Report by the Director-General to the Special Session of the Executive Board on Ebola
Dr Margaret Chan
Director-General of the World Health Organization
Mister chairman, distinguished members of the Executive Board, Excellencies, Ambassadors, colleagues in the UN system, ladies and gentlemen,
The outbreak of Ebola virus disease in parts of West Africa is the largest, longest, most severe, and most complex in the nearly four-decade history of this disease. This was West Africa’s first experience with the virus, and it delivered some horrific shocks and surprises. The world, including WHO, was too slow to see what was unfolding before us.
Ebola is a tragedy that has taught the world, including WHO, many lessons, also about how to prevent similar events in the future. Factors of culture, history, geography, and weak road and health infrastructures produced a mix of opportunities that the virus quickly exploited.
Exceptionally mobile populations moving across exceptionally porous borders infected new areas, re-infected others, and eluded contact tracing teams. Health systems, already weakened during years of civil war and unrest, collapsed under the weight of this disease.
Prior to the outbreak, Guinea, Liberia, and Sierra Leone had only 1 to 2 doctors per nearly 100,000 population. Ebola cut this number down considerably. The number of infected doctors, nurses, and other health care staff, at nearly 850 with 500 deaths, was unprecedented for Ebola, as was the fact that these infections were still occurring in December, a year into the outbreak.
The entry of Ebola into two new countries via infected air travellers was also unprecedented.
The disease was unexpected and unfamiliar to everyone, from clinicians and laboratory staff to governments and their citizens. Ebola preyed on fear of the unfamiliar. The disease also preyed on a deep-seated cultural tradition: compassion. That is, compassionate care for the ill and ceremonial care of their bodies if they die.
Ladies and gentlemen,
The outbreak elicited an extraordinary outpouring of assistance from many, including the US, UK, France, Cuba and China, the European Union, the African Union, and ECOWAS, and many other countries and partners too numerous to mention. I must also highlight the unprecedented extraordinary leadership and efforts of governments in the affected countries. All this was done in a spirit of global solidarity with the people of Guinea, Liberia, and Sierra Leone and their governments. Countless agencies, nongovernmental organizations, like MSF and Save the Children, doctors and nurses, and volunteers courageously risked their lives to help patients survive.
Development partners, including many African countries, provided funds, equipment, mobile laboratories, and training. Foreign military personnel provided logistical support and constructed new treatment facilities.
Working with partners, WHO helped establish 27 laboratories, oversaw the construction and operation of many Ebola treatment centres, and coordinated the deployment of nearly 60 foreign medical teams provided by 40 organizations.
The skills, compassion, and courage of these teams, amounting to at least 2,000 medical staff, proved instrumental in the operation of 66 Ebola treatment facilities.
Researchers, the pharmaceutical industry, and regulatory authorities joined forces to fast-track the development of Ebola vaccines, therapies, and point-of-care diagnostic tests.
Last September, the UN Secretary-General, in collaboration with WHO, established the UN Mission for Emergency Ebola Response. Many UN agencies provided, under the UNMEER umbrella, much needed technical and logistical support to the three countries.
More than 100 countries in six regions have invested heavily in preparedness measures, often with support from other countries and many experts in WHO.
WHO staff contributed to these response, preparedness, and R&D efforts in no small way, often taking on tasks not previously performed by WHO. I thank them for their commitment and dedication.
WHO currently has a field presence in all of Guinea’s 34 prefectures, all of Liberia’s 15 counties, and all of Sierra Leone’s 14 districts. Nearly 700 WHO-deployed staff are in the three countries right now.
I have drawn staff from all relevant departments at headquarters and in the regions. These people are emotionally and physically exhausted. Many have been in the field for months. They deserve some recognition.
Of course, the big question everyone is asking is this. Have these tremendous efforts by affected countries and the international community turned the tide? Have we bent the curve far enough so that conventional control measures can work to get cases down to zero?
The data tell us we have bent the curve and avoided the worst-case scenario. We must now focus on the proven public health measures needed to get the job done.
Cases are clearly declining in all three countries, but we must maintain the momentum and guard against complacency and donor fatigue. Getting to zero cases of Ebola in the three remaining countries is our collective goal. This can be done but is not going to be easy.
As we have seen time and time again, an upsurge in new cases can follow a single unsafe burial or violent act of community resistance. Both of these high-risk situations are still occurring.
Although systems of data collection, reporting, and sharing have improved, we know that not all cases, and especially not all deaths, are being detected and reported. Poor communications and road systems increase the likelihood that cases and deaths are being missed, especially in very remote rural areas.
Ladies and gentlemen,
The Ebola outbreak points to the need for urgent change in three main areas: to rebuild and strengthen national and international emergency preparedness and response, to address the way new medical products are brought to market, and to strengthen the way WHO operates during emergencies.
