Offline: “Our systems simply couldn't cope”

Abstract

“Ebola was an enormous stress test on the organisation.” Last week Ian Smith, Executive Director of the Director-General's Office at WHO, led an internal discussion among staff about the painful lessons to be learned by the agency from the Ebola virus disease outbreak. It was an extraordinary gathering in Salle A on the first floor of WHO's headquarters in Geneva. WHO was beginning a conversation with itself about why, in the words of the Ebola Interim Assessment Panel, “early warnings…did not result in an effective and adequate response”. The meeting room was small, packed, expectant, and tense. Ian Smith was joined by the agency's star cast handling Ebola—Sylvie Briand (Director of WHO's Pandemic and Epidemic Diseases Department), Rick Brennan (Director of WHO's Department of Emergency Risk Management and Humanitarian Response), and Christy Feig (WHO's Director of Communications). David Nabarro, UN Secretary-General Ban Ki-moon's Special Envoy on Ebola, sat at the back of the room frenetically writing notes throughout the hour and a half meeting. The “ExD”, as Ian Smith was introduced, began by locating lessons from Ebola in the context of ongoing WHO reforms. He outlined three streams of reform (programmatic, governance, and managerial), eight areas of work within those streams, and 31 outputs that reforms would deliver. 84% of these reforms were now being implemented. That figure will reach 100% by the end of the year. The question people might therefore ask, Ian said, was this: shouldn't the reforms have helped WHO deal with Ebola? Surely the answer should have been yes. I took his silent implication to be that the reforms had failed to adapt the agency to the risks and threats facing the health of the world's peoples. Ian drew four lessons from Ebola. First, WHO was “seriously under-resourced” to respond effectively to the outbreak. Partly, this failure was the result of the global financial crisis. Partly, it was because WHO had laid off key staff who should have been part of the outbreak response. Second, WHO's systems were “not appropriate” for dealing with an emergency. WHO was designed for negotiated, consensus-building technical and normative work. Ebola demanded rapid assessments and quick decisions—“our systems simply couldn't cope”. Third, WHO was hampered by its silo organisation. Its three vertical levels—headquarters, regional offices, and countries—did not work together harmoniously. And its humanitarian and outbreak response teams operated very differently, again diminishing the agency's operational effectiveness. Finally, WHO was “not the best culture…for a rapid and effective emergency response”. The agency was just too slow to get to grips with a crisis.View Large Image Copyright © 2015 WHOSylvie Briand argued that WHO reforms had improved WHO's response—“this time we were better”, she concluded (comparing the way WHO responded to Ebola with its “dysfunctional” response to H1N1 in 2009). WHO streamlined the way it produced guidance, which was both timely and useful in the field. There were some challenges. She cited three: translation of its guidance into French, dissemination of that guidance, and version control. Rick Brennan called this moment an “unprecedented era”. There were more people in need of humanitarian assistance today than at any point in recorded history. WHO has “never been so overstretched”. Ebola “exposed weaknesses at every level”—in health systems, in the global response, in global health governance, and, yes, in WHO itself. Christy Feig spoke about the difficulty of establishing effective communication networks. The agency needed more French speakers and more staff deployed in communities. The discussion that followed was respectful but passionate. The biggest lesson, said one staff member, was about strengthening public health systems in countries. Or perhaps WHO needed to bring in more external expertise. It certainly needed to professionalise its approach to emergency responses. The agency needed surge capacity. Ian Smith noted that “The world is expecting a lot” from WHO. David Nabarro spoke with particular wisdom. Emergencies in today's world are continuous, he said. WHO had to adapt to the fact that “emergency is always”. The UN is not only about serving member states. It is about serving people. Don't be “hidebound by ministers”. If you want to learn lessons, don't focus on the organisation, focus on the problem—saving lives, identifying signals of danger, and speed. We live, David said, in “a world that is more disturbed than at any time in our lives”. The UN is needed now more than ever.View Large