WHO Director-General addresses Institute of Medicine Ebola workshop
Dr Margaret Chan
Director-General of the World Health Organization
Distinguished experts, colleagues in public health, ladies and gentlemen,
I thank the Institute of Medicine for organizing this workshop and bringing together so many well-known experts representing such a wide range of disciplines. Together, we need to explore every avenue for upgrading the world’s outbreak preparedness and response capacities.
I will be giving you an outline of weaknesses and shortcomings revealed by the outbreak, an overview of some specific challenges all responders faced, and a discussion of some successes as well as setbacks.
Ladies and gentlemen,
I have been asked to speak about the views of WHO 18 months after the outbreak was reported in March of last year. Our views go back further, to the events that followed the occurrence of the first case, in a remote village in Guinea, in December 2013.
The virus circulated for nearly three months, undetected, off every radar screen, initially misdiagnosed as cholera, then later thought to be Lassa fever, a viral haemorrhagic fever that is endemic in that part of Africa.
In Liberia and Sierra Leone, the virus also circulated undetected for several weeks, gaining a head-start with explosive momentum. National and international responses ran behind the virus and did not begin to catch up until late October of last year.
This is the first point I want to make. No regime for global governance can manage the invisible.
The first core capacity required to implement the International Health Regulations is an ability to “detect events involving disease or death above expected levels for the particular time and place in all areas within the territory.”
But how can countries that routinely experience deaths from diseases like malaria, Lassa fever, yellow fever, typhoid fever, dengue, and cholera recognize an unusual event in the midst of all this background noise from diseases with similar early symptoms? This is another fundamental problem that stands in the way of early detection and response.
Ladies and gentlemen,
This is the second point I want to make. The IHR have not performed as intended.
A key objective when revising the IHR was to move away from a passive approach to controlling epidemic spread at borders to a proactive approach that could detect an event early and contain it, before it had a chance to spread internationally.
That objective was justified, as WHO and its partners had contained hundreds of outbreaks, also of Ebola, at source, with little or no international spread, for more than a decade.
However, as we have learned, this proactive approach works only when countries have core capacities for early detection, timely notification, and response in place.
The importance of having this capacity in place was well-illustrated when Nigeria, Senegal, and Mali experienced their first imported cases. They caught the first case quickly, launched an emergency response, and stopped onward transmission entirely or held it to just 20 cases.
Recent expert groups convened by WHO have identified three main weaknesses of the IHR.
First, compliance with the obligation to build core capacities for event detection and response has been dismal. Eight years after the IHR came into force, fewer than a third of WHO Member States meet the minimum requirements for core capacities to implement the IHR.
Second, many countries imposed measures, such as restrictions on travel and trade, that went well beyond the temporary recommendations issued by the Emergency Committee last August.
The third weakness is the absence of a formal alert level of health risk other than the declaration of a public health emergency of international concern.
Last week, I convened a Review Committee to assess the performance of the IHR during the Ebola outbreak and advise me on changes needed, both immediately and longer-term through possible amendments. This advice will feed into a number of reforms currently under way at WHO.
I am personally overseeing changes that include the establishment of a global health emergency workforce, a new emergency programme with an operational platform that can shift into high gear quickly, performance benchmarks that show exactly what is meant by “high gear”, and the funding needed to make this happen.
Ladies and gentlemen,
Looking back, the perception of the outbreak at WHO is that of a steep uphill struggle, with many barriers along the way. The challenges faced fall into three broad categories.
First, the absence of national detection and response capacities at nearly every level of the health system, compounded by poorly functioning transportation and communication infrastructures.
Second, the weak preparedness and response capacities within the international community, including extremely limited surge capacity.
And third, the many tensions that arise between the sovereign right of nations to govern what happens in their territories and the need for solidarity and collective action against a shared threat.
A disease like Ebola will expose every gap in health system capacity and exploit every opportunity opened by these gaps.
At the start of the outbreak, the three countries had only one to two doctors per 100,000 population. Hospitals had no isolation wards, no culture of infection prevention and control, and frequently no electricity or running water.
Systems for data collection were rudimentary, fragmented, paper-driven, and designed for monthly, not daily, reporting. Only one laboratory in the region was equipped to diagnose viral haemorrhagic fevers. Waiting a week or more for test results was the norm.
Even after the arrival of mobile labs, services were frequently overwhelmed. Backlogs in testing left gaps of a week or more when the picture of the outbreak’s evolution went blank. Hundreds of suspected and probable cases were never tested.
Populations mistrusted the government, its health system, and its staff, and preferred to seek care from traditional healers. They did not welcome teams of foreign responders and resisted their presence, often violently.
Road transportation, whether of patients or diagnostic samples, was primitive, greatly increasing the time needed to reach treatment centres or carry laboratory samples and results back and forth.
Because of the severe shortage of treatment beds, people suffering from common and treatable diseases, like malaria, were held together with very ill Ebola patients in crowded facilities, forced to wait a week or even longer for diagnostic results. The risk of getting infected under such conditions was extremely high.
The international community was also poorly prepared. Though Ebola had been known for nearly four decades, no vaccines, point-of-care diagnostic tests, or treatments beyond supportive care were available.
As Ebola had previously been a rare disease, expertise was in short supply. All responders had trouble finding sufficient numbers of experienced clinicians and epidemiologists. Previously, no clinical teams, apart from those provided by MSF or deployed under the WHO GOARN umbrella, had responded to an Ebola outbreak.
