This article is from the source 'nytimes' and was first published or seen on . It last changed over 40 days ago and won't be checked again for changes.
You can find the current article at its original source at http://www.nytimes.com/2014/09/04/world/africa/cuts-at-who-hurt-response-to-ebola-crisis.html
The article has changed 5 times. There is an RSS feed of changes available.
| Version 1 | Version 2 |
|---|---|
| Cuts at W.H.O. Hurt Response to Ebola Crisis | Cuts at W.H.O. Hurt Response to Ebola Crisis |
| (about 1 hour later) | |
| With treatment centers overflowing, and alarmingly little being done to stop Ebola from sweeping through West African villages and towns, Dr. Joanne Liu, the president of Doctors Without Borders, knew that the epidemic had spun out of control. | With treatment centers overflowing, and alarmingly little being done to stop Ebola from sweeping through West African villages and towns, Dr. Joanne Liu, the president of Doctors Without Borders, knew that the epidemic had spun out of control. |
| The only person she could think of with the authority to intensify the global effort was Dr. Margaret Chan, the director general of the World Health Organization, which has a long history of fighting outbreaks. If the W.H.O., the main United Nations health agency, could not quickly muster an army of experts and health workers to combat an outbreak overtaking some of the world’s poorest countries, then what entity in the world would do it? | The only person she could think of with the authority to intensify the global effort was Dr. Margaret Chan, the director general of the World Health Organization, which has a long history of fighting outbreaks. If the W.H.O., the main United Nations health agency, could not quickly muster an army of experts and health workers to combat an outbreak overtaking some of the world’s poorest countries, then what entity in the world would do it? |
| “I wish I could do that,” Dr. Chan said when the two met at the W.H.O.'s headquarters in Geneva this summer, months after the outbreak burgeoned in a Guinean rain forest and spilled into packed capital cities. The W.H.O. simply did not have the staffing or ability to flood the Ebola zone with help, said Dr. Chan, who recounted the conversation. It was a fantasy, she argued, to think of the W.H.O. as a first responder ready to lead the fight against deadly outbreaks around the world. | |
| The Ebola epidemic has exposed gaping holes in the ability to tackle outbreaks in an increasingly interconnected world, where diseases can quickly spread from remote villages to cities housing millions of people. | The Ebola epidemic has exposed gaping holes in the ability to tackle outbreaks in an increasingly interconnected world, where diseases can quickly spread from remote villages to cities housing millions of people. |
| The W.H.O., the United Nations agency assigned in its constitution to direct international health efforts, tackle epidemics and help in emergencies, has been badly weakened by budget cuts in recent years, hobbling its ability to respond in parts of the world that need it most. Its outbreak and emergency response units have been slashed, veterans who led previous fights against Ebola and other diseases have left, and scores of positions have been eliminated — precisely the kind of people and efforts that might have helped blunt the outbreak in West Africa before it ballooned into the worst Ebola epidemic ever recorded. | |
| Unlike the SARS crisis of 2003, which struck countries in Asia and elsewhere that had strong governments and ample money to spring to action, the Ebola outbreak has waylaid nations that often lack basic health care, much less the ability to mount big campaigns to stamp out epidemics. | Unlike the SARS crisis of 2003, which struck countries in Asia and elsewhere that had strong governments and ample money to spring to action, the Ebola outbreak has waylaid nations that often lack basic health care, much less the ability to mount big campaigns to stamp out epidemics. |
| The disease spread for months before being detected because much of the work of spotting outbreaks was left to desperately poor countries ill prepared for the task. Once the W.H.O. learned of the outbreak, its efforts to help track and contain it were poorly led and limited, according to some doctors who participated, contributing to a sense that the problem was not as bad as it actually was. Then, as the extent of the epidemic became obvious, critics say the agency was slow to declare its severity and come up with plans, and has still not marshaled the people and supplies needed to help defeat the disease and treat its victims. | The disease spread for months before being detected because much of the work of spotting outbreaks was left to desperately poor countries ill prepared for the task. Once the W.H.O. learned of the outbreak, its efforts to help track and contain it were poorly led and limited, according to some doctors who participated, contributing to a sense that the problem was not as bad as it actually was. Then, as the extent of the epidemic became obvious, critics say the agency was slow to declare its severity and come up with plans, and has still not marshaled the people and supplies needed to help defeat the disease and treat its victims. |
