From Ebola to Zika: Why the World Needs WHO Reform

The following is a guest post by Daniel Chardell, research associate in the International Institutions and Global Governance program at the Council on Foreign Relations.

As the Zika virus spreads like wildfire across the Americas, the World Health Organization (WHO), still reeling from the Ebola crisis, has once again come under scrutiny for its management of an infectious disease outbreak. Until last year, Zika, a mosquito-borne pathogen thought to cause microcephaly and incomplete brain development, was unknown in the Western Hemisphere. But microcephaly surged in Brazil in 2015, with evidence suggesting that Zika, a virus originally found in Uganda, is the cause.

Already, the WHO has come under fire for appearing caught off guard by news of Zika, which the Pan American Health Organization—the agency’s regional branch for the Western Hemisphere—deemed an emergency back in May. Eager to stave off criticism, WHO Director-General Margaret Chan switched into high gear, declaring Zika a public health emergency of international concern (PHEIC) on February 1. With Brazil preparing to host the Olympics this summer, however, concerns persist that the WHO hasn’t moved aggressively enough.

Criticism of the WHO being asleep at the wheel is not new. Just over two years ago, the worst-ever Ebola outbreak erupted in West Africa, claiming more than 11,300 lives. Nearly all deaths took place in Guinea, Liberia, and Sierra Leone, where weak health systems, distrust of government and foreign aid workers, traditional mourning practices, and porous borders enabled and exacerbated the outbreak. Ebola not only served as a stark reminder that, in a hyperconnected world, outbreaks can rapidly transform from local into global emergencies. It also revealed the deficiencies of the WHO and the anarchic emergency response system it oversees.

Late last year, CFR’s International Institutions and Global Governance program hosted a workshop on prospects for WHO reform in light of lessons learned from the Ebola crisis. Several priorities for reform crystallized over the course of the discussion that are germane to the ongoing Zika outbreak and, more broadly, to the future of pandemic preparedness and global health security.

Regulatory Breakdown

The International Health Regulations (IHR)—the legal regime undergirding global management of cross-border infectious disease threats—all but collapsed in the face of the Ebola crisis. The IHR require all countries to establish minimum “core capacities” to prevent, detect, and respond to infectious disease outbreaks within their borders, and to immediately notify the WHO when they occur. The WHO is empowered to declare public health emergencies of international concern, and all countries are obligated to abide by the WHO’s recommendations regarding travel and trade restrictions on outbreak-affected countries.

In practice, however, the IHR are replete with gaps, and Ebola brought these to the fore. West African political leaders and WHO officials initially downplayed Ebola, dismissing increasingly dire warnings from Médecins Sans Frontières (MSF) as alarmist. Chan waited months before declaring a PHEIC in August 2014, by which time nearly one thousand people had died and the virus had spread to Nigeria. Why the delay? For starters, fears that alarm would spark instability and exact a heavy economic toll. Unfortunately, such fears were borne out: in the panic of the crisis, nearly a quarter of WHO member states imposed travel bans, border closures, and other unnecessary measures on Ebola-affected countries, contrary to their legal obligations under the IHR. These restrictions not only disrupted the flow of foreign aid workers to and from the region, but wrought economic hardship on Guinea, Liberia, and Sierra Leone. Far from encouraging a decisive outbreak response, Ebola revealed that countries have a clear disincentive to sound the alarm when outbreaks flare up. New means of incentivizing more rapid PHEIC declarations, punishing those who violate the IHR, and providing insurance to emergency-affected countries are needed.

Substandard Health Systems

More broadly, Ebola reflected the failure of the WHO to facilitate universal implementation of the core surveillance and response capacities prescribed by the IHR. As of November 2014, just one-third of all WHO member states had met these standards. The abysmal rate of implementation reflects the WHO’s powerlessness to hold its members to account and failure to prioritize capacity-building, an area in which the WHO has the authority and legitimacy to lead.

One promising development has been the Obama administration’s Global Health Security Agenda (GHSA), a partnership of nearly fifty countries launched in 2014 that administers an external review of IHR implementation. Although a step in the right direction, the GHSA remains an informal coalition, not a formal international organization with the legitimacy afforded by a constitution and universal membership. In this regard, the WHO remains unmatched and indispensable. Until all countries achieve the core capacities, an outbreak anywhere could snowball into a global crisis.

Weak Leadership

The director-general of the WHO, Margaret Chan, has long been the object of ire for critics of the WHO. At the height of the Ebola crisis, Chan infamously affirmed that the WHO was merely a technical agency, not the first responder, and that public health is ultimately the responsibility of governments. Her remarks, though not incorrect, revealed just how out of touch the WHO really was. Precisely at the moment the world needed a leader, Chan demurred. But the problem goes deeper than bad public relations. In fact, Chan’s belated declaration of a PHEIC was symptomatic of the WHO’s systemic flaws, including lack of accountability and a weak chain of command between headquarters in Geneva and technically unqualified appointees leading its field offices.

Many are already looking forward to 2017, when Margaret Chan’s tenure ends. The next leader of the WHO must demonstrate the courage and political savvy to confront governments that would obstruct decisive action against public health emergencies.

Crisis of Identity

The Ebola outbreak took place amid a historic transformation in global health governance. This landscape has become increasingly crowded, with a growing array of governments, NGOs, private foundations, multinational corporations, public-private partnerships, and international organizations partaking in public health–related activities. The most important global health institutions—such as the Gates Foundation, the Global Fund, and Gavi—account for a growing proportion of development assistance for health. These younger, more agile institutions far outspend the WHO, which has been compelled to maintain a policy of zero nominal budgetary growth since the early 1990s.

Ebola was a crisis that demanded urgent action. But these longer-term trends—a dwindling budget in real terms, an ever-expanding agenda, and the emergence of specialized competitors—point to a broader existential crisis for the World Health Organization.

The WHO has a central role to play in outbreak and emergency response. To achieve its potential, however, the WHO must focus on those areas where it alone can add value: coordinating responses to international health emergencies, issuing technical guidance, setting standards, forging partnerships to mobilize resources, coordinating research and development, and building strong public health systems in developing countries. Despite its initially lethargic response, the WHO proved essential to ramping up clinical testing and rapid dissemination of an Ebola vaccine. As scientists around the world scurry to study Zika and, hopefully, deliver a vaccine, the WHO should play a central role in coordinating research and mobilizing resources.

To be clear, Zika is not Ebola, as Chatham House’s Michael Edelstein and Brian McCloskey aptly note. However, barring implementation of the abovementioned reforms, the institutional deficiencies that hindered the WHO’s response to the Ebola outbreak will persist in the fight against Zika and future outbreaks—with equally tragic effect.

The WHO’s deficiencies are well-documented, but the remedies are clear. The only missing ingredient is the political will to implement them. If Zika has a silver lining, it may well be that this outbreak has added fuel to the dwindling political momentum for WHO reform. For the good of global health, leaders must enact these reforms before that fuel is spent.

To learn more, read the full report: “The Future of the WHO: Lessons Learned and Priorities for Reform”