Ebola crisis built over months as WHO missed chances


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Health workers in protective gear pose at the entrance of the Ebola treatment unit of the John F. Kennedy Medical Center, in the Liberian capital Monrovia, Liberia, on Oct. 13, 2014. Health workers in protective gear pose at the entrance of the Ebola treatment unit of the John F. Kennedy Medical Center, in the Liberian capital Monrovia, Liberia, on Oct. 13, 2014.


Poor communication, a lack of leadership and underfunding plagued the World Health Organization’s initial response to the Ebola outbreak, allowing the disease to spiral out of control.
The agency’s reaction was hobbled by a paucity of notes from experts in the field; $500,000 in support for the response that was delayed by bureaucratic hurdles; medics who weren’t deployed because they weren’t issued visas; and contact-tracers who refused to work on concern they wouldn’t get paid.
Director-General Margaret Chan described by telephone how she was “very unhappy” when in late June, three months after the outbreak was detected, she saw the scope of the health crisis in a memo outlining her local team’s deficiencies. The account of the WHO’s missteps, based on interviews with five people familiar with the agency who asked not to be identified, lifts the veil on the workings of an agency designed as the world’s health warden yet burdened by politics and bureaucracy.
“It needs to be a wakeup call,” said Lawrence Gostin, a professor of global health law at Georgetown University in Washington. The WHO is suffering from “a culture of stagnation, failure to think boldly about problems, and looking at itself as a technical agency rather than a global leader.”
Contagion spiral
Two days after receiving the memo about her team’s shortcomings, Chan took personal command of the agency’s Ebola plan. She moved to replace the heads of offices in Guinea, Liberia and Sierra Leone, and upgraded the emergency to the top of a three-tier level, said the five people, who declined to be identified because the information isn’t public. Chan agreed to respond to their accounts in an interview.
“I was not fully informed of the evolution of the outbreak,” she said today. “We responded, but our response may not have matched the scale of the outbreak and the complexity of the outbreak.”
Now, as the virus that has killed more than 4,400 people threatens to spread to more countries at a catastrophic economic cost, attention is turning to how the contagion spiraled.
The Geneva-based agency isn’t the only body facing criticism. The U.S. Centers for Disease Control and Prevention was blamed this week for taking too long to step up airline passenger screening and for its advice to an Ebola-exposed nurse seeking to travel with a fever.
Alarming reality
The WHO received its first report about Ebola cases in Guinea on March 21, though it took more than three months to convene a meeting of regional health ministers or open a regional coordination center.
The aid group Doctors Without Borders was concerned that the virus had spread to Conakry, Guinea’s capital, as early as April, and called the outbreak “unprecedented,” said Meinie Nicolai, president of the group’s operational center in Brussels. As late as May 18, the WHO suggested the contagion was under control.
“We were accused of panicking,” Nicolai said in a telephone interview. “I think they considered this epidemic much too lightly.”
The WHO’s higher echelons began to comprehend the alarming reality on the ground when Pierre Formenty, the agency’s top Ebola expert, gave a slide presentation to a steering committee of the Global Outbreak Alert & Response Network, known as GOARN, in Geneva on June 24, four of the people said.
Formenty’s charts showed how the outbreak in Sierra Leone, Liberia and Guinea was outstripping the capacity to respond on the ground. Attending the meeting for the WHO was Bruce Aylward, the agency’s assistant director-general for polio and emergencies, who was briefed by three steering-committee members the previous day, two of the people said.
Numbers speak
Even as more than 400 people had been deployed through the WHO, the presentation showed that the situation had escalated in just a few weeks.
“That was what was striking and deeply concerning,” Aylward recalled in an Oct. 15 e-mail. In his opinion, the outbreak was already high on the WHO’s agenda. Formenty didn’t respond to an e-mailed interview request.
By the third week of June, more than 500 Ebola cases were reported, including 338 deaths. The number of new infections was doubling every 24 days. Eight weeks later, the tally reached 2,914, eclipsing the case total reported in the 24 previous Ebola outbreaks combined. Cases are on track to top 9,000 this week.
Begging WHO
Formenty described how a greater proportion of patients suffered only respiratory symptoms, making them harder to detect -- in contrast with other Ebola outbreaks, one person said.
Aylward, a 22-year WHO veteran, said he immediately e-mailed Chan and another senior colleague to relay the latest developments, including the GOARN collaborators’ concerns about a lack of WHO leadership that made at least one partner believe the agency was “compromising” rather than aiding the operational response.