In 2010, a Review Committee convened by the World Health Assembly under the International Health Regulations to assess the response to the 2009 influenza pandemic warned that the world was ill-prepared to respond to a severe influenza pandemic or to any similarly global and threatening public health emergency.
The Committee noted that WHO responded well to geographically focused short-term outbreaks but did not have the systems and capacities in place to respond to a health emergency that was both severe and sustained.
The Committee’s recommendations for strengthened preparedness included calls for the establishment of a more extensive public health reserve workforce that could be mobilized to support a sustained emergency response, the creation of a contingency fund to support surge capacity, and a comprehensive research and evaluation programme.
Concerning the need for new medical products, the world must never again find itself empty-handed when a severe epidemic-prone disease strikes, especially one that has been known for nearly 40 years. This was the view expressed by governments, scientists, executives from the pharmaceutical industry, and public health experts during a meeting on Ebola vaccines convened by WHO.
Ladies and gentlemen,
The Ebola outbreak revealed some inadequacies and shortcomings in this Organization’s administrative, managerial, and technical infrastructures. I am proposing a package of reforms, but want to highlight a few in this address to you.
The proposals before you repeat the need for a dedicated contingency fund to support rapid responses to outbreaks and emergencies.
Our standard recruitment procedures are too slow for use in emergencies. We need streamlined procedures for this purpose.
We need to apply the “one WHO” approach, whereby all three levels of the Organization use the same standard operating procedures, tools, and frameworks for risk assessment, monitoring, and accountability during emergencies.
The severity of the outbreak underscores the need to enhance crisis management and field experience during emergencies in WHO country offices.
WHO’s regional structure has advantages, for example, in tailoring the implementation of global strategies and guidelines to local cultures and conditions (and we learned from the Ebola outbreak how important culture is), in shaping the response of neighbouring countries to shared threats, like polio or malaria, and in helping countries to build and certify the core capacities set out in the International Health Regulations to be better prepared for the next emergency.
As events since the start of this century have shown, outbreaks rarely have only local or regional consequences in our highly interconnected and interdependent world.
The International Health Regulations need more teeth. They provide the principal line of collective defence against the threat from emerging and epidemic-prone diseases. The world will never reach true health security until more countries, and eventually all countries, have core capacities in place.
We need a far more rigorous methodology for evaluating these capacities than self-assessments in a questionnaire. And we need to treat the importance of getting these capacities in place like the emergency that it is.
We need to stop thinking about core capacities as something that should be tacked onto a country’s health systems, like an extra arm. No.
The capacities needed to undertake sensitive surveillance, provide laboratory support, manage data collection and reporting, and mount a response need to be an integral part of the health system.
Health systems also need adequate numbers of well-trained health care workers and these people need to be appropriately paid.
This is one of the biggest lessons the world learned last year. Well-functioning health systems are not a luxury. Well-functioning health systems are the cushion that keeps sudden shocks from reverberating throughout the fabric that holds societies together, ripping them apart. As we learned control depends on community engagement and community leadership at every stage.
In West Africa, what began as a health crisis quickly escalated into a humanitarian, social, economic, and security crisis. Schools, markets, businesses, airline and shipping routes, and borders closed. Tourism shut down, further deepening the blow to struggling economies. Countries resorted to using their defence and military forces for the command and control of containment measures.
We also need to think about the Review Committee’s advice to establish a more extensive public health reserve workforce. I see this workforce as having three components.
First, countries must be supported to build their own workforce for responding to emergencies, trained and drilled to perform with military precision. The workforce must be paid.
In Guinea, WHO trained some of the country’s young doctors in the basic principles of outbreak epidemiology and control. In Mali, the government used medical students, with training in epidemiology, to quickly build up teams for aggressive contact tracing. These people know the country and its culture and will be there, in the countries, long after foreign medical teams leave.
Second, WHO needs to strengthen its own workforce. Outbreak detection and response benefit greatly from the experience and knowledge of senior field epidemiologists. We need more of them.
Third, preparedness calls for greater surge capacity external to WHO, especially for responding to severe and sustained events.
WHO is right now working with the World Food Programme to establish a common operational platform, especially for the provision of logistical support.
We need to build on existing networks, especially our network of collaborating laboratories, which includes nearly 100 WHO-certified laboratories conducting surveillance and testing for measles, polio, yellow fever, and other epidemic-prone diseases. We need to discuss surge capacity with institutional partners in the Global Outbreak Alert and Response Network, or GOARN. Both networks are unique assets at WHO. We have been collaborating with them for many years and I want to recognize those countries that have supported these networks.
GOARN is an immense resource for WHO. For their part, institutions value the experience that staff receive during GOARN deployments.
Ladies and gentlemen,
As I conclude, I urge all of us to turn the 2014 Ebola crisis into an opportunity to build a build a stronger system to defend our collective global health security.
Well-off countries need to support others in building stronger health systems that include IHR core capacities.
The volatile microbial world will always deliver surprises.
Never again should the world be caught by surprise, unprepared.