GENEVA -- In a delay that some say may have cost lives, the World
Health Organization resisted calling the Ebolaoutbreak 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.
Those arguments struck critics,
experts and several former WHO staff as wrong-headed.
"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 neighborhood," 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 "mobilizes 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 spiraling 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 Thursday, 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 is the only agency with the
authority to lead a global response to health crises, by providing medical,
laboratory and other support when there are outbreaks of unusual or new
diseases. Its handling of the Ebola epidemic has been roundly criticized and
led to a new call for reforms. The vacuum of leadership at WHO was so damaging
the U.N. created the Mission for Ebola Emergency Response to take over the
overall fight against the disease.
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
neighboring 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.
 |
|
Staff of Doctors without Borders
carry the body of a person who died at an Ebola treatment center in Guekedou,
Guinea, on April 1, 2014.
SEYLLOU/AFP/Getty Images
|
Chan, the WHO leader, declined
interview requests with AP for this story. But Dr. Bruce Aylward, WHO's top
Ebola official, said labeling the Ebola outbreak a global emergency would have
been no magic bullet.
"What you would expect is the
whole world wakes up and goes, `Oh my gosh, this is a terrible problem, we have
to deploy additional people and send money,'" he said. "Instead what
happened is people thought, `Oh my goodness, there's something really dangerous
happening there and we need to restrict travel and the movement of
people.'"
Former WHO doctor Matthieu Kamwa
said that logic doesn't fly. 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 tip of an iceberg"
WHO announced the discovery of Ebola
in Guinea on March 23, 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.
The virus typically overpowers the immune system, causing leaks in blood vessels
that can lead to organ failure and shock. There is no licensed treatment or
vaccine and the death rate can be as high as 90 percent.
The signs this was no ordinary
outbreak were there from the beginning, and many are recorded in a memo sent to
WHO's Africa director on March 25: The virus had never been seen in Guinea
before; health workers were dying, panic was setting in and reports of
infections had already come in from neighboring Liberia and Sierra Leone.
Its spread to Conakry was
particularly disturbing.
"From the start we were very
worried about cases in the capital," said Briand, the WHO official.
"We told ourselves: `From the capital it can go elsewhere.'"
Guinean officials never tried to
hide the scope of the outbreak, government spokesman Albert Damantang Camara
said Thursday.
In mid-April, by which point there
had been at least 100 deaths in Guinea, an experienced Ebola expert with WHO's
Africa office wrote to a Geneva staffer saying the situation had taken a critical
turn: many health workers at the capital's Donka Hospital had been exposed to
the virus.
"What we see is the tip of an
iceberg," said Jean-Bosco Ndihokubwayo. The scientist requested the help
of half a dozen veteran outbreak responders, writing in all-caps in the email's
subject line: "WE NEED SUPPORT."
WHO official Stella Chungong said
she was very worried, warning in an email that terrified health workers might
abandon Donka Hospital and -- equally alarming -- new Ebola cases were coming
out of nowhere.
"We need a drastic ... change
(of) course if we hope to control this outbreak," she said.
WHO dispatched a top Ebola expert,
Pierre Formenty, to the region. But many of the other managers sent to Conakry
"had no idea how to manage an Ebola epidemic," according to Marc
Poncin, who was mission chief in Guinea for Doctors Without Borders, also known
by its French acronym MSF.
In public, WHO downplayed concerns.
Spokesman Gregory Hartl told reporters in early April that "this outbreak
isn't different from previous outbreaks." In a twitter message sent by
Hartl -- and preserved by Britain's ITV News -- he is shown asking: "You
want to disrupt the economic life of a country, a region (because) of 130
suspect and confirmed cases?"
The 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"
As the
epidemic spread, WHO struggled with competing crises.
In some ways the World Health
Organization is small -- its roughly 7,000 employees make it less than half the
size of the U.S. Centers for Disease Prevention and Control -- but its
responsibilities are wide-ranging. Among other things, it monitors some 800
outbreaks every year. Most don't make international headlines.
By mid-2014, several had.
The first was polio, which came back
from the brink of extinction to claw its way into conflict zones such as Syria.
Its rise was labeled an international health emergency in May. The second was
the baffling Middle Eastern Respiratory Syndrome, or MERS, which had sickened
nearly 700 people and killed 204, mostly in the Arabian peninsula, by early
June.
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.
The triple threat came at a time of
steeply reduced budgets for WHO following the 2008 financial crisis. Cuts have
continued since; its outbreak department shrank by about 20 percent in 2013.
At a June 2 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.
One alleged motivation was mining.
