Ebola: Responses to a public health emergency Contents

3The international public health system

The World Health Organization’s response

42.We have already mentioned the slow initial response to the epidemic. This was attributed by many witnesses to delays in WHO sounding the alarm and declaring a Public Health Emergency of International concern; something which WHO carries primary responsibility for. WHO was involved in the initial diagnosis of Ebola in March 2014, at which point it classified the outbreak as a Grade 2 crisis under its internal system (which has 3 grades). Dr Bruce Aylward identified some difficulties WHO faced: “In terms of the real challenge […] part of it was an organisation that was not designed to be an operational field-based organisation being asked to play such a role.”69

43.In September 2014 the UN created its first emergency health mission, the UN Mission for Ebola Emergency Response (UNMEER), to oversee the scaling up of the response on the ground, including the humanitarian response. Dr Aylward spoke about the necessity and purpose of this model in leveraging political support in extraordinary circumstances:

I believe that parts of that were necessary and would be necessary in future were we dealing with a rapidly escalating infectious pathogen or high-threat pathogen that has the capacity to destabilise on a multi-country level, or even a regional or global level. We have to look very carefully at what parts of the architecture internationally already exist that we should have been using much earlier and more effectively and then, when we do bring in something like a Secretary-General-led mechanism, we should be very, very clear that that role is going to be really around leveraging the political assets and support needed for this, as well as having executive authorities over the agencies that would play a role going forward. That would really only be in the extraordinary circumstances, as Ebola was.70

44.Evidence indicates WHO struggled to cope, partly, though by no means exclusively, because it was operating in a context of reduced funding. The Institute of Development Studies told us, “The failures by WHO, including delayed visas and payments and poor communication, occurred in the context of the job losses and funding costs that saw the WHO lost $1 billion in core funding after the financial crisis.”71 Dr David Nabarro echoed this, when explaining why WHO’s response was slow. He said that “perhaps most importantly, the World Health Organization’s outbreak and emergency operations have been declining in capacity for many years.”72 He also stated, however:

Through the governance of the WHO, there has been a steady shift away from preparedness to deal with these quite rare events of outbreaks.

There was a pandemic in 2009-10 of what was called swine flu or influenza H1N1. An inquiry of WHO’s response to that showed that it was ill prepared to deal with a pandemic, and suggested a number of changes. However, the governing bodies of WHO still chose to encourage the organisation to prioritise the high-mortality conditions, which is a very sensible governance decision, and money for these outbreaks was not preserved.

In summary, there were certainly problems because eyes were not focused on the Ebola outbreak, particularly in June/July. There were announcements made, but they were not pushed hard enough by the organisation and, in retrospect, all of us feel, if only there had been a louder shouting three months early, the situation would have been much better. The organisation has had to experience a decline in its resources for outbreaks and emergencies. Those are in part due to the governance decisions and the financing structure of the organisation, where money is attached to particular priorities by the donors.73

45.When we asked Dr Aylward what level of funding WHO would need to respond fully to outbreaks, he estimated that it would be around $500 million, of which about $150 million would have to be additional funding.74 The Secretary of State told us, “We have been part of how some of that money is being provided. As ever, the UK can show leadership but we need other countries to be prepared to step up to the plate.”75

46.A major WHO reform programme has been ongoing since 2011; parts of which have accelerated since the Ebola epidemic. Dr Jeremy Farrar expressed his opinion that:

[…] if now is not the time to reform the WHO, I do not believe there will ever a time to do it. I have been involved in each of the major epidemics of the last 12 years, going back to SARS. I was very involved in that and lost a lot of very good friends during SARS. We have called, after all of those, for reform, and yet we have not grasped that nettle after each of them. This must surely now be the wakeup call that that is required.

His recommendation was “to reform the issues related to epidemics, preparedness and capacity to respond, because I think that is doable in the next two years [in the remaining time of Dr Margaret Chan’s leadership of WHO].”76

47.A number of high profile reports have been released over the course of the past year, which have looked in detail at WHO in the wake of the Ebola epidemic. These include the Report of the Ebola Interim Assessment Panel (the Stocking report)77 and the Report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola.78 Those reports have broadly agreed on a number of areas where reform of WHO is required, including in the need for improved capacity to deliver an emergency public health response, as part of a dedicated centre for outbreak response. We do not repeat their conclusions and recommendations here, but we do support them.

