The World Health Organization (WHO), the U.N. agency responsible for leadership on matters of global health, was sharply criticized for its response to the Ebola outbreak in West Africa in 2014. Health care providers argued that the WHO had been too slow to sound the alarm and was unprepared for the challenges that the deadly disease presented. Then-WHO Director-General Margaret Chan acknowledged her agency’s shortcomings and promised important reforms. Fast forward six years to another, more widespread and arguably greater, global health crisis — coronavirus — and early reviews of the WHO’s actions are much more nuanced.
Dr. Tom Frieden, former director of the U.S. Centers for Disease Control and Prevention and now president and CEO of the public health initiative Resolve to Save Lives, said the WHO’s response to the coronavirus pandemic “has been much better than the Ebola response.”
“This is an unprecedented situation,” Frieden told us via email, “and the WHO is generally doing a good job,” although he noted that the agency’s formal designation of the outbreak as a pandemic on March 11 “was slightly overdue.”
Frieden added that, given how rapidly the new disease is spreading, it’s difficult for any entity to keep up, especially one with the bureaucratic complexity of the WHO. “We are a more interconnected world,” he said. “That allows diseases to spread quickly, making WHO’s job, and everyone else working on preparedness and response, more difficult.”
Life Under Lockdown
Difficult is an understatement for world bodies such as the WHO, national governments and local authorities grappling with how to contain Covid-19, the disease caused by the coronavirus. Some countries (South Korea) have handled it better than others (Italy), although everyone has stumbled and struggled to tackle what President Trump called “an invisible killer.”
The United States has now joined Europe and Asia in essentially shutting down in a bid to flatten the curve and stop the number of Covid-19 cases from increasing exponentially. In countries around the world, the cascading pattern has become a familiar, and frightening, one: Borders have closed, transportation and entire industries have ground to a halt, stocks have cratered, businesses large and small have shuttered, grocery store shelves and streets have emptied, schools have closed, people are sheltering indoors and social distancing has become the norm for an unspecified period of time as hospitals gird for a coming onslaught of patients for which they are scarcely prepared.
As of March 27 when we went to press, nearly 550,000 cases of Covid-19 and nearly 25,000 deaths had been confirmed on every continent except Antarctica. That includes nearly 90,000 cases in the U.S., although those figures are likely to surge as testing ramps up. One jarring report by British researchers warned that without any action, 2.2 million people in the U.S. could die. Meanwhile, the economic toll is incalculable.
Fearful of a collapse even worse than the Great Depression, the U.S. government is propping the economy up with more than $2 trillion in stimulus spending — with potentially more to come.
The costs of coronavirus will be felt for years to come — as will the lessons we learn from our handling of the crisis, which will likely reshape our thinking about public health, just as 9/11 reshaped our approach toward national security.
But the crisis should not have come as a surprise. For years, experts have been warning about the possible emergence of a global pandemic that not only fundamentally alters our way of life, but also tests the very notion of 21st-century globalization.
In fact, as Politico reported in a March 16 article, shortly before Trump’s inauguration, members of the Obama administration held a transition exercise in which they gave the incoming president’s team a briefing on a theoretical new pandemic that could wreak havoc on health care systems around the world.
It was a scenario Obama faced six years ago when the country was gripped by panic over another disease that, like coronavirus, also had the potential to spread worldwide but was, in some ways, even more terrifying: Ebola.
Two Terrifyingly Different Diagnoses
While both Ebola and Covid-19 pose enormous health challenges, they do so in different ways.
The coronavirus, whose symptoms largely mimic the flu, is transmitted through droplets in the air, often by infected people coughing or sneezing nearby (generally within six feet). Droplets can also land on surfaces, where the virus can live for up to several days. It is not known to what degree the virus can be spread by people with no symptoms — and experts say that a large portion of people infected with the coronavirus may have little to no symptoms. But older people and those with pre-existing health conditions are more at risk of developing severe symptoms such as trouble breathing that require hospitalization. Experts have estimated the mortality rate of Covid-19 at anywhere from 1.4% to 3.6%, although the figure is likely lower given that many people with mild or no symptoms aren’t tested.
In contrast to the coronavirus, Ebola can only be spread by direct contact with an infected person’s blood or other bodily fluids such urine and sweat — and only after they have already developed symptoms (although the disease can also be spread by contact with the body of a deceased patient). While transmission is greater with coronavirus, a diagnosis of Ebola is far more bleak. The disease is often fatal. In addition to flu-like symptoms, it causes vomiting, diarrhea, decreased liver and kidney function, black stools and both internal and external bleeding, including the oozing of blood from the gums and whites of the eyes.
The extreme symptoms and high fatality rate of Ebola caused widespread panic in 2014 that prompted the WHO and governments to move aggressively — albeit belatedly — to tackle the outbreak.
The global response focused on containing the disease and concentrating resources on the three countries most affected by it: Guinea, Liberia and Sierra Leone, all of which had poor health care systems.