Guinea has the world's largest reserves of bauxite, for example, and the
mineral is its main source of foreign currency. Guinean officials' insistence on
only reporting confirmed cases was intended to "minimize artificially the
magnitude of the Ebola outbreak to reassure expatriates working in the mining
industry," Formenty, the WHO Ebola expert, wrote in another trip report.
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 criticized WHO for
publishing conflicting figures.
"They were not happy," she
said. In a memo sent to Chan days later, WHO officials noted the Guinean
authorities interpreted the discrepancy between WHO and Guinean figures
"as a threat to their credibility."
Meanwhile, WHO employees wondered
whether headquarters should be doing more. On June 4, 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 June 10, 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."
Declaring an international emergency
is no guarantee of ending an outbreak but it functions as a kind of a global
distress call.
"It's important because it
gives a clear signal that nobody can ignore the epidemic anymore," said
Dr. Joanne Liu, MSF's international president.
In a meeting at WHO headquarters on
July 30, 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. U.S. 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.
 |
A health worker takes the temperature
of U.S. Marines arriving to take part in Operation United Assistance on
October 9, 2014 near Monrovia, Liberia.
John Moore/Getty Images
|
"A doctor who should know
better"
WHO and MSF often work in tandem but
are sometimes at odds over everything from epidemic response to vaccination
drives. The tensions that flared over Ebola highlighted some of the U.N. agency's weaknesses --
including a failure to lead.
WHO did send reinforcements,
including doctors, lab experts and logisticians -- an "unprecedented"
deployment, Chan said in September. Many were praised by fellow responders,
but, in the initial stages at least, there were problems with consistency.
"It's not that we don't have
competent people in Africa," said Oyewale Tomori, a former WHO staffer who
now serves on the agency's Ebola Emergency Committee. "It's that they
never get to a position where they can act."
He said one problem was a tendency
within WHO to reward those who deferred to local authorities.
That's an issue that came up in
Guinea, where the Doctors Without Borders chief there, Poncin, complained that
WHO officials kept contradicting his group's warnings, something he said
pleased a government that "didn't want to frighten investors."
There were personnel issues
elsewhere.
In Liberia, MSF's Lindis Hurum said
she sent a letter complaining about a WHO consultant who was proposing
"completely unrealistic" treatments.
In mid-August, a Senegalese
scientist working for WHO caught Ebola while working in Sierra Leone. At the
time, staff with MSF, WHO and other aid organizations were all staying at the
Luawa Resort Hotel in Kailahun, a safari lodge of bungalows with shared
kitchens and public spaces.
But instead of checking into a
treatment center -- the very clinics where health workers were desperately
trying to persuade people with Ebola to seek help -- he confined himself to his
hotel room, and arranged for his own tests outside the clinic, according to MSF
emergency coordinator Ewald Stals, who was there at the time.
"We were pretty shocked that he
was still at the hotel," Stals said. "You would expect more mature
and responsible behavior from a doctor who should know better."
Stals said two other suspect cases
in the hotel appeared within hours: A cleaning lady and a handyman. Though both
tested negative, Stals said the incidents were enough to spook many of the MSF
staffers; 14 of the 22 deployed there left Kailahun.
"We really struggled to keep
the (Ebola clinic) open," Stals said. "It meant we had to run the
treatment center with eight people instead of 22."
The Ebola-infected WHO scientist,
who later recovered, could not be reached for comment.
The experience soured MSF on sharing
lodgings. Others at the hotel, including the CDC and a mobile lab from Canada,
also left. But WHO refused to vacate the hotel until a phone call between the
two agencies' top leaders resolved the stand-off.
During the call, Chan asked Liu if
MSF could curb its public criticisms of the U.N. agency.
"I said, 'I'm giving you a huge
favor by not bringing up this story," Liu said.
"A sinking ship"
The World Health Organization has
pledged to reform itself, but past experience suggests that's unlikely.
Reform proposals have been kicking
around since the mid-1990s at least. In the wake of the 2009 swine flu
pandemic, a major review suggested, among other things, a $100 million crisis
fund and an emergency health workforce. The ideas came to naught but have been
revived following the Ebola crisis.
"It's very much reshuffling the
deck chairs on a sinking ship," said Kelley Lee, an academic and author of
a book on WHO.
Infectious diseases expert Osterholm
said the global health agency isn't the only one to be blamed and that the
entire world failed to respond quickly enough to stop Ebola from becoming a
humanitarian disaster.
"The global health response
system is broken," he said. The WHO member countries don't seem willing to
overhaul the agency, leaving the world dangerously unprepared to deal with
future health crises.
"What happens if MERS blows up
or there's an Ebola-like event in East Africa?" he asked. "I'm not
sure WHO has a plan for that."
© 2015 The Associated Press. All
Rights Reserved. This material may not be published, broadcast, rewritten, or
redistributed.