Margaret Chan, Director-General of the World Health Organization, speaks at a special high-level meeting regarding the Ebola virus outbreak in west Africa during the 69th United Nations General Assembly in New York City, on Sept. 25, 2014.
Other groups on the ground are “begging WHO to lead the coordination of the response,” Aylward wrote in the e-mail to Chan, according to two people.
After Chan read the message, the 67-year-old director-general called all the team leaders to her office and asked why not one of them had informed her of the situation, one of the people said. No one responded. The following day, she called Luis Sambo, WHO’s regional director for Africa, telling him to cancel all travel plans and organize an urgent meeting with officials in affected and neighboring countries.
“I asked for a detailed briefing to help me to appreciate what is at stake, what is the increased response we need,” Chan said today. She declined to comment on the sequence of events. Sambo’s office said it had no immediate response, and it would consider Bloomberg’s request to speak to him.
Stop Ebola
“The details of the response will get a proper review later,” Chan said. “I am very committed to transparency and accountability, but now I need to bring my team to focus our attention on scaling up our response to stop the Ebola outbreak.”
Though Chan set in motion the replacement of the heads of the three affected West African countries at the end of June, the last one departed this month, one person said.
The difficulty in hiring and firing employees on the basis of competence spans the entire United Nations, yet the WHO is the only branch where regional heads get selected by secret vote rather than hand-picked by the director-general, said Julio Frenk, who worked at the agency from 1998 to 2000 and is now dean of the Harvard School of Public Health.
“There’s a lack of transparency and a lot of political manipulation,” Frenk said.
No doctors
There are other reasons why straightforward interventions that had worked so well -- and so quickly -- in the past to contain Ebola in other countries weren’t powerful enough to stop the outbreak this year.
The three countries affected are among the poorest in the world, and had only recently emerged from years of conflict and civil unrest. Only one or two doctors were in place to serve large communities before the virus appeared, with health professionals concentrated in cities. Isolation wards, even basic infection and control measures, were virtually non-existent, according to the WHO.
Hand tied
The WHO’s response capacity was likewise weak and eroded following budget cuts, according to an Oct. 8 report in the Lancet medical journal. Its operating budget is a third the size of the CDC’s, Gostin and Georgetown University colleague Eric Friedman wrote in the article.
Contributions that donors are obliged to pay declined to 25 percent of the agency’s revenue in 2010-2011 from 80 percent in 1978-1979, according to an analysis piece by David Legge, from the School of Public Health at La Trobe University in Melbourne, published two years ago in the British Medical Journal. The remaining voluntary contributions get earmarked for particular projects, depriving the agency of the flexibility it needs to shift funds around.
Amid the cutbacks, the agency’s outbreak and response arm lost more than 1,000 staff, half of them in the Africa region, two of the people said. The departed included Michael Ryan, director of global alert and response, and Tom Grein, an experienced field epidemiologist. The remaining staff members were overstretched by outbreaks of a respiratory virus in the Middle East, two strains of avian influenza, armed conflict in Syria, and a drive to eradicate polio in Pakistan.
“WHO is operating with one hand tied behind its back,” said Fran Baum, a professor of public health at Flinders University in Adelaide, South Australia.
Leadership style
WHO’s regionalized structure, and the political barriers it creates, has long frustrated the member countries trying to deal with international crises, said Michael Leavitt, U.S. secretary of health and human services from 2005 to 2009. Politics and bureaucracy can also interfere with the outbreak reporting and response, he said.
“In an emergency, that becomes a very serious problem,” Leavitt said. “It requires something with a more autocratic approach.”
Gro Harlem Brundtland, the WHO’s director-general during the 2003 SARS outbreak, didn’t let such impediments stop her issuing a call for health authorities worldwide to work together to stop the infectious lung disease in its tracks within days of it being brought to the agency’s attention.
Lately, the agency has lost the confidence of some member states, said Gostin of Georgetown University. Many civil society groups that advocate for health causes around the world have also grown to dislike dealing with WHO because of failures to cooperate, he said. He recalled a meeting on global health law in Johannesburg where he wore a WHO shirt to speak on the podium.
“I was roundly booed,” he said. “It’s not that they distrust global health organizations; they distrust WHO.”

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