Will Ebola change the game? Ten essential reforms before the next pandemic. The report of the Harvard-LSHTM Independent Panel on the Global Response to Ebola

Abstract

The west African Ebola epidemic that began in 2013 exposed deep inadequacies in the national and international institutions responsible for protecting the public from the far-reaching human, social, economic, and political consequences of infectious disease outbreaks. The Ebola epidemic raised a crucial question: what reforms are needed to mend the fragile global system for outbreak prevention and response, rebuild confidence, and prevent future disasters? To address this question, the Harvard Global Health Institute and the London School of Hygiene & Tropical Medicine jointly launched the Independent Panel on the Global Response to Ebola. Panel members from academia, think tanks, and civil society have collectively reviewed the worldwide response to the Ebola outbreak. After difficult and lengthy deliberation, we concluded that major reforms are both warranted and feasible. The Panel's conclusions offer a roadmap of ten interrelated recommendations across four thematic areas: All countries need a minimum level of core capacity to detect, report, and respond rapidly to outbreaks. The shortage of such capacities in Guinea, Liberia, and Sierra Leone enabled Ebola to develop into a national, and worldwide, crisis. •Recommendation 1: The global community must agree on a clear strategy to ensure that governments invest domestically in building such capacities and mobilise adequate external support to supplement efforts in poorer countries. This plan must be supported by a transparent central system for tracking and monitoring the results of these resource flows. Additionally, all governments must agree to regular, independent, external assessment of their core capacities.•Recommendation 2: WHO should promote early reporting of outbreaks by commending countries that rapidly and publicly share information, while publishing lists of countries that delay reporting. Funders should create economic incentives for early reporting by committing to disburse emergency funds rapidly to assist countries when outbreaks strike and compensating for economic losses that might result. Additionally, WHO must confront governments that implement trade and travel restrictions without scientific justification, while developing industry-wide cooperation frameworks to ensure private firms such as airlines and shipping companies continue to provide crucial services during emergencies. When preventive measures do not succeed, outbreaks can cross borders and surpass national capacities. Ebola exposed WHO as unable to meet its responsibility for responding to such situations and alerting the global community. •Recommendation 3: A dedicated centre for outbreak response with strong technical capacity, a protected budget, and clear lines of accountability should be created at WHO, governed by a separate Board.•Recommendation 4: A transparent and politically protected WHO Standing Emergency Committee should be delegated with the responsibility for declaring public health emergencies.•Recommendation 5: An independent UN Accountability Commission should be created to do system-wide assessments of worldwide responses to major disease outbreaks. Rapid knowledge production and dissemination are essential for outbreak prevention and response, but reliable systems for sharing epidemiological, genomic, and clinical data were not established during the Ebola outbreak. •Recommendation 6: Governments, the scientific research community, industry, and non-governmental organisations must begin to develop a framework of norms and rules operating both during and between outbreaks to enable and accelerate research, govern the conduct of research, and ensure access to the benefits of research.•Recommendation 7: Additionally, research funders should establish a worldwide research and development financing facility for outbreak-relevant drugs, vaccines, diagnostics, and non-pharmaceutical supplies (such as personal protective equipment) when commercial incentives are not appropriate. An effective worldwide response to major outbreaks needs leadership, clarity about roles and responsibilities, and robust measures for accountability, all of which were delayed or absent during the Ebola epidemic. •Recommendation 8: For a more timely response in the future, we recommend the creation of a Global Health Committee as part of the UN Security Council to expedite high-level leadership and systematically elevate political attention to health issues, recognising health as essential to human security.