Offline: A pervasive failure to learn the lessons of Ebola

Abstract

Post-Ebola reverie has given birth to a plethora of expert panels to consider what went wrong. The latest parade of global health specialists appointed to learn lessons gathered at the Wellcome Trust in London last week. Under the auspices of the US Institute of Medicine (IOM), a Commission to “deliberate and evaluate options to strengthen global, regional, and local systems to better prepare, detect, and respond to epidemic diseases” spent 2 days amassing evidence. There was no shortage of experience brought to bear on these important matters. Here were Margaret Chan, Jeremy Farrar, Ilona Kickbusch, David Heymann, Larry Gostin, Joy Phumaphi, Joanne Liu, and Peter Piot all wrestling with a seemingly intractable challenge. The statements offered to the Commission were arresting. Colin McIff (US State Department) called the meeting “one of the last opportunities to make WHO fit for purpose”. Margaret Chan was gratified that WHO was branded a “convenient scapegoat”, rather than the prime sinner, in the Ebola debacle. And Barbara Stocking, who chaired her own panel reviewing WHO's response to Ebola, called for more attention to the idea of global health security. But the purpose of the meeting was not to talk. It was to identify the best system for an epidemic response. Four models were proposed. Charles Clift argued the case for a reformed WHO. He wasn't hopeful. He called the idea of WHO reform “a fantasy”. He thought WHO a bloated bureaucracy that could be trimmed considerably. The system for electing regional directors should be scrapped. The Director-General should serve only one 7-year term. Ilona Kickbusch opted for what she called “WHO Plus”. WHO should create a centre for outbreak and humanitarian management reporting directly to the Director-General. Yasushi Katsuma proposed an executive agency—WHO as host to an array of actors under the nominal leadership of the UN Secretary-General. The advantage would be to retain the technical resources of WHO, while bringing in additional expertise and freeing decision making from a corrosive WHO culture and a dysfunctional World Health Assembly. And Daniel López-Acuña was charged with making the case for a new “independent entity with interagency composition under the authority of the UN Secretary-General”. He made it clear that this model was not his preference (“old wine in new bottles”). Instead, he argued that the failure to address Ebola was a matter of failing to implement existing commitments. None of these models was especially convincing. The idea of a perfect system to “prepare, detect, and respond to epidemic diseases” seems a dangerous mirage, an optical illusion caused by the prevailing political conditions—namely, a deep unwillingness to confront the most important cause of the Ebola failure. Which was leadership. The most telling moment came in Margaret Chan's remarks. Having set out the failures that Ebola exposed—an absence of national detection and response capacities, weak preparedness and response systems across the international community, and unresolved tensions, such as between the need for collective action and national sovereignty—she turned to the role of WHO. She acknowledged that WHO had fallen short of expectations. “We could have done better”, she said. But then she made this claim: “WHO can give advice, but it cannot interfere”. One could feel a sense of acute disappointment and sadness in the room. WHO is our planet's only multilateral global health agency. If WHO cannot interfere when there is a crisis, who can? Joanne Liu (Médecins Sans Frontières) expressed the feeling of many people by challenging Dr Chan. As the discussion concluded, WHO's Director-General answered her critics. “I interfere”, she said, contradicting her earlier position. But she did so through informal channels, such as picking up the telephone and talking directly to heads of state. What she did not do, and would not do, is “name, blame, and shame”. Dr Chan is sincere in her view. I have heard her articulate it in many settings, public and private. But the lesson of Ebola, and of many emerging threats to health, is that this informal approach, relying as it does on the integrity of political leaders, is insufficient. WHO should, using the best available evidence, “name, blame, and shame”. Dr Chan's honourable approach during the Ebola outbreak manifestly failed. That is the lesson the IOM must learn. That is the lesson the global health community needs to embrace—and act upon.