1 June 2015
“The world is ill-prepared to respond to any severe, sustained and threatening public health emergency.”1
How to respond to national crises or emergencies is one of the great challenges facing governments at all levels. The current Ebola crisis is a case in point. The continuing epidemic of the Ebola virus disease (EVD) in West Africa is the most devastating outbreak of Ebola in history. To date there have been more than 24,000 confirmed, suspected and probable cases of the virus, and it has taken more than 10,000 lives.2 Over 800 health care workers have been affected, and nearly 500 have died of Ebola. A formal notification of the Ebola virus outbreak in Guinea was published by the WHO on 23 March 2014 and on 8 August the WHO declared the epidemic to be a "public health emergency of international concern.”3
In the fall of 2014, the outbreak became a humanitarian crisis of such magnitude that UN Secretary General Ban-Ki Moon considered it a danger to political stability in the region.4 World Health Organization (WHO) Director-General Dr. Margaret Chan described it “as the greatest peacetime challenge” to the United Nations and its agencies, noting that states hardest hit by the outbreak may even be pushed to the brink of state failure. On 18 September 2014 the UN Security Council unanimously determined the Ebola outbreak as a “threat to international peace and security” in resolution 2177, the Council’s first to deal with a public health crisis. In the resolution, the UNSC urged UN member states to provide more resources to fight the outbreak.
The goal of the WHO Ebola Response Roadmap of August 2014 was to stop Ebola transmission in affected countries within 6-9 months and to prevent international spread. It aimed at achieving full geographic coverage of Ebola response activities in countries with widespread transmission. Further, it aimed at ensuring emergency response in countries with initial or local cases, and at strengthening preparedness of all countries to detect and respond to an Ebola exposure, particularly in states with land borders with affected countries and those with international transportation hubs.5
Emergency response in affected countries
International organizations, states and aid organizations from all over the world have responded to the crisis with multiple steps. In resolution 2177 the Security Council established the UN Mission for Ebola Emergency Response (UNMEER) as a temporary measure to meet immediate needs related to the fight against Ebola. UNMEER is the first-ever UN emergency health mission. The goal of the mission is set on a 70-70-60 template: it aims to get 70 percent of the cases isolated and treated and 70 percent of the deceased safely buried within 60 days.
The emergency response in countries affected by Ebola aims to contain the disease and end its further transmission. This involves identifying, tracing and caring for people with Ebola; preventing further infection and ensuring safe and dignified burials of the deceased. Its implementation requires trained staff, technical equipment, and funds. States have pledged USD $5.1 billion to the UN, but so far less than half has been provided.
In order to reduce international spread of Ebola, the CDC, WHO, and others have assisted Guinea, Liberia, Sierra Leone and Mali in developing and implementing exit screening. This includes a health questionnaire, measuring body temperature, and assessing patients with a fever. Those who do not pass the screening are not allowed to board international flights.
Dealing with Ebola has also highlighted the vulnerability of neglected health care systems in the countries with widespread transmission. It has been referred to as an “emergency within an emergency” and the WHO has noted high numbers of deaths from other causes such as malaria and other infectious diseases, or zero capacity for safe childbirth in the countries hardest hit by Ebola. The WHO highlights the need to build stronger public health care systems.6
Prevention & preparedness in other countries
As our societies are more interlinked than ever, an infectious disease such as Ebola can have devastating, global effects. Those at risk for exposure to such a disease and those who develop symptoms in other countries must be rapidly and safely identified, isolated and treated. In order to attain this, public health care systems must step up their preparedness to treat persons that are at risk and those who have been infected with the disease.
Those arriving from affected high-risk countries must be screened at airports and other transit points, and they must receive information on further evaluation, monitoring and treatment. In the U.S., the Centers for Disease Control and Prevention inform state and local public health care authorities of persons in need of monitoring and evaluation entering their jurisdictions.7
To prepare U.S. health care providers to respond to Ebola in the U.S., the CDC and the Office of the Assistant Secretary for Preparedness and Response at the U.S. Department of Health and Human Services developed a tiered approach. Acute health care facilities serve as frontline healthcare facilities, Ebola assessment hospitals or as Ebola treatment centres – creating a three-step system to safely and rapidly identify, isolate, evaluate, manage, and transfer (if needed) travellers or patients who have possible or confirmed Ebola. Technical assistance was rapidly provided to hospitals near airports with large numbers of travellers from countries affected with Ebola and near communities with West African travellers and expatriates.
