nxxx,2014-09-04,a,001,bs-bk,e2 vol.clxiii no. … marc santora the organizers of the new york city...
TRANSCRIPT
By MARC SANTORA
The organizers of the NewYork City St. Patrick’s Day pa-rade said on Wednesday thatthey were lifting a ban on openlygay groups marching under theirown banner, bringing to a closemore than two decades of bitterprotests and controversy thatthrust an annual celebration intothe national gay rights debate.
The decision is a striking re-flection of the evolution of gayrights in the city and in Americansociety, and is a measure ofchanging attitudes in the hier-archy of the Roman CatholicChurch.
Every year, the parade kicksoff with a Mass at St. Patrick’sCathedral, the most prominentCatholic church in the country,and the policy of banning gaygroups from marching has longbeen seen by gay rights advo-cates as a reflection of thechurch’s hostility.
In recent months, Catholic offi-cials have tried to emphasize thechurch’s acceptance of gays andlesbians as individuals, while de-fending the church’s opposition
to same-sex marriage. That rhe-torical shift has been embracedby Cardinal Timothy M. Dolan,who will serve as grand marshalfor the parade next year.
“I have no trouble with the de-cision at all,” Cardinal Dolan saidat an evening news conference
announcing his appointment asgrand marshal. “I think the deci-sion is a wise one.”
The parade organizers’ retreatcomes after years of mountingpolitical and corporate pressure,and as many states have legal-ized same-sex marriage. Soon af-
ter taking office in January, May-or Bill de Blasio, a Democrat, saidhe would not march as long asgay groups were banned. Andsince the beer giant Guinnesspulled its financial support forthe most recent parade, other
Gay Groups to March in St. Patrick’s Day Parade as a Ban Falls
DAMON WINTER/ THE NEW YORK TIMES
Gay rights demonstrators at the St. Patrick’s Day parade along Fifth Avenue in March.
Continued on Page A24
U(D54G1D)y+%!.!&!=
outbreak had been a typical outbreak, nobody would be saying we did too little, too late.”
the outbreak began close to the borders of three neighboring countries — Guinea, Sierra Leone and Liberia — and spread surprisingly fast. Since then, the W.h.O. has engaged more than 400 people to work on the outbreak, includ-ing employees of other agencies in its network, and in August the agency declared the epidemic
an international emergency, hoping to stop it from crossing more borders. Dr. Chan has met with presidents in the region, and last week the W.h.O. announced what it called a road map for a “massively scaled” international response.
the current outbreak has killed more than 1,900 people and spread to the point that the W.h.O. warns that more than 20,000 people could become infected. Sick people are dying on
A6 N INTERNATIONALTHE NEW YORK TIMES THURSDAY, SEPTEMBER 4, 2014
ability to respond in parts of the worldthat need it most. Its outbreak andemergency response units have beenslashed, veterans who led previousfights against Ebola and other diseaseshave left, and scores of positions havebeen eliminated — precisely the kind ofpeople and efforts that might havehelped blunt the outbreak in West Af-rica before it ballooned into the worstEbola epidemic ever recorded.
Unlike the SARS crisis of 2003, whichstruck countries in Asia and elsewherethat had strong governments and amplemoney to spring to action, the Ebolaoutbreak has waylaid nations that oftenlack basic health care, much less theability to mount big campaigns to stampout epidemics.
The disease spread for months beforebeing detected because much of thework of spotting outbreaks was left todesperately poor countries ill preparedfor the task. Once the W.H.O. learned ofthe outbreak, its efforts to help trackand contain it were poorly led and lim-ited, according to some doctors whoparticipated, contributing to a sensethat the problem was not as bad as it ac-tually was. Then, as the extent of theepidemic became obvious, critics saythe agency was slow to declare its se-verity and come up with plans, and hasstill not marshaled the people and sup-plies needed to help defeat the diseaseand treat its victims.
“There’s no doubt we’ve not been asquick and as powerful as we might havebeen,” said Dr. Marie-Paule Kieny, aW.H.O. assistant director general.
Another W.H.O. leader agreed. “Ofcourse in retrospect I really wish thatwe had jumped much higher much ear-lier,” said Dr. Keiji Fukuda, the assistantdirector general in charge of outbreakresponse. “Of course I wish we’d pouredin more and more earlier.” But, he add-ed, “if this outbreak had been a typicaloutbreak, nobody would be saying wedid too little, too late.”
The outbreak began close to the bor-ders of three neighboring countries —Guinea, Sierra Leone and Liberia — andspread surprisingly fast. Since then, theW.H.O. has engaged more than 400 peo-ple to work on the outbreak, includingemployees of other agencies in its net-work, and in August the agency de-clared the epidemic an internationalemergency, hoping to stop it from cross-ing more borders. Dr. Chan has metwith presidents in the region, and lastweek the W.H.O. announced what itcalled a road map for a “massivelyscaled” international response.
The current outbreak has killed morethan 1,900 people and spread to thepoint that the W.H.O. warns that morethan 20,000 people could become in-fected. Sick people are dying on thestreet. Some feel the entire model theworld uses to fight outbreaks needs tobe rethought, so that an agency like theW.H.O. has the structure and mandateto take command.
But Dr. Chan said that governmentshave the primary responsibility “to takecare of their people,” calling the W.H.O.a technical agency that provides adviceand support. Still, she noted that her or-ganization, like many governments andagencies, was not prepared.
“Hindsight is always better,” Dr.Chan said. “All the agencies I talked to— including the governments — all of usunderestimated this unprecedented, un-usual outbreak.”
A Shift in EmphasisThe W.H.O., founded in 1948, is re-
sponsible for taking on a wide range ofglobal health issues, from obesity to pri-mary health care. But since the world’shealth needs far outstrip the financialcontributions of the W.H.O.’s 194 mem-ber nations, those priorities compete.
