22 September 2014
The suffering inflicted by the Ebola outbreak—and the ineffective reactions to it—reveals a massive failure of global health governance.
David P Fidler
Professor David P Fidler
Associate Fellow, Centre on Global Health Security


Moses Tarkulah stands by as colleagues enter a suspected Ebola case ward in Monrovia, Liberia, on 16 September 2014. Photo by Getty Images.
Moses Tarkulah stands by as colleagues enter a suspected Ebola case ward in Monrovia, Liberia, on 16 September 2014. Photo by Getty Images.


States and international organizations are scrambling, from the Security Council to the streets of Monrovia, to triage the damage to social order and human dignity from the outbreak of Ebola in West Africa. It remains to be seen whether scaled-up responses can control the epidemic. But, there awaits another reckoning—the challenge of identifying what went wrong, where mistakes were made, why we ended up in crisis and how to ensure a similar failure does not happen again.

To start, the UN Security Council should establish an independent investigation into the outbreak and the international community’s responses. The Security Council declared the outbreak a threat to international peace and security, and supporting an investigation would underscore this decision’s seriousness. The investigation should probe what happened from the local level to the office of the director-general of the World Health Organization. It should gather information on when and how other actors in global health—countries, regional organizations, NGOs and airlines and other corporations—responded. Conducting forensics on the outbreak is warranted given the finger-pointing already underway, and the investigation cannot be left in the WHO’s hands.

Supported by the African Union, African countries should insist that the WHO’s Executive Board and Health Assembly re-visit recent decisions on budget issues and WHO reform. Press coverage has speculated whether budget cuts to the WHO’s communicable disease surveillance and response capabilities adversely affected its ability to react effectively to the outbreak. As the Ebola crisis demonstrates, decisions about priorities and budgets might have unintended consequences that fall disproportionately on countries and societies least able to manage dangerous disease events.

The Ebola tragedy must also inform the negotiation of the Sustainable Development Goals (SDGs) underway at the UN. The proposed SDG framework finalized in July included lessons from the Ebola outbreak in the objective of strengthening capacity, especially in developing countries, ‘for early warning, risk reduction, and management of national and global health risks’. While reporting and commentary lament the lack of public health capacity in affected West African nations, global health experts have, for years, identified this problem in many countries and regions in the developing world and worried about the lack of any serious strategy to address it. The development of the SDGs within the UN provides an opportune moment to focus high-level political attention on this neglected, festering weakness in global health.

The WHO director-general, Margaret Chan, should instruct the Review Committee established under the International Health Regulations (2005) (IHR) to analyze the functioning of the regulations during the Ebola outbreak, as she did in 2010 in connection with the H1N1 influenza epidemic. Many questions about the use and effectiveness of the IHR have arisen with the Ebola outbreak. They range from the length of time it took the director-general to declare it a public health emergency of international concern to alleged violations of the IHR by governments imposing travel and trade measures that hurt West African nations and impeded efforts to get assistance into these afflicted countries.

The Ebola-specific analysis should revisit the recommendations from the H1N1 epidemic. The committee recommended, for example, that the WHO strengthen its capacity for sustained responses to public health emergencies of international concern—which raises questions about WHO budget cuts in this area. The committee also proposed establishing a contingency fund to support ‘surge capacity’ for responding to international public health emergencies—a recommendation not taken up seriously anywhere in global health governance, but one that, if it had been followed, might have helped the response to the Ebola outbreak.

Such suggestions are tough medicine, but what has happened in West Africa needs more than military-dependent expeditionary campaigns and humanitarian triage in already desperate conditions.

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