After the Ebola crisis, can the WHO rise to the challenge of Zika?
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The fast-spreading Zika virus outbreak has presented much of the world with a public health crisis. It may also have presented the World Health Organization with a shot at redemption.

The global health agency is still bruised from harsh criticism over its handling of two recent crises. Its response to the mild 2009 H1N1 flu pandemic was seen as an expensive overreaction in some quarters. Five years later, instead of overreacting, the WHO was faulted for not responding urgently enough to the West Africa Ebola outbreak.

For the WHO and its director-general, Dr. Margaret Chan, Zika could be a chance to get it right.

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“She has to be a leader,” said Lawrence Gostin, a global health law expert who has been critical of Chan. “Epidemics are health events, but they’re also political events.”

Earlier this month, as public concern about Zika grew, the WHO declared the complications associated with the virus to be a global health emergency. Since then it has issued a series of recommendations about travel and ways to reduce the risk of sexual transmission of a virus about which relatively little is known.

This week, Chan traveled to Brazil to meet with officials there.

Still, it’s unclear whether the WHO can strike the delicate balance between underreacting and overreacting — and in the process restore some luster to its tarnished reputation. Already, Gostin and others say the agency has been too cautious: too slow to call the outbreak a crisis, too reluctant to quickly advise pregnant women to avoid travel to Zika-affected places, too conservative in its estimate of how much the response to Zika will cost.

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In an interview with STAT, Chan acknowledged the WHO is rebuilding itself and responding to the advice of a string of recommendations following the Ebola crisis. But she also said that the organization was reliant on the support of its member states. She noted that funding for a $100 million contingency fund and an independent emergency response center has been slow to materialize.

“This is a test of the political will of my member states. If they don’t come up with funding support, I think we’re going back to square one,” she said from the agency’s headquarters in Geneva. “You want a strong WHO? Invest in WHO.”

The past few years have been tough at the WHO, which has faced deep funding cuts, staff reductions, and an increase in targeted funding — earmarked money that the agency can’t spend as it needs to, but that is directed to the program of the donor’s choice. These factors have left the agency ill-equipped to respond to international health emergencies, outside experts who have reviewed the WHO’s Ebola response have concluded.

Alex Hogan/STAT

Are you at risk for contracting Zika virus? Your level of risk depends in part on your living conditions.

None of that, however, has softened the criticism from current and former health officials who believe that the WHO’s issues go beyond fiscal concerns.

Ron Klain, who served as the Obama administration’s Ebola czar during the worst of the crisis, described the WHO as a “disappointment” when it comes to its emergency responses.

“It’s an organization that does not function in these crises very effectively,” Klain told STAT. “The United States cannot be the backup for a global organization at all times in all places. From a global organization perspective, we are reliant on a WHO that does not cut the mustard.”

Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University, described Chan as a “very decent, compassionate, hardworking human being” — but also as a director-general who doesn’t challenge the agency’s member states that have collectively underfunded the organization. She has 16 months remaining in her final term at the agency’s helm.

“She’s fighting for her legacy now,” Gostin said.

The reality is that the WHO has had perpetual funding problems. Every two years the organization’s member states approve a budget, but it is more aspirational than take-it-to-the-bank funding. In the last budget round — last May, when memories of the unthinkably bad Ebola crisis were very fresh — the WHO asked for an 8 percent increase from countries. Five percent was supposed to be a mandatory assessment increase, with an additional 3 percent voluntary contribution. The mandatory increase was rejected.

There’s only $25 million in the $100 million contingency fund. And the independent outbreak response center, which was endorsed by various panels that assessed the WHO’s response to Ebola, has attracted only 45 percent of a proposed $342 million budget.

Chan said she takes as a hopeful sign the fact that a number of major countries, including the United States, have written to ask for a detailed budget for the emergency response center. The European Union also signed the request.

She suggested the WHO would like to complete the job of restoring itself — and its reputation. But to do that, she said, countries need to do more than talk about reform. They need to pay for it.

Part of the issue is that the WHO has a chicken-and-egg problem, as the prominent journal the Lancet noted in an editorial last summer.

“The reason why WHO is so poorly resourced is that it lacks the confidence of donors. As the agency continues to underperform because of chronic underinvestment, so that lack of confidence (and the resultant unwillingness to invest) only worsens,” the authors wrote.

Despite its funding problems, WHO has tools at its disposal. It can and is galvanizing research efforts; it is already pushing researchers and journal editors to allow pre-publication sharing of data. It can coordinate work on Zika vaccines and needed research, a task it has already started. And it can advise on matters like reducing the risk of transmission through blood transfusions and through sex, as well as on options for mosquito control.

But at the end of the day, decisions about how to approach and conduct mosquito control and how much to spend on it can only be made by national, regional, and local governments. If they don’t act or don’t act effectively, the WHO can’t make them, said Michael Osterholm, director of the Center for Infectious Diseases Research and Policy at the University of Minnesota.

He said vector control — public health shorthand for eliminating the Aedes mosquitos that spread the Zika virus — “is in every way a localized effort.”

“They don’t have the authority to do anything,” Osterholm said of the WHO. “They don’t have the resources to do any of it. If we blame WHO for this, shame on us because we’re continuing to miss the lessons of these crises. The world’s public health governance is a mess.”

Rick Berke contributed reporting.

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