The threat of emergent infectious dis-eases jumped high onto that list 20years ago, when an outbreak of plaguein India created a panic, sending about200,000 people fleeing. The next year inZaire, now the Democratic Republic ofCongo, Ebola killed about 245 people.With fears of cross-border infectionshigh, a new urgency arose: improvingthe world’s ability to stop outbreaks.
The W.H.O. took the lead, at the re-quest of its member nations. A crew ofpassionate outbreak veterans assem-bled a unique department, using an ear-ly form of electronic crowdsourcing todetect outbreaks and dispatching ex-perts to the field. Three years after theeffort solidified, the W.H.O. played a bigrole in responding to a cluster of deadlypneumonia cases in Asia. The new virusbecame known as SARS, and it was con-tained within the year, with most casesoccurring in China.
To aid the fight, wealthy individualsoffered the W.H.O. “literally hundredsof millions because their businesseswere affected,” said Dr. Jim Yong Kim,president of the World Bank and a for-mer director at the W.H.O. “But asSARS burned out, those guys disap-peared, and we forgot very quickly.”
Soon, the global financial crisisstruck. The W.H.O. had to cut nearly $1billion from its proposed two-year budg-et, which today stands at $3.98 billion.(By contrast, the budget of the Centersfor Disease Control and Prevention for2013 alone was about $6 billion.) Thecuts forced difficult choices. More em-phasis was placed on efforts like fight-ing chronic global ailments, includingheart disease and diabetes. The whimsof donors also greatly influenced theW.H.O.’s agenda, with gifts, often to ad-vance individual causes, far surpassingdues from member nations, which ac-count for only 20 percent of its budget.
At the agency’s Geneva headquar-ters, outbreak and emergency re-sponse, which was never especially wellfunded, suffered particularly deeplosses, leaving offices that look, one con-sultant said, like a ghost town. TheW.H.O.’s epidemic and pandemic re-
sponse department — including a net-work of anthropologists to help over-come cultural differences during out-breaks — was dissolved, its duties splitamong other departments. Some of themain outbreak pioneers moved on.
“That shaping of the budget did affectthe area of responding to big outbreaksand pandemics,” said Dr. Fukuda, whoestimated that he now had 35 percentfewer employees than during the 2009H1N1 flu pandemic — more than doublethe cuts for the organization as a whole.
“You have to wonder are we makingthe right strategic choices?” he said.“Are we ready for what’s coming downthe pike?”
The entire W.H.O. unit devoted to thescience of pandemic and epidemic dis-eases — responsible for more than adozen killers, including flu, cholera, yel-low fever and bubonic plague — hasonly 52 regular employees, includingsecretaries, according to its director, Dr.Sylvie Briand, who said that could be in-creased during outbreaks. Before theEbola epidemic, her department hadjust one technical expert on Ebola andother hemorrhagic diseases.
Across Africa, the ranks of the agen-cy’s regional emergency outbreak ex-perts, veterans in fighting Ebola, werecut from more than a dozen to three.“How can you immediately respond toan outbreak?” said Dr. Francis C. Kaso-lo, a W.H.O. director. “It did affect us.”
And a separate section of the W.H.O.responsible for emergency responsewas whittled “to the bone” during thebudget cuts — to 34 staff members fromabout 94 — according to Dr. Bruce Ayl-ward, its assistant director general.
“You can’t make a cut that big, thatdeep, and it’s not going to have an effecton your operational capacity,” he said.
His group, charged with responding
to wars, disasters and resurgent polio,was asked in August to assist with Ebo-la, too. “At no time that I can think of inthe recent past have we been dealingwith such a scale of human misery oversuch a broad geography due to such arange of hazards,” he said, includingenormous population displacements inSyria, Iraq, the Central African Republicand South Sudan. But, officials warn,multiple, overlapping challenges maywell be a feature of the future.
The W.H.O. hoped to balance itsbudget cuts by strengthening the abilityof countries to respond to public healththreats on their own. It put out new reg-ulations for nations to follow to helpcontain outbreaks. But by 2012, thedeadline it set, only 20 percent of na-tions had enacted them all. In Africa,fewer than a third of countries had pro-grams to detect and stop infectious dis-eases at their borders. The W.H.O.’sstrategy was often more theory than re-ality.
“There never were the resources toput those things in place in many partsof the world,” said Dr. Scott F. Dowell, aspecialist formerly with the C.D.C.
A Disease Finds Its OpeningThe Ebola virus took full advantage
of these poorly prepared nations andthe holes at the W.H.O.
Given the weakness in surveillance,the outbreak was not identified untilMarch, in Guinea, roughly three monthsafter a villager was believed to havecontracted the virus from an animal,possibly a fruit bat. The delay alloweddozens of cases to spread through vil-lages and even to Conakry, a capital ofmore than one and a half million people.Right away, Doctors Without Bordersdeclared the outbreak unprecedented in
its reach, the only group to do so.Hastening the spread, hospitals
lacked basic infection-control essentialslike running water, protective gownsand gloves. Many doctors and nursescaught the virus from their patients,passed it to others, and died. The vul-nerability and collapse of medical facili-ties revealed how far there is to go inachieving the W.H.O.’s top priority —ensuring basic global health care.
“This kind of outbreak would nothave developed in an area with strongerhealth systems,” Dr. Fukuda said.
In the crucial weeks after the dis-covery, daily meetings brought togethernational authorities and foreign re-sponders at the W.H.O. office in Cona-kry. But an absence of strong leader-ship and professionalism was notablefrom the beginning, participants said.
“It’s purely improvisation,” said MarcPoncin, the emergency coordinator forDoctors Without Borders in Conakry.“There is no one to take responsibility,absolutely no one, since the beginningof the crisis.”
