How Successful was the UN in Fighting Ebola?
By Maya Garner
In August 2014, the UN declared a public emergency over the outbreak of the Ebola virus in Western Africa. Primarily affecting the three countries of Guinea, Liberia and Sierra Leone, the outbreak became the focus of international attention and the cause of much panic in the western world. Lasting from 2013 until summer 2016 when the outbreaks were declared over, Ebola haemorrhagic fever infected more than 28,000 people and took the lives of more than 11,000, a death toll of nearly 40%. The World Health Organization (WHO) took an official lead in the efforts to combat the outbreak. A resurgence of the virus, which was to become the second largest Ebola outbreak the world had seen, appeared in the Democratic Republic of Congo in 2018 and continues today, making it timely to examine just how effective international efforts and those of the UN have been in fighting Ebola against the virus.
Ebola virus leads to fever, vomiting and diarrhoea, which may result in severe dehydration. Death is often caused by low blood pressure from fluid loss or blood loss from haemorrhage. The virus is transmitted between humans through contact with the body fluids of an infected person, primarily blood, vomit, and faeces. Transmission through contact with infected bodies of the deceased during burial rituals likely accounted for more than two- thirds of Ebola cases in Guinea in 2014. Fruit bats are believed to be the natural reservoir for the Ebola virus with the disease spreading to other animals. Initial cases in humans likely occurred through contact with bats or other animals before being transmitted through human-to-human contact. Where proper medical sanitary conditions and isolation procedures are the norm, widespread outbreaks are unlikely. The international discourse surrounding the West Africa epidemic revealed a large degree of ignorance about the disease, creating an unfounded panic that an Ebola epidemic might occur in the industrialised West. Ebola primarily affected the three West African countries with limited occurrence in Mali and Nigeria, plus a single case reported in Senegal. There were minimal cases in Europe and North America – four in the US and one each in Italy, the UK and Spain.
The World Health Organization (WHO), the UN specialized agency dealing with public health issues ranging from infectious and non-infectious diseases to food security and workplace safety, came in for its share of criticism due to the way it responded to the West Africa Ebola crisis. By the time WHO declared the Ebola crisis a Public Health Emergency of International Concern (PHEIC) in August 2014, there had been more than 1700 cases and nearly 1000 deaths. Internal UN communications revealed that there had been discussions about the political consequences of declaring an emergency, of triggering angry responses from the governments of the countries involved, and of the negative impact on their economies. This left a distinct impression that political considerations outweighed public health priorities and delayed the emergency declaration.
Yet while WHO leadership spoke of lacking knowledge about Ebola at the time, internal documents show that the agency’s Geneva headquarters was aware of the severity of the situation yet chose to consider an emergency declaration only as a “last resort,” lest doing so would intensify political pressure in the affected countries. So, while declaring an emergency had been considered in June, it wasn’t until August that the decision was taken to do so. In the interim, a warning from Doctors Without Borders went unheeded. A former WHO doctor Matthieu Kamwa stated that “people died because things were not done.” Warnings about the severity of the outbreak were there from the moment Ebola first appeared in Guinea the deaths of infection control staff and healthcare personnel, and the spread of the disease to the capital Conakry. WHO spokesperson Gregory Hartl initially downplayed the issue, stating in April that “this outbreak isn’t different from previous outbreaks.” The ensuing delay sparked a debate as to whether WHO should be stripped of its authority to declare public health emergencies as lead agency for global responses.
When WHO finally did declare an international emergency, the U.S. sent 3,000 troops to the most effected areas and pledged to build Ebola clinics along with Britain and France, while China and Cuba pledged to send health workers. In laying out a roadmap for ending the epidemic within six to nine months, WHO failed to create the needed international response to contain the outbreak effectively. In part this can be attributed to the serious reduction in available emergency response funds in recent years. While the WHO effort included healthcare training for staff, it fell short in terms of providing direct care for patients and/or a strategic overview of infection control. It also experienced a shortfall in resources. The agency also experienced problems in deployment of professionals to the right places and positions. Former WHO General Director of Margaret Chan was to state later that “[the epidemic] overwhelmed the capacity of WHO”, that it was “a crisis that cannot be solved by a single agency or single country.” WHO’s response to the outbreak revealed discrepancies between the agency’s operational abilities and the international community’s expectations as to how it should deal with global outbreaks. WHO was criticised for not exercising effective leadership and a series of organizational reforms were proposed.
There are four types of Ebola that can affect humans. The Zaire ebolavirus, the most dangerous strain, is responsible for most of the reported cases. This virus is so named because it first occurred in Zaire, the present Democratic Republic of Congo (DRC). While the West African Ebola outbreak was eventually overcome in 2016, the Democratic Republic of Congo (DRC) currently continues to combat an ongoing outbreak first identified in August 2018. By November 22, 2019, 3,298 cases had been recorded of which less than 30% survived, making it the world’s second largest recorded Ebola outbreak, and the largest of ten recorded over the years in the DRC. By June 2019, the virus had reached Uganda through three infected members of a Congolese family, but was contained. A WHO review in April 2019 and again in June subsequent to the Uganda episode, concluded that the outbreak did not constitute a Public Health Emergency of International Concern. However, in July 2019, WHO did declare the DRC outbreak an international public health emergency. This was reiterated in October, showing yet again WHO’s propensity for delay despite its own projections months previously of increasing cases. Past outbreaks in the DRC had never exceeded 320 cases whereas in February 2019 the numbers had reached 1,000 cases. Despite this, , it was to take WHO an additional five months before declaring an emergency even though the death toll had reached more than 1,000 in May.
The situation in the DRC is particularly worrying given the pernicious military conflict in the affected province of Kivu and surrounding areas, with many attacks targeting healthcare facilities. The Kivu military conflict puts a strain on international response capacity since certain areas are inaccessible to medical personnel and health worker security is in jeopardy. The conflict has caused Oxfam and the International Rescue Committee to suspend their efforts in the country, which has placed an additional burden on WHO.
On the upside, in 2019 WHO pre-approved the Ebola vaccine, paving the way for preventative treatment and infection control within the DRC and outside its borders. However, adequate coordination and infection control are strained by the plight of thousands of internally displaced persons, as well as the risk of transmission of the disease through the many displaced seeking to flee the country. These conditions make ring vaccination programmes difficult to implement, having decimated leadership capacity and with it the ability to coordinate and create effective responses.
Now, the UN has to mediate fighting f an epidemic while seeking to operate in an area of military conflict. Since October 2019, the virus appears to have been confined in isolated zones, but it is still too early to predict the outcome and there is a continued threat of international spread.
WHO showed inadequate leadership during the West African Ebola crisis. It delayed the international emergency declaration and lacked adequate coordination and communication in its operational activities. Now, with the prospect of a new vaccine taking effect, containment of the disease depends on the effectiveness of the ring vaccination programmes. This can only happen through proper on-the-ground coordination and operational efficiency. This is an opportunity and a test allowing the international community to witness and assess not just WHO’s abilities but the sincerity of its reforms.