Harsh criticism of its Ebola response pushes WHO to open up, do better

The Ebola crisis has exposed weaknesses in health systems, the significant lack of international experts ready to be deployed in an emergency, and the world’s ill-preparedness to contain an outbreak of such a large scale.

But nowhere do these realities sting more than at the world’s premier health body, which has suffered intense scrutiny not just from the media, but also among experts and peers from the global health community. That included Médecins Sans Frontières, its most vocal critic, which while admittedly has its own shortcomings, received praise for its tireless work on the ground. The World Health Organization meanwhile has been subjected to never-ending questions over what it did and did not do.

An independent panel of experts, headed by former Oxfam GB chief Barbara Stocking, is expected to submit a report at the upcoming World Health Assembly containing findings of its assessment of the whole institution’s response to the pandemic, and recommendations on what and where can it do better next time.

The panel has yet to release its findings, but it seems the public at large has already come to its own conclusions. There seem to be firm opinions on the slowness of the global health body’s response, its failure to take on a leadership role in a crisis that badly needed one, and the incompetencies besmirching the three levels of the organization.

Some of it may have some basis. Amid the Ebola surge, the organization was responding to myriad emergencies, from the spreading of the Middle East respiratory syndrome in Saudi Arabia to the evolving bird flu strain in China, as well as other humanitarian crises from Syria to the Central African Republic. That meant it had limited capacity to take on another crisis, especially as it was operating on a reduced emergency budget.

But Dr. Bruce Aylward, who’s been charged by Director-General Margaret Chan to head the organization’s overall response to the pandemic, refers to some of the criticisms as untrue, suggesting that they could have been borne out of incorrect assumptions about the organization’s role and function in an outbreak like Ebola.

A misunderstanding

The senior WHO official doesn’t admit to knowing the full picture of what happened in the organization’s initial response. He was not involved in WHO’s Ebola response until August, when the organization declared the epidemic a public health emergency of international concern and he was asked to be involved.

But he said he’s gone back and tried to looked at what his organization did in those early days, and was “quite impressed” with what the team did back then. Senior experts within the organization with Ebola experience were dispatched as soon as tests from Guinea came back positive of Ebola. Physicians with expertise on infection prevention and control, and intensive care were dispatched to assist clinicians, as well as field coordinators, medical anthropologists, clinical case managers, data management persons, surveillance epidemiologists, lab experts, logisticians and those who can do administrative work.

By May, the organization had deployed 112 experts from different WHO offices, hired consultants and those coming from the organization’s partner institutions like the Global Outbreak Alert and Response Network. They were spread out across the three most-affected countries as well as in the WHO regional office in Brazzaville, Congo.

The organization also immediately classified the crisis as grade 2, and escalated it to grade 3 — the highest category, which required substantial international response — by June. Further, as early as April, Dr. Keiji Fukuda categorized the crisis as a “difficult” and “challenging” outbreak, acknowledging the organization’s different responses as well as those of its partners.

These actions, Aylward claimed, should debunk accusations — specifically those made by its harshest critic, MSF — that the organization did not recognize the Ebola outbreak as a crisis.

MSF’s frustration on the lack of people running treatment centers can be attributed in part to a “failure to understand what the role of different organizations are” in such an emergency, he suggested.

“What they were critical of was that they wanted more people running treatment centers — and we all did,” WHO’s Ebola czar told Devex from Conakry, Guinea, a day after attending the fifth meeting of the International Health Regulations Committee in Geneva, Switzerland. “WHO doesn’t run treatment centers … [but] we’ve been very, very aggressively trying to bring in additional partners to do that role.”

Indeed, WHO’s mandate lends six main roles to the health agency, none of which involves direct clinical care. Even so, there remain some confusion among several members of the global health community about its role. There are those that still view the organization as being both responsible for providing technical guidance and directly responding to crises.

Daniel Esptein, WHO’s spokesman based in Washington, D.C., seconded the misconception.

“I guess when people hear the name World Health Organization, they think we have a core group of doctors ready to jump on a plane and head to any outbreak at short notice and start treating people,” Epstein said. “[But] we’re not clinicians for the most part you know. We’re experts in clinical care but we don’t have people whose primary role is to go treat people who are sick. Our primary role is really to work with governments and partners to help them get the resources they need to treat people who are sick.”

Another misconception, he said, relates to accusations that the organization did not recognize the nature of the emergency.

“It already was an emergency … People misconstrue the declaration of the public health emergency of international concern [in August] as the first time we highlighted the nature of the outbreak,” he said.

Epstein however acknowledged that the health agency was not as good at Ebola communications. Like many other organizations, its initial messaging was very negative — that “Ebola kills” — which they later learned drove people away from treatment centers and did not help curb the outbreak at all.

Thankfully, not a lot of people blame WHO for the affected countries’ weak health systems, as the organization’s main function in this area is more at the policy and strategy level. This included helping countries strengthen their surveillance systems, for instance, so that they’ll have the capacity to meet their IHR obligations to rapidly notify, verify and respond to health threats if and when they come.

A disheartening accusation

Despite the fact that a misunderstanding of its role in the pandemic was the reason behind much of the criticism it received, WHO has taken active steps to ensure the lessons it has learned from its Ebola response will result in positive changes.

It has for instance already addressed several requests member states made in January at the 36th session of the executive committee. This included releasing a report identifying the different functions, support and roles it undertook and continues to do under the U.N. Mission for Ebola Emergency Response.

The organization has also been more active in making public its work on the Ebola epidemic and other crises. Recently, it published its own “Ebola diaries,” where those working under the banner of WHO shared their stories from the field.

Such actions, Epstein said, is a conscious effort on the part of the organization to let the public know more of what it is doing on the ground. Accusations that WHO isn’t doing anything on the ground have had a negative impact on some — if not all — of the global health agency’s staff.

“[The criticisms] weren’t entirely unexpected. I mean organizations that are operational should expect criticism, but I think the level and the tone, and kind of the blame game, probably had an effect on some people at WHO,” Epstein said. “Disheartening a bit, because really we were doing our best. We were working very hard. We were doing everything we could.”

But he insists he finds a “positive story” in all of it. WHO was able to mount a massive response involving the whole system and different country governments. It also helped turn around a disaster that could potentially have even more extremely lethal effects.

In addition, stinging criticism allowed the organization to look into its own systems and deeply analyze its work, which he finds is “unprecedented” in the U.N. system.

Have there been other international organizations that went through the kind of retrospection and self-criticism that WHO is undertaking? What other major lessons from its much-criticized Ebola response should it learn from? Share your thoughts below.

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