In the latest Lancet, a report from an independent panel of experts lambastes the World Health Organization for its handling of the Ebola outbreak. The panel makes 10 recommendations to help get the WHO in better shape for the next global epidemic alert.
I wish I could tell you not to worry, that the WHO will heed these recommendations and handle its next epidemic much better, so that the outbreak will never get as widespread and disturbing as Ebola was last year.
But I did my PhD dissertation on how the WHO plans for and responds to health problems like infectious diseases that don't respect borders, and my sad conclusion is: Not gonna happen.
I agree wholeheartedly with many of the new recommendations -- like that the WHO should focus on supporting countries with technical advice, and create a dedicated center for outbreak response. But if the WHO carries out even one of the 10, it will be a miracle.
Why should you care? Well, it's widely thought that the WHO botched the Ebola outbreak: It was late in releasing information, and was even called out by Doctors Without Borders for its lackadaisical response.
And why did it botch the response? Because it is not built to rapidly balance politics with medicine, which is exactly what’s required in an epidemic. It can't be helpful doctor and tough enforcer at the same time.
The independent panel, launched by the Harvard Global Health Institute and the London School of Hygiene & Tropical Medicine, includes world health experts and former high-level WHO officials, but it seems to forget how the WHO works. The experts have made pie-in-the-sky recommendations that the WHO is unlikely and probably even unable to implement, making it more likely that it will repeat its mistakes.
I spent close to four years working on my dissertation, which had the riveting title "Exit, Voice and (Trojan) Loyalty: The World Health Organization and the Dynamics of International Disease Control." Luckily for you, you don’t need to read it (not even my mom has, to be honest). There are just two quotes you need to understand pretty much everything about my dissertation and how the WHO responds to infectious disease risks.
Quote No. 1: “Our clients are our member states.”
A WHO official told me this during my first week researching in the archives. You might think the WHO works for the health of the people. Unfortunately, that’s a common misunderstanding. The WHO’s first priority is to the governments of its member states. Understanding that allows you to make sense of the WHO’s actions (or lack thereof) during an epidemic.
It also makes many of the recommendations from the panel impractical. The panel is basically asking the WHO to go rogue and bite the hands that feed it, criticize sensitive and capricious governments that, if threatened, will simply throw the WHO and all of its officials out of the country.
The panel's experts wants the WHO to get tough with countries that aren’t cooperating. They want countries to submit to inspections to make sure their abilities to detect epidemics are up to snuff. They want the WHO to reprimand countries that don’t report epidemics quickly enough, and “confront governments that implement trade and travel restrictions without scientific justification.”
I’ll believe it when I see it. The WHO’s first priority is to the governments with which it works.
That priority brings the benefit of being able to do vaccination campaigns and tuberculosis control in horrible places like North Korea or Syria.
But the downside is that the WHO will almost never “get tough” with governments that aren’t cooperating. It's only ever done that once -- by issuing travel advisories during SARS when information on disease spread was slow — and it was reprimanded for it by member states' governments.
That's why the WHO is even less likely to cross governments in the future. And that’s what happened with Ebola: Internal emails revealed that the WHO resisted declaring an outbreak out of concern it would anger African governments.
The WHO's clients are its member states.
I don’t like it any more than you, but that’s the reality of how the WHO works. Somebody has to work with the North Koreas of the world.
Quote No. 2: “When we enter that room, we are not scientists anymore. We are about business.”
An African government official told me this during a global WHO conference that was trying to set safety standards. She was a scientific expert in her field, lamenting how science went out the window the minute they started negotiations. I thought it captured pretty accurately the false separation between politics and science that the WHO and other UN technical organizations have tried to create.
In theory, the WHO does “risk analysis” on one side, which is supposed to be scientific and objective, and “risk management,” the political process of balancing the scientific information with values, culture and politics, on the other. In reality the two are never separate.
Much of my dissertation focused on what happens at the WHO when trying to make concrete policy with uncertain science: politics inevitably intervenes (Sheila Jasanoff at Harvard has done wonderful work on this front.)
So when the International Health Regulations from 2005 required that the WHO convene an expert committee before declaring an epidemic, it hoped to make this more of a scientific process but instead turned it into a political one.
The expert panel’s recommendations don’t address this but entrench it. They suggest there should be a standing expert committee that would somehow be both transparent and “politically protected.” How? The expert panel gives no hints.
So what is to be done? What has worked: Soft power
The WHO is excellent at working with governments on cooperative endeavors. Its people are masters of the art of the possible.
The WHO has been highly successful, for example, in getting countries to prepare for pandemic influenza. They’ve done workshops, trainings, drafted pandemic preparedness plans and helped experts inside countries to get governments of poor countries to think about a problem that otherwise would not be as high on the agenda as HIV, malaria or tuberculosis.
By WHO’s count, well over half the countries in the world have developed pandemic influenza plans. There is no international law telling countries to make a plan. The WHO isn’t punishing those countries that have not created plans, nor is it shaming them.
The problem is that during an epidemic, you might need someone to be the bad guy.
WHO’s model has been to work in partnership with countries to try to build capacity in this area. And this strategy of soft power and cooperation has largely worked so far.
The problem is that during an epidemic, you might need someone to be the bad guy and call out countries that are being secretive. Asking the WHO to serve both functions is not only undermining the WHO’s strengths but actively trying to get the WHO to annoy its funders and its main clients.
We’d be better served to recognize this sooner rather than later. The UN should create a different organization that can serve as the tough guy during epidemics. The expert panel hints at this by recommending the UN Security Council create a global health committee (recommendation eight.)
A new committee would allow the WHO to stay neutral, cooperate with the global pariah states when necessary, and provide technical expertise -- all things it is great at -- while giving this other organization the teeth that the WHO lacks.
No matter how expert panels ask the WHO to take on the additional role of global policeman, it just isn’t going to happen.