The role of international organizations
Controlling the international spread of infectious diseases is one of the core functions of the WHO. It monitors diseases, alerts the global community when needed, and provides assistance to affected countries. It relies on collaborating centres, disease experts, member states, and donors.
On 9 January 2015, a WHO Special Session of the Executive Board of the on the Ebola Emergency raised the concern that the WHO’s focus on technical support and normative guidance has left a gap in institutional capacity for and appreciation of the importance of operations. In paragraph 5 it states: “that the international community expects WHO to be able to mount a comprehensive and rapid response, whenever and wherever an emergency that impacts public health arises that outstrips national capacity…. Today WHO has the essential institutional experience and country presence needed, but is not designed or capacitated to fulfil this function. To rectify this, WHO must substantially strengthen and modernize its emergency management capacity.”8
A package of five proposals for adapting, modernizing and reforming WHO are presented and “if implemented, these changes could capacitate the Organization to successfully lead in protecting the most vulnerable populations from the devastating public health impacts of emergencies.”9
The WHO Global Alert and Response system is meant to be an integrated approach to epidemics and other public health emergencies based on strong national public health systems and capacity and an effective international system for coordinated response. Its core functions are to support member states in implementing national capacity for epidemic preparedness and response; support national and international training programmes; coordinate and support member states in pandemic and seasonal influenza response; develop standardized approaches for readiness and response to major epidemic-prone diseases (e.g. meningitis, yellow fever, plague) and strengthen biosafety, biosecurity and readiness for outbreaks of dangerous and emerging pathogens outbreaks.10
In times of outbreaks, technical collaboration and response is available through the WHO’s Global Outbreak Alert and Response Network (GOARN), formed of existing institutions and networks pooling together expertise, human and technical resources for rapid response to epidemics. GOARN combats the international spread of epidemics, ensures that technical assistance reaches affected states, and contributes to long-term epidemic preparedness and capacity building.11 An independent study on GOARN published in 2011 found that while the network is essential in enabling WHO to fulfill its alert and response responsibilities, it could be further developed. The institutional status of GOARN remains vague and needs to be clarified. In addition, its strategic capacities should be strengthened and it could improve in learning from past missions.12
The International Health Regulations (IHR), a legally binding agreement adopted by 194 countries - including the WHO’s 193 member states - in 2005, and in force since 2007, aims to prevent, protect against, control and provide a public health response to international spreads of diseases. It’s a framework for managing and coordinating global heath crises and it aims to improve the capacity of all countries to detect, assess, notify and respond to public health threats. For example, the IHR put in place specific procedures for disease surveillance and reporting to the WHO by states, for determining whether a public health emergency is of international concern, and for coordinating international response.
The IHR framework only works if it is implemented by states. State parties were supposed to implement key requirements on surveillance and response by 15 June 2012. But nearly half of all member states of the WHO have received an extension until 2014. Implementation is a challenge in many technical areas, including legislation, points of entry, surveillance and response, laboratory capacity, human resource development and chemical /radionuclear safety.13
Another important task is to trigger and facilitate collaboration on research and development of cures to a particular disease. In relation to the current Ebola outbreak, the WHO has facilitated expert meetings in order to find a cure for Ebola and is discussing different treatment options with affected countries. Ebola vaccines are already being tested on voluntary humans and by the end of the year there may be a vaccine that can already have some impact on containing the outbreak. Experts have also debated using blood transfusions from Ebola survivors or convalescent plasma, the latter is dependent on sufficient technical expertise that may not be available in countries affected by the virus.
Experts are invited to elaborate on the following issues:
How can we prevent, contain or minimize global epidemics?
- What has worked, and not worked, in the response to the Ebola outbreak?
- Are current international mechanisms in place sufficient, and if not, what recommendations should be made to national governments?
- How can the 5 proposals from the WHO’s Special Session of the Executive Board be taken forward?