•Recommendation 9: Additionally, decisive, time-bound governance reforms will be needed to rebuild trust in WHO in view of its failings during the Ebola epidemic. With respect to outbreak response, WHO should focus on four core functions: supporting national capacity building through technical advice; rapid early response and assessment of outbreaks (including potential emergency declarations); establishing technical norms, standards, and guidance; and convening the global community to set goals, mobilise resources, and negotiate rules. Beyond outbreaks, WHO should maintain its broad definition of health but substantially scale back its expansive range of activities to focus on core functions (to be defined through a process launched by the WHO Executive Board).•Recommendation 10: The Executive Board should mandate good governance reforms, including establishing a freedom of information policy, an Inspector General's office, and human resource management reform, all to be implemented by an Interim Deputy for Managerial Reform by July 2017. In exchange for successful reforms, governments should finance most of the budget with untied funds in a new deal for a more focused WHO. Finally, member states should insist on a Director-General with the character and capacity to challenge even the most powerful governments when necessary to protect public health. These ten recommendations are concrete, actionable, and measurable. High-level political leadership is now needed to translate this roadmap into enduring systemic reform so that the catastrophe of the Ebola outbreak will never be repeated. “We do not have the capacity to respond to this crisis on our own. If the international community does not stand up, we will be wiped out. We need your help. We need it now.”Naimah Jackson, Team Leader, Médecins Sans Frontières Ebola Treatment Center, Monrovia. Address to the UN Security Council, Sept 18, 20141Naimah JKP MSF addresses UN Security Council emergency session on Ebola.http://www.msf.org/article/msf-addresses-un-security-council-emergency-session-ebolaDate: 2014Google Scholar The west African Ebola epidemic that began in 2013 was a human tragedy that exposed a global community altogether unprepared to help some of the world's poorest countries control a lethal outbreak of infectious disease. The outbreak engendered acts of outstanding courage and solidarity, but also immense human suffering, fear, and chaos, largely unchecked by high-level political leadership or reliable and rapid institutional responses. The outbreak continues as of November, 2015. It has infected more than 28 000 people and claimed more than 11 000 lives,2WHOEbola situation reports.http://apps.who.int/ebola/ebola-situation-reportsDate: 2015Google Scholar brought national health systems to a halt, rolled back hard-won social and economic gains in a region recovering from civil wars, sparked worldwide panic, and cost several billion dollars in short-term control efforts and economic losses.3UN Office of the Special Envoy on EbolaResources for Results III.https://ebolaresponse.un.org/sites/default/files/rriii_finalf_updated.pdfDate: 2015Google Scholar, 4Financial Tracking ServiceAppeal: Ebola virus outbreak—overview of needs and requirements (inter-agency plan for Guinea, Liberia, Sierra Leone, region). October 2014–June 2015.https://fts.unocha.org/pageloader.aspx?page=emerg-emergencyDetails&emergID=16506Google Scholar Guinea, Liberia, and Sierra Leone were most badly affected. The Ebola outbreak is a stark reminder of the fragility of health security in an interdependent world, and of the importance of building a more robust global system to protect all people from such risks.5Heymann DL Chen L Takemi K et al.Global health security: the wider lessons from the west African Ebola virus disease epidemic.Lancet. 2015; 385: 1884-1901Summary Full Text Full Text PDF PubMed Scopus (285) Google Scholar A more humane, competent, and timely response to future outbreaks needs greater willingness to assist affected populations, and systematic investments to enable the global community to perform four key functions: 1.Strengthen core capacities within and between countries to prevent, detect, and respond to outbreaks when and where they occur.2.Mobilise faster and more effective external assistance when countries are unable to prevent an outbreak from turning into a crisis.3.Rapidly produce and widely share relevant knowledge, from community mobilisation strategies to protective measures for health workers, and from epidemiological information to rapid diagnostic tests.4.Provide stewardship over the whole system, entailing strong leadership, coordination, priority-setting, and robust accountability from all involved.6Frenk J Moon S Governance challenges in global health.N Engl J Med. 2013; 368: 936-942Crossref PubMed Scopus (215) Google Scholar The Ebola outbreak emphasised failures in performing all four of these functions. Clarity about roles, responsibilities, and rules—and accountability for adherence to them—is essential in a complex system that must involve local, national, regional, and international actors spanning the public, private, and non-profit sectors. Yet, this clarity and accountability was fundamentally absent. Without addressing these governance