This story was updated at 5:10 p.m., Nov. 23.
The World Health Organization must be overhauled and countries worldwide must reassess their roles if they are to protect against future crises such as the West African Ebola outbreak, according to a major report released late Sunday by a panel of international experts.
The group, convened by the Harvard Global Health Institute and the London School of Hygiene and Tropical Medicine, called for a rebuilding of the WHO’s emergency response capacity, which has been crippled by funding cuts in recent years.
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It said the Geneva-based global health agency should strip itself of unnecessary programs and focus instead on efforts it is uniquely capable of handling. And it called on countries and donors to stop tying WHO funding to specific programs, noting that four of every five dollars the agency receives is earmarked by donors.
In what seems like a coded indictment of the agency’s Director General, Dr. Margaret Chan, the panel’s report stressed that the WHO must be led by a strong leader unafraid of standing up to the agency’s member states. It also called for the creation of a global health committee within the UN Security Council to bring quick attention to emerging health crises.
The recommendations were drafted by the Independent Panel on the Global Response to Ebola, drawn up of academics, think tank researchers, and leaders of nongovernmental organizations. Their report, published in the journal The Lancet, is one of a number of reviews assessing the Ebola response that have or will soon be released.
While the report addressed the roles that should be played by individual governments, the United Nations, and others in the event of a global health crisis, its harshest criticism was leveled at Geneva. “The reputation and credibility of WHO has suffered a particularly fierce blow,” said the panel, which also focused most of its recommendations on reforms there.
It added: “Our primary goal is to convince high-level political leaders worldwide to make necessary and enduring changes to better prepare for future outbreaks while memories of the human costs of inaction remain vivid and fresh.”
The unprecedented outbreak was more than 10 times larger than all previous known Ebola outbreaks combined. The most recent figures suggest it killed at least 11,314 people and that at least 28,634 people were infected. Early last week it appeared the outbreak might be over. But on Friday Liberia reported three new cases, its first since the summer.
Quick action will be critical to reforming the WHO, outside experts watching the process said. Effecting change is difficult and if reform is to flow from the aftermath of the Ebola crisis, the WHO will need to move swiftly to embrace a few key recommendations that can be pushed through, suggested Dr. Jeremy Farrar, director of the Wellcome Trust, a British charity that funds biomedical research.
Infectious diseases expert Michael Osterholm concurred. Osterholm, who heads the University of Minnesota’s Center for Infectious Diseases Research and Policy, said the momentum for reform will stall if the various groups critiquing the Ebola response draw up long wish lists. “There can’t be a list of 110 recommendations,” he said flatly.
This panel issued 10, though several were made up of multiple parts. A number were aimed at strengthening the WHO’s emergency response capacity. While the panel demurred from advising the WHO on what programs it should cut, it did state firmly that responding to global health crises is one of the reasons the agency exists.
“The reputation and credibility of WHO has suffered a particularly fierce blow.”
Independent Panel on the Global Response to Ebola
Dr. Peter Piot, one of the panel’s cochairs and director of the London School of Hygiene and Tropical Medicine, said the head of the proposed center for emergency preparedness and response should report directly to the WHO director general and should be shielded from political pressure.
The panel said countries that report disease outbreaks promptly should be publicly praised. Those that hold back information that puts the world at risk should be “named and shamed,” Piot said.
The report also advises the WHO to publicly criticize countries that impose unwarranted trade and travel restrictions during outbreaks; the fear of those kinds of reprisals encourages affected countries to hide rather than disclose.
The report does not directly criticize Chan, who declared Ebola a global emergency two months after Doctors Without Borders warned the situation was out of control. Three members of the panel interviewed by STAT sidestepped the question of whether the report’s multiple references to the need for a strong WHO leader was an indictment of the current director general. They said the panel wanted to look forward, not back.
“Member states should insist on a director general with the character and capacity to challenge even the most powerful governments when necessary to protect public health,” the panel wrote. Internal emails obtained by the Associated Press suggested that the WHO was reluctant to declare the outbreak an emergency, fearing it would antagonize the affected countries.
The WHO said it is already working to address some of the shortcomings that were raised in the report as well as in earlier appraisals of its Ebola response. “There were operational problems in early 2014 and that is what the reforms at WHO are all about. We are building the capacities to do that and moving from a technical/political organization to an operational one,” the agency said in a brief emailed statement when asked to comment on the report.
Chan promised reform at the UN health agency’s annual general meeting last May.
“I have heard what the world expects from WHO,” Chan said in her speech opening the World Health Assembly. “As director general of WHO, I am committed to building an organization with the culture, systems, and resources to lead the response to outbreaks and other health emergencies.”
Chan’s second and final term ends on June 30, 2017, and would-be successors are likely already positioning themselves. Whether WHO member states will want an assertive and proactive director general remains to be seen, though recent history provides some cause for doubt.
Dr. Gro Harlem Brundtland headed the WHO during the 2003 SARS crisis. A former Norwegian prime minister, Brundtland made tough calls; under her, the WHO warned against unnecessary travel to China, Toronto, and other SARS-affected locations. The travel advisories were loathed by the countries named and won Brundtland no friends in their capitals. That tool has never been used since.
“At the end of the day, countries are sovereign. They’re going to do what’s in their best interests,” acknowledged Dr. Ashish Jha, a panel cochair and director of the Harvard Global Health Institute. “But the reason we have entities like the WHO is to be able to act in ways that are necessary for the world’s health, even when an individual country is thinking narrowly about its own short-term interest.”
There have been other recent attempts to reform the WHO, notably after the SARS outbreak and the 2009 flu pandemic — which left some countries arguing that the global health agency had overreacted. But those efforts stalled when policymakers’ attention shifted to new crises.
With the waning of the Ebola outbreak and the recent attacks on Paris and Beirut, global security concerns may put global health reform on the back burner. But if the world lets this opportunity slip, it will “remain wholly unprepared for the next epidemic,” the panel wrote in its report.
Said Jha: “I don’t think we have a choice on this. I think letting this one go is not only a disservice to the people who died unnecessarily in West Africa, but it represents a huge vulnerability for all of us going forward.”