Stopping previous Ebola outbreakshad required meticulous tracking: mon-itoring people who had close contactwith infected individuals and isolatingthem if they developed symptoms. Pre-viously, “if we missed a case,” said Dr.Simon Mardel, a British emergencydoctor deployed by the W.H.O. to helpwith the effort, “it was like a failure.”
This time, the number of contacts be-ing followed was disastrously low fromthe beginning, only 8 percent in the epi-center of Guéckédou, Guinea, in earlyApril, according to another doctor sentby the W.H.O. That meant the diseasewas silently spreading. Dr. Mardel saidhe thought the more experiencedW.H.O. leaders who had left the agency“would have been very vocal, and theywould have sought to put it right quick-ly, as a matter of urgency.” A single per-son who traveled and became sick couldtouch off a conflagration.
It was not that responders were nottrying. Victims’ contacts were spreadacross a wide area, hours away on badroads. The payment of local workershad somehow been overlooked, so theystopped doing vital, risky jobs. Essen-tial protective equipment was not deliv-ered to many who needed it. Bottles ofbleach were given out without buckets.The W.H.O. lacked relationships withsome longstanding organizations withlarge networks of health workers in theregion.
Traditions that contributed to Ebola’sspread, including funerals wheremourners came into contact withcorpses, were not fully recognized orconfronted, said Dr. Pierre Rollin, anoutbreak specialist at the Centers forDisease Control and Prevention whoworked within the W.H.O. umbrella.
Some villagers blocked roads withtree trunks and drove Ebola workersaway with stones, accusing them of
bringing in the disease. Adding to thetension, only bare-bones clinical carewas provided to try to treat patients, re-ducing the chances of yielding survi-vors who could act as ambassadors forthe cause. Some doctors deployed bythe W.H.O. said it should have giventhem more tools to care for patients.
Institutional and personal tensionsflared. “Everyone’s working at a fe-vered pace,” Dr. Dowell said. “There’sconfusion and chaos. It argues for a sys-tem that’s organized as much as pos-sible ahead of time so people know theirroles.”
One consultant thought it strangethat the W.H.O. would not send Twittermessages with links to the C.D.C.’s Ebo-la prevention information, part of a pol-icy not to promote material from otheragencies. Various offices within theW.H.O.’s balkanized hierarchy also jock-eyed for position.
The difficulties in tracking cases andgaining access to villages led many tothink the outbreak was burning out. “Icame home sort of thinking, with a littleluck, that’s wrapped up,” said Dr. DanielBausch, an Ebola outbreak veteranfrom Tulane University, who returned inMay from a W.H.O. mission in Guinea.
The outbreak was not gone, just hid-den. An herbalist in Sierra Leone con-tracted the virus treating Guinean pa-tients. More than a dozen mourners ather funeral fell ill and seeded Sierra Le-one. Some of them traveled back toGuinea and rekindled the outbreakthere. After a lull of several weeks,cases re-emerged in Liberia, too, andreached the capital, Monrovia.
Dr. Bausch flew to Sierra Leone inJuly. “I was like, ‘where is everybody?’”referring to the shortage of health work-ers fighting the disease. “We all recog-nized we were really understaffed. Weneeded more people in the field.”
In some treatment centers, two orthree doctors, wearing stifling gownsand masks in the heat, were caring forup to 90 patients. With the only W.H.O.logistician in the country working else-where, Dr. Bausch did not have anyoneto accompany him and manage suppliesof protective equipment, he said.
Dr. Bausch worked in Kenema, SierraLeone, where he had helped set up a re-search program for another hemor-rhagic fever, Lassa, which was commonin the region. He knew some of the near-ly two dozen health workers there whodied after Ebola hit.
“It would be a logical question to ask,since Lassa was there, why was it sohard to switch gears” to Ebola?, Dr.Bausch said. But research institutesprovided money for science, he said, notfor disease surveillance and treatment.Those tasks had been left to the govern-ment of Sierra Leone, “one of the poor-est countries on earth,” he said. “I al-ways felt bad about this.”
In late July in Liberia, two Americansworking at a missionary hospital fellsick and were soon evacuated home. ALiberian-American brought the virus byplane to Nigeria, Africa’s most populousnation. Suddenly, the world seemed tounderstand the threat.
The question now, experts wonder, iswhether the leaner, retooled W.H.O. —heavy on technical know-how, light onlogistical muscle — can surge in a waythat will help lead the world in bringingone of the most challenging health cri-ses in recent history to a close. W.H.O.’sroad map calls for $490 million from do-nors, and thousands of foreign and localhealth workers to contain the outbreak.Yet few foreign medical teams have yetanswered the call.
“It is incumbent on the internationalcommunity to really respond now,” saidDr. Kasolo, a W.H.O. director in Africa.“Otherwise history will judge us badly.”
Cuts at W.H.O. Hurt Response to Ebola Crisis, Officials Say
PHOTOGRAPHS BY DANIEL BEREHULAK FOR THE NEW YORK TIMES
From Page A1
Health workers, above, prepared toenter a high-risk ward at an Ebolatreatment center in Monrovia, Li-beria, run by Doctors Without Bor-ders. At left, relatives of a man whodied of what appeared to be Ebolawaited outside their home in Mon-rovia while a team of workerssprayed and disinfected the area.
MICHAEL APPLETON FOR THE NEW YORK TIMES
Dr. Margaret Chan, the director general of the W.H.O., with Dr. Da-vid Nabarro, left, the United Nations senior system coordinator forEbola, and Dr. Keiji Fukuda, an assistant director general at W.H.O.
