplomat, familiar with the workings of WHO management, who said
relations between Geneva and AFRO were weak.
"There was never anybody from AFRO on the coordination calls ...
They were invisible throughout."
AFRO Director Dr Luis Sambo denied his bureau was slow to react,
saying he immediately sent an emergency coordinator to Guinea,
deployed international experts and disbursed money to help the
Guinean government.
Despite some differences of opinion on conference calls,
coordination remained strong with Geneva from March onwards, Sambo
told Reuters.
However, experts contrasted the handling of the outbreak with the
WHO's exemplary management of the 2003 SARS crisis.
During SARS, then WHO director general Gro Harlem Brundtland – a
former Norwegian prime minister - gave free rein to staff in Geneva
and aggressively pushed China to take greater action.
Brundtland was not re-elected and Chan, a former director of health
in Hong Kong who orchestrated its fight against SARS, has taken a
more low key approach in dealing with national governments since she
took office in 2007.
"Dr. Chan feels that national governments need to take the lead,"
said Georgetown's Gostin. "But if you have governments with such
fragile health systems and wide distrust among its own population,
WHO needs to take the lead."
With SARS the WHO could rely on robust Asian health care systems,
but when Ebola hit Liberia it had only 50 doctors, and rural clinics
lacked even basic equipment like latex gloves.
When it became clear health care systems were buckling under the
strain in Liberia, Sierra Leone and Guinea, the WHO declared Ebola
an international public health emergency on Aug. 8.
WHO headquarters took responsibility for coordination away from
AFRO, sending experienced staff to run country offices.
Peter Piot, a former WHO official who co-discovered the Ebola virus
in 1976, said the delay in doing this was a crucial factor in
allowing the epidemic to reach unprecedented levels.
"It took another five months and 1,000 deaths before the WHO
declared this a public health emergency," said Piot, director of the
London School of Hygiene and Tropical Medicine.
Some diplomats suggest the WHO may have hesitated to flag up the
Ebola outbreak after it was accused of overhyping the 2009 H1N1
swine flu epidemic and pandering to pharmaceutical firms.
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"Could it have declared earlier? Sure," said Keiji Fukuda, WHO
assistant director-general for health security, who had led the
fight against H1N1. "We're always having to balance, because if
you're perceived as crying wolf it doesn't help."
BUDGET CUTS
WHO insiders say cuts to the WHO's budget after the 2008 financial
crisis left it ill-prepared to fight major epidemics. Its $2 billion
annual spending is less than a third the size of the CDC budget, and
smaller than that of many U.S. hospitals.
With most of WHO's funding allocated by donors to specific diseases,
such as polio or HIV-AIDS, the outbreak and crisis department had
its funding cut by 51 percent. Dealing with hemorrhagic fevers was
increasingly left to the AFRO bureau.
Francis Kasolo, head of a WHO regional Ebola response center set up
in Guinea, said budget cuts forced AFRO to cut its epidemic team
from 12 to four staff over the past two years.
A 2011 proposal by a WHO committee for a $100 million task force to
tackle epidemics that might have prevented Ebola spinning out of
control was not approved by member states.
When Ebola struck, WHO's international outbreak team in Geneva led
by Fukuda was already swamped by outbreaks of MERS and H7N9 in
China.
Kasolo said the WHO brought in hundreds of foreign experts and
health workers, paid for construction of Ebola clinics and supplied
thousands of protective suits but it did not have the skills or
personnel to run the centers, as MSF was asking.
"We're a public health agency not a clinical management agency,"
said Kasolo. "We don't run hospitals but we can provide the
necessary guidance on how the hospital should run."
LAGGING FROM THE START
WHO officials say the epidemic raced ahead of efforts to control it
from the start because Guinea took more than three months to notify
the agency of the disease.
The traditional practice of cleaning bodies by hand at funerals
spread the virus, which is transmitted by body fluids.
First detected in central Africa, Ebola had never struck West Africa
and doctors had no idea what they were seeing. The outbreak was
initially misdiagnozed as cholera.
Only on March 13 did Guinea notify the WHO, which sent a team to the
southeast the next day. Samples dispatched to a laboratory in France
showed on March 21 what many feared – Ebola had struck a completely
unprepared region.
"It was way too late," said AFRO's Sambo, "Hundreds of unidentified
people were already infected."
Once alerted to the outbreak, however, the WHO appeared to
underestimate its scale dramatically. At Geneva HQ, there was a
consensus that it was better not to cause panic.
When drug-maker GlaxoSmithKline told the WHO in March it had an
experimental vaccine, the agency said it was focused on containment,
only to ask the firm to fast-track clinical trials in August as the
outbreak span out of control, a GSK spokeswoman said.
At least three times in April and May, new Ebola cases in West
Africa seemed to dry up, creating a false sense that the outbreak
was contained.
By contrast, MSF warned as early as March 31 that the geographic
spread of the outbreak made it "unprecedented". It received a strong
rebuttal from a WHO spokesman.
"A few days or a week after our statements, there was always WHO
saying 'no, it's not true'," said MSF's Lugli. "Except later they
confirmed it."
The key to defeating Ebola is tracing people who have come into
contact with infected people, monitoring them and quickly isolating
new infections. In this too, the WHO and local governments
struggled, partly due to popular resistance.
Communities hid their sick because of mistrust of foreign doctors
clad in plastic suits that led to attacks on aid workers. Ebola
clinics were seen as death traps, while people resented a ban on
their traditional burial practices.
Local politics also played a role. In both Guinea and Sierra Leone,
regions affected by the virus were home to ethnic groups resistant
to central government and when health workers tried to trace victims
in May, they were denied access.
But Michel Poncin, MSF emergency coordinator in Guinea, said the WHO
failed to establish its own network of community contacts, relying
instead on government officials. Teams were often not paid, given
vehicles or fuel.
"WHO kept saying it's not our role to do it, we just advise the
health ministry," he said. "I've been really shocked by the WHO's
level of amateurism in responding to this crisis."
(Additional reporting by Kate Kelland; editing by Pascal Fletcher
and Giles Elgood)
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