| “There’s no doubt we’ve not been as quick and as powerful as we might have been,” said Dr. Marie-Paule Kieny, a W.H.O. assistant director general. | “There’s no doubt we’ve not been as quick and as powerful as we might have been,” said Dr. Marie-Paule Kieny, a W.H.O. assistant director general. |
| Another W.H.O. leader agreed. “Of course in retrospect I really wish that we had jumped much higher much earlier,” said Dr. Keiji Fukuda, the assistant director general in charge of outbreak response. “Of course I wish we’d poured in more and more earlier.” But, he added, “if this outbreak had been a typical outbreak, nobody would be saying we did too little, too late.” | Another W.H.O. leader agreed. “Of course in retrospect I really wish that we had jumped much higher much earlier,” said Dr. Keiji Fukuda, the assistant director general in charge of outbreak response. “Of course I wish we’d poured in more and more earlier.” But, he added, “if this outbreak had been a typical outbreak, nobody would be saying we did too little, too late.” |
| The outbreak began close to the borders of three neighboring countries — Guinea, Sierra Leone and Liberia — and spread surprisingly fast. Since then, the W.H.O. has engaged more than 400 people to work on the outbreak, including employees of other agencies in its network, and in August the agency declared the epidemic an international emergency, hoping to stop it from crossing more borders. Dr. Chan has met with presidents in the region, and last week the W.H.O. announced what it called a road map for a “massively scaled” international response. | The outbreak began close to the borders of three neighboring countries — Guinea, Sierra Leone and Liberia — and spread surprisingly fast. Since then, the W.H.O. has engaged more than 400 people to work on the outbreak, including employees of other agencies in its network, and in August the agency declared the epidemic an international emergency, hoping to stop it from crossing more borders. Dr. Chan has met with presidents in the region, and last week the W.H.O. announced what it called a road map for a “massively scaled” international response. |
| The current outbreak has killed more than 1,900 people and spread to the point that the W.H.O. warns that more than 20,000 people could become infected. Sick people are dying on the street. Some feel the entire model the world uses to fight outbreaks needs to be rethought, so that an agency like the W.H.O. has the structure and mandate to take command. | The current outbreak has killed more than 1,900 people and spread to the point that the W.H.O. warns that more than 20,000 people could become infected. Sick people are dying on the street. Some feel the entire model the world uses to fight outbreaks needs to be rethought, so that an agency like the W.H.O. has the structure and mandate to take command. |
| But Dr. Chan said that governments have the primary responsibility “to take care of their people,” calling the W.H.O. a technical agency that provides advice and support. Still, she noted that her organization, like many governments and agencies, was not prepared. | But Dr. Chan said that governments have the primary responsibility “to take care of their people,” calling the W.H.O. a technical agency that provides advice and support. Still, she noted that her organization, like many governments and agencies, was not prepared. |
| “Hindsight is always better,” Dr. Chan said. “All the agencies I talked to — including the governments — all of us underestimated this unprecedented, unusual outbreak.” | “Hindsight is always better,” Dr. Chan said. “All the agencies I talked to — including the governments — all of us underestimated this unprecedented, unusual outbreak.” |
| A Shift in Emphasis | A Shift in Emphasis |
| The W.H.O., founded in 1948, is responsible for taking on a wide range of global health issues, from obesity to primary health care. But since the world’s health needs far outstrip the financial contributions of the W.H.O.'s 194 member nations, those priorities compete. | |
| The threat of emergent infectious diseases jumped high onto that list 20 years ago, when an outbreak of plague in India created a panic, sending about 200,000 people fleeing. The next year in Zaire, now the Democratic Republic of Congo, Ebola killed about 245 people. With fears of cross-border infections high, a new urgency arose: improving the world’s ability to stop outbreaks. | The threat of emergent infectious diseases jumped high onto that list 20 years ago, when an outbreak of plague in India created a panic, sending about 200,000 people fleeing. The next year in Zaire, now the Democratic Republic of Congo, Ebola killed about 245 people. With fears of cross-border infections high, a new urgency arose: improving the world’s ability to stop outbreaks. |
