Introduction 

The increasing frequency of global health emergencies that affect multiple nations and regions necessitates a better understanding of the role global governance systems play in combatting public health crises. Much like the global nature of today’s international security situations, health emergencies demand a robust global management system that minimizes the damage of epidemics while maintaining economic and political stability in the face of crisis. In the past decade, governments have responded to multiple global health emergencies with limited staff, resources, and information. No crisis has exposed the deficiencies of the global health management system more than the recent Ebola outbreak in West Africa, beginning in 2013 and ending in 2015. Ebola is a rare and deadly virus that spreads by direct human contact and is characterized by fever, weakness, vomiting and unexplained bleeding. This epidemic not only caused 28,000 cases of Ebola, and 11,000 lives lost, but it also led to an increased distrust of the World Health Organization (WHO) and healthcare workers, worldwide hysteria and panic, and economic slowdown.

Looking back to this time four years ago, the Ebola crisis exposed significant gaps in global healthcare management in the developing world. Scholar David Fidler of the Council on Foreign Relations, explains that “although unprecedented in international cooperation on health, the current regime complex for global health governance suffers from defects that many experts believe are responsible for suboptimal outcomes for individual and population health.” Knowing that there have been advances in global healthcare management, Fidler, like many in the field, believes that minimal change will occur if global leaders like the United States and the UN don’t focus attention on building up the capacity for international actors to address global health crises. Understanding the need for change begs the question: What policies do global health actors like the WHO and the Center for Disease Control (CDC) need to reform in order for our response to global health crises to improve?

The Case of the Ebola Outbreak

In December 2013, the first Ebola virus infections of this outbreak occurred in the West African country of Guinea. Patient zero was a small boy in a village in Southern Guinea, who was documented as having symptoms of a mysterious disease. Local health workers first classified it as cholera-like diarrhea, then as hemorrhagic fever. Because Ebola had never been diagnosed in the region before, it was not on the radar. Over the course of the next year, the outbreak infected tens of thousands of people, spreading primarily through Guinea, Sierra Leone, and Liberia. The region was susceptible to the rapidly spreading disease because of the porousness of the national borders, which allowed people to freely move between countries. Furthermore, because the Kissi ethnic group lives in a region spread over all three countries’ borders, the disease spread with them, as seen in Figure 1.

The Ebola epidemic hit a region that was moving towards economic and social stability after civil conflict had made the region unstable. Because of poor infrastructure and the inability of the region to diagnose and contain the first incidents of Ebola, the virus was able to quickly spread through the region. It was not until March of the following year that international Non-Governmental Organizations (NGOs) began setting up operations in the region to help deal with the spread of the disease. Most notably was Doctors without Borders, who stepped in to try to control the virus and grab the world’s attention.

By July of 2014, international attention grew and concern for the virus spreading to other countries became paramount. Some countries attempted to prevent the spread of the virus by encouraging schools, universities, and other organizations to implement travel bans or quarantine travelers, which only increased the growing sense of fear in the international community. The number of new cases continued to grow, and the number of deaths steadily rose. This was when the most external funding came to try to deal with the virus, including $200 million coming from the World Bank. By the end of 2014, the virus had spread to neighboring countries; however, the number of cases began to decrease, and the spread was being contained.

During this global health crisis, a number of weaknesses and issues with how the WHO, CDC, and the health ministries dealt with the epidemic became apparent. The most detrimental issues included the process of reporting and documenting infections, the insufficient health infrastructure, and the general lack of accountability of the WHO and its regional partners.

Reporting Disease and Accountability

The length of time it took for the international community to recognize the crisis and respond hampered the containment efforts. Because there is no incentive for countries to report disease, the countries affected did not immediately report the virus to national representatives. This is in contrast to the process of reporting disease that is spelled out in the International Health Regulations (IHR), which are legally binding for all WHO member states. According to the WHO, the goal of the IHR is “to help the international community prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide.” The IHR requires countries to report outbreaks to WHO, and subsequently explains the procedures for the response by the WHO and the reporting country. This process is important because it helps dispatch emergency response teams to the region and sets in motion security measures.

