IN A DELAY that some say may have cost lives, the World Health Organisation resisted calling the Ebola outbreak in West Africa a public health emergency until last summer, two months after staff raised the possibility and long after a senior manager called for a drastic change in strategy, The Associated Press has learned.
Among the reasons the United Nations agency cited in internal deliberations: worries that declaring such an emergency — akin to an international SOS — could anger the African countries involved, hurt their economies or interfere with the Muslim pilgrimage to Mecca.
“That’s like saying you don’t want to call the fire department because you’re afraid the fire trucks will create a disturbance in the neighbourhood,” said Michael Osterholm, a prominent infectious diseases expert at the University of Minnesota.
In public comments, WHO Director-General Dr. Margaret Chan has repeatedly said the epidemic caught the world by surprise.
“The disease was unexpected and unfamiliar to everyone, from (doctors) and laboratory staff to governments and their citizens,” she said in January. Last week, she told an audience in London that the first sign that West Africa’s Ebola crisis might become a global emergency came in late July, when a consultant fatally ill with the disease flew from Liberia to a Nigerian airport.
But internal documents obtained by AP show that senior directors at the health agency’s headquarters in Geneva were informed of how dire the situation was early on and held off on declaring a global emergency. Such an alert is meant to trigger a surge in outside help, or, as a WHO document put it, “ramps up political pressure in the countries affected” and “mobilises foreign aid and action.”
When WHO experts discussed the possibility of an emergency declaration in early June, one director viewed it as a “last resort.”
The delay in declaring an emergency was one of many critical problems that hobbled the agency’s ability to contain the epidemic. When aid agency Doctors Without Borders warned Ebola was spiralling out of control, WHO contradicted it, even as WHO’s own scientists called for backup. When WHO did send staffers to Africa, they were of mixed caliber.
Fellow responders said many lacked Ebola experience; one WHO consultant who got infected with Ebola broke his own agency’s protocol, putting others at risk and getting WHO kicked out of a hotel, the AP found.
In an email yesterday, WHO said: “People often confuse the declaration of a Public Health Emergency of International Concern with our operational response. It is very different. WHO mounted a strong operational response a year ago when we were notified the outbreak was Ebola.”
WHO’s handling of the Ebola epidemic has been roundly criticised and led to a new call for reforms.
Dr Sylvie Briand, head of the pandemic and epidemic diseases department at WHO, acknowledged that her agency made wrong decisions but said postponing the alert made sense at the time because it could have had catastrophic economic consequences.
“What I’ve seen in general is that for developing countries it’s sort of a death warrant you’re signing,” she said.
As Ebola continued to spread in the summer, the situation on the ground grew increasingly desperate, with only a fraction of the needed treatment beds available in Liberia and Sierra Leone. Some regions didn’t even have enough soap and water; patients were literally dying outside the gates of Ebola clinics as foreign mine workers evacuated and neighbouring countries restricted travel.
By the time WHO declared an international emergency, nearly 1,000 people were already dead. Overall, more than 10,000 are thought to have died in the year since the outbreak was announced.
Former WHO doctor Matthieu Kamwa who worked as the agency’s representative to the Democratic Republic of Congo during a 2008 Ebola outbreak, said sounding the alarm sooner would have saved lives.
“People died because things were not done,” he said.
THE FIRST WARNINGS
WHO announced the discovery of Ebola in Guinea on 23 March, when it posted a two-sentence update on its website saying a “rapidly evolving outbreak” had been confirmed after months of mysterious deaths in the nation’s forest region and capital city, Conakry.
Though WHO dispatched a top Ebola expert, Pierre Formenty, to the region, many of the other managers had no idea how to manage an Ebola epidemic, according to Marc Poncin, who was mission chief in Guinea for Doctors Without Borders.
In public, WHO downplayed concerns while news kept getting worse throughout April. Formenty said teams in Conakry had seen patients pop up all over the city with no known link to other cases.
“This means there is one part of the epidemic that is hidden,” he wrote later in an internal trip report. “The Ebola outbreak could restart at any time.”
‘OVERWHELMED WITH OUTBREAKS’
By mid-2014, WHO was struggling with a number of competing crises like:
It was around that time that West Africa’s Ebola epidemic surpassed the previous largest outbreak, in Uganda, where it infected 425 people in 2000 and killed about half.
At a June meeting in Geneva, scientist Stephane Hugonnet warned that the agency was “overwhelmed with outbreaks.”
In Africa, the true reach of Ebola was being obscured by Guinea’s Ministry of Health, which only shared information on confirmed cases and deaths, according to WHO documents. That was a problem because refusing to report suspect and probable cases meant the world wasn’t getting an accurate picture of the epidemic.
Another issue was the hajj in October. If Saudi Arabia further restricted travel in the wake of the outbreak, that could become a political liability for Guinea, an overwhelmingly Muslim country.
WHO struggled to get the Guineans to open up, and at one point in June dispatched Briand to convince them to be more transparent. Briand said the dispute spilled out publicly when the Guinean government criticised WHO for publishing conflicting figures.
Meanwhile, WHO employees wondered whether headquarters should be doing more.
On 4 June, scientist Lucien Manga wrote to Briand to tell her senior staff in Africa had proposed declaring the Ebola outbreak a global emergency.”What do you think and what is your advice?” Manga asked in an email.In a response tapped out over her iPhone the following day, Briand argued against the idea, saying it wouldn’t help control the epidemic and might harm the countries involved.
“It may be more effective to use other diplomatic means for now.”
On 10 June, Briand, her boss Dr Keiji Fukuda and others sent a memo to WHO chief Chan, noting that cases might soon pop up in Mali, Ivory Coast and Guinea Bissau. But it went on to say that declaring an international emergency or even convening an emergency committee to discuss the issue “could be seen as a hostile act.”
In a meeting at WHO headquarters on 30 July, Liu said she told Chan, “You have the legitimacy and the authority to label it an emergency…You need to step up to the plate.”
After WHO declared the international emergency. US President Barack Obama ordered up to 3,000 troops to West Africa and promised to build more than a dozen 100-bed field hospitals. Britain and France also pledged to build Ebola clinics; China sent a 59-person lab team and Cuba sent more than 400 health workers.
- With reporting by Michelle Hennessy.
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