Image Copyright © 2015 WHOView Large Image Copyright © 2015 WHOView Large Image Copyright © 2015 WHO “Ebola was an enormous stress test on the organisation.” Last week Ian Smith, Executive Director of the Director-General's Office at WHO, led an internal discussion among staff about the painful lessons to be learned by the agency from the Ebola virus disease outbreak. It was an extraordinary gathering in Salle A on the first floor of WHO's headquarters in Geneva. WHO was beginning a conversation with itself about why, in the words of the Ebola Interim Assessment Panel, “early warnings…did not result in an effective and adequate response”. The meeting room was small, packed, expectant, and tense. Ian Smith was joined by the agency's star cast handling Ebola—Sylvie Briand (Director of WHO's Pandemic and Epidemic Diseases Department), Rick Brennan (Director of WHO's Department of Emergency Risk Management and Humanitarian Response), and Christy Feig (WHO's Director of Communications). David Nabarro, UN Secretary-General Ban Ki-moon's Special Envoy on Ebola, sat at the back of the room frenetically writing notes throughout the hour and a half meeting. The “ExD”, as Ian Smith was introduced, began by locating lessons from Ebola in the context of ongoing WHO reforms. He outlined three streams of reform (programmatic, governance, and managerial), eight areas of work within those streams, and 31 outputs that reforms would deliver. 84% of these reforms were now being implemented. That figure will reach 100% by the end of the year. The question people might therefore ask, Ian said, was this: shouldn't the reforms have helped WHO deal with Ebola? Surely the answer should have been yes. I took his silent implication to be that the reforms had failed to adapt the agency to the risks and threats facing the health of the world's peoples. Ian drew four lessons from Ebola. First, WHO was “seriously under-resourced” to respond effectively to the outbreak. Partly, this failure was the result of the global financial crisis. Partly, it was because WHO had laid off key staff who should have been part of the outbreak response. Second, WHO's systems were “not appropriate” for dealing with an emergency. WHO was designed for negotiated, consensus-building technical and normative work. Ebola demanded rapid assessments and quick decisions—“our systems simply couldn't cope”. Third, WHO was hampered by its silo organisation. Its three vertical levels—headquarters, regional offices, and countries—did not work together harmoniously. And its humanitarian and outbreak response teams operated very differently, again diminishing the agency's operational effectiveness. Finally, WHO was “not the best culture…for a rapid and effective emergency response”. The agency was just too slow to get to grips with a crisis. Sylvie Briand argued that WHO reforms had improved WHO's response—“this time we were better”, she concluded (comparing the way WHO responded to Ebola with its “dysfunctional” response to H1N1 in 2009). WHO streamlined the way it produced guidance, which was both timely and useful in the field. There were some challenges. She cited three: translation of its guidance into French, dissemination of that guidance, and version control. Rick Brennan called this moment an “unprecedented era”. There were more people in need of humanitarian assistance today than at any point in recorded history. WHO has “never been so overstretched”. Ebola “exposed weaknesses at every level”—in health systems, in the global response, in global health governance, and, yes, in WHO itself. Christy Feig spoke about the difficulty of establishing effective communication networks. The agency needed more French speakers and more staff deployed in communities. The discussion that followed was respectful but passionate. The biggest lesson, said one staff member, was about strengthening public health systems in countries. Or perhaps WHO needed to bring in more external expertise. It certainly needed to professionalise its approach to emergency responses. The agency needed surge capacity. Ian Smith noted that “The world is expecting a lot” from WHO. David Nabarro spoke with particular wisdom. Emergencies in today's world are continuous, he said. WHO had to adapt to the fact that “emergency is always”. The UN is not only about serving member states. It is about serving people. Don't be “hidebound by ministers”. If you want to learn lessons, don't focus on the organisation, focus on the problem—saving lives, identifying signals of danger, and speed. We live, David said, in “a world that is more disturbed than at any time in our lives”. The UN is needed now more than ever.