12 January 2017
Most disease outbreaks are detected promptly and quickly controlled, local and national authorities implement well-rehearsed protocols. They liaise with their counterparts across borders and inform the World Health Organization. When the systems work properly there are no dramatic headlines in the newspapers or in TV programmes reflecting high levels of anxiety. But the difficulties with controlling disease outbreaks in recent years, extensively covered by the media, have led to scrutiny and criticism of the work of the World Health Organization. The general conclusion was that the WHO-led disease control systems are not working well enough.
I became involved in outbreaks when 8,000 cases of Severe Acute Respiratory Syndrome (SARS) were reported from 37 countries between November 2002 and July 2003. More than 750 people died. There were major economic losses for the most affected countries. In September 2005, leaders from South East Asia became concerned about the potential for the H5N1 Avian Influenza outbreak to cause a severe influenza pandemic and that it would be much worse than SARS. They told Kofi Annan, Secretary-General of the United Nations, that they wanted to be sure of predictable and effective responses in the event of a pandemic. I worked for some years as the UN’s influenza coordinator and widespread preparedness work was undertaken over several years. There have been sporadic human cases of avian influenza but no pandemic: an influenza pandemic originating from another source appeared in 2009. Fortunately that pandemic was relatively mild: the systems that had been set up are still not robust enough to protect the world in the face of a severe pandemic. Since then, leaders have increasingly focused on the need to ensure that people are protected in the event of major health threats, and that they enjoy Health Security.
Outbreaks of new infectious diseases usually result from microbes that pass from animals to humans (like influenza). Other threats to health occur when people cannot access health care – such as when there are wars and emergencies, when health facilities are destroyed or when supplies and health care professionals are just not available. Indeed, all crises are bad for people’s health – especially for the health of those most vulnerable. Services are quickly overloaded and essential medicines are in short supply. Women and children are particularly at risk because of constraints on access to reproductive health care and pregnancy and delivery support, as well as services for young children. People with chronic diseases, injuries and mental illness are typically underserved as well.
An outbreak of an unknown disease is frightening both to communities and to those who respond, especially in the early stages as responses strategies are being developed. The 2014 -15 West Africa Ebola epidemic and Haiti’s cholera outbreak between 2010 and 2017 resulted in widespread sickness and caused thousands to die. They also led to people moving away out of fear. This is why it is essential to engage communities in all responses. Outbreaks and control measures may undermine local economies and upset food systems: they may impact on tourism, travel and trade. The World Health Organization must be in a position to support national authorities, provide guidance and offer strategic direction. Excellence, courage, tenacity and trust are essential attributes of WHO’s contribution.
I worked as special envoy of UN Secretary-General Ban Ki-moon during the Ebola outbreak. I helped him engage with world leaders on a strategy to anticipate the outbreak's extraordinary force and devastating potential. We knew that a powerful response was needed. We worked hand in hand with national leaders, helped them to mobilize all the assets that were available. We worked closely with local communities and their leaders, established means for coordination, monitored progress closely, and resolved to be much better prepared for the next Global Health Crisis. WHO needs to be ready to perform these functions, ensuring that communities, nations, regions and the world have the best possible systems for responding to all kinds of health crises. The systems should be staffed by experts. They should be well tested, guaranteeing prompt, consistent and trusted performance whatever the scale of the crisis.
The Way Forward
WHO’s Member States want better services in all types of crises. Over the past 18 months, a series of commissions and reports have examined WHO’s response to Ebola. I chaired the Director-General’s Advisory Group on the Reform of WHO’s Work in Outbreaks and Health Emergencies. We proposed a series of measures that go far beyond the status quo.
We concluded that WHO must assist national authorities and support partner organisations in ways that are predictable and effective. WHO’s procedures must be consistent and performance should be transparently assessed. Services should be delivered through a single WHO-wide programme, workforce and budget. Its implementation will reflect the varying needs of different countries (and regions) and take advantage of their capabilities. Major outbreaks require partnership across a huge number of global stakeholders, including countries, multiple UN agencies, donors and the private sector. WHO must build up its internal capacity and get better at working with multiple partners and bring them together. This is how WHO prepares for unprecedented future challenges.
The programme must be adequately financed and fully implemented, constantly tested (through simulation) and linked to partners. There must be surge capacity with an adaptable response even in the face of the most exacting demands.
The programme must cover preparedness, threat detection and response, as well as risk-based prevention, drawing on the International Health Regulations. The programme must focus on strengthening country level capabilities - including in fragile settings. This will strengthen information management and contribute to health systems development.
The programme must be impartial, offering strategic direction for all actors, focusing on responding to the needs of local people and empowering them to be resilient in the face of all possible health threats – including infectious disease outbreaks. WHO should be standard setter, trusted partner, effective catalyst and coordinator: a demanding role that calls for people trained to the highest possible standards. WHO must mobilize sufficient resources for preparedness as well as response, maintaining capability through well-conducted simulations.
In May 2016, the World Health Assembly endorsed the establishment of a single organization-wide WHO Health Emergencies Programme, workforce and budget, with consistent procedures and performance standards. The Programme is to be implemented in ways that reflect the needs of different countries and regions, while, at the same time, taking full advantage of their capabilities.
The evolution of the WHO Health Emergencies Programme over the last 12 months provides a sound basis for better performance. But it needs to be adequately resourced, constantly tested through simulations and linked to other systems for responding to health crises within national, regional and multilateral domains. In this way it will be possible to demonstrate to all concerned that there are functional mechanisms for responding to all health crises. As Director-General, I will be committed to ensuring consistency of performance, transparency and accountability. Innovative results-based funding will be needed, linked to innovative approaches, well-documented partnerships and a surge capacity which permits an adaptable response even in the face of the most exacting demands.