issues, we will remain wholly unprepared for the next epidemic, which might very well be more devastating, virulent, and transmissible than Ebola or previous disease outbreaks.7Gates B The next epidemic—lessons from Ebola.N Engl J Med. 2015; 372: 1381-1384Crossref PubMed Scopus (166) Google Scholar, 8World Bank GroupPreparing for the Next Outbreak.http://pubdocs.worldbank.org/pubdocs/publicdoc/2015/7/267501437591636421/Preparing-for-the-Next-Outbreak-FINAL-English.pdfDate: 2015Google Scholar, 9Report of the Review Committee on the functioning of the International Health Regulations (2005) in relation to Pandemic (H1N1).http://apps.who.int/gb/ebwha/pdf_files/WHA64/A64_10-en.pdfDate: 2009Google Scholar The Independent Panel on the Global Response to Ebola is a joint initiative of the Harvard Global Health Institute and the London School of Hygiene & Tropical Medicine to review the global community's response to the Ebola outbreak. The 19 members come from academia, think tanks and civil society around the world, with expertise in Ebola, disease outbreaks, public and global health, international law, development and humanitarian assistance, and national and global governance. The Panel took a global, system-wide view with a special focus on rules, roles, and responsibilities to identify changes necessary to prevent and prepare for future outbreaks. This Panel report outlines the main weaknesses exposed during different phases of the Ebola outbreak, followed by ten concrete, interrelated recommendations across four thematic areas: preventing major disease outbreaks, responding to major disease outbreaks, research—production and sharing of data, knowledge, and technology, and governing the global system, with a focus on WHO. Our primary goal is to convince high-level political leaders worldwide to make necessary and enduring changes to better prepare for future outbreaks while memories of the human costs of inaction remain vivid and fresh. The Ebola outbreak witnessed many types of failures. For analytical purposes, we divide the epidemic roughly into four phases, underlining the most salient issues that arose. During the initial phase from December, 2013, to March, 2014, the first infections occurred in a remote rural area of Guinea where no outbreaks of Ebola had previously been identified.10WHOGround zero in Guinea: the outbreak smoulders—undetected—for more than 3 months.http://www.who.int/csr/disease/ebola/ebola-6-months/guinea/en/Date: 2015Google Scholar The lack of capacity in Guinea to detect the virus for several months was a key failure, allowing Ebola eventually to spread to bordering Liberia and Sierra Leone. This phase underscored the problem of inadequate investments in health infrastructure, despite national governments' formal commitments to do so under the International Health Regulations (2005),11WHOInternational Health Regulations. World Health Organization, Geneva2005Google Scholar and awareness among donors that many lower income countries would need substantial external support. It also underscored inadequate arrangements between governments and WHO to share, validate, and respond robustly to information on outbreaks. In March, 2014, a second phase began in which intergovernmental and non-governmental organisations began to respond, starting with Médecins Sans Frontières, which already had teams on the ground. That month, both Guinea and Liberia confirmed Ebola outbreaks to WHO. By March 24, Ebola was confirmed in Conakry, home to more than one in seven Guineans. Two months later Ebola had spread to three capital cities with international airports. Without any approved drugs, vaccines or rapid diagnostic tests, health workers struggled to diagnose patients and provide effective care. Without sufficient protective gear, and initially without widespread understanding of the virus, hundreds of health workers themselves became ill and died. Despite Médecins Sans Frontières' warnings about the unprecedented scope of the outbreak,12Médecins Sans FrontièresPushed to the limit and beyond: a year into the largest ever Ebola outbreak.http://www.msf.org.uk/sites/uk/files/ebola_pushed_to_the_limit_and_beyond.pdfDate: 2015Google Scholar national authorities in Guinea downplayed it for fear of creating panic and disrupting economic activity.12Médecins Sans FrontièresPushed to the limit and beyond: a year into the largest ever Ebola outbreak.http://www.msf.org.uk/sites/uk/files/ebola_pushed_to_the_limit_and_beyond.pdfDate: 2015Google Scholar, 13Frontline PBS Outbreak. Inside the troubled early days of Guinea's Ebola response.http://www.pbs.org/wgbh/pages/frontline/health-science-technology/outbreak/watch-inside-the-troubled-early-days-of-guineas-ebola-response/Date: 2015Google Scholar Internal documents14Cheng M Satter F Emails: UN health agency resisted declaring Ebola emergency.http://bigstory.ap.org/article/2489c78bff86463589b41f3faaea5ab2/emails-un-health-agency-resisted-declaring-ebola-emergencyDate: 