By Abdul Tejan-Cole
The novel Coronavirus (COVID-19) outbreak has been declared a pandemic. As at March 18, 2020, there were 191,127 confirmed cases out of which there were 7,807 deaths. The Western Pacific Region, including China, accounts for 91,845 of the confirmed cases and 3,357 deaths. Europe, including Italy, has 74,760 confirmed cases with 3,352 deaths. Eastern Mediterranean Region has 18,060 confirmed cases and 1,010 deaths. The Americas has 4,979 confirmed cases including 68 deaths. South-East Asia has 538 confirmed cases and 9 deaths and Africa 233 confirmed cases and 4 deaths. One hundred and fifty plus countries in all continents save Antarctica have reported cases.
At the forefront of the global fight against the Coronavirus is the World Health Organization (WHO). To many who followed the Ebola epidemic between 2013-2016, this will be very shocking news. During that epidemic, which mostly affected Guinea, Liberia and Sierra Leone, the consensus in the global health community was that the WHO fell short of its responsibilities and failed to deliver on its mission of providing leadership on global health matters, putting people first, placing health at the center of the global agenda, engaging countries and strengthening partnerships and working towards a world in which everyone can live healthy and productive lives.
True, the three countries at the epicenter of the outbreak lacked sufficiently trained personnel and had limited resources and weak national health systems, but the structural failure of global health governance on the part of the WHO contributed significantly to the 28,000 confirmed cases and 11,000 deaths and the devastating social and economic situation in Liberia, Guinea and Sierra Leone.
Most of the reviews that were conducted after the Ebola epidemic pointed a finger at the WHO especially for its delay to take action and for the lack of an operational response in the outbreak. Even the WHO’s internal review reached the same conclusion. It stated that the initial response was slow and insufficient, it was not aggressive in alerting the world, the surge capacity was limited, it did not work effectively in coordination with other partners, there were shortcomings in risk communication, and there was confusion of roles and responsibilities at the Headquarters, Regional Office and Country Offices of the organization. In addition, the first field epidemiologists sent to support initial response efforts were said to have little knowledge of Ebola and broke WHO protocols for disease outbreak management. A Sierra Leonean doctor told me at the time that the team was “full of theory but lacking in practicals.” The WHO’s response was so botched that the head of its Freetown office had to be recalled. Although it was commended by some scholars for publishing numerous technical guidance documents, hosting a series of meetings on vaccine options, developing diagnostic tools and expanded laboratory services, yet none of these activities provided direct patient care, strategic managerial oversight or the infection control that the outbreak response needed. The vacuum was filled by the first-ever United Nations emergency health mission, the UN Mission for Ebola Emergency Response (UNMEER), which was established as a temporary measure to provide immediate financial, human resource, and logistic support for affected countries with the primary objectives of stopping the outbreak, treating the infected, ensuring access to essential services, creating stability, and preventing further escalation.
Other independent assessments of the WHO’s response were just as damning. The Harvard and London School of Hygiene & Tropical Medicine panel called for more active engagement by WHO with the greater global community in managing infectious disease outbreaks, the creation of a dedicated independent center for outbreak response and the formation of a politically insulated WHO Standing Emergency Committee for public health emergencies of international concern (PHEIC) declaration.
The Commission on a Global Health Risk Framework for the Future (CGHRF) which included Oyewale Tomori (Vice Chair), President of the Nigerian Academy of Science, Irene Akua Agyepong from Ghana and Yvette Chesson-Wureh from Liberia, issued a comprehensive report entitled – “The Neglected Dimension of Global Security – A framework to Counter Infectious Disease Crises” in January 2016. The report contained twenty-six recommendations encompassing “three broad areas: first, reinforcing national public health capabilities and infrastructure as the foundation of a country’s health system and the first line of defence against potential pandemics; second, reinforcing international leadership and coordination for preparedness and response; and third, accelerating research and development in the infectious disease arena. Together, these recommendations amount to a comprehensive, costed, and coherent framework to make the world much safer against the threat of infectious disease.” It also called for the involvement of the World Bank and International Monetary Fund to help finance and strengthen the implementation of International Health Regulations (IHR) core capacities.
