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Why did Ebola virus disease claim so many lives in West Africa?

Yasushi KATSUMA
Deputy Dean and Professor, Faculty of International Research and Education (FIRE), Waseda University
Dean, Graduate School of Asia-Pacific Studies (GSAPS), Waseda University

1. Addressing the Ebola virus

Ebola virus disease (also known as Ebola hemorrhagic fever) is an acute viral infection that was discovered in present-day South Sudan in 1976. It can only be contracted through blood and other bodily fluids; however, it is extremely virulent and infectious. Although there have been 10 Ebola outbreaks in Africa, the first large-scale outbreak occurred in 2014. Over 28,000 people were infected, and more than 11,000 people died by January 2016. Why did the 2014 Ebola virus disease outbreak claim so many lives in West Africa?

To explore this issue, I interviewed staff members at the United Nations (UN) Secretariat as well as its Funds and Programmes in New York, the World Health Organization (WHO) and Médecins Sans Frontières (MSF) in Geneva, in addition to survivors, health workers and medical professionals, government officials, staff members of non-governmental organizations (NGOs) and UN agencies in Conakry, the capital city of Guinea, between 2015 and 2016.

This article will review the disease’s transmission in West Africa and the subsequent actions taken by local and international actors, and then try to answer the following two research questions: (1) Why couldn’t the WHO declare a Public Health Emergency of International Concern (PHEIC) sooner?; and (2) What forced the UN Secretary-General to establish the UN Mission for Ebola Emergency Response (UNMEER)? After answering these research questions, based on the lessons learnt from what occurred in Guinea, I would like to make some proposals in order to improve global health governance.

2. International response to the Ebola virus disease outbreak in West Africa

In December 2013, a boy died of hemorrhagic fever in the southeastern forest region of Guinea, near the border with neighboring countries of Sierra Leone and Liberia. This boy is believed to be the first victim of the Ebola virus disease in Guinea. The Ebola virus was confirmed in March 2014, based on laboratory test results, and the Guinea’s Ministry of Health declared an Ebola outbreak. In the same month, the MSF, an international NGO, issued a warning that the “geographical expansion was unprecedented,” and then expanded its activities in Guinea and Liberia.

Ebola Treatment Center in the suburbs of Conakry

Wearing personal protective equipment

Yet, the Guinea’s Minister of Health and the WHO Director-General did not draw attention to the Ebola virus disease in West Africa at the WHO World Health Assembly held in Geneva in May of that year. Consequently, international response was not mobilized.

In June, with a growing sense of crisis, the MSF stated that the Ebola outbreak was now “uncontrollable” and requested greater support. The steering committee of the Global Outbreak Alert and Response Network (GOARN) prompted a more effective guidance from the WHO. Accordingly, the WHO Director-General declared a Grade 3 emergency in July, within the Emergency Response Framework (ERF), and gave increased priority to Ebola within the WHO. Then, in August, the WHO and the governments of Guinea, Liberia and Sierra Leone launched a joint response plan. It was later at this stage that the WHO Director-General finally declared Ebola a PHEIC.

Guinea’s National Coordination for the Fight against Ebola

A few days later in Guinea, the President announced a state of emergency, and formed the National Coordination for the Fight against Ebola. Under the leadership of the Ebola National Coordinator, full-scale activities were started to be implemented in Guinea.

Nonetheless, the WHO-led international measures were considered inadequate, and the MSF made an emergency declaration in September that “the world is losing the battle to contain it. Leaders are failing to come to grips with this transnational threat.” After that, the UN Secretary-General established UNMEER, which was unconventional.

As a result of the expanded international response, together with efforts made by each country, the WHO said all known chains of transmission have been stopped in West Africa in January 2016.

3. Why couldn’t the WHO declare a PHEIC sooner?

The WHO Director-General declares a PHEIC, based on the 2005 International Health Regulations (IHR), for global public health threats, particularly ones requiring a coordinated international response. Such declarations have been made four times since 2005: the global pandemic of H1N1 influenza in 2009, the wild polio in 2014, the Ebola outbreak in West Africa in 2014, and the Zika fever in 2016. Out of these, the action taken for the Ebola outbreak has been criticized for its delay in making a PHEIC declaration.

At first, opinions were split within Guinea between the Government and the MSF. Although Guinea’s Ministry of Health acknowledged an Ebola outbreak in March 2014, there was no perceived need for an international response. On the contrary, the MSF alerted the international community that the spread of the disease was unprecedented in the same month, and that it had become uncontrollable in June. Against this backdrop of conflicting views, it is possible to say that the WHO decided to respect the Guinean government’s opinion. Still, only a few months later, the WHO was eventually forced to make a PHEIC declaration, and the President of Guinea announced a state of emergency, as the infection reached as far as Conakry, the capital city of Guinea.

A number of reasons delayed the PHEIC declaration. To begin with, because this was the first Ebola outbreak in West Africa, the Guinean government did not have sufficient experience in responding to the disease. Moreover, the government was optimistic, believing that even if an outbreak occurred in the southeastern forest region of Guinea, it would not affect Conakry. From the fear of a PHEIC declaration triggering economic damage, the government did not proactively disclose information. This caused a strain on the relationship with the MSF that had requested a rapid international response from the international community from the outset.

The second reason is related to the organizational structure of the WHO. It was originally anticipated that the WHO Regional Office for Africa (AFRO) would take the lead for further assistance. However, due to its limited human resources and funding, AFRO was unable to fulfill its role successfully. The WHO, an inter-governmental body with a head office in Geneva, declared a Grade 3 emergency within the organization itself in July, but the PHEIC declaration was not made public until August, out of consideration for the governments’ intent of the member countries, such as Guinea.

