Tough medicine for health governance
States and international organisations are scrambling, from the United Nations Security Council to the streets of Monrovia, to triage the damage to social order, economic growth, development strategies and human dignity caused by West Africa’s Ebola outbreak. It remains to be seen whether scaled-up – but still insufficient – responses can control this epidemic. But another reckoning awaits: the challenge of identifying what went wrong, where mistakes were made, why the crises ended up happening, and how to ensure that this nightmare does not happen again. This reckoning implicates the G20 as much as it does the World Health Organization (WHO).
The death, suffering and fear produced by the Ebola outbreak – and the ineffective reactions to it – reveal a massive failure of global governance. This failure affects more than the health sector. Over the past 15 years, global governance strategies increasingly emphasised health’s importance to security, economic and development interests that states pursue individually and collectively. Connecting health with these political interests sought to ensure that countries do not treat health problems as ‘merely humanitarian’ issues. Global economic governance embraced this strategy by paying more attention to health in the G7/8, the International Monetary Fund, the World Bank, the World Trade Organization and – through its development agenda – the G20.
However, Ebola demonstrates how little these efforts have delivered in the West African states where the epidemic is undermining social order, damaging economic performance and diminishing prospects for development. In September, the G20 finance ministers and central bank governors expressed concerns about Ebola’s impact on stability and growth in West Africa. In October, the World Bank warned that, without improvements in containing Ebola, the economic impact could be “catastrophic”. Even the humanitarian response has been shockingly tardy, fragmented, underfunded and ineffective. To make matters worse, a small number of Ebola cases in the United States and Europe has shifted attention to the risks in developed countries.
On every measure, the outbreak has been a debacle for health’s place in global governance. Getting past this calamity requires conducting outbreak forensics and devising reforms to address problems. To begin this scrutiny, the UN Security Council should establish an independent investigation into the outbreak and the international community’s responses. The Security Council declared the outbreak a threat to international peace and security. Launching an investigation would underscore this decision’s seriousness. The investigation should probe what happened from the local level to the office of the WHO Director General.
Focus areas for investigation
This investigation should gather information on when and how other actors – countries, regional organisations, non-governmental organisations (NGOs), airlines and other corporations – responded. It must probe how the UN Peacebuilding Commission, which has had all of the Ebola-affected West African countries on its agenda for many years, has addressed the weak health systems in these countries, which contributed to the outbreak’s spread and impact.
Second, supported by the African Union, African countries should insist that WHO’s executive board and Health Assembly revisit recent decisions on budget issues related to WHO reform. Media coverage has speculated whether cuts to the communicable-disease surveillance and response budget adversely affected WHO’s ability to react effectively to the outbreak. As the Ebola crisis demonstrates, decisions about WHO priorities and budgets might have unintended consequences that fall disproportionately on countries least able to manage dangerous disease events.
Third, Margaret Chan, WHO Director General, should instruct the Review Committee established under the International Health Regulations 2005 (IHR) to analyse the functioning of the regulations during the Ebola outbreak, as she did in 2010 in connection with the H1N1 influenza epidemic. The IHR are the main international legal rules applicable to serious disease events. Many questions about the regulations have arisen during the Ebola outbreak. They range from how long it took the Director General to declare it a public health emergency of international concern to alleged IHR violations by governments imposing travel and trade measures that hurt West African nations and impeded efforts to get assistance into afflicted countries.
The Review Committee should revisit the recommendations it made after the H1N1 epidemic. The committee recommended, for example, that WHO strengthen its capacity for sustained responses to public health emergencies of international concern – which raises questions about WHO’s budget cuts in this area. The committee also proposed establishing a contingency fund to support “surge capacity” for responding to international public health emergencies – a recommendation not taken up seriously anywhere in global governance, but one that, if it had been followed, might have helped responses to the Ebola outbreak.
Fourth, this tragedy must inform UN negotiations on the post-2015 Sustainable Development Goals (SDGs). The proposed framework finalised in July included lessons from the Ebola outbreak in the objective of strengthening capacity, especially in developing countries, “for early warning, risk reduction, and management of national and global health risks”. While reporting and commentary lament the lack of public health capacity in affected West African countries, health experts have, for years, identified this problem in the developing world and worried about the lack of any strategy to address it. Development of the SDGs provides an opportune moment to focus on this neglected, festering weakness in global health.
Fifth, at its Brisbane Summit in November, the G20 must take advantage of the political and media attention this event generates to support ongoing Ebola response efforts and advance longer-term strategies on health and development. The G20 should highlight the economic and development implications of the outbreak, encourage members to address unmet needs in international actions to contain the epidemic, and task its Development Working Group to examine how the G20 can contribute more productively to mitigating the threats to economic growth and development posed by the health problems exposed by the Ebola outbreak.
These suggestions are tough medicine for many communities with a stake in health as a global governance priority. But what has happened in West Africa requires more than crisis-driven expeditionary medical campaigns dependent on the military delivering inadequately resourced humanitarian triage in increasingly desperate conditions. In this awful context, the G20 has a responsibility it can begin to shoulder at the Brisbane Summit.
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