As the battle to snuff out the Ebola epidemic in West Africa continues, amid hopeful signs of ebbing, fears of an even more deadly and widespread infectious disease’s emerging in the future are motivating efforts to reform global health institutions that faltered in the current outbreak.
On Sunday, the W.H.O.’s executive board — representatives of 34 member states elected to help guide the agency — unanimously endorsed a resolution aimed at overhauling its capacity to head off and respond to outbreaks and other health emergencies.
“Did it have to happen this way?” a representative from Sierra Leone asked, reading the country’s statement to participants at the meeting in Geneva and referring to the large death toll from Ebola, which many viewed as avoidable with better preparedness. “There needs to be a system in place to react in a more effective and timely way.”
Critical provisions of the resolution adopted Sunday include the creation of a global cadre of emergency public health workers, the establishment of a fund that could be tapped quickly, and stepped-up support for the development of vaccines, diagnostics and treatments for emerging infectious diseases. These steps were all recommended but not put in place after a review of the response to the 2009 influenza pandemic.
The board also asked the organization’s director general to ensure that the W.H.O.’s in-country staff members were selected for their expertise. Some critics have said the early response to Ebola was hobbled in part because some W.H.O. workers lacked important qualifications or had been chosen largely for political reasons.
“Too many times the technical is overruled by the political in W.H.O.,” Dr. Thomas R. Frieden, director of the Centers for Disease Control and Prevention and a member of the W.H.O.’s executive board, said at Sunday’s meeting. “We have to reverse that.”
In interviews over the past week, Dr. Frieden and other global health experts said there was widespread agreement on the need to change the agency, which is governed by its 194 member states. “If we don’t do it now, it’s hard to imagine it ever happening,” Dr. Frieden said.
Resolutions like the one adopted on Sunday are rare.
“What you see here is the potential for some of the most wide-ranging and sweeping reforms in any area of W.H.O. that we’ve seen almost since the organization was established,” said Dr. Bruce Aylward, an assistant director general at the organization who now leads the Ebola response at its headquarters in Geneva. Dr. Aylward spoke at a news conference after the resolution’s adoption.
As Ebola surged out of control last summer, leaders of the organization, the United Nations’ specialized agency for health, initially countered critics by arguing that it was primarily meant to provide technical advice and not services.
“We are not the first responder,” Dr. Margaret Chan, the director-general, said in an interview in September. The W.H.O.’s outbreak response departments had been pared back significantly in recent years because of a sharp drop in the organization’s overall budget and a sense that other priorities were more pressing.
In recent weeks, however, Dr. Chan has shifted her stance, describing the W.H.O. as the only agency with the international mandate to manage the health aspects of major crises.
“Disease outbreak response is, in fact, in our Constitution,” she said in a telephone interview.
Dr. Chan’s call for international support to improve the W.H.O.’s ability to respond came as some global health experts had begun to discuss establishing new bodies that could function within areas of the W.H.O.’s core mission, effectively sidelining it.
The aid group Doctors Without Borders has been a particularly strong critic of the W.H.O., as well as other international actors. “It has become alarmingly evident that there is no functioning global response mechanism to a potential pandemic in countries with fragile health systems,” Jerome Oberreit, the group’s international secretary general, said at the meeting. “The first lesson we must retain is that thousands have died because of international negligence.”
Dr. Chan has been passionate about defending the roles that she believes her agency is expected to fill. She reportedly wiped away tears after hearing that some member states supported an alternative to the W.H.O. at a meeting last year, according to an official who was present. (Dr. Chan said she was a frequent crier when asked about the incident.)
In contrast, on Sunday, member nations unequivocally endorsed a central role for the organization in global emergency preparedness and response. Their resolution directs the W.H.O.’s leaders to strengthen operational capabilities, accelerate changes in staffing policy, and adopt modern technologies like web portals for coordination.
It also called for improvements in sharing information during outbreaks. In one notable case, staff members working for the W.H.O. in Guinea learned of several suspected Ebola cases across the border in Sierra Leone in March, but the W.H.O.’s representative in Sierra Leone later said he had never been informed about two of them. Illnesses multiplied for two months before Sierra Leone’s outbreak was detected, confirmed and declared.
Even with the recommended changes, some W.H.O. officials said they had hoped the executive board would go further in some areas, including calling for a command-and-control-type leadership structure prevalent in the United States and other countries for simplifying emergency management. The group’s leadership and crisis response expertise are spread out across departments and regions. The officials also hoped for a clearer statement of the need for dedicated systems and resources to run emergency operations.
“You can’t just flick a switch and your day-to-day systems operate as emergency systems,” Dr. Aylward said in a telephone interview.
The W.H.O.’s leaders will also be left to develop the more stringent ways to evaluate a country’s outbreak preparedness that they have called for to adhere to international regulations. Countries currently assess their own preparedness.
And while the resolution gives the W.H.O.’s leadership a mandate to push through change, and requires the agency to end the current outbreak, it stops short of promising funding to expand programs, in essence challenging the agency to prove itself first.
Sunday’s only firm commitment for the reforms and other steps to fight the current Ebola outbreak and prepare for future ones came from Britain, whose representative committed an initial $10 million to a new W.H.O. contingency fund for emergencies. Participants in the meeting said money needed to be available more quickly in the event of an outbreak. The current system involves fund-raising while an outbreak is underway.
One solution being developed by the World Bank is the creation of a funding group for pandemics, which might include private insurance markets and other contingency funds that would pay out if certain conditions were met, like the declaration of an international emergency or a high number of deaths.
“Finance can be a strong driver of preparedness,” Joachim von Amsberg, a vice president at the World Bank, said last week in an interview about the proposal. For example, countries might be offered reduced premiums in exchange for taking certain preparedness steps, and an assured market for vaccines could help encourage manufacturers to develop new products.
There are concerns, however, that any new financing body could draw money away from the W.H.O.
“It will become yet another rival organization,” said Lawrence O. Gostin, a professor of global health at Georgetown University, who speculated that the funding group might become a separate agency akin to GAVI, the Vaccine Alliance, and to the Global Fund to Fight AIDS, Tuberculosis and Malaria, which he said had proved more attractive to donors than the W.H.O. in the past.
The process of getting to Sunday’s resolution showed how complicated changing a large, multilateral organization can be. A technical group composed of representatives from dozens of member states, led by the United States and South Africa, worked through the night on Friday debating everything from minute wording to broad concepts of humanitarian intervention. Further measures will need to be passed by the group’s decision-making body, the World Health Assembly, in May.
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