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Philosophical Transactions of the Royal Society B: Biological Sciences logoLink to Philosophical Transactions of the Royal Society B: Biological Sciences
. 2017 Apr 10;372(1721):20160307. doi: 10.1098/rstb.2016.0307

What we have learnt about the World Health Organization from the Ebola outbreak

Clare Wenham 1,
PMCID: PMC5394645  PMID: 28396478

Abstract

The World Health Organization's (WHO) reputation became irrefutably damaged during the Ebola outbreak, with a general consensus in the global health community that it fell short of its leadership responsibilities. This commentary offers a brief synopsis of the WHO's role during the outbreak and suggests that the disease outbreak demonstrates the tension that exists between the organization's normative and operational roles in health crises. While the WHO did offer some normative leadership during the Ebola outbreak, as per its constitution, it did not provide an effective operational response, yet nor did it have a mandate to do so. This division between the normative and operational was further highlighted by the discrepancy between what the global community expects the WHO to do in a health emergency, and what it is able to do with its financial and organizational constraints. Finally, the commentary considers the introduction of the WHO Health Emergency Programme, but suggests that this too may suffer from the same structural concerns that need to be addressed if the WHO is to continue in the role the global health community expects it to play, as both a normative and operational leader in global disease control.

This article is part of the themed issue ‘The 2013–2016 West African Ebola epidemic: data, decision-making and disease control’.

Keywords: Ebola, security, World Health Organization, normative, operational, health emergencies

1. Ebola

The Ebola epidemic in West Africa (2013–2016) was catastrophic. Previously successful infection control mechanisms for haemorrhagic fevers were not enacted quickly enough, or to the extent required to bring the outbreak under control. The outbreak soon overwhelmed epidemic response mechanisms at national, regional and global levels. Piot [1] (among others) has suggested that a perfect storm of factors contributed to the scale of disaster caused by this outbreak. These factors included the unprecedented size of the outbreak, the lack of sufficiently trained personnel, limited resources, weak national health systems, the spread of the outbreak to urban settings, a time lag between the initial appearance of the pathogen and the reporting of it to the national and international communities, the highly porous international borders, mis-trust of government and health officials, the virus' first appearance in West Africa, an exodus of international health providers and a structural failure of global health governance [2,3]. The result was over 28 000 cases and 11 000 deaths, totalling more than all previous outbreaks [4]. Beyond the alarming number of cases, the outbreak has had a considerable socio-economic impact on the lives of millions of survivors and unaffected people, through the indirect consequences of lack of routine healthcare facilities, disruption to routine education provision, decline in employment rates and food insecurity [5,6].

Since the outbreak, several reviews have sought to understand the failures that contributed to the inability of the national and international communities to stop the spread of the virus and to avoid the humanitarian disaster that unfolded [714]. All reviews attribute some blame to the World Health Organization (WHO) for its delay to take action and for a lack of an operational response in the outbreak. However, while the WHO made some pivotal mistakes, as it itself admits [8], the outbreak exposed tensions between the normative and operational roles of the WHO, and furthermore between what the WHO is able to do (suffering from financial and organizational constraints) and what the global community expects the WHO to do.

2. Key moments for the World Health Organization during the outbreak

The WHO first received news of the virus' emergence in March 2014 [15]. In response, the organization sent field epidemiologists to West Africa, who established initial response efforts such as contact tracing, laboratory support and infection control mechanisms, mirroring that which they had implemented in previous Ebola outbreaks. Yet, it has been suggested that those sent had little knowledge of Ebola and had even broken WHO protocols for disease outbreak management [16]. Kamradt-Scott [17] has suggested that the many criticisms received by the WHO of their initial activity may not be a fair representation of the organization's response to the outbreak, in that it was its largest deployment of field epidemiologists (112 experts by May 2014 [18]) who acted commensurately with the level of the threat that was believed to be posed by the disease at that time [18]. Vitally, however, the WHO failed to take into account the range of factors that contributed to Ebola transmission, and provided an inadequate response to the second wave of the outbreak appearing in May 2014 [19, p. 7]. As the organization has suggested, its own shortcomings at this time were numerous:

The initial response was slow and insufficient, we were not aggressive in alerting the world, our surge capacity was limited, we did not work effectively in coordination with other partners, there were shortcomings in risk communication, and there was confusion of role and responsibilities at the three levels [Headquarters, Regional Office and Country Offices] of the organisation [20,21].