C M Y K Nxxx,2014-09-04,A,006,Bs-4C,E1
A6 N INTERNATIONALTHE NEW YORK TIMES THURSDAY, SEPTEMBER 4, 2014
ability to respond in parts of the worldthat need it most. Its outbreak andemergency response units have beenslashed, veterans who led previousfights against Ebola and other diseaseshave left, and scores of positions havebeen eliminated — precisely the kind ofpeople and efforts that might havehelped blunt the outbreak in West Af-rica before it ballooned into the worstEbola epidemic ever recorded.
Unlike the SARS crisis of 2003, whichstruck countries in Asia and elsewherethat had strong governments and amplemoney to spring to action, the Ebolaoutbreak has waylaid nations that oftenlack basic health care, much less theability to mount big campaigns to stampout epidemics.
The disease spread for months beforebeing detected because much of thework of spotting outbreaks was left todesperately poor countries ill preparedfor the task. Once the W.H.O. learned ofthe outbreak, its efforts to help trackand contain it were poorly led and lim-ited, according to some doctors whoparticipated, contributing to a sensethat the problem was not as bad as it ac-tually was. Then, as the extent of theepidemic became obvious, critics saythe agency was slow to declare its se-verity and come up with plans, and hasstill not marshaled the people and sup-plies needed to help defeat the diseaseand treat its victims.
“There’s no doubt we’ve not been asquick and as powerful as we might havebeen,” said Dr. Marie-Paule Kieny, aW.H.O. assistant director general.
Another W.H.O. leader agreed. “Ofcourse in retrospect I really wish thatwe had jumped much higher much ear-lier,” said Dr. Keiji Fukuda, the assistantdirector general in charge of outbreakresponse. “Of course I wish we’d pouredin more and more earlier.” But, he add-ed, “if this outbreak had been a typicaloutbreak, nobody would be saying wedid too little, too late.”
The outbreak began close to the bor-ders of three neighboring countries —Guinea, Sierra Leone and Liberia — andspread surprisingly fast. Since then, theW.H.O. has engaged more than 400 peo-ple to work on the outbreak, includingemployees of other agencies in its net-work, and in August the agency de-clared the epidemic an internationalemergency, hoping to stop it from cross-ing more borders. Dr. Chan has metwith presidents in the region, and lastweek the W.H.O. announced what itcalled a road map for a “massivelyscaled” international response.
The current outbreak has killed morethan 1,900 people and spread to thepoint that the W.H.O. warns that morethan 20,000 people could become in-fected. Sick people are dying on thestreet. Some feel the entire model theworld uses to fight outbreaks needs tobe rethought, so that an agency like theW.H.O. has the structure and mandateto take command.
But Dr. Chan said that governmentshave the primary responsibility “to takecare of their people,” calling the W.H.O.a technical agency that provides adviceand support. Still, she noted that her or-ganization, like many governments andagencies, was not prepared.
“Hindsight is always better,” Dr.Chan said. “All the agencies I talked to— including the governments — all of usunderestimated this unprecedented, un-usual outbreak.”
A Shift in EmphasisThe W.H.O., founded in 1948, is re-
sponsible for taking on a wide range ofglobal health issues, from obesity to pri-mary health care. But since the world’shealth needs far outstrip the financialcontributions of the W.H.O.’s 194 mem-ber nations, those priorities compete.
The threat of emergent infectious dis-eases jumped high onto that list 20years ago, when an outbreak of plaguein India created a panic, sending about200,000 people fleeing. The next year inZaire, now the Democratic Republic ofCongo, Ebola killed about 245 people.With fears of cross-border infectionshigh, a new urgency arose: improvingthe world’s ability to stop outbreaks.
The W.H.O. took the lead, at the re-quest of its member nations. A crew ofpassionate outbreak veterans assem-bled a unique department, using an ear-ly form of electronic crowdsourcing todetect outbreaks and dispatching ex-perts to the field. Three years after theeffort solidified, the W.H.O. played a bigrole in responding to a cluster of deadlypneumonia cases in Asia. The new virusbecame known as SARS, and it was con-tained within the year, with most casesoccurring in China.
To aid the fight, wealthy individualsoffered the W.H.O. “literally hundredsof millions because their businesseswere affected,” said Dr. Jim Yong Kim,president of the World Bank and a for-mer director at the W.H.O. “But asSARS burned out, those guys disap-peared, and we forgot very quickly.”
Soon, the global financial crisisstruck. The W.H.O. had to cut nearly $1billion from its proposed two-year budg-et, which today stands at $3.98 billion.(By contrast, the budget of the Centersfor Disease Control and Prevention for2013 alone was about $6 billion.) Thecuts forced difficult choices. More em-phasis was placed on efforts like fight-ing chronic global ailments, includingheart disease and diabetes. The whimsof donors also greatly influenced theW.H.O.’s agenda, with gifts, often to ad-vance individual causes, far surpassingdues from member nations, which ac-count for only 20 percent of its budget.
At the agency’s Geneva headquar-ters, outbreak and emergency re-sponse, which was never especially wellfunded, suffered particularly deeplosses, leaving offices that look, one con-sultant said, like a ghost town. TheW.H.O.’s epidemic and pandemic re-
sponse department — including a net-work of anthropologists to help over-come cultural differences during out-breaks — was dissolved, its duties splitamong other departments. Some of themain outbreak pioneers moved on.
“That shaping of the budget did affectthe area of responding to big outbreaksand pandemics,” said Dr. Fukuda, whoestimated that he now had 35 percentfewer employees than during the 2009H1N1 flu pandemic — more than doublethe cuts for the organization as a whole.
“You have to wonder are we makingthe right strategic choices?” he said.“Are we ready for what’s coming downthe pike?”
The entire W.H.O. unit devoted to thescience of pandemic and epidemic dis-eases — responsible for more than adozen killers, including flu, cholera, yel-low fever and bubonic plague — hasonly 52 regular employees, includingsecretaries, according to its director, Dr.Sylvie Briand, who said that could be in-creased during outbreaks. Before theEbola epidemic, her department hadjust one technical expert on Ebola andother hemorrhagic diseases.