| The W.H.O. took the lead, at the request of its member nations. A crew of passionate outbreak veterans assembled a unique department, using an early form of electronic crowdsourcing to detect outbreaks and dispatching experts to the field. Three years after the effort solidified, the W.H.O. played a big role in responding to a cluster of deadly pneumonia cases in Asia. The new virus became known as SARS, and it was contained within the year, with most cases occurring in China. | The W.H.O. took the lead, at the request of its member nations. A crew of passionate outbreak veterans assembled a unique department, using an early form of electronic crowdsourcing to detect outbreaks and dispatching experts to the field. Three years after the effort solidified, the W.H.O. played a big role in responding to a cluster of deadly pneumonia cases in Asia. The new virus became known as SARS, and it was contained within the year, with most cases occurring in China. |
| To aid the fight, wealthy individuals offered the W.H.O. “literally hundreds of millions because their businesses were affected,” said Dr. Jim Yong Kim, president of the World Bank and a former director at the W.H.O. “But as SARS burned out, those guys disappeared, and we forgot very quickly.” | To aid the fight, wealthy individuals offered the W.H.O. “literally hundreds of millions because their businesses were affected,” said Dr. Jim Yong Kim, president of the World Bank and a former director at the W.H.O. “But as SARS burned out, those guys disappeared, and we forgot very quickly.” |
| Soon, the global financial crisis struck. The W.H.O. had to cut nearly $1 billion from its proposed two-year budget, which today stands at $3.98 billion. (By contrast, the budget of the Centers for Disease Control and Prevention for 2013 alone was about $6 billion.) The cuts forced difficult choices. More emphasis was placed on efforts like fighting chronic global ailments, including heart disease and diabetes. The whims of donors also greatly influenced the W.H.O.'s agenda, with gifts, often to advance individual causes, far surpassing dues from member nations, which account for only 20 percent of its budget. | |
| At the agency’s Geneva headquarters, outbreak and emergency response, which was never especially well funded, suffered particularly deep losses, leaving offices that look, one consultant said, like a ghost town. The W.H.O.'s epidemic and pandemic response department — including a network of anthropologists to help overcome cultural differences during outbreaks — was dissolved, its duties split among other departments. Some of the main outbreak pioneers moved on. | |
| “That shaping of the budget did affect the area of responding to big outbreaks and pandemics,” said Dr. Fukuda, who estimated that he now had 35 percent fewer employees than during the 2009 H1N1 flu pandemic — more than double the cuts for the organization as a whole. | “That shaping of the budget did affect the area of responding to big outbreaks and pandemics,” said Dr. Fukuda, who estimated that he now had 35 percent fewer employees than during the 2009 H1N1 flu pandemic — more than double the cuts for the organization as a whole. |
| “You have to wonder are we making the right strategic choices?” he said. “Are we ready for what’s coming down the pike?” | “You have to wonder are we making the right strategic choices?” he said. “Are we ready for what’s coming down the pike?” |
| The entire W.H.O. unit devoted to the science of pandemic and epidemic diseases — responsible for more than a dozen killers, including flu, cholera, yellow fever and bubonic plague — has only 52 regular employees, including secretaries, according to its director, Dr. Sylvie Briand, who said that could be increased during outbreaks. Before the Ebola epidemic, her department had just one technical expert on Ebola and other hemorrhagic diseases. | The entire W.H.O. unit devoted to the science of pandemic and epidemic diseases — responsible for more than a dozen killers, including flu, cholera, yellow fever and bubonic plague — has only 52 regular employees, including secretaries, according to its director, Dr. Sylvie Briand, who said that could be increased during outbreaks. Before the Ebola epidemic, her department had just one technical expert on Ebola and other hemorrhagic diseases. |
| Across Africa, the ranks of the agency’s regional emergency outbreak experts, veterans in fighting Ebola, were cut from more than a dozen to three. “How can you immediately respond to an outbreak?” said Dr. Francis C. Kasolo, a W.H.O. director. “It did affect us.” | Across Africa, the ranks of the agency’s regional emergency outbreak experts, veterans in fighting Ebola, were cut from more than a dozen to three. “How can you immediately respond to an outbreak?” said Dr. Francis C. Kasolo, a W.H.O. director. “It did affect us.” |