With mounting public pressure [22], the WHO finally declared Ebola a Public Health Emergency of International Concern (PHEIC) on 8 August 2014. This PHEIC occurred five months after the WHO first received information about the Ebola threat, by which point there had already been 1711 cases and 932 deaths [23]. Such delay undoubtedly contributed to the unprecedented scale of the outbreak. It has been suggested that the delay in declaring a PHEIC was due in part to placating delicate political and economic situations in West Africa [24, p. 1307], highlighting the tenuous position the WHO occupies in the global health mosaic. After the PHEIC declaration, the WHO sought to coordinate and mobilize the necessary response to eliminate disease spread. However, funds allocated for emergency response had been drastically reduced in previous years [8, p. 6], and despite the launch of a WHO Roadmap in August 2014 strategizing the end of the epidemic within six to nine months, a coordinated international response with WHO at the helm failed to materialize [25] with the outbreak rapidly developing into a humanitarian emergency.

However, after the initial errors of downplaying the outbreak [26], the WHO did maintain continued activity in tackling Ebola. The WHO documents its role in training healthcare workers and burial teams in infection control, community engagement activities and providing epidemiological data [27]. Furthermore, the organization published numerous technical guidance documents, hosted a series of meetings on vaccine options, developed diagnostic tools and expanded laboratory services [21, p. 1309]. Yet none of these activities provided direct patient care, strategic managerial oversight or the infection control that the outbreak response needed. Ultimately, due to a vacuum of international leadership in the operational response (which several in the international community expected the WHO to perform), the patient care, infection control and management were left to others, including Médecins Sans Frontières (MSF), a new UN body (United Nations Mission for Ebola Emergency Response—UNMEER) and the even domestic and international militaries [10,19,28].

3. Tensions between the normative and operational roles of World Health Organization

As the only United Nations (UN) agency tasked exclusively with health, the WHO conceives itself to be:

‘the directing and coordinating authority in international health work’ [29, p. 2].

Moreover, for disease outbreaks, the WHO acknowledges:

‘a central and historic responsibility [for the WHO] has been the management of the global regime for the control of the international spread of disease’ [30, p. 1].

From this constitutional position, it is unsurprising that the global community looked to the WHO, as the apex of the global health landscape, to mount a response to the outbreak. Yet, these tasks that the WHO assumes are both normative in function and do not prescribe the WHO an operational role to provide the on-the-ground response at time of crisis. Lee [31] describes the work of the WHO as a leader in global health, shaping research and knowledge, setting norms and standards, providing technical support and monitoring health situations (p. 20). As McInnes highlights [21, p. 1305]:

‘The operational ability to act in a crisis is notable by its omission’.

As has been noted by McInnes, Gostin & Friedman and Yach [21,32,33], this distinction between the normative and operational roles of the WHO has been missed in several of the analyses of the WHO's failure to respond to the Ebola outbreak.

Normatively, the WHO did respond to the outbreak, through the declaration of the PHEIC (albeit delayed), the production of technical advice, community engagement activities, the sharing of epidemiological data, support with the development of vaccines and healthcare worker training activities. It could even be argued that the framing of the disease as a security threat by the global health community and the media as a security threat, and the ultra-securitized response of deploying domestic and international militaries are consequences of the WHO's normative agenda to encourage a discourse of global health security for infectious disease control more broadly.

However, these normative achievements have been overlooked by the global community's assessments of the WHO's activity during the outbreak. Instead the focus has been on the operational role, notably that the WHO did not provide a sufficient operational response to the Ebola outbreak. Yet, this global community (including NGOs, civil society and the media) who had such high expectations for action are not the member states that the WHO represents and it is interesting to observe that the affected states (Guinea, Liberia and Sierra Leone) have not voiced such criticisms about the organization. As such, there appears to have been a mismatch between the expectations placed on the WHO by the global community, and what the WHO is mandated (and able) to do.

As WHO Director General Margaret Chan stated:

‘It was a fantasy to think of the WHO as a first responder ready to lead the fight against a deadly outbreak’ [34].

The WHO works within a Westphalian system that expects states to provide a response to health needs of their citizens [35], with the WHO providing (normative) technical advice and recommendations to support state activity. As the affected states suffered from chronically underfunded, weak health systems and had not met their commitments to the International Health Regulations (2005) [3638], they were unable to respond on their own. The WHO did not have operational authority or resources to respond on their behalf, with this role being assumed by other actors in the global health landscape better equipped and resourced to do so, including MSF (offering over 4000 staff and spending over €96 million on the response effort) and domestic and international militaries (deploying over 5000 personnel at a cost of US$2 billion) [19,39].

4. World Health Organization challenges

Beyond the tension between the normative and operational roles that the WHO should have played during the outbreak, the organization currently does not have the capacity or organizational culture to deliver substantially on either goal [8, pp. 6, 15]. For the past two decades, the WHO has been in the process of reform, trying to address concerns of politics and priority setting, financing, governance and managerial challenges. These institutional weaknesses further played a role in the WHO's inability to lead the response to the Ebola outbreak.