2015Google Scholar suggest similar concerns might have influenced WHO, which publicly characterised the outbreak in March as “relatively small still”.15Samb S WHO says Guinea Ebola outbreak small as MSF slams international response.http://www.reuters.com/article/2014/04/01/us-guinea-ebola-idUSBREA301X120140401Date: 2014Google Scholar WHO's Global Alert and Response Network sent an expert team to support national efforts, as did others such as the US Centers for Disease Control and Prevention. However, those teams withdrew from Guinea and Liberia in May when reported cases decreased, even as viral transmission continued.16Garrett L Ebola's lessons: how the WHO mishandled the crisis.https://www.foreignaffairs.com/articles/west-africa/2015-08-18/ebola-s-lessonsDate: 2015Google Scholar In late May, Sierra Leone became the third country to declare an Ebola outbreak to WHO. For the first time in the known history of Ebola, the virus had spawned sustained outbreaks in three countries. This should have raised substantial alarm, as coordination was weak between the national governments of Liberia, Guinea, and Sierra Leone, the borders extremely porous, and human movement and trade highly fluid. In late June, Médecins Sans Frontières labelled the situation as “out of control” and publicly called for more international attention and resources.17Doctors Without Borders Canada/Médecins Sans Frontières (MSF) CanadaEbola in west Africa: “the epidemic is out of control.”.http://www.msf.ca/en/article/ebola-west-africa-epidemic-out-controlDate: 2014Google Scholar This second phase witnessed three interrelated failures. First, in a failure of political leadership, some national authorities did not call for greater international assistance despite the humanitarian crisis, and in some cases downplayed the outbreak. Second, WHO's in-country technical capacity was weak, shown by its decision to withdraw its international team too soon and its poor responses in Guinea and Sierra Leone to requests for technical guidance from ministries of health and health-care providers.18Cheng M Satter R Larson KAP Investigation: bungling by UN agency hurt Ebola response.http://bigstory.ap.org/article/3ba4599fdd754cd28b93a31b7345ca8b/ap-investigation-bungling-un-agency-hurt-ebola-responseDate: 2015Google Scholar, 19ReutersAHF: failed global Ebola response demands new leadership.http://uk.reuters.com/article/2015/02/24/ca-ahf-ebola-response-idUKnBw245381a+100+BSW20150224Date: 2015Google Scholar Third, WHO did not mobilise global assistance in countering the epidemic despite ample evidence the outbreak had overwhelmed national and non-governmental capacities—failures in both technical judgment and political leadership. The third phase began in July as cases, global attention, panic, and responses all grew. Funding increased, with the World Bank committing US$200 million in the first major external financing response.20The World BankEbola: World Bank Group mobilizes emergency funding to fight epidemic in west Africa.http://www.worldbank.org/en/news/press-release/2014/08/04/ebola-world-bank-group-mobilizes-emergency-funding-for-guinea-liberia-and-sierra-leone-to-fight-epidemicDate: 2014Google Scholar Media attention and public interest substantially increased after the evacuation of two infected US aid workers from Liberia.21Belluz J Hoffman S Why we fail at stopping outbreaks like Ebola.http://www.vox.com/2014/9/30/6843117/slow-ebola-virus-epidemic-response-WHO-after-brantly-Americans-infected/in/5740388Date: 2014Google Scholar Fear and hysteria in response to Ebola infections in the USA later led to quarantines of returning aid workers and other measures counterproductive for controlling the epidemic.22Yale Global Health Justice Partnership and American Civil Liberties UnionFear, Politics, and Ebola How Quarantines Hurt the Fight Against Ebola and Violate the Constitution. Yale Global Health Justice Partnership, Connecticut2015Google Scholar Dozens of countries, private companies, and universities began implementing travel restrictions, and many airlines ceased flying into the region.23WHOStatement on the 1st meeting of the IHR Emergency Committee on the 2014 Ebola outbreak in west Africa.http://www.who.int/mediacentre/news/statements/2014/ebola-20140808/en/Date: 2014Google Scholar On Aug 7, WHO convened the International Health Regulations Emergency Committee, and the next day the Director-General officially designated the Ebola outbreak a public health emergency of international concern (“an extraordinary event which is determined...to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response.”11WHOInternational Health Regulations. World Health Organization, Geneva2005Google Scholar) Detected cases grew exponentially. Ebola treatment centres in all three countries were stretched beyond capacity and forced to turn away patients at their gates.12Médecins Sans FrontièresPushed to the limit and beyond: a year into the largest ever Ebola