At the time, President Obama dispatched the Centers for Disease Control and Prevention to West Africa to help with the response, including surveillance, testing and training nearly 25,000 health care workers. It took two years for the outbreak to subside and in that time, a total of 28,616 cases and 11,310 deaths were reported in Guinea, Liberia and Sierra Leone.
Outside of this epicenter, however, the number of cases was extremely minimal. In the U.S., there were only 11 cases of Ebola, most of them medical workers who had been exposed to the virus in West Africa and returned to the U.S. for treatment. Of the 11, two died.
Coronavirus is an altogether different beast. That’s why Tolbert Nyenswah, a senior research associate at the Johns Hopkins Bloomberg School of Public Health who helped lead Liberia’s response to the 2014 Ebola outbreak, says that while the WHO “has done a very good, decent job” in responding to the coronavirus pandemic, “it cannot really be compared” to what happened with Ebola a few years ago.
“Ebola was killing more people faster, but not so many people at risk as compared to corona, where the mortality rate is low, but the transmission [rate] is high,” Nyenswah told us.
Still, there are some lessons that can be gleaned from the Ebola outbreak — namely the importance of rapid response.
Nyenswah pointed out that it took the WHO nearly six months to declare Ebola an international public health emergency following the outbreak in 2014.
This time, the global health body “made a very positive move” in formally declaring a public health emergency of international concern (PHEIC) within weeks of China’s acknowledgment of coronavirus outbreak last December. That declaration was followed by the creation of a global response plan calling for $675 million in donor funding targeted toward fighting the virus. As of mid-March, only a portion of that total had been received, although on March 13, the WHO announced the creation of a Solidarity Response Fund that would raise money from both public and private sectors to help countries with less advanced health systems respond to the pandemic. Facebook and Google are among the global corporations lined up to support the new fund.
Bound by Budgets, Beholden to Donors
However important such steps may be, they also highlight the WHO’s inherent weaknesses.
Established in 1948 and based in Geneva, the WHO works with 194 member states in over 150 offices across six regions. Its mandate is expansive and includes tackling communicable diseases such as HIV/AIDs, tuberculosis and malaria, as well as non-communicable diseases such as heart disease and cancer. It works to improve access to essential health services in some of the world’s poorest countries and supports initiatives ranging from polio eradication to maternal health. In addition, it monitors an array of health-related issues such as food security, climate change, drug use and road safety. It’s also responsible for setting international health standards and coordinating global responses to emergencies such as the coronavirus pandemic.
Yet experts say the WHO’s staff — 7,000 — and its budget — $4.4 billion for 2018 and 2019 — are not commensurate with such a broad mandate.
Dr. Jennifer Huang Bouey, senior policy researcher at the Rand Corporation, says that in addition to budgetary and workforce constraints, the majority of WHO’s budget comes from voluntary contributions, making it more or less beholden to its donors. Huang Bouey suggests that the health agency can provide important medical guidance and coordinate vital technical support, but there are limits to what the WHO can, or perhaps dares to, do. “[C]an it criticize countries for their lack of action or mistakes?” she asked via email. “Not really, especially [with regard] to its donors.”
A background report on the WHO created by the Council on Foreign Relations says that the WHO has become “increasingly dependent on voluntary contributions” over the past decade and that this, in turn, has increased pressure on the organization to respond to donor interests.
In the case of the United States, historically the WHO’s largest contributor, Huang Bouey pointed to “ups and downs” in recent support for the global health agency. She cited significant declines in U.S. financial support from 2017 to the present and the Trump administration’s plan to further slash U.S. contributions to the world body in its proposed fiscal 2021 budget (also see “Show Me the Money: Congress Giveth What the President Keeps Trying to Taketh Away” in the March 2020 issue).
While Congress is likely to reject the most extreme proposed cuts, any reduction in U.S. contributions “will further reduce the WHO’s capabilities,” Huang Bouey said.
Like many of her colleagues, Huang Bouey believes the WHO is “doing its job” with regard to Covid-19, providing almost daily situation reports in addition to virus prototype research, test kit dissemination and supplying medical expertise through its regional offices. Still, the Trump administration’s proposal to cut overall global health spending by as much as $3 billion from the $9 billion that was authorized last year will “almost certainly hurt pandemic preparedness and response,” including that of the WHO.
Frieden, who is also affiliated with the Council on Foreign Relations as senior fellow for global health, agrees that the WHO “needs much more financial support.” Similarly, individual countries, particularly those with weaker health systems, need help building their preparedness for outbreaks like Ebola and the coronavirus. “What we lack now is sustained financing to close those gaps,” Frieden told us.
Huang Bouey emphasized that, given chronic funding and occasional management problems, the WHO has to rely on individual countries and donors in marshalling resources to address global health crises. This means that, in actuality, the agency “has a limited role in global pandemic response.”
No Teeth
Perhaps the biggest limitation of the WHO is that it has no enforcement authority. It can issue recommendations on policies such as travel restrictions and medical exports, but countries can ignore them. It can call for global unity but cannot compel countries to work together. And it relies on governments to report outbreaks and share information, but it cannot hold them accountable if they keep the WHO in the dark. And because it relies on donor support, it cannot publicly shame donors that have flouted their obligations.
