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First response, revisited

The Ebola outbreak in West Africa has starkly exposed major gaps in plans to tackle emerging infectious diseases. Lessons must be learned.

It is encouraging that the United States last week committed 3,000 military personnel and US$750 million to lend logistical support to civilian efforts to tackle the Ebola outbreak in West Africa. Civilian efforts also received a major, if belated, boost from United Nations intervention, with a Security Council resolution (see page 469).

Six months into the outbreak, this massive deployment of the US military and the combined resources of the UN is a damning indictment of the World Health Organization (WHO), the UN’s health arm charged with tackling outbreaks of potential international concern.

The international community has debated pandemic planning and outbreak response intensely over the past decade, following the SARS (severe acute respiratory syndrome) epidemic and the increased awareness of the threat of avian flu.

“ Strengthening health-care systems everywhere will be the best defence against outbreaks. ”

In 2005, the WHO member states agreed the International Health Regulations (IHR), designed to help the international community to respond better to outbreaks. And last year, the WHO adopted an Emergency Response Framework to guide its own actions.

These frameworks have failed miserably in this outbreak, and the WHO has been slow and, so far, ineffective. There has been some progress in disease surveillance, but the world is little better prepared to quickly stamp out a threatening outbreak than it was a decade ago.

Earlier this month, WHO director-general Margaret Chan told The New York Times: “We are not the first responder … the government has first priority to take care of their people and provide health care. WHO is a technical agency.” Fair enough, but if the WHO is not the first responder to an emergency such as this, then who is? The Ebola outbreak clearly demonstrates that response to such events cannot be left to the non-governmental organizations (NGOs) and governments of some of the poorest countries in the world.

The IHR states that countries must boost their surveillance and outbreak-response capacities, and that individual governments must foot the bill. The aspirations are correct: strengthening health-care systems everywhere will be the best defence against outbreaks of potential international concern. But the reality is that few poor countries have anything that resembles a working outbreak-response system.

Rich countries must make a greater effort to help poor countries to boost their health-care systems to defend against outbreaks, which would also contribute to the UN’s Millennium Development Goals of achieving reductions in child and maternal mortality and other causes of morbidity and mortality. The case is strong for a new global health fund to help build functioning health systems, on the scale of the multibillion-dollar Global Fund to Fight AIDS, Tuberculosis and Malaria.

But building better health-care systems will take time. One immediate step should be to create an international contingency fund. A 2011 independent review of the IHR called for the creation of a pot of at least $100 million that the WHO could immediately tap in the event of a public-health emergency. But that sensible proposal has been taken nowhere by the WHO’s member states. It should be resuscitated, and its size realistically estimated — $100 million is probably on the low side.

Also lacking is the capacity to quickly deploy medical supplies, emergency field hospitals, and people trained in the many aspects of outbreak response — from surveillance, epidemiology and virology to implementing public-health control measures, patient care and biosafety.

Rapid emergency response to outbreaks must inevitably be done on a case-by-case basis, drawing on the resources of individual country donors, the UN and NGOs. Flexible international plans and agreements should be put in place to allow this. A large reserve corps of appropriately trained staff should also be established. Lack of personnel has been the biggest bottleneck in the Ebola response.

In principle, the WHO should be the body best placed to oversee international response to outbreaks. It has a total budget of $4 billion for 2014 and 2015, less than many large Western hospitals, but it also spreads itself too thin by trying to do too much. The organization’s budget for outbreak response is just $110 million a year, and funding for preparedness and surveillance is just $140 million. Moreover, funds have dwindled and the organization has lost vital in-house expertise and talent for responding to outbreaks.

If member states want the WHO to be more active in outbreak response, they must fund it adequately. But the slow and bureaucratic WHO must also demonstrate that it is up to the task, and can spend its money wisely and act fast.

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Nature special: Ebola outbreak in West Africa

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First response, revisited. Nature 513, 459 (2014).

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