Many agencies and organizations, in their great desire to help, took on roles that went well beyond their mandates and previous experience. Those with no experience in the clinical management of Ebola took several months to become operational.
For a time, MSF, WHO staff, Samaritans Purse, and some brave teams from Uganda employed by WHO, worked on alone, shoulder to shoulder with heroic health workers in the three countries. More than 500 of them lost their lives.
Apart from the shortage of expertise, one of the biggest barriers to staffing treatment centres was the absence of referral care for ill and possibly infected health workers. Medical evacuation by air was complicated for multiple reasons, and this difficulty deterred several countries from sending medical teams.
As case incidence began to grow exponentially, no one could build treatment facilities fast enough. In September of last year, MSF announced that its capacities in Liberia were overwhelmed and began turning patients away.
No internationally agreed procedures were in place for coordinating the activities of the multiple response teams that eventually arrived.
The problems created by the tensions between the rights of sovereign states and the need for global solidarity are likely the most difficult to address.
Let me give some examples that we in WHO encountered. A WHO GOARN team was assembled, equipped, and ready to travel. The government refused to issue visas.
Our efforts to quickly put WHO country offices on an emergency footing were frustrated by one government’s insistence on reviewing and approving my hand-picked appointments. Some were initially refused, and this led to a loss of precious time.
In another case, one government abruptly decided to report only confirmed cases, and not suspected and probable cases, as required by WHO. That decision shut our eyes to what was really happening in the country.
Much has been written about the extraordinary population mobility in the three countries. People readily cross porous borders. Contact tracing teams do not.
Many countries imposed travel restrictions that isolated the three countries and vastly increased their hardship. Several airlines suspended flights to West Africa. This impeded the arrival of desperately needed response teams, equipment, and humanitarian aid.
Let me remind you. It is not the ministry of health that takes the decision to seal a border, cancel visas, or prohibit an airplane carrying an Ebola patient from passing over its airspace or landing for refuelling.
As a final example, WHO advised against certain extreme control measures, as evidence strongly suggested they would be counter-productive. WHO can advise, but we cannot interfere. No external authority can dictate what happens within a sovereign state.
Ladies and gentlemen,
One of the objectives of this workshop is to improve the resilience of the global health infrastructure to future outbreaks and emergencies. In this context, a final observation may be helpful.
We did indeed manage to climb that steep and slippery slope.
Leadership, including command and control, by the presidents of the three countries was decisive.
Community engagement was decisive. The distribution of messages and leaflets does not win the cooperation of communities. This happens when communities understand and own the problem, and carve out their own socially and culturally acceptable solutions. For example, when communities worked out their own way to separate the sick from the healthy, that solution was far more effective than quarantines enforced by armed military personnel.
With 32 labs deployed to the three countries and Nigeria, the speed and precision of diagnostic testing eventually approached that on offer in wealthy countries. Most labs deliver results within 24 hours.
With support from CDC, WHO and others, data collection and reporting improved considerably, but is still far from perfect.
The number of treatment beds grew fairly rapidly until it became more than sufficient. When building treatment centres in Liberia, WHO developed a prototype floor plan that maximized safety for patients and care providers. The floor plan was then used by UK and US military personnel to construct additional treatment centres.
To reduce some of the chaos of uncoordinated and sometimes inappropriate assistance, we made an inventory of the qualifications and skills of foreign medical teams and developed a register, so that needs during the next outbreak can be matched with the most appropriate teams. This, too, saves time.
Ebola-specific specifications were developed for personal protective equipment. WHO brought manufacturers together with experienced clinicians to select the best designs that offered maximum protection, yet allowed clinicians to work in reasonable comfort under hot and humid conditions.
The world is on the verge of having a safe and effective vaccine. We have pre-qualified four rapid point-of-care diagnostic tests. We are developing a blueprint, with generic clinical trial protocols and arrangements for fast-track regulatory approval, to expedite the development of new medical products during the next emergency.
As we moved into the final phase of tracking the last cases and breaking the last transmission chains, WHO deployed nearly 1000 staff to 68 field sites in the three countries.
The outbreak is not yet over, but we are nearly there.
All of these achievements were made possible by the unprecedented collaboration of multiple partners. As just one example, laboratory support involved collaboration with 19 institutions and partners in two major networks.
At the same time, as the head of the World Health Organization, I do not want this distinguished audience to leave with the impression that this Organization showed no leadership. This is certainly the impression created by the narrative in most media reports.
We were slow at the start, but we made quick course corrections. These changes created many of the conditions that made it possible for multiple responders, national and international, to work to their full advantage.
Ladies and gentlemen,
Managing the global regime for controlling the international spread of disease is a central and historical responsibility of WHO. We have much experience and many networks of collaborating laboratories and institutional partners that kick in and work well for well-known epidemic-prone diseases.
However, these assets are insufficient to manage a disease event that is unexpected, severe, and sustained. As I said, we need to explore together every avenue for upgrading the world’s outbreak preparedness and response capacities.
I have a final comment. Informal arrangements exist between WHO and the UN Secretary-General for activating all assets within the UN system to address an urgent health problem.
Previous triggers include the threat from H5N1 avian influenza, the 2009 influenza pandemic and, of course, the Ebola outbreak in West Africa.
These arrangements can be formalized. Triggers can be more precisely defined, so that UN assets kick in quickly. This is one proposal for strengthening global governance for health that can move forward rapidly.