| And a separate section of the W.H.O. responsible for emergency response was whittled “to the bone” during the budget cuts — to 34 staff members from about 94 — according to Dr. Bruce Aylward, its assistant director general. | And a separate section of the W.H.O. responsible for emergency response was whittled “to the bone” during the budget cuts — to 34 staff members from about 94 — according to Dr. Bruce Aylward, its assistant director general. |
| “You can’t make a cut that big, that deep, and it’s not going to have an effect on your operational capacity,” he said. | “You can’t make a cut that big, that deep, and it’s not going to have an effect on your operational capacity,” he said. |
| His group, charged with responding to wars, disasters and resurgent polio, was asked in August to assist with Ebola, too. “At no time that I can think of in the recent past have we been dealing with such a scale of human misery over such a broad geography due to such a range of hazards,” he said, including enormous population displacements in Syria, Iraq, the Central African Republic and South Sudan. But, officials warn, multiple, overlapping challenges may well be a feature of the future. | His group, charged with responding to wars, disasters and resurgent polio, was asked in August to assist with Ebola, too. “At no time that I can think of in the recent past have we been dealing with such a scale of human misery over such a broad geography due to such a range of hazards,” he said, including enormous population displacements in Syria, Iraq, the Central African Republic and South Sudan. But, officials warn, multiple, overlapping challenges may well be a feature of the future. |
| The W.H.O. hoped to balance its budget cuts by strengthening the ability of countries to respond to public health threats on their own. It put out new regulations for nations to follow to help contain outbreaks. But by 2012, the deadline it set, only 20 percent of nations had enacted them all. In Africa, fewer than a third of countries had programs to detect and stop infectious diseases at their borders. The W.H.O.'s strategy was often more theory than reality. | |
| “There never were the resources to put those things in place in many parts of the world,” said Dr. Scott F. Dowell, a specialist formerly with the C.D.C. | “There never were the resources to put those things in place in many parts of the world,” said Dr. Scott F. Dowell, a specialist formerly with the C.D.C. |
| A Disease Finds Its Opening | A Disease Finds Its Opening |
| The Ebola virus took full advantage of these poorly prepared nations and the holes at the W.H.O. | The Ebola virus took full advantage of these poorly prepared nations and the holes at the W.H.O. |
| Given the weakness in surveillance, the outbreak was not identified until March, in Guinea, roughly three months after a villager was believed to have contracted the virus from an animal, possibly a fruit bat. The delay allowed dozens of cases to spread through villages and even to Conakry, a capital of more than one and a half million people. Right away, Doctors Without Borders declared the outbreak unprecedented in its reach, the only group to do so. | Given the weakness in surveillance, the outbreak was not identified until March, in Guinea, roughly three months after a villager was believed to have contracted the virus from an animal, possibly a fruit bat. The delay allowed dozens of cases to spread through villages and even to Conakry, a capital of more than one and a half million people. Right away, Doctors Without Borders declared the outbreak unprecedented in its reach, the only group to do so. |
| Hastening the spread, hospitals lacked basic infection-control essentials like running water, protective gowns and gloves. Many doctors and nurses caught the virus from their patients, passed it to others, and died. The vulnerability and collapse of medical facilities revealed how far there is to go in achieving the W.H.O.'s top priority — ensuring basic global health care. | |
| “This kind of outbreak would not have developed in an area with stronger health systems,” Dr. Fukuda said. | “This kind of outbreak would not have developed in an area with stronger health systems,” Dr. Fukuda said. |
| In the crucial weeks after the discovery, daily meetings brought together national authorities and foreign responders at the W.H.O. office in Conakry. But an absence of strong leadership and professionalism was notable from the beginning, participants said. | In the crucial weeks after the discovery, daily meetings brought together national authorities and foreign responders at the W.H.O. office in Conakry. But an absence of strong leadership and professionalism was notable from the beginning, participants said. |
