The 68th World Health Assembly opened in Geneva on Monday with a one-two punch: An opening address by German Chancellor Angela Merkel, declaring the need for a major reform of the World Health Organization (WHO), and a speech by WHO Director General Margaret Chan saying that such a reform is under way.
This is no mere bureaucratic reshuffle; it means a dramatic and overdue change in the whole global health system, triggered by an Ebola outbreak in West African countries with almost no health system at all.
Proposed reforms include an independent rapid-response outbreak team, an emergency fund, detailed performance metrics and new powers to pressure governments into action. The implications for Canada are likely to be as momentous as for the rest of the world.
The anatomy of a disease outbreak has evolved since WHO was formed by the United Nations following World War II. Globalization in the past 35 years has doubtless greatly enhanced international trade; it has also accelerated the rise and spread of "emerging" diseases. One of the earliest non-African cases of HIV/AIDS was said to have been a sexually active airline cabin attendant.
Similarly, SARS in one sick Chinese doctor spread from a hotel hallway in Hong Kong to hospitals in greater Toronto. Vancouver escaped only because one nurse at VGH had read the Hong Kong papers and alerted doctors when a SARS case turned up here. The H1N1 "swine flu" virus circled the world from Mexico and the southwestern U.S. in a matter of weeks. At least 57 British Columbians died in that outbreak.
In January 2014, a Canadian nurse returning from a winter holiday in China died in Red Deer, Alberta, of H5N1. A few weeks later, measles from the Netherlands spread through religious communities here in the Lower Mainland.
Some epic triumphs
Since its inception, WHO has struggled to keep up with new diseases while trying to deal with the perennials. It has achieved some epic triumphs, such as the eradication of smallpox and the impending end of polio. (Only those of us in our 70s can recall the dread all North American parents once felt about polio.)
Dr. Margaret Chan, as the Canadian-trained Medical Officer of Health in Hong Kong, achieved her own triumph in 1997 by shutting down the first outbreak of H5N1 "bird flu" in humans. By ordering the culling of all poultry in Hong Kong, she broke the chain of transmission. She also handled her health system's transition from British colony to Chinese "Special Administrative Region," and Hong Kong's public health system remains one of the best.
Chan was therefore an attractive candidate to be WHO's next director general, especially with China's backing. She took over in 2006 from Norwegian Gro Harlem Brundtland, and was re-elected in 2012. But she has presided over an increasingly bureaucratic and cautious organization.
Sometimes Chan committed simple gaffes, like praising North Korea for the lack of obesity in its people. Other errors were more serious. In 2003, Brundtland had announced a SARS travel advisory against Toronto -- which inflicted severe economic and political consequences. As a result, in 2009 the organization was hesitant to declare the new H1N1 outbreak a pandemic. Technically it was, but saying so would oblige member states to adopt expensive measures like screening incoming travellers. Then WHO failed to explain that pandemics don't always involve zombies in the streets, and was laughed at in the media.
More seriously, WHO was ethically compromised by its failure to name the origin of the cholera outbreak in Haiti: Nepalese peacekeepers under UN auspices. To this day, the UN denies its responsibility for the 738,000 cases and 8,900 deaths that Haiti has suffered, and WHO, as a UN agency, has maintained a shamefaced silence. (It's also said little about the cholera outbreak in Cuba, brought home by doctors fighting it in Haiti.)
In one sense, WHO is not a "world" organization, but a loose federation of more or less autonomous regional offices. In some cases the regional offices are run by political appointees, not by WHO's Geneva office. Their competence is open to question.
The Pan American Health Organization, for example, has watched a painful new mosquito-borne disease, chikungunya, spread from one case in the Caribbean in December 2013 to over 1.1 million as of May 15, 2015. But most countries haven't reported at all this year; Haiti quit reporting in the summer of 2014. So the real extent is unknown but likely several million. Chikungunya cases occur from Paraguay to Mexico, and it's likely to become resident in the southern U.S. before long.
Regional autonomy was likely a factor in the early spread of Ebola. After the outbreak began in southern Guinea in December 2013, it went unnoticed for months. Not until March 2014 was it clearly Ebola, far from its usual hot zone in central Africa. Equally clearly, it was out of control. The African regional office didn't respond as quickly or as effectively as it should have.
She who hesitates
Significantly, WHO was hesitant to declare a "public health emergency of international concern" in West Africa. Liberia and Sierra Leone, where Ebola had quickly spread, are still recovering from savage civil wars, and Guinea is also a poor country. The dire economic and political consequences of reduced travel and investment were obvious. WHO hesitated until August 6 before declaring the obvious.
Months earlier, Medecins Sans Frontieres (Doctors Without Borders) had been screaming for action. One of the biggest and most effective non-governmental organizations in the world, with over 5 million donors and a billion-euro budget, MSF is politically independent.
The current president of MSF International is Dr. Joanne Liu, a Canadian who literally spoke truth to power -- first to the European Union and then to the UN Security Council. Without ever raising her voice, Dr. Liu did a good impression of an exasperated drill sergeant kicking recruits' asses and taking names.
Liu was also among the first to call for military forces’ construction, transportation and logistic abilities to support healthcare workers fighting Ebola in the field. The U.S. and other nations soon adopted the approach. Some, like China and Cuba, saw the political advantage to be gained by taking part in the effort; Canada contributed some valuable lab experts, who tested patients' blood samples for Ebola.
More like MSF
While Liberia is now officially Ebola-free, Guinea and Sierra Leone are still fighting flare-ups. One missed case could trigger another fast-spreading outbreak, and the thought of Ebola becoming endemic to West Africa, as cholera has become in Haiti, is appalling. As it is, WHO estimates its Ebola response from now until December will cost about $425 million in Canadian dollars. But it's raised only $103 million so far.
Clearly, WHO's present model -- underfunded, over-politicized -- is due for reform. What Angela Merkel called for, and Margaret Chan promised, has been discussed for months: a unified program for health emergencies, a set of performance metrics especially for the first 72 hours of an outbreak, a "global health emergency workforce," a new business model for that workforce, and a $100 million contingency fund to pay for its launch.
Significantly, Chan said her new rapid response teams would include "logisticians, medical anthropologists, and experts in risk communication." Getting the right people and equipment where needed, and explaining why they were there to the locals, have been two major failures in West Africa. Ebola centers were built that never saw a patient; riots and murders resulted from imposing a Western healthcare model on people culturally unprepared a threat like this.
While the emergency workforce would report to Chan and her successors, it would operate with a freedom from political constraint that's clearly modeled on MSF. WHO puts up with an absurd amount of nonsense from member states like Saudi Arabia, which has dragged its heels on stopping Middle East Respiratory Syndrome (MERS). The new emergency workforce, financially "ring-fenced" against retaliation, would be free to embarrass the House of Saud into behaving more professionally.
The new "good cop, bad cop" approach is an awkward one, but it reflects a sad reality: Most if not all countries are run by people who care more their own political wellbeing than for their people's welfare. That makes governments themselves a hazard to public health. But they fear embarrassment more than any emerging disease. If WHO's new rapid response teams can apply some therapeutic pressure on such rulers, that alone should smother many outbreaks.
Canadians should be deeply committed to making the new workforce a success. We've had first-hand experience with outbreaks of new diseases. We have plenty of experienced healthcare workers, a superb exemplar in Dr. Liu, and many fences to mend with the UN and the global health community. The new workforce will be a good place to start.