Taking into account that the MSF had been sending out warnings globally since March, this delay of several months may have resulted in unnecessary loss of lives.

4. Why did the UN Secretary-General establish UNMEER?

Even though the WHO made the PHEIC declaration in August 2014, and then international response mobilized, the prospects of the Ebola virus, which had already become a major outbreak, ending was bleak. In September, the UN Secretary-General established UNMEER, based on the resolutions made at the Security Council and General Assembly. While political and peace missions led by the UN Secretary-General are familiar to many, UNMEER was an unconventional UN health mission to fight an infectious disease. It operated until July 2015 when the activities were handed over to the WHO.

There were a number of reasons for establishing UNMEER. For one, as limitations of the WHO's capability to lead and coordinate field activities became apparent, the UN needed to demonstrate its strong leadership both internally and externally. It was unprecedented for the UN Secretary-General to take a lead in the fight against an infectious disease, which would normally be assigned to the WHO. Although temporary, the WHO showed hesitance because it appeared that UNMEER would be structured above the WHO, an autonomous specialized agency in the UN family. This caused tension between the UN Secretary-General and the WHO Director-General, who would not generally be in a superior-subordinate relationship.

The second reason was that although a proposal for the Office for Coordination of Humanitarian Affairs (OCHA) to take action and utilize the Central Emergency Response Fund (CERF) for Ebola being a humanitarian crisis was made, this did not come to fruition. Humanitarian crises due to natural disasters and armed conflicts were increasing, and it was decided that OCHA neither had the experience, framework, nor funding to undertake this new type of humanitarian crisis caused by an infectious disease.

Finally, a large amount of funds needed to be mobilized without a moment’s delay. The quickest way to do this was to have a new UN mission endorsed by the Security Council and the General Assembly, allowing the UN Secretariat to have access to its regular budgets.

It appears that there was no other option but to establish UNMEER due to: (1) the WHO's limited capability to lead and coordinate field activities surfacing, (2) coordination by OCHA being difficult and (3) the need to procure a large amount of funds. However, UNMEER was heavily criticized within Guinea, since the value-added effects of its activities were considered questionable.

5. Proposals to improve global health governance

Genie III portable platform sent from Japan

Based on the lessons learnt from Guinea, I would like to make a few proposals in order to improve the governance of global health.

First, it is crucial that each country acquires the minimum core public health capacities required for crisis management according to the IHR, which should be supported by international development cooperation. Because the laboratory facilities in Guinea were located in Conakry, the actual circumstances of the Ebola virus disease were not fully assessed in rural areas. In such a context, the Genie III portable platform provided by Japan was highly appreciated by the Guinean government.

Second, even though the WHO Director-General makes the final decision regarding a PHEIC declaration, the health risk evaluation that forms the basis for this decision should be performed scientifically by an independent, dedicated organization.

Third, at the country level, the UN country team (UNCT) should be prepared to coordinate country initiatives and international response to fight infectious diseases, utilizing existing coordination mechanisms, such as the UN Development Assistance Framework (UNDAF) and thematic groups. The WHO will continue to retain its role as a lead agency in health, but the UNCT should coordinate cross-sectoral activities in the field. The Ebola virus disease spread throughout Guinea partially due to traditional healers praying over Ebola virus carriers, as well as friends and family members touching infected bodies to bid them farewell. This calls for multi-sectoral approach to fight infectious diseases, including health education, contact tracing and safe burial.

Lastly, if a complex humanitarian crisis accompanied by an infectious disease outbreak occurs in the future, OCHA should become involved in the response, instead of establishing a new UN mission such as UNMEER. OCHA must strengthen its capabilities in order to respond to humanitarian health crises by taking initiatives such as dispatching UN Humanitarian Coordinators with experience in infectious disease control and activating cluster approach for humanitarian coordination.

Yasushi KATSUMA
Deputy Dean and Professor of the Faculty of International Research and Education (FIRE), Waseda University
Dean of the Graduate School of Asia-Pacific Studies (GSAPS), Waseda University

Currently, Professor Yasushi KATSUMA is Advisory Board Member for the Human Development Report of the United Nations Development Programme (UNDP); Vice President of the Japan Society for International Development; Board Member of the International Human Rights Law Association; and Board Member of the Japan Association for United Nations Studies.

Before joining the faculty of Waseda University, he volunteered in Honduras for a UK project, conducted development research in Southeast Asia, the Russian Far East and South America as a consultant of the Engineering Consulting Firms Association (ECFA), and worked as a staff member of the United Nations Children’s Fund (UNICEF) in Mexico, Afghanistan, Pakistan and Tokyo.

Professor KATSUMA graduated from Downingtown Area High School in Pennsylvania as an exchange student sponsored by the International Fellowship, Inc., while attending Kwansei Gakuin Senior High School in Hyogo. After studying abroad as an exchange student at the University of California at San Diego, he received a B.A from the International Christian University, a LL.B. and a LL.M. from Osaka University, and a Ph.D. from the University of Wisconsin at Madison.

His recent research interests include human development, the Sustainable Development Goals (SDGs), global health governance, human security for children, and human rights in Asia.

His publications in English include the following: East Asia and the United Nations: Regional Cooperation for Global Issues (2010, co-edited); The Role and Challenges of Japanese NGOs in the Global Health Policymaking Process (2009, co-authored); “Global health governance and Japan’s contributions” (2008); “Human security approach for global health” (2008, co-authored).