| “It’s purely improvisation,” said Marc Poncin, the emergency coordinator for Doctors Without Borders in Conakry. “There is no one to take responsibility, absolutely no one, since the beginning of the crisis.” | “It’s purely improvisation,” said Marc Poncin, the emergency coordinator for Doctors Without Borders in Conakry. “There is no one to take responsibility, absolutely no one, since the beginning of the crisis.” |
| Stopping previous Ebola outbreaks had required meticulous tracking: monitoring people who had close contact with infected individuals and isolating them if they developed symptoms. Previously, “if we missed a case,” said Dr. Simon Mardel, a British emergency doctor deployed by the W.H.O. to help with the effort, “it was like a failure.” | Stopping previous Ebola outbreaks had required meticulous tracking: monitoring people who had close contact with infected individuals and isolating them if they developed symptoms. Previously, “if we missed a case,” said Dr. Simon Mardel, a British emergency doctor deployed by the W.H.O. to help with the effort, “it was like a failure.” |
| This time, the number of contacts being followed was disastrously low from the beginning, only 8 percent in the epicenter of Guéckédou, Guinea, in early April, according to another doctor sent by the W.H.O. That meant the disease was silently spreading. Dr. Mardel said he thought the more experienced W.H.O. leaders who had left the agency “would have been very vocal, and they would have sought to put it right quickly, as a matter of urgency.” A single person who traveled and became sick could touch off a conflagration. | This time, the number of contacts being followed was disastrously low from the beginning, only 8 percent in the epicenter of Guéckédou, Guinea, in early April, according to another doctor sent by the W.H.O. That meant the disease was silently spreading. Dr. Mardel said he thought the more experienced W.H.O. leaders who had left the agency “would have been very vocal, and they would have sought to put it right quickly, as a matter of urgency.” A single person who traveled and became sick could touch off a conflagration. |
| It was not that responders were not trying. Victims’ contacts were spread across a wide area, hours away on bad roads. The payment of local workers had somehow been overlooked, so they stopped doing vital, risky jobs. Essential protective equipment was not delivered to many who needed it. Bottles of bleach were given out without buckets. The W.H.O. lacked relationships with some longstanding organizations with large networks of health workers in the region. | It was not that responders were not trying. Victims’ contacts were spread across a wide area, hours away on bad roads. The payment of local workers had somehow been overlooked, so they stopped doing vital, risky jobs. Essential protective equipment was not delivered to many who needed it. Bottles of bleach were given out without buckets. The W.H.O. lacked relationships with some longstanding organizations with large networks of health workers in the region. |
| Traditions that contributed to Ebola’s spread, including funerals where mourners came into contact with corpses, were not fully recognized or confronted, said Dr. Pierre Rollin, an outbreak specialist at the Centers for Disease Control and Prevention who worked within the W.H.O. umbrella. | Traditions that contributed to Ebola’s spread, including funerals where mourners came into contact with corpses, were not fully recognized or confronted, said Dr. Pierre Rollin, an outbreak specialist at the Centers for Disease Control and Prevention who worked within the W.H.O. umbrella. |
| Some villagers blocked roads with tree trunks and drove Ebola workers away with stones, accusing them of bringing in the disease. Adding to the tension, only bare-bones clinical care was provided to try to treat patients, reducing the chances of yielding survivors who could act as ambassadors for the cause. Some doctors deployed by the W.H.O. said it should have given them more tools to care for patients. | Some villagers blocked roads with tree trunks and drove Ebola workers away with stones, accusing them of bringing in the disease. Adding to the tension, only bare-bones clinical care was provided to try to treat patients, reducing the chances of yielding survivors who could act as ambassadors for the cause. Some doctors deployed by the W.H.O. said it should have given them more tools to care for patients. |
| Institutional and personal tensions flared. “Everyone’s working at a fevered pace,” Dr. Dowell said. “There’s confusion and chaos. It argues for a system that’s organized as much as possible ahead of time so people know their roles.” | Institutional and personal tensions flared. “Everyone’s working at a fevered pace,” Dr. Dowell said. “There’s confusion and chaos. It argues for a system that’s organized as much as possible ahead of time so people know their roles.” |