Across Africa, the ranks of the agen-cy’s regional emergency outbreak ex-perts, veterans in fighting Ebola, werecut from more than a dozen to three.“How can you immediately respond toan outbreak?” said Dr. Francis C. Kaso-lo, a W.H.O. director. “It did affect us.”
And a separate section of the W.H.O.responsible for emergency responsewas whittled “to the bone” during thebudget cuts — to 34 staff members fromabout 94 — according to Dr. Bruce Ayl-ward, its assistant director general.
“You can’t make a cut that big, thatdeep, and it’s not going to have an effecton your operational capacity,” he said.
His group, charged with responding
to wars, disasters and resurgent polio,was asked in August to assist with Ebo-la, too. “At no time that I can think of inthe recent past have we been dealingwith such a scale of human misery oversuch a broad geography due to such arange of hazards,” he said, includingenormous population displacements inSyria, Iraq, the Central African Republicand South Sudan. But, officials warn,multiple, overlapping challenges maywell be a feature of the future.
The W.H.O. hoped to balance itsbudget cuts by strengthening the abilityof countries to respond to public healththreats on their own. It put out new reg-ulations for nations to follow to helpcontain outbreaks. But by 2012, thedeadline it set, only 20 percent of na-tions had enacted them all. In Africa,fewer than a third of countries had pro-grams to detect and stop infectious dis-eases at their borders. The W.H.O.’sstrategy was often more theory than re-ality.
“There never were the resources toput those things in place in many partsof the world,” said Dr. Scott F. Dowell, aspecialist formerly with the C.D.C.
A Disease Finds Its OpeningThe Ebola virus took full advantage
of these poorly prepared nations andthe holes at the W.H.O.
Given the weakness in surveillance,the outbreak was not identified untilMarch, in Guinea, roughly three monthsafter a villager was believed to havecontracted the virus from an animal,possibly a fruit bat. The delay alloweddozens of cases to spread through vil-lages and even to Conakry, a capital ofmore than one and a half million people.Right away, Doctors Without Bordersdeclared the outbreak unprecedented in
its reach, the only group to do so.Hastening the spread, hospitals
lacked basic infection-control essentialslike running water, protective gownsand gloves. Many doctors and nursescaught the virus from their patients,passed it to others, and died. The vul-nerability and collapse of medical facili-ties revealed how far there is to go inachieving the W.H.O.’s top priority —ensuring basic global health care.
“This kind of outbreak would nothave developed in an area with strongerhealth systems,” Dr. Fukuda said.
In the crucial weeks after the dis-covery, daily meetings brought togethernational authorities and foreign re-sponders at the W.H.O. office in Cona-kry. But an absence of strong leader-ship and professionalism was notablefrom the beginning, participants said.
“It’s purely improvisation,” said MarcPoncin, the emergency coordinator forDoctors Without Borders in Conakry.“There is no one to take responsibility,absolutely no one, since the beginningof the crisis.”
Stopping previous Ebola outbreakshad required meticulous tracking: mon-itoring people who had close contactwith infected individuals and isolatingthem if they developed symptoms. Pre-viously, “if we missed a case,” said Dr.Simon Mardel, a British emergencydoctor deployed by the W.H.O. to helpwith the effort, “it was like a failure.”
This time, the number of contacts be-ing followed was disastrously low fromthe beginning, only 8 percent in the epi-center of Guéckédou, Guinea, in earlyApril, according to another doctor sentby the W.H.O. That meant the diseasewas silently spreading. Dr. Mardel saidhe thought the more experiencedW.H.O. leaders who had left the agency“would have been very vocal, and theywould have sought to put it right quick-ly, as a matter of urgency.” A single per-son who traveled and became sick couldtouch off a conflagration.
It was not that responders were nottrying. Victims’ contacts were spreadacross a wide area, hours away on badroads. The payment of local workershad somehow been overlooked, so theystopped doing vital, risky jobs. Essen-tial protective equipment was not deliv-ered to many who needed it. Bottles ofbleach were given out without buckets.The W.H.O. lacked relationships withsome longstanding organizations withlarge networks of health workers in theregion.
Traditions that contributed to Ebola’sspread, including funerals wheremourners came into contact withcorpses, were not fully recognized orconfronted, said Dr. Pierre Rollin, anoutbreak specialist at the Centers forDisease Control and Prevention whoworked within the W.H.O. umbrella.
Some villagers blocked roads withtree trunks and drove Ebola workersaway with stones, accusing them of
bringing in the disease. Adding to thetension, only bare-bones clinical carewas provided to try to treat patients, re-ducing the chances of yielding survi-vors who could act as ambassadors forthe cause. Some doctors deployed bythe W.H.O. said it should have giventhem more tools to care for patients.
Institutional and personal tensionsflared. “Everyone’s working at a fe-vered pace,” Dr. Dowell said. “There’sconfusion and chaos. It argues for a sys-tem that’s organized as much as pos-sible ahead of time so people know theirroles.”
One consultant thought it strangethat the W.H.O. would not send Twittermessages with links to the C.D.C.’s Ebo-la prevention information, part of a pol-icy not to promote material from otheragencies. Various offices within theW.H.O.’s balkanized hierarchy also jock-eyed for position.
The difficulties in tracking cases andgaining access to villages led many tothink the outbreak was burning out. “Icame home sort of thinking, with a littleluck, that’s wrapped up,” said Dr. DanielBausch, an Ebola outbreak veteranfrom Tulane University, who returned inMay from a W.H.O. mission in Guinea.
