Could the international community have done a better job when confronted with the outbreak of Ebola in West Africa? Although the virus appears to be largely contained now, this comes after at least 27,000 people were infected, with 11,000 of them dying. The virus also had the opportunity to spread within the human population for over a year, providing it a potentially dangerous opportunity to adapt to us as hosts.

To find out whether we could have managed the outbreak better, the World Health Organization (WHO) recently convened an Ebola Interim Assessment Panel, which analyzed various aspects of the organization’s response. This panel, commissioned by the WHO Director-General, included the Dean of the Harvard School of Public Health, the founding Director of the UK's national Health Service, and other international public health leaders. It recently released its final report on the crisis.

Late Recognition of the Crisis

As the Ebola outbreak turned into a crisis, the WHO’s regional headquarters in Africa attempted to convey the seriousness of the problem to the central body of the WHO, but those messages either didn’t reach the appropriate organizational leaders or these leaders didn’t realize their importance. Early warnings about the outbreak, including some from Doctors without Borders, didn’t result in an adequate response. As one humanitarian organization leader who was working on the ground said, “We didn’t really pay attention to the Ebola outbreak at first, because the numbers were so small.”

Despite the urgency conveyed to the WHO by some organizations, it seemed that WHO leaders hoped that the Ebola crisis could be resolved via good diplomacy, rather than by scaling up emergency responses. According to this report, the WHO’s typical approach to decision making in emergencies is primarily reactive, not proactive, which contributed to their “sit back and wait” attitude.

Though the WHO acknowledged the situation as an “unprecedented outbreak” as early as April 2014, this recognition failed to trigger an appropriate mobilization of international resources and communication. Consequently, the affected counties lacked current information about the virus’s rapid spread. Local response was left in the hands of humanitarian aid NGOs, which means the response lacked coordination, was conducted without an understanding of outbreak's the big picture, and didn't use the same reporting/care/containment norms.

During a public health crisis, the WHO typically coordinates key actors and governments. For the Ebola outbreak, the WHO should have played a key role in coordinating surveillance, but there were long delays in WHO involvement. The report states that the WHO has extensive experience with outbreaks, health promotion, and social mobilization, which makes it especially surprising that it took until August/September 2014 for the organization to realize that traditional approaches to containment would not be sufficient for this outbreak—Ebola transmission would only be brought under control if surveillance, community mobilization, and delivery of appropriate health care were executed in tandem.

Failure to Engage Communities

The authors of the WHO Ebola Interim Assessment Panel report were surprised and dismayed by the WHO’s lack of engagement with local communities. They reported that difficulty in effectively engaging affected communities was a problem that could have been foreseen if there had been social/political analysis alongside epidemiological analysis. As a community leader from Liberia said, “At first there was confusion – we didn’t know what Ebola was, what to do. We didn’t know where to start; there were dead bodies in all our houses; rumors about witchcraft.” Local leaders such as this did not receive culturally appropriate guidance from the WHO.

In terms of the local politics, each affected country was unique. Since many communities in region were in post-conflict situations, there were high levels of distrust towards authority figures. Guinea had recently emerged from long period of unrest, and communities there were still not fully engaged with the central government. This meant that infected people who were never on lists of Ebola patients continue to be found, in part because infected people are reluctant to share their contact information.

In Sierra Leone, large numbers of NGOs were mobilized late in the emergency. Additionally, the police force and the military were utilized to different extents, because it wasn't clear what their roles should be. By contrast, in Liberia, there was considerably more activity on the ground, including radio messages in 17 of the languages spoken there. The panel states that, in the future, roles for government entities need to be better defined for more effective outbreak containment.

According to the report, social scientists and medical anthropologists could have been better utilized to develop appropriate messaging, as they understand local beliefs, behaviors, and customs. Traditional cultural practices, including burial and funeral customs, contributed to virus transmission, but culturally sensitive messages and community engagement weren’t prioritized. The bleak public messaging that did exist emphasized the lack of treatment for Ebola, which created a sense of fatalism that dampened community willingness to engage in prevention techniques.

The panel concludes that better engagement with community leaders was needed. Women were not utilized effectively during this outbreak, and women’s organizations are critical for changing behaviors and educating communities. As one medical anthropologist working in the Ebola response stated, “Ebola is the fire; Women are the water. And it is the water that puts out the fire.” For future outbreaks, a higher priority needs to be placed on culturally sensitive messaging, engagement with community leaders, and educating local women’s groups.