outbreak.http://www.msf.org.uk/sites/uk/files/ebola_pushed_to_the_limit_and_beyond.pdfDate: 2015Google Scholar A growing lack of trust between population groups and government authorities hindered community mobilisation and public education.24MacDougall C Liberia's military tries to remedy tension over Ebola quarantine. The New York Times, Monrovia2015Google Scholar In the ensuing weeks, the global community mobilised, with new commitments of financing, health personnel, and logistical support from the African Union, China, Cuba, the European Union, the UK, the USA, the World Bank, the International Monetary Fund, and the UN agencies. The UN Security Council passed Resolution 2177 declaring the outbreak a threat to international peace and security, the only time it has done so regarding an outbreak and only the second resolution ever (after HIV/AIDS in 2000) to focus on a disease.25UN Security CouncilWith spread of Ebola outpacing response, Security Council adopts resolution 2177 (2014) urging immediate action, end to isolation of affected states.http://www.un.org/press/en/2014/sc11566.doc.htmDate: 2014Google Scholar The UN Secretary General created a new entity to coordinate the international response, the UN Mission for Emergency Ebola Response.26Special Representative of the UN Secretary General arrives in Accra to establish the UN Mission for Ebola Emergency Response Headquarters. United Nations, New York2014Google Scholar Additionally, trials for two candidate vaccines were launched in Europe and the USA, and WHO convened an expert group to develop guidance for the ethics of using experimental therapies.27WHOEthical considerations for use of unregistered interventions for Ebola virus disease. WHO, Geneva2014Google Scholar Despite increased mobilisation of political attention and resources, this third phase witnessed several failures. First, public and private restrictions on trade and travel further harmed an already suffering region and hindered control efforts.16Garrett L Ebola's lessons: how the WHO mishandled the crisis.https://www.foreignaffairs.com/articles/west-africa/2015-08-18/ebola-s-lessonsDate: 2015Google Scholar, 28Nierle T Jochum B Ebola: the failures of the international outbreak response.http://www.msf.org/article/ebola-failures-international-outbreak-responseDate: 2014Google Scholar Second, the operational response commenced slowly, taking months for funding, personnel, and other resources to reach the region.28Nierle T Jochum B Ebola: the failures of the international outbreak response.http://www.msf.org/article/ebola-failures-international-outbreak-responseDate: 2014Google Scholar, 29Grépin KA International donations to the Ebola virus outbreak: too little, too late?.BMJ. 2015; 350: h376Crossref PubMed Scopus (26) Google Scholar, 30Gettleman J As Ebola rages, poor planning thwarts efforts. The New York Times, New York2014Google Scholar Third, the creation of the UN Mission for Emergency Ebola Response bypassed the pre-existing UN body for emergency coordination, the Office for the Coordination of Humanitarian Affairs, further blurring the lines of responsibility for international coordination. Fourth, field staff often reinvented strategies for community mobilisation and contact tracing because relevant lessons from previous Ebola outbreaks in Uganda and the Democratic Republic of Congo were not effectively transferred.31Abramowitz SA McLean KE McKune SL et al.Community-centered responses to Ebola in urban Liberia: the view from below.PLoS Negl Trop Dis. 2015; 9: e0003706Google Scholar Fifth, international staff with Ebola sometimes received experimental therapies (albeit, the efficacy and risks of which were unknown) and were evacuated while national staff largely were not, a demoralising and often deadly distinction for many health workers.32Jambawai M We are dying of Ebola; where is the world? Africa Review.http://www.africareview.com/Opinion/No-outside-help-as-Ebola-devastates-Sierra-Leone/-/979188/2464846/-/wvre5nz/-/index.htmlDate: 2014Google Scholar, 33Green A Sheik Humarr Khan.Lancet. 2014; 384: 740Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar Sixth, there was poor understanding of how to take into account community beliefs, practices, and solutions, properly address rumours, and involve local leaders—with sometimes fatal consequences for health workers and communities.34Liu J Disease outbreak: Finish the fight against Ebola.Nature. 