The outbreak was not gone, just hid-den. An herbalist in Sierra Leone con-tracted the virus treating Guinean pa-tients. More than a dozen mourners ather funeral fell ill and seeded Sierra Le-one. Some of them traveled back toGuinea and rekindled the outbreakthere. After a lull of several weeks,cases re-emerged in Liberia, too, andreached the capital, Monrovia.
Dr. Bausch flew to Sierra Leone inJuly. “I was like, ‘where is everybody?’”referring to the shortage of health work-ers fighting the disease. “We all recog-nized we were really understaffed. Weneeded more people in the field.”
In some treatment centers, two orthree doctors, wearing stifling gownsand masks in the heat, were caring forup to 90 patients. With the only W.H.O.logistician in the country working else-where, Dr. Bausch did not have anyoneto accompany him and manage suppliesof protective equipment, he said.
Dr. Bausch worked in Kenema, SierraLeone, where he had helped set up a re-search program for another hemor-rhagic fever, Lassa, which was commonin the region. He knew some of the near-ly two dozen health workers there whodied after Ebola hit.
“It would be a logical question to ask,since Lassa was there, why was it sohard to switch gears” to Ebola?, Dr.Bausch said. But research institutesprovided money for science, he said, notfor disease surveillance and treatment.Those tasks had been left to the govern-ment of Sierra Leone, “one of the poor-est countries on earth,” he said. “I al-ways felt bad about this.”
In late July in Liberia, two Americansworking at a missionary hospital fellsick and were soon evacuated home. ALiberian-American brought the virus byplane to Nigeria, Africa’s most populousnation. Suddenly, the world seemed tounderstand the threat.
The question now, experts wonder, iswhether the leaner, retooled W.H.O. —heavy on technical know-how, light onlogistical muscle — can surge in a waythat will help lead the world in bringingone of the most challenging health cri-ses in recent history to a close. W.H.O.’sroad map calls for $490 million from do-nors, and thousands of foreign and localhealth workers to contain the outbreak.Yet few foreign medical teams have yetanswered the call.
“It is incumbent on the internationalcommunity to really respond now,” saidDr. Kasolo, a W.H.O. director in Africa.“Otherwise history will judge us badly.”
Cuts at W.H.O. Hurt Response to Ebola Crisis, Officials Say
PHOTOGRAPHS BY DANIEL BEREHULAK FOR THE NEW YORK TIMES
From Page A1
Health workers, above, prepared toenter a high-risk ward at an Ebolatreatment center in Monrovia, Li-beria, run by Doctors Without Bor-ders. At left, relatives of a man whodied of what appeared to be Ebolawaited outside their home in Mon-rovia while a team of workerssprayed and disinfected the area.
MICHAEL APPLETON FOR THE NEW YORK TIMES
Dr. Margaret Chan, the director general of the W.H.O., with Dr. Da-vid Nabarro, left, the United Nations senior system coordinator forEbola, and Dr. Keiji Fukuda, an assistant director general at W.H.O.
C M Y K Nxxx,2014-09-04,A,006,Bs-4C,E1
A6 N INTERNATIONALTHE NEW YORK TIMES THURSDAY, SEPTEMBER 4, 2014
ability to respond in parts of the worldthat need it most. Its outbreak andemergency response units have beenslashed, veterans who led previousfights against Ebola and other diseaseshave left, and scores of positions havebeen eliminated — precisely the kind ofpeople and efforts that might havehelped blunt the outbreak in West Af-rica before it ballooned into the worstEbola epidemic ever recorded.
Unlike the SARS crisis of 2003, whichstruck countries in Asia and elsewherethat had strong governments and amplemoney to spring to action, the Ebolaoutbreak has waylaid nations that oftenlack basic health care, much less theability to mount big campaigns to stampout epidemics.
The disease spread for months beforebeing detected because much of thework of spotting outbreaks was left todesperately poor countries ill preparedfor the task. Once the W.H.O. learned ofthe outbreak, its efforts to help trackand contain it were poorly led and lim-ited, according to some doctors whoparticipated, contributing to a sensethat the problem was not as bad as it ac-tually was. Then, as the extent of theepidemic became obvious, critics saythe agency was slow to declare its se-verity and come up with plans, and hasstill not marshaled the people and sup-plies needed to help defeat the diseaseand treat its victims.
“There’s no doubt we’ve not been asquick and as powerful as we might havebeen,” said Dr. Marie-Paule Kieny, aW.H.O. assistant director general.
Another W.H.O. leader agreed. “Ofcourse in retrospect I really wish thatwe had jumped much higher much ear-lier,” said Dr. Keiji Fukuda, the assistantdirector general in charge of outbreakresponse. “Of course I wish we’d pouredin more and more earlier.” But, he add-ed, “if this outbreak had been a typicaloutbreak, nobody would be saying wedid too little, too late.”
The outbreak began close to the bor-ders of three neighboring countries —Guinea, Sierra Leone and Liberia — andspread surprisingly fast. Since then, theW.H.O. has engaged more than 400 peo-ple to work on the outbreak, includingemployees of other agencies in its net-work, and in August the agency de-clared the epidemic an internationalemergency, hoping to stop it from cross-ing more borders. Dr. Chan has metwith presidents in the region, and lastweek the W.H.O. announced what itcalled a road map for a “massivelyscaled” international response.
The current outbreak has killed morethan 1,900 people and spread to thepoint that the W.H.O. warns that morethan 20,000 people could become in-fected. Sick people are dying on thestreet. Some feel the entire model theworld uses to fight outbreaks needs tobe rethought, so that an agency like theW.H.O. has the structure and mandateto take command.
But Dr. Chan said that governmentshave the primary responsibility “to takecare of their people,” calling the W.H.O.a technical agency that provides adviceand support. Still, she noted that her or-ganization, like many governments andagencies, was not prepared.