In the case of coronavirus, the WHO had to wait for China to report the outbreak on Dec. 30, 2019, although people may have begun falling ill to the disease weeks earlier. An international team of disease experts sponsored by the WHO did not arrive in China until mid-February, too late in the estimation of some health leaders, including U.S. Health and Human Services Secretary Alex Azar. Azar told news outlets that the U.S. had offered to send disease experts to China as early as Jan. 6, but had not received permission to do so.
“No country wants to say, ‘My country has this disease,’” Nyenswah acknowledged. “We saw in West Africa how all of us barricaded ourselves from the rest of the world. So, China delayed a bit in responding to this outbreak.”
What was needed, he argues, was more forceful action from the WHO.
“The WHO should have moved directly,” he said. “They should have insisted and moved in and gotten things going.”
Instead, Nyenswah said WHO experts went into China “when the outbreak was already out of control and had become a global problem. Now, everyone’s afraid.”
Nyenswah argues that his experience fighting Ebola in West Africa highlights the central problem: The WHO does not have any way to hold individual countries accountable, whether for financial support (beyond a basic assessment from member states), disease reporting or in terms of instituting WHO protocols during an outbreak.
“The WHO requires countries to report out, but that’s not binding on countries. The WHO says countries should or should not close their borders, but [enforcement of] that level of political decision-making is not there,” Nyenswah told us.
“Right now, Italians are dealing with Italians, Chinese are dealing with Chinese, the U.S. president is concentrating on the U.S. This kind of outlook is stretching world peace,” he added. “If the world was together, we would know how to deal with testing, with airlines, with travel. But now, everybody is confused. It’s the kind of environment where disease flourishes.”
In fact, on the day that WHO Director-General Tedros Adhanom Ghebreyesus announced the agency’s designation of the coronavirus as a pandemic, he both defended the WHO’s actions and acknowledged that some countries were not heeding its directives.
“WHO has been in full response mode since we were notified of the first cases,” Ghebreyesus said. “And we have called every day for countries to take urgent and aggressive action. We have rung the alarm bell loud and clear.”
Ghebreyesus said that while some countries are struggling with a lack of capacity or resources, others “are struggling with a lack of resolve.
Leadership in the Face of Limitations
Nyenswah suggested the answer lies with the U.N. Security Council, which can exert greater pressure than the WHO can to hold nations accountable during times of crisis. He cites the success he and other leaders in the fight against Ebola had in getting the Security Council to pass a resolution declaring the virus “a threat to international peace and security.” The resolution called on member nations to send health care workers and supplies to the hardest-hit areas of West Africa. In addition, then-U.N. Secretary-General Ban Ki-moon established a United Nations Mission for Ebola Emergency Response (UNMEER) to increase the WHO’s operational and logistical capacities. Importantly, the secretary-general also appointed a special Ebola envoy to coordinate the work.
“I don’t see that kind of cooperation right now,” Nyenswah lamented. “During Ebola, when the secretary-general appointed the envoy to mobilize resources, technology and advising, you found everything started to come together and was better organized. [The envoy] briefed the General Assembly from Monrovia [Liberia], and people saw that it was real.”
Nyenswah said that while the WHO is “taking the right steps now” and “doing all of the things necessary that can be done within [its] mandate,” it is “time for the U.N. to come in at the Security Council level and show some of the lessons learned” from the fight against Ebola.
He noted that he and colleagues at Johns Hopkins are trying to reach out to the Security Council now because “its leadership is critical” and because “the WHO has such limitations.”
Sometimes, of course, nations simply decide not to cooperate with the WHO or not use the medical advice and tools that it provides. While research firms partnering with the WHO produced over a million Covid-19 test kits in the month following the PHEIC announcement, the United States decided to create its own test kit through the Centers for Disease Control and Prevention. It turned out that the vast majority of those kits or their prototypes were defective, meaning that the U.S. faced a lengthy delay in virus testing, possibly losing critical ground in the fight to contain the disease.
At the same time, nations around the world were benefiting from the availability of properly working kits sent out by the WHO. Thousands of people were able to be tested when the results were most needed — a factor that experts say helped countries like South Korea and Singapore successfully curb the contagion. Now, experts in the U.S., including Frieden, are calling for an investigation of what went wrong with the testing regimen here.
“There will always be things you look back on and wish you’d done differently in an epidemic response,” Frieden said of the WHO’s leadership on Covid-19. He praises the agency’s staff for “working hard to support countries, organizations, governments and businesses.”
As for the financial and logistical pressures the WHO faces today, and may continue to face in the future, Frieden warns: “In our interconnected world, we are only as safe as the country with the weakest system to find, stop and prevent disease threats. As Covid-19 highlights, the next epidemic is just a flight away.”
About the Author
Deryl Davis is a contributing writer to The Washington Diplomat.
