Ebola, Zika and the Weakness of the Global Health Regime
When it first began at the end of December 2013 in a rural village in Guinea, the Ebola virus had been restricted to a few neighboring villages. By March 2014, it had spread to Liberia and Sierra Leone, and in the coming months it would spread to at least 8 other countries around the world. Yet, the World Health Organization (WHO) did not declare a Public Health Emergency (PHE) until August 2014. By September, global concern had risen to such a degree that travel restrictions from the three most severely impacted countries were imposed by dozens of countries.
The WHO was widely, and justifiably, criticized for its failure to swiftly sound the alarm about the global spread of the Ebola virus. The Global Health Institute and London School of Hygiene and Tropical Medicine, which analyzed the WHO’s response to the Ebola epidemic, concluded that the WHO should be stripped of its role in declaring disease outbreaks to be an international emergency following its failure to warn the world of the dangers of Ebola in West Africa. This raises disturbing questions more generally about the strength (and weakness) of the global health regime currently in place, and whether conflicts of interest and politicization of issues related to the issuance of declaring a health emergency are preventing a more robust response.
The WHO, which includes virtually all countries in the world as members, is prevented from being nimble because of its size, as responsive as it might be by virtue of its multilateral decision-making protocol, and ultimately, more effective by virtue of the manner in which it operates.
Sometimes what is needed is a firm hand to rise above the chatter of the decision-making process – in other words, a strong leadership that will say, “this is the right thing to do, and it is urgent.” Given the stakes at hand, one has to wonder how it can be allowed to have adopted such a ‘reactive’ approach to problem-solving, and how it can be perceived to be so behind the curve in tackling the increasing range of pandemics and other health-related issues that have become globalized by virtue of a combination of travel patterns, porous borders, and weak governance.
The WHO has only issued public health emergencies four times since 2007 (when declaring such emergencies first became an established procedure, which is itself surprising): in 2009, for the influenza epidemic; in 2014, when it seems that polio had become resurgent; and again in August of that year for Ebola, and in 2016 for Zika. Since its founding in 1948 there have been numerous pandemics, and since 2000, at least three, but the WHO did not declare a PHE for HIV (which has killed more than 30 million people), SARS, MERS, and other viruses which have either seriously impacted individual countries, or more than one country. This is certainly true with the Zika virus. By the time the WHO had issued it PHE in February of 2016, the virus was already “spreading explosively,” and had, by that time, already impacted 23 countries.
First identified in Uganda in 1947, and having resided primarily in monkeys since that time, the Zika virus has grown exponentially among human populations since 1952 (also in Uganda). In the case of Brazil, which is currently the epicenter of the virus, the virus is believed to have first appeared in 2013. By May 2015, human cases had spiked dramatically throughout the Americas, and the WHO had estimated that up to four million people would be infected by the end of 2015. Yet, the WHO did not set up a global response unit until February 2016, and at that time, the emphasis was on whether Zika can cause microcephaly. It was only then that the WHO recommended ‘emergency’ status for the virus. Even then, the WHO did not recommend a plan of action to countries most impacted by Zika (the most obvious of which would have been a plan for mosquito control).
The Rio Olympics have been hit by allegations of a conflict of interest over the dangers of the Zika virus to tens of thousands of athletes and fans who will travel there in August. Some health experts have accused the WHO of brushing off the potential danger to public health – in Brazil and beyond — and of being too close to the International Olympic Committee (IOC) to be adopting impartial and unbiased policy on this issue. The WHO said that postponing or moving the Olympics would not stop Zika from spreading, and that it would reach other continents regardless of where the Games are held. This is undoubtedly true – but it makes no sense for the world’s premier global health organization to promote holding the games in the epicenter of the pandemic.
An open letter signed by 150 international doctors and scientists criticized an apparent agreement between the WHO and the IOC, stating that the WHO entered into an official partnership with the IOC, in a Memorandum of Understanding that remains secret, casting doubt on the WHO’s neutrality, and calling a failure to postpone or more the venue of the Games “irresponsible.” The irony is that the two organizations did indeed sign a very public MOU in 2010 which stated that both will work at the international and country level to promote activities and policy choices to help people reduce their risk of diseases.
It is bad enough that some multilateral organizations have succumbed to bureaucratic inertia and harmful politicization, but when the organization charged with maintaining the world’s health fails to live up to its organizational imperative and raison d’etre — “the attainment by all peoples of the highest possible level of health” — it is dangerous. We are living in the era of man-made risk, where natural risks are increasingly colliding with risks of our own making. The Ebola and Zika pandemics are perfect examples of this. Given that these risks can only increase with time, it is high time that we get our houses of oversight in good order, so as to be in a favorable position to do battle going forward. The coming ‘summer of Zika” should serve as reminder to everyone that our margin for error is increasingly small.