“Hindsight is always better,” Dr.Chan said. “All the agencies I talked to— including the governments — all of usunderestimated this unprecedented, un-usual outbreak.”
A Shift in EmphasisThe W.H.O., founded in 1948, is re-
sponsible for taking on a wide range ofglobal health issues, from obesity to pri-mary health care. But since the world’shealth needs far outstrip the financialcontributions of the W.H.O.’s 194 mem-ber nations, those priorities compete.
The threat of emergent infectious dis-eases jumped high onto that list 20years ago, when an outbreak of plaguein India created a panic, sending about200,000 people fleeing. The next year inZaire, now the Democratic Republic ofCongo, Ebola killed about 245 people.With fears of cross-border infectionshigh, a new urgency arose: improvingthe world’s ability to stop outbreaks.
The W.H.O. took the lead, at the re-quest of its member nations. A crew ofpassionate outbreak veterans assem-bled a unique department, using an ear-ly form of electronic crowdsourcing todetect outbreaks and dispatching ex-perts to the field. Three years after theeffort solidified, the W.H.O. played a bigrole in responding to a cluster of deadlypneumonia cases in Asia. The new virusbecame known as SARS, and it was con-tained within the year, with most casesoccurring in China.
To aid the fight, wealthy individualsoffered the W.H.O. “literally hundredsof millions because their businesseswere affected,” said Dr. Jim Yong Kim,president of the World Bank and a for-mer director at the W.H.O. “But asSARS burned out, those guys disap-peared, and we forgot very quickly.”
Soon, the global financial crisisstruck. The W.H.O. had to cut nearly $1billion from its proposed two-year budg-et, which today stands at $3.98 billion.(By contrast, the budget of the Centersfor Disease Control and Prevention for2013 alone was about $6 billion.) Thecuts forced difficult choices. More em-phasis was placed on efforts like fight-ing chronic global ailments, includingheart disease and diabetes. The whimsof donors also greatly influenced theW.H.O.’s agenda, with gifts, often to ad-vance individual causes, far surpassingdues from member nations, which ac-count for only 20 percent of its budget.
At the agency’s Geneva headquar-ters, outbreak and emergency re-sponse, which was never especially wellfunded, suffered particularly deeplosses, leaving offices that look, one con-sultant said, like a ghost town. TheW.H.O.’s epidemic and pandemic re-
sponse department — including a net-work of anthropologists to help over-come cultural differences during out-breaks — was dissolved, its duties splitamong other departments. Some of themain outbreak pioneers moved on.
“That shaping of the budget did affectthe area of responding to big outbreaksand pandemics,” said Dr. Fukuda, whoestimated that he now had 35 percentfewer employees than during the 2009H1N1 flu pandemic — more than doublethe cuts for the organization as a whole.
“You have to wonder are we makingthe right strategic choices?” he said.“Are we ready for what’s coming downthe pike?”
The entire W.H.O. unit devoted to thescience of pandemic and epidemic dis-eases — responsible for more than adozen killers, including flu, cholera, yel-low fever and bubonic plague — hasonly 52 regular employees, includingsecretaries, according to its director, Dr.Sylvie Briand, who said that could be in-creased during outbreaks. Before theEbola epidemic, her department hadjust one technical expert on Ebola andother hemorrhagic diseases.
Across Africa, the ranks of the agen-cy’s regional emergency outbreak ex-perts, veterans in fighting Ebola, werecut from more than a dozen to three.“How can you immediately respond toan outbreak?” said Dr. Francis C. Kaso-lo, a W.H.O. director. “It did affect us.”
And a separate section of the W.H.O.responsible for emergency responsewas whittled “to the bone” during thebudget cuts — to 34 staff members fromabout 94 — according to Dr. Bruce Ayl-ward, its assistant director general.
“You can’t make a cut that big, thatdeep, and it’s not going to have an effecton your operational capacity,” he said.
His group, charged with responding
to wars, disasters and resurgent polio,was asked in August to assist with Ebo-la, too. “At no time that I can think of inthe recent past have we been dealingwith such a scale of human misery oversuch a broad geography due to such arange of hazards,” he said, includingenormous population displacements inSyria, Iraq, the Central African Republicand South Sudan. But, officials warn,multiple, overlapping challenges maywell be a feature of the future.
The W.H.O. hoped to balance itsbudget cuts by strengthening the abilityof countries to respond to public healththreats on their own. It put out new reg-ulations for nations to follow to helpcontain outbreaks. But by 2012, thedeadline it set, only 20 percent of na-tions had enacted them all. In Africa,fewer than a third of countries had pro-grams to detect and stop infectious dis-eases at their borders. The W.H.O.’sstrategy was often more theory than re-ality.
“There never were the resources toput those things in place in many partsof the world,” said Dr. Scott F. Dowell, aspecialist formerly with the C.D.C.
A Disease Finds Its OpeningThe Ebola virus took full advantage
of these poorly prepared nations andthe holes at the W.H.O.
Given the weakness in surveillance,the outbreak was not identified untilMarch, in Guinea, roughly three monthsafter a villager was believed to havecontracted the virus from an animal,possibly a fruit bat. The delay alloweddozens of cases to spread through vil-lages and even to Conakry, a capital ofmore than one and a half million people.Right away, Doctors Without Bordersdeclared the outbreak unprecedented in
its reach, the only group to do so.Hastening the spread, hospitals
lacked basic infection-control essentialslike running water, protective gownsand gloves. Many doctors and nursescaught the virus from their patients,passed it to others, and died. The vul-nerability and collapse of medical facili-ties revealed how far there is to go inachieving the W.H.O.’s top priority —ensuring basic global health care.
“This kind of outbreak would nothave developed in an area with strongerhealth systems,” Dr. Fukuda said.