As suggested by Harman & Rushton [40], leadership in global health is often driven by money and the ability to fund global health projects (p. 2). No agency can manage an outbreak either normatively or operationally when it controls only a small, depleted budget [41, p. 1324]. One of the key challenges the WHO has faced has been its precarious financing mechanisms [42, p. 41], and notably the amount of funds available to respond to an outbreak has been severely reduced [43]. Divergence between the distribution and conditionalities of voluntary and assessed contributions mean that the WHO is limited in its ability to manage its own budget, with funding for health security apparently not being the focus of donor resources [44, p. 41–42]. This has been further compounded by the organization's policy of zero nominal growth resulting in even less purchasing power for its routine emergency activities [8, p. 6]. Even if the WHO had the remit to launch an operational response to the Ebola outbreak, without commensurate funding, the organization would not have been able to do so and therefore its budget constraints impacted the operational role that the global community expected. A second challenge for the organization is its own structure, with several commentators recognizing the weaknesses in the organization's set-up and tensions between headquarters, regional offices and country offices [44,45]. This has become even more important in the wake of Ebola, where differing activity emerged from the Geneva, AFRO regional and in-country offices without a coherent strategy [10].

5. World Health Organization health emergencies programme

Moving on from the criticisms faced by the Ebola crisis will be hard for the WHO. As suggested by the LSHTM-Harvard panel

‘the WHO is going to need fundamental reform to ensure that it can gain back the confidence from its members and the global health community.’ [47, p. 2216]

Importantly, the WHO has listened to the many concerns raised from its handling of the Ebola outbreak and the organization has been revisiting its reform deliberations. Perhaps the most pertinent of these in the wake of Ebola has been the establishment of the new Health Emergencies Programme [46]. The focus of this activity is for the WHO to have a coordinating body for disease outbreaks, with:

‘one programme, with one workforce, one budget, one set of rules and processes and one clear line of authority’ [46].

This programme offers a notable shift in the role of the WHO to date, explicitly including an operational role for the organization in responding to health emergencies when a state is unable to show the necessary operational leadership and management on their own [46]. While the programme incorporates many of the functions that the WHO currently performs in disease management (such as through the Global Outbreak Alert and Response Network), the inclusion of a mandate for operations is new, and a direct reflection of the criticisms it faced during the Ebola epidemic. Interestingly, this departure suggests that the WHO is evolving to meet the expectations placed on it by the global community, rather than maintaining the focus on its role in ‘coordinating and directing’ (i.e. the normative) as per its constitution [29, p. 2]. The success of this initiative will only become apparent when the next global disease concern emerges. Yet, even despite the commitment at the World Health Assembly to operationalize a response to global health emergencies [47], this programme is facing a funding gap between financial contributions and required funds for activity [48]. Accordingly, this new programme may suffer from the same challenges as the organization faces more broadly and any operational activity responding to health emergencies too may fail, or face criticism from the global community, given the ongoing lack of funds [47,49].

6. Conclusion

The WHO's reputation has become irrefutably damaged by the Ebola outbreak, with the general consensus in the global health community that it fell short of its leadership responsibilities [41]. This commentary has shown a synopsis of the WHO's role in the epidemic, but has suggested that beyond the widespread criticism, we must remain reticent of the WHO's abilities to respond to an outbreak from both a normative and operational perspective. While there is some evidence of the WHO performing a normative role during the crisis, albeit patchily, it is apparent that the global community also expected an operational response from the WHO. However, as the WHO was unable to provide this on-the-ground response in West Africa, this allowed other actors, notably MSF, militaries and UNMEER, to perform this function. These efforts offered the global community further ammunition for their WHO criticisms.

This does not mean that the WHO does not and should not strive to be a leader in global health. As stated by Gostin & Friedman in their analysis of leadership in the Ebola outbreak:

A global health leader steers the overall direction of epidemic response, drives consensus towards a coherent strategy, ensures necessary functions are satisfied and coordinated many participators [32, p. 1903].

Such a position equally suggests that there is a normative role for the WHO as a leader in future outbreaks, without insinuating that there must be a simultaneous operational role. However, the WHO, through the creation of the Health Emergencies Programme, has sought to bridge the divide between the normative and operational, offering a response mechanism to future emergency disease concerns. Yet, the challenges that the WHO faces from financing and organizational divisions will not be overcome with this new programme, and therefore for the WHO to be in a position to actually respond to an outbreak, these fundamental structural concerns will need to be addressed comprehensively to allow the WHO the resources and power to perform the role that the global community expects.

Acknowledgements

I thank the two anonymous reviewers who provided comments on an earlier draft.

Competing interests

I declare I have no competing interests.

Funding

I received no funding for this study.

References


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