Gaps in Communications and preparedness

Early in the outbreak, the WHO failed to establish itself as the authoritative body regarding Ebola. Despite setting up an Emergency Media team, the WHO’s communication strategy couldn’t counteract media criticism of the WHO response, which made a challenging situation appear even bleaker. This problem was exacerbated by the WHO’s delayed declaration of a Public Health Emergency of International Concern (PHEIC), by leaked documents, and by misleading twitter messages posted by the WHO.

The Ebola Interim Assessment Panel recommends that the WHO re-establish itself as the authoritative body communicating on health emergencies, and states that the WHO needs to fulfill its role rapidly and accurately when informing governments and the public about the extent and severity of an outbreak.

The Ebola outbreak demonstrated that erosion of core funding for WHO has resulted in inadequate research and development for neglected and rare but deadly diseases. The Ebola Interim Assessment Panel states that a program of further development of diagnostics, therapeutics, and vaccines must be established so that the global health community is better prepared for the next infectious disease outbreak.

During the Ebola outbreak, the WHO assisted in fast-tracking vaccine development and provided leadership in conducting trials for candidate vaccines/experimental therapies. While these were important contributions, it took several months for the WHO to organize these initiatives, and earlier mobilization would have been more helpful. The panel recommends that the WHO establish a center for emergency preparedness and response, which will work on humanitarian support and outbreak response for the future.

Delays in Declaring a Public Health Emergency of International Concern

Included among the report’s findings are insights into why the outbreak was not declared a Public Health Emergency of International Concern (PHEIC) until relatively late. An earlier declaration of a PHEIC would have resulted in countries having a legal duty under the International Health Regulations to respond promptly to the emergency. The late declaration of the emergency allowed governmental involvement to be delayed and inconsistent as the outbreak expanded.

There were many factors that contributed to this delay, including a limited understanding of the context and nature of the Ebola outbreak, unreliable reporting on the spread of the virus, challenging negotiations with affected countries, and problems with internal WHO decision making and information sharing.

In the affected countries of Guinea, Sierra Leone, and Liberia, risk assessments related to the viral outbreak were complicated by weak healthcare and public health systems. These countries have little ability to monitor of epidemiological trends.

The data on the number of affected persons was particularly murky. In some countries, national public health authorities denied the number of infected citizens and underplayed the extent of the outbreak, while other countries attempted to exploit the outbreak for economic or political gain. Different agencies were using conflicting definitions of what counted as infected person, while certain groups with personnel on the ground refused to share data for aggregation purposes at all.

There was a poor public understanding of the risks of transmission, in part because local politicians and media didn’t provide helpful explanations regarding this risk. Citizens were engaging in cultural burial practices that perpetuated the virus’s spread, and there was inadequate messaging about the dangers of handling the bodies of those killed by the virus. Due in part to the dearth of intelligible communications about Ebola, some affected communities began hiding infected or deceased people. Not only did this enhance the spread of the disease, it exacerbated the confusion about the number of infections and deaths.

A large portion of the delay in declaring a PHEIC, however, can be attributed to the WHO itself. Some of the problems stemmed from political dilemmas that the WHO faced. There were internal concerns about challenging governments, and worries about the economic/trade implications of a PHEIC.

The WHO was also hesitant to declare a PHEIC because of how the media responded when it named the 2009 H1N1 Influenza outbreak a PHEIC. Some critics thought that the WHO had exaggerated the danger of that situation, spreading undue fear and panic. As a result, when facing the Ebola epidemic, the WHO exhibited excessive caution, waiting to ensure that the situation merited PHEIC status.

Finally, part of the delay was attributable to the WHO’s organizational culture. It’s a highly normative organization, unaccustomed to handling large-scale, long-term, multi-country emergencies. The organizational culture is not conducive to open dialog between employees of different ranks, and information isn’t always spread widely within it. In other words, the WHO struggles to respond quickly to emergent situations because its culture is not agile and it can take time for decisions to be made.

However, the WHO is just one of many organizations that contributed to the delay in giving the Ebola outbreak the attention it deserved. The international community was also slow to notice warnings that this outbreak was a true emergency, partially because previous Ebola outbreaks were small and contained. Unfortunately, we don’t have an intermediate level of epidemic threat between “outbreak” and “emergency,” which contributed to our hesitance to raise the threat level.

Conclusions

Moving forward, the Ebola Interim Assessment panel makes several recommendations for ways to improve International Health Regulations so that future PHEICs are declared more promptly and can be responded to more effectively. These include organizational changes within the WHO, incentives for countries to accurately report Ebola data to the organization, improvement of the organization system for WHO member-states, and the establishment of an intermediate health crisis level between “outbreak” and full-scale PHEIC. Once these changes are implemented, handling of future public health crises should be greatly simplified and improved.