48.The World Health Organization has acknowledged its shortcomings in dealing with the Ebola epidemic, due to inadequate funding, a structure which was ill-suited to responding to such a crisis, and a reform process which has been too slow to achieve results. This is a failing on the part of the international community and all of its Member States, including the UK. WHO needs radical reform and quickly. We fully endorse the proposals which have been put forward by both the Ebola Interim Assessment Panel and the Independent Panel on the Global Response to Ebola, and stress that these need to be implemented with great urgency. The UK should lead efforts for radical reform of the World Health Organization, including for greater funding from its Member States; it should maintain the pressure on WHO to be efficient and effective, even after the reforms are achieved, to ensure that it can properly fulfil its role as the lead organisation for responding to public health emergencies. We ask that DFID give us regular updates on the progress of the reform process, beginning with the response to this report.

The International Health Regulations

49.The International Health Regulations (IHR) are the legally binding regulations which govern how all WHO Member States work together for global health security. They were agreed in 2005 and include commitments to build capacities to detect, assess and report public health events. The Stocking report found that “the global community does not take seriously its obligations under the International Health Regulations.”79 The Secretary of State told us that “there are about 80 countries that still have not really complied with those regulations, but many of them are the ones who are the least able to deal with outbreaks”.80 She went on to say that DFID is “working alongside the G7 and the WHO in their work in making sure that countries that have not implemented the IHR are able to do that. As ever, we cannot do it all but we are playing a key role in that more international lobbying side too.”81 In the wake of the epidemic, in May 2015, WHO set up a Review Committee on the Role of the International Health Regulations (2005) in the Ebola Outbreak and Response which aims to assess the effectiveness of the IHR and recommend reforms.

50.The IHR also describe the process for the Director-General of WHO to declare a Public Health Emergency of International Concern (PHEIC). The WHO Secretariat response to the Report of the Ebola Interim Assessment Panel did not “fully agree with the Panel’s assessment that the determination of PHEIC was delayed”.82 Dr Aylward explained to us that a PHEIC “is not designed to grade an escalating crisis”, but rather “is to prevent inappropriate restrictions on travel and trade, [meaning] there is almost by definition a reticence to declare until absolutely necessary […] The IHR and PHEIC are not well designed.”83 He also described WHO’s three-tiered grading system, but noted that “this was not a trigger for the international community.” 84 Given the criticisms of WHO made to us by witnesses, and WHO’s delay in declaring a PHEIC, its understanding of what a PHEIC is and is for appears to be at odds to the wider understanding in the international community.

51.International health security requires that countries take their obligations under the International Health Regulations seriously; this requires the current review process to come up with meaningful reform. In addition, there is a clear difference of understanding, between the World Health Organization and others, in what purpose a declaration of a Public Health Emergency of International Concern serves. A clear warning system for public health emergencies is needed, to facilitate the political escalation of a crisis and mobilise the international community when necessary. DFID should work to make sure that the countries in which it works take their obligations under the International Health Regulations seriously and commit fully to implementing the core capacities. As part of the process of reform of the International Health Regulations, the UK should press for a more transparent and clearly understood grading system for public health emergencies.

69 Q64

70 Q81

71 Institute of Development Studies (EBO0001) para 1.2

72 Q49

73 Q49

74 Q90

75 Q124

76 Q18

77 World Health Organization, Report of the Ebola Interim Assessment Panel (July 2015)

79 World Health Organization, Report of the Ebola Interim Assessment Panel (July 2015), page 5

80 Q123

81 Q126

82 World Health Organization, WHO Secretariat response to the Report of the Ebola Interim Assessment Panel (August 2015), page 2

83 Q66

84 Ibid

© Parliamentary copyright 2015

Prepared 14 January 2016