Also in January 2016, the High-level Panel on the Global Response to Health Crises chaired by former Tanzanian President, Jakaya Mrisho Kikwete, finalized its report titled “Protecting Humanity from Future Health Crises.” It notes that the high risk of major health crises is widely underestimated, and that the world’s preparedness and capacity to respond is woefully insufficient. Future epidemics could far exceed the scale and devastation of the West Africa Ebola outbreak and made twenty-seven recommendations for action at the national, regional and international levels, including many measures that cut across governance levels and require engagement with all sectors of society. The panel was “convinced that there is no substitute for having a single global health leader with significant resources to determine and execute global health priorities. The World Health Organization (WHO) should become this leader.” It recommended forming a Centre for Emergency Preparedness and Response within WHO, securing appropriate financing for the WHO and establishing a more robust periodic review of compliance with the IHR’s Core Capacity requirements, strengthening the WHO’s operational capacities, and enhancing the Inter-Agency Standing Committee (IASC) coordination mechanisms to better respond to health crises.
Although most of these reforms have not been fully implemented, somehow the WHO seems to have rebounded from the black eye it suffered during the Ebola outbreak. Its response to the current coronavirus pandemic has so far been pretty impressive. One of the reasons for this is that in 2017 it elected a new Director-General, Tedros Adhanom Ghebreyesus. The former Ethiopian Health Minister replaced Margaret Chan, who presided over the Ebola epidemic. Dr Tedros, who became the first African to head the WHO, has been the face of the WHO during the current pandemic. His competence and superlative communications skills have been in full display during every press conference.
Initiatives like the “safe-hands challenge” have been a big hit. He joined the WHO with immense national and global experience and reputation. Under Tedros, the Ministry of Health in Ethiopia reduced HIV infection prevalence from double digit to 4.2 in cities and 0.6 in rural areas. He had served as Chair of the Roll Back Malaria Partnership (2007-2009), Programme Coordinating Board of UNAIDS (2009-2010) and the Global Fund to fight AIDS, Tuberculosis and Malaria (2009-2011) and Co-Chair of The Partnership for Maternal, Newborn & Child Health (2005-2009).
Under his leadership, Ethiopia supported the African Union’s initiative and sent 200 Ethiopian health workers to join the African Union response team. Dr Tedros was named as one of the 50 people who would change the world in 2012 by the UK Wired Magazine. The Magazine wrote: "Dr Tedros has used innovative techniques to save the lives of millions of Ethiopians. Rather than building expensive hospitals, he has set up programmes to train 35,000 health workers. The workers then go on to provide care in nearly every community across Ethiopia -- especially for women and children, who are often the most vulnerable and underserved. As a result of this, women have access to family planning and are now able to plan the timing and spacing of their children. And children now receive life-saving vaccines and treatment for deadly illnesses such as pneumonia, malaria and diarrhoea. In five years, his work has reduced the death rate of Ethiopian children under five by 28 per cent.”
In addition to Tedros’ impressive leadership skills, the WHO also set up a new Division of Emergency Preparedness, an emergency unit to support Member States for the implementation of national capacities for epidemic preparedness and response, including laboratory capacities and early warning alert and response systems and to develop standardized approaches for readiness and response to major epidemic-prone diseases. It has also invested in setting up the WHO Academy, a proposed state-of-the-art school to provide new learning opportunities for staff and public health professionals globally and has streamlined its recruitment processes. The new Department of Digital Health seeks to enhance the WHO’s role in assessing digital technologies, and support countries to make decisions about how to prioritize, integrate and regulate them. The Innovation Hub seeks to identify and match with country needs innovations that have the potential to improve the health of millions.
We need to be cautiously optimistic about the progress of these reforms. A lot more still needs to be done. The WHO needs to address concerns of politics and priority setting and financing challenges. It has immense budget limitations and has to compete with new global health initiatives such as UNAIDS, GAVI the Vaccine Alliance, the US President's Emergency Plan For AIDS Relief (PEPFAR), Stop TB Partnerships, and The Global Fund to Fight AIDS, Tuberculosis and Malaria that run parallel health systems. It has its work cut out for it if it is to provide the requisite leadership on global health during major outbreaks. We need a fully functional WHO that shapes the health research agenda, sets norms and standards, articulates evidence-based policy options and provides technical support to countries if the words of renowned French microbiologist, Louis Pasteur, are not to come true – “Gentlemen, it is the microbes who will have the last word.”
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