Kevin Sack of the New York Times reported on the political mess that was the reporting process in the Ebola crisis. Based on interviews with WHO staff, the representatives of the African Regional Office of the WHO were dispatched to gather information about the outbreak, but politics came before the needs of the people. Underfunded offices, unclear reporting lines, and incompetent representatives led to information not being transmitted to the WHO headquarters in Geneva. The WHO regional office also rejected help from the CDC because they wanted to handle the problem without help, which upset US officials. The CDC director at the time explained to Sacks that he was unsure who was leading the Ebola response, further showing the blurred reporting process, and ultimately caused delays in aid.

The lack of accountability from the WHO, and its local and regional representatives is also prevalent in this crisis. The Harvard Global Health Institute and the London School of Hygiene and Tropical Medicine (LSHTM) Independent Panel on the Global Response to Ebola site this issue as one of the main reasons that the response to the Ebola outbreak was not quick.  The Panel explains that there is no incentive for local communities to report cases of disease to the appropriate WHO representatives. This stems from the distrust of healthcare officials because some villages viewed them as tools for the government to get more foreign aid funding. Others distrusted the health workers because they said they couldn’t follow their normal burial practices of washing the bodies, which was important to their culture, yet furthered the spread of disease. The delay in reporting caused the Ebola epidemic to spread more quickly and overwhelmed on-the-ground response teams.

Accountability doesn’t only apply to reporting the disease at the start, but also to the WHO’s response to the reports. The Harvard report states that the WHO was slow to send out the response teams, and quick to pull out their teams when the situation started improving. Sacks also mentions reports of healthcare workers who left the region only to see the situation worsen.

Insufficient Infrastructure

A second glaring weakness evident during the Ebola crisis is the missing infrastructure to deal with epidemics. As seen during the crisis, families struggled to get their sick to hospitals because of the lack of proper roads, and even if they reached a medical facility, they could be turned away due to the overcrowded conditions.

The slow response resulted from a lack of hospitals, doctors, nurses, and medical equipment in the developing world. Infrastructure overhaul and prioritizing emergency care require appropriate funds, yet before the Ebola crisis, money was not being funneled into these types of programs. The lack of capacity at the local level to address and report cases of infectious disease makes it challenging for organizations like the WHO to mobilize a quick response specific to the needs of the situation.

Recommendations

The Harvard-LSHTM Independent Panel on the Global Response to Ebola provides a number of recommendations that urge the global governance system to make needed changes to their response to epidemics and call on political leaders to make those changes. Their recommendations focus specifically on the global response systems and their ability to build up global capacity.

Their recommendations are helpful, and the independent nature of this panel shows the critical nature of these recommendations. Their most crucial recommendation is their section on good governance reforms for the WHO, which recommends the WHO refocus on their core functions (providing leadership, shaping the research agenda, translation and dissemination of valuable knowledge, setting norms, articulating ethical and evidence-based policy options, providing technical support, catalyzing change, and monitoring the health situation and assessing health trends) and ask member states to demand a Director-General who will challenge government leaders who choose not to cooperate with reporting procedures. This will help ensure accountability at all levels of the WHO, and in their coordination with national governments.

Considering these recommendations, the WHO should go further by implementing the following reforms:

1. Speed up the global response by creating a streamlined system for reporting cases of disease. This may involve incentivizing the reporting process or making it easier for local doctors and health administrators to report to national authorities and WHO representatives, which will then report to the WHO headquarters. It should be the role of the WHO to respond to every disease threat swiftly and appropriately.
2. Increase funding to the African Regional Office of the WHO to re-implement their corps of anthropologists who work with villages on cultural practices to disease prevention and general healthcare practices. This was clearly a shortcoming of the regional office and re-implementing this office could help avoid distrust of healthcare workers in the future.
3. Encouraging grassroots organizations and NGOs in the region to refocus efforts on local healthcare capacity building. The global response needs to be matched with infrastructure improvements on the ground. Infrastructure was a main issue in the spread of Ebola and increasing the capacity of villages to fight disease will help contain the spread. This would also help the WHO be able to act faster, because they will be able to work in better cooperation with local healthcare providers.

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