The World Bank, headed for the first time by a doctor, wants to create a cadre of outbreak specialists who could be sent anywhere to end deadly epidemics.
A similar idea, floated by a World Health Organization panel three years ago in the wake of the swine flu pandemic, didn’t get enough support. The WHO says the idea might not be practical and countries should ideally have the capacity to respond themselves.
The Ebola outbreak, which has so far sickened more than 20,000 people in eight countries, shows major weaknesses in global health security. The 2003 SARS outbreak and the 2009 swine flu pandemic were reminders, too, yet the measures necessary to stop Ebola from mushrooming into a three-continent scourge weren’t in place. World Bank President Jim Yong Kim is determined to ensure lessons are learned this time.
“What the Ebola epidemic has taught every single one of us is that we were not prepared for an outbreak of this size,” Kim, a Harvard University-trained physician and anthropologist, told reporters in Liberia on Dec. 2. “I for one, as president of the World Bank Group, will continue to remind all of the leaders that this flaw that was exposed must be taken care of and must be taken care of as quickly as possible.”
The virus has killed at least 7,842 people, mostly in Sierra Leone, Liberia and Guinea, according to the WHO. If it continues to spread further in Africa, it could cost as much as $32.6 billion by the end of 2015, the Washington-based World Bank estimated in October.
Kim, who previously headed the WHO’s HIV/AIDS department, has voiced his opinions on Ebola more than a dozen times in op-eds, speeches, statements, media briefings and in webcasts detailing the World Bank’s response and what needs to be done. He’s also been critical of the initial global response, describing it as “late, inadequate and slow.”
“Our president is responding to a crisis that he sees first and foremost as a major impediment to the twin objectives of the bank, which are to eliminate extreme poverty and to share prosperity,” said Tim Evans, the World Bank’s senior director of health, nutrition and population. “The fact that he’s had experience with pandemics before and global health perhaps increases his legitimacy as an advocate to bring this epidemic to an end as soon as possible.”
The World Bank’s observations on the current epidemic and its proposals for global health security will be discussed at a meeting of the WHO’s 34-member executive board at its Geneva headquarters on Jan. 26. The WHO secretariat will review the response by WHO, the United Nations system as a whole and other international partners, according to a provisional agenda.
The WHO has come under fire for grasping the magnitude of the Ebola threat too late, which raised questions about its ability to respond to important disease outbreaks. Director- General Margaret Chan said in October that her organization’s initial response may not have matched the scale and complexity of the outbreak.
After declaring Ebola “a public health emergency of international concern” on Aug. 8, the WHO produced a plan for a scaled-up response to the Ebola outbreak and has worked with scientists from around the world to develop vaccines and therapies, including potential cures, in clinical trials.
Still, one of the casualties of the current outbreak may be the WHO itself, said Adam Kamradt-Scott, a senior lecturer at the University of Sydney’s Center for International Security Studies, who is calling for support for the embattled UN agency.
“There is a genuine risk that governments will use the Ebola outbreak as a basis for further undermining the WHO’s authority, which would simply be disastrous,” Kamradt-Scott said.
The health agency had been subjected to “extensive budget cuts” as part of a reform process, he said. “While this doesn’t entirely explain why the organization was slow to respond to the outbreak, it has certainly had an impact on the WHO’s operational response. Rather than erode the organization’s capacity further, Ebola should be a wakeup call that we can’t have global health security without appropriate investment.”
A letter co-authored by Kamradt-Scott backing WHO and endorsed by almost 100 public health workers, academics and researchers in international relations is slated for publication in the Lancet medical journal on Jan. 10, he said.
“In terms of how we tackle diseases and pandemics and problems in our world, I do think we have to have a serious look at the World Health Organization,” British Prime Minister David Cameron told parliament in London on Nov. 26.
The WHO may have more competition for donor money, with the World Bank calling for a pandemic emergency facility, as well as a global health reserve corps to expedite the response to future outbreaks.
The World Bank’s idea is to create a team made up of specially trained experts in areas spanning infectious diseases, logistics, supply-chain management and medical evacuations, Evans said.
“Surge capacity to respond in a timely and definitive way to an epidemic is absolutely essential,” Evans said in an interview. “We need to make sure that the institutions that are meant to respond are much more fit-for-purpose and that we have an ever-ready financing capability that can be deployed on the appropriate outbreak trigger to mobilize the scale and the speed of a response that is required to mitigate the impact of any future pandemic.”
The World Bank is in discussion with the WHO and major donor countries about its proposal for a reserve corps, according to Evans, a former WHO assistant director-general. Kim’s idea would be to ensure a rapid-fire brigade could be assembled at a day’s notice or less. Plans are still at an early stage and details such as employment arrangements have yet to be worked out, Evans said.
“I’m sort of scratching my head on how that can work,” Susan Desmond-Hellmann, chief executive officer of the Bill and Melinda Gates Foundation, told reporters on a Dec. 18 conference call. “I am intrigued by the notion of a corps that could go in when needed, but I am also aware, having lived through SARS and its aftermath, that it’s very hard to maintain momentum in between outbreaks.”
The idea isn’t new. Three years ago, a WHO panel reviewing the swine flu pandemic recommended a global health emergency force be created, backed by a $100 million contingency fund, to help respond to health emergencies. The global financial crisis and “pandemic fatigue” that followed stymied any progress, the University of Sydney’s Kamradt-Scott said.
While a reserve group is a great idea in principle, the sticking point is “how to make it a practical reality,” said Keiji Fukuda, WHO’s assistant director-general for health security.
“The long-term goal is to have every country be in a position to mount its own response,” Fukuda said in a Nov. 20 e-mail. “In a full pandemic situation, especially something like a severe influenza pandemic in which most, if not all, countries are going to have to take urgent actions, there is no other good solution.”
There is no cure for Ebola, a virus that spreads from contact with bodily fluids such as blood, vomit and feces. While drugmakers are developing experimental medicines, the current practice is to provide supportive care, especially fluids.
The current crisis, greater than all previous Ebola outbreaks combined, underscores the importance of strengthening primary care and health systems, Desmond-Hellmann said.
“There is nothing better than people in the community who know the community, know the cultural norms,” she said. “My strong bias is to strengthen health systems as the best, first line of defense, and then if we need to respond to an epidemic anywhere in the world, you are starting from so much of a better place.”
Evans agreed there are basic public health functions and capacities that every country needs, including the ability to detect, diagnose and report diseases.
“At the same time though, it’s not simply the national preparedness and response that’s necessary,” he said. “We also need to strengthen the global response capability.”
Not everyone thinks a fresh intervention force is needed.
“We should be ready,” says Julio Frenk, dean of the Harvard School of Public Health in Boston and a former minister of health in Mexico. “That doesn’t mean that you have a standby group sitting at the UN waiting to be called on.”
A new UN agency would duplicate bureaucracy and add yet more competition among agencies with similar mandates, Kamradt- Scott said. The money would be better spent supporting the Global Outbreak Alert and Response Network, a 14-year-old collaboration among the WHO and groups including the Red Cross, U.S. Centers for Disease Control and Prevention, and Doctors Without Borders, he said.
“The solution for bureaucratic inefficiency cannot be yet another bureaucracy that replicates the function of existing networks like the WHO-led Global Outbreak Alert and Response Network,” Kamradt-Scott said.
_ With assistance from John Lauerman in Boston and Simeon Bennett in Geneva.