- Are the International Health Regulations (2005) enough?
- How can the International Health Regulations be better implemented and monitored?
- How can the GOARN be developed?
- The aftermath: What challenges (financial, humanitarian, medical, political) can we expect in West Africa if and when the Ebola epidemic is contained?
- Do large communities on the move, such as refugee populations, irregular migrants and mixed migratory flows, pose a risk during epidemics?
- How do we respond to the fiscal challenges that may erupt during epidemics?
- What lessons have been learned in response to the Ebola crisis that might have application to the prevention of, or response to, other emergencies?
LIST OF PARTICIPANTS
InterAction Council Members
1. H.E. Mr. Olusegun Obasanjo (former President), Nigeria
2. H.E. Mr. Andrés Pastrana (former President), Colombia
3. Dr. Thomas S. Axworthy, Distinguished Senior Fellow, Munk School of Global Affairs, University of Toronto (Canada)
4. Ms. Jess Camburn, Director, Enhancing Learning and Research for Humanitarian Assistance (U.K.)
5. Prof. C.O. Onyebuchi Chukwu, former Minister of Health (Nigeria)
6. Dr. Rainer Engelhardt, Assistant Deputy Minister/Chief Science Officer, Public Health Agency of Canada (Canada)
7. Mr. Nicholas Fogg, former Mayor of Marlborough (U.K.)
8. Dr. Jörg Hoffmann, Consultant in Communicable Disease Control, Public Health Wales (U.K.)
9. Ms. Ruth Hopkins, Senior Lecturer, College of Human and Health Sciences, Swansea University (U.K.)
10. Prof. Iliona Kickbusch, Director of the Global Health Programme, The Graduate Institute of International and Development Studies, Geneva (Germany)
11. Dr. Brian McCloskey, Director of Global Health, Public Health England; UK Strategy Advisor, Office of the UN Special Envoy on Ebola (U.K.)
12. Prof. Colin McInnes, UNESCO Professor of HIV/AIDS and Health Security in Africa and Director of the Centre for Health and International Relations, Aberystwyth University (U.K.)
13. Dr. Joanna Nurse, Medical Adviser and Head of Department, Commonwealth Secretariat (U.K.)
14. Dr. John Wyn Owen, Chair, Health Protection Committee, Wales (U.K.)
15. Dr. Mark Salter, Consultant in Global Health, Public Health England (U.K.)
16. Dr. Quentin Sandifer, Executive Director of Public Health Services and Medical Director, Public Health Wales (U.K.)
17. Dr. Shunmay Yeung, Clinical Senior Lecturer, Global Health Department & Clinical Research Department, London School of Hygiene and Tropical Medicine (Japan)
1 What this – the largest Ebola outbreak in history – tells the world, Deadly pathogens exploit weak health systems http://www.who.int/csr/disease/ebola/ebola-6-months/lessons/en/
2 As of 11 March 2015, WHO Global Alert and Response (GAR) Situation reports Ebola situation report by the WHO http://apps.who.int/ebola/current-situation/ebola-situation-report-11-march-2015 and Ebola: Mapping the outbreak http://www.bbc.com/news/world-africa-28755033
3 WHO, Ebola Response Roadmap, 28 August 2014, http://apps.who.int/iris/bitstream/10665/131596/1/EbolaResponseRoadmap.pdf?ua=1
5 WHO, Ebola response roadmap, August 2014, http://www.who.int/csr/resources/publications/ebola/response-roadmap/en/
6 What this – the largest Ebola outbreak in history – tells the world, Deadly pathogens exploit weak health systems http://www.who.int/csr/disease/ebola/ebola-6-months/lessons/en/
7 Systems for Rapidly Detecting and Treating Persons with Ebola Virus Disease — United States, Weekly, March 6, 2015 / 64(08);222-225 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6408a5.htm?s_cid=mm6408a5_w
12 Independent Evaluation of the Global Outbreak Alert and Response Network, Egbert Sondorp, Christopher Ansell, Robert Hartley Stevens and Emma Denton, April 2011, WHO/HSE/GCR/GOARN/2011.2
13 WHO Department of Global Capacities Alert and Response, Activity Report 2012