2015; 524: 27-29Crossref PubMed Scopus (6) Google Scholar A fourth phase began towards the end of 2014 as the epidemic turned a corner. The total number of cases began to decline in the hardest hit countries as community leaders and organisations joined control efforts, even before large-scale global assistance arrived. Ebola had been imported into Nigeria, Mali, and Senegal in the second half of 2014. Nevertheless, rapid information sharing, and mobilisation of health workers for contact tracing and patient care had limited the outbreak in Senegal to one confirmed infection.35Mirkovic K Thwing J Diack PA the Centers for Disease Control and Prevention (CDC)Importation and containment of Ebola virus disease—Senegal, August–September 2014.MMWR Morb Mortal Wkly Rep. 2014; 63: 873-874PubMed Google Scholar In Nigeria, the Nigerian Center for Disease Control, previous experience with polio eradication efforts and a lead poisoning emergency were all cited as important factors in successful control of the outbreak in Africa's most populous country.36Shuaib F Gunnala R Musa EO et al.the Centers for Disease Control and Prevention (CDC)Ebola virus disease outbreak—Nigeria, July–September 2014.MMWR Morb Mortal Wkly Rep. 2014; 63: 867-872PubMed Google Scholar By the end of January, 2015, more than $5 billion had been committed for the Ebola response (although the proportion of these funds actually spent on Ebola and in the affected countries remains unclear).37Grabowski A Hohlfelder E When losing track means losing lives: accountability lessons from the Ebola crisis.http://one-org.s3.amazonaws.com/us/wp-content/uploads/2015/07/White_Paper_Ebola.pdfDate: 2015Google Scholar Research and development efforts were quickly operationalised despite uncertainty on processes for regulatory approval, with at least three vaccine candidates, three blood products, and five drug candidates in clinical trials, with WHO playing a coordinating role.38WHOEbola R&D effort—vaccines, therapeutics, diagnostics.http://www.who.int/medicines/ebola-treatment/ebola_r_d_effort/en/Date: Jan 30, 2015Google Scholar During this phase, the binding constraints were no longer political attention, funding, or human resources, but operational coordination, accountability for effective use of funds, and maintaining momentum to prevent new infections. Amidst the crisis, many acts of courage, solidarity, innovation, and leadership prevailed, often at a substantial personal cost. In west Africa more than 800 local health workers contracted Ebola caring for the sick; more than 500 of those caregivers died.39WHOEbola situation report–17 June 2015.http://apps.who.int/ebola/current-situation/ebola-situation-report-17-june-2015Date: 2015Google Scholar Community members volunteered to trace contacts, local leaders educated communities, and religious authorities promoted new burial practices to prevent transmission. Several non-governmental organisations vocally advocated for a stronger global response, treated patients, trained health workers, supported community mobilisation and longer-term recovery efforts. Additionally to massive funding from traditional donors, the African Union, the Economic Community of West African States, Cuba, and China made substantial contributions of personnel, funding, logistics, and technology (Huang Y, Council on Foreign Relations, personal communication).40Garrett L How Cuba could stop the next Ebola outbreak.http://foreignpolicy.com/2015/05/06/cuba-ebola-west-africa-doctors/Date: 2015Google Scholar Private foundations and companies contributed funds, with $245 million from the top five contributors, along with meaningful in-kind assistance, such as air lifts.3UN Office of the Special Envoy on EbolaResources for Results III.https://ebolaresponse.un.org/sites/default/files/rriii_finalf_updated.pdfDate: 2015Google Scholar The initiation and conduct of clinical trials were accelerated amidst the challenging conditions of an outbreak, enabled by the cooperative efforts of industry, research funders, regulatory authorities in the USA, Europe, and west Africa, scientists, and directly affected communities. These positive steps notwithstanding, this Panel's overarching conclusion is that the long-delayed and problematic international response to the outbreak resulted in needless suffering and death, social and economic havoc, and a loss of confidence in national and global institutions. Failures of leadership, solidarity, and systems came to light in each of the four phases (panel 1). Recognition of many of these has since spurred proposals for change. We focus on the areas that the Panel identified as needing priority attention and action.Panel 1Summary of system weaknesses exposed across four phases of the Ebola outbreakPre-outbreak and Phase 1: December, 2013–March, 2014•Inadequate national investment and donor support for building national health systems capable of detecting and responding to disease outbreaks•Inadequate arrangements to monitor country commitments to do soPhase 2: April, 2014–July, 2014•Little incentive for countries to report outbreaks early•Insufficient overall technical capacity among national and international teams•WHO slow to mobilise global attention or assistancePhase 3: August, 2014–October, 2014•Government and private sector disregard for WHO recommendations regarding travel and trade restrictions•Slow global operational response•Unclear responsibility for international coordination•Weak channels for lessons from previous Ebola outbreaks•Little acce