| One consultant thought it strange that the W.H.O. would not send Twitter messages with links to the C.D.C.'s Ebola prevention information, part of a policy not to promote material from other agencies. Various offices within the W.H.O.'s balkanized hierarchy also jockeyed for position. | |
| The difficulties in tracking cases and gaining access to villages led many to think the outbreak was burning out. “I came home sort of thinking, with a little luck, that’s wrapped up,” said Dr. Daniel Bausch, an Ebola outbreak veteran from Tulane University, who returned in May from a W.H.O. mission in Guinea. | The difficulties in tracking cases and gaining access to villages led many to think the outbreak was burning out. “I came home sort of thinking, with a little luck, that’s wrapped up,” said Dr. Daniel Bausch, an Ebola outbreak veteran from Tulane University, who returned in May from a W.H.O. mission in Guinea. |
| The outbreak was not gone, just hidden. An herbalist in Sierra Leone contracted the virus treating Guinean patients. More than a dozen mourners at her funeral fell ill and seeded Sierra Leone. Some of them traveled back to Guinea and rekindled the outbreak there. After a lull of several weeks, cases re-emerged in Liberia, too, and reached the capital, Monrovia. | The outbreak was not gone, just hidden. An herbalist in Sierra Leone contracted the virus treating Guinean patients. More than a dozen mourners at her funeral fell ill and seeded Sierra Leone. Some of them traveled back to Guinea and rekindled the outbreak there. After a lull of several weeks, cases re-emerged in Liberia, too, and reached the capital, Monrovia. |
| Dr. Bausch flew to Sierra Leone in July. “I was like, ‘where is everybody?’ ” referring to the shortage of health workers fighting the disease. “We all recognized we were really understaffed. We needed more people in the field.” | |
| In some treatment centers, two or three doctors, wearing stifling gowns and masks in the heat, were caring for up to 90 patients. With the only W.H.O. logistician in the country working elsewhere, Dr. Bausch did not have anyone to accompany him and manage supplies of protective equipment, he said. | In some treatment centers, two or three doctors, wearing stifling gowns and masks in the heat, were caring for up to 90 patients. With the only W.H.O. logistician in the country working elsewhere, Dr. Bausch did not have anyone to accompany him and manage supplies of protective equipment, he said. |
| Dr. Bausch worked in Kenema, Sierra Leone, where he had helped set up a research program for another hemorrhagic fever, Lassa, which was common in the region. He knew some of the nearly two dozen health workers there who died after Ebola hit. | Dr. Bausch worked in Kenema, Sierra Leone, where he had helped set up a research program for another hemorrhagic fever, Lassa, which was common in the region. He knew some of the nearly two dozen health workers there who died after Ebola hit. |
| “It would be a logical question to ask, since Lassa was there, why was it so hard to switch gears” to Ebola?, Dr. Bausch said. But research institutes provided money for science, he said, not for disease surveillance and treatment. Those tasks had been left to the government of Sierra Leone, “one of the poorest countries on earth,” he said. “I always felt bad about this.” | “It would be a logical question to ask, since Lassa was there, why was it so hard to switch gears” to Ebola?, Dr. Bausch said. But research institutes provided money for science, he said, not for disease surveillance and treatment. Those tasks had been left to the government of Sierra Leone, “one of the poorest countries on earth,” he said. “I always felt bad about this.” |
| In late July in Liberia, two Americans working at a missionary hospital fell sick and were soon evacuated home. A Liberian-American brought the virus by plane to Nigeria, Africa’s most populous nation. Suddenly, the world seemed to understand the threat. | In late July in Liberia, two Americans working at a missionary hospital fell sick and were soon evacuated home. A Liberian-American brought the virus by plane to Nigeria, Africa’s most populous nation. Suddenly, the world seemed to understand the threat. |
| The question now, experts wonder, is whether the leaner, retooled W.H.O. — heavy on technical know-how, light on logistical muscle — can surge in a way that will help lead the world in bringing one of the most challenging health crises in recent history to a close. W.H.O.'s road map calls for $490 million from donors, and thousands of foreign and local health workers to contain the outbreak. Yet few foreign medical teams have answered the call so far. | |
| “It is incumbent on the international community to really respond now,” said Dr. Kasolo, a W.H.O. director in Africa. “Otherwise history will judge us badly.” | “It is incumbent on the international community to really respond now,” said Dr. Kasolo, a W.H.O. director in Africa. “Otherwise history will judge us badly.” |