In the crucial weeks after the dis-covery, daily meetings brought togethernational authorities and foreign re-sponders at the W.H.O. office in Cona-kry. But an absence of strong leader-ship and professionalism was notablefrom the beginning, participants said.
“It’s purely improvisation,” said MarcPoncin, the emergency coordinator forDoctors Without Borders in Conakry.“There is no one to take responsibility,absolutely no one, since the beginningof the crisis.”
Stopping previous Ebola outbreakshad required meticulous tracking: mon-itoring people who had close contactwith infected individuals and isolatingthem if they developed symptoms. Pre-viously, “if we missed a case,” said Dr.Simon Mardel, a British emergencydoctor deployed by the W.H.O. to helpwith the effort, “it was like a failure.”
This time, the number of contacts be-ing followed was disastrously low fromthe beginning, only 8 percent in the epi-center of Guéckédou, Guinea, in earlyApril, according to another doctor sentby the W.H.O. That meant the diseasewas silently spreading. Dr. Mardel saidhe thought the more experiencedW.H.O. leaders who had left the agency“would have been very vocal, and theywould have sought to put it right quick-ly, as a matter of urgency.” A single per-son who traveled and became sick couldtouch off a conflagration.
It was not that responders were nottrying. Victims’ contacts were spreadacross a wide area, hours away on badroads. The payment of local workershad somehow been overlooked, so theystopped doing vital, risky jobs. Essen-tial protective equipment was not deliv-ered to many who needed it. Bottles ofbleach were given out without buckets.The W.H.O. lacked relationships withsome longstanding organizations withlarge networks of health workers in theregion.
Traditions that contributed to Ebola’sspread, including funerals wheremourners came into contact withcorpses, were not fully recognized orconfronted, said Dr. Pierre Rollin, anoutbreak specialist at the Centers forDisease Control and Prevention whoworked within the W.H.O. umbrella.
Some villagers blocked roads withtree trunks and drove Ebola workersaway with stones, accusing them of
bringing in the disease. Adding to thetension, only bare-bones clinical carewas provided to try to treat patients, re-ducing the chances of yielding survi-vors who could act as ambassadors forthe cause. Some doctors deployed bythe W.H.O. said it should have giventhem more tools to care for patients.
Institutional and personal tensionsflared. “Everyone’s working at a fe-vered pace,” Dr. Dowell said. “There’sconfusion and chaos. It argues for a sys-tem that’s organized as much as pos-sible ahead of time so people know theirroles.”
One consultant thought it strangethat the W.H.O. would not send Twittermessages with links to the C.D.C.’s Ebo-la prevention information, part of a pol-icy not to promote material from otheragencies. Various offices within theW.H.O.’s balkanized hierarchy also jock-eyed for position.
The difficulties in tracking cases andgaining access to villages led many tothink the outbreak was burning out. “Icame home sort of thinking, with a littleluck, that’s wrapped up,” said Dr. DanielBausch, an Ebola outbreak veteranfrom Tulane University, who returned inMay from a W.H.O. mission in Guinea.
The outbreak was not gone, just hid-den. An herbalist in Sierra Leone con-tracted the virus treating Guinean pa-tients. More than a dozen mourners ather funeral fell ill and seeded Sierra Le-one. Some of them traveled back toGuinea and rekindled the outbreakthere. After a lull of several weeks,cases re-emerged in Liberia, too, andreached the capital, Monrovia.
Dr. Bausch flew to Sierra Leone inJuly. “I was like, ‘where is everybody?’”referring to the shortage of health work-ers fighting the disease. “We all recog-nized we were really understaffed. Weneeded more people in the field.”
In some treatment centers, two orthree doctors, wearing stifling gownsand masks in the heat, were caring forup to 90 patients. With the only W.H.O.logistician in the country working else-where, Dr. Bausch did not have anyoneto accompany him and manage suppliesof protective equipment, he said.
Dr. Bausch worked in Kenema, SierraLeone, where he had helped set up a re-search program for another hemor-rhagic fever, Lassa, which was commonin the region. He knew some of the near-ly two dozen health workers there whodied after Ebola hit.
“It would be a logical question to ask,since Lassa was there, why was it sohard to switch gears” to Ebola?, Dr.Bausch said. But research institutesprovided money for science, he said, notfor disease surveillance and treatment.Those tasks had been left to the govern-ment of Sierra Leone, “one of the poor-est countries on earth,” he said. “I al-ways felt bad about this.”
In late July in Liberia, two Americansworking at a missionary hospital fellsick and were soon evacuated home. ALiberian-American brought the virus byplane to Nigeria, Africa’s most populousnation. Suddenly, the world seemed tounderstand the threat.
The question now, experts wonder, iswhether the leaner, retooled W.H.O. —heavy on technical know-how, light onlogistical muscle — can surge in a waythat will help lead the world in bringingone of the most challenging health cri-ses in recent history to a close. W.H.O.’sroad map calls for $490 million from do-nors, and thousands of foreign and localhealth workers to contain the outbreak.Yet few foreign medical teams have yetanswered the call.
“It is incumbent on the internationalcommunity to really respond now,” saidDr. Kasolo, a W.H.O. director in Africa.“Otherwise history will judge us badly.”
Cuts at W.H.O. Hurt Response to Ebola Crisis, Officials Say
PHOTOGRAPHS BY DANIEL BEREHULAK FOR THE NEW YORK TIMES
From Page A1
Health workers, above, prepared toenter a high-risk ward at an Ebolatreatment center in Monrovia, Li-beria, run by Doctors Without Bor-ders. At left, relatives of a man whodied of what appeared to be Ebolawaited outside their home in Mon-rovia while a team of workerssprayed and disinfected the area.
MICHAEL APPLETON FOR THE NEW YORK TIMES
Dr. Margaret Chan, the director general of the W.H.O., with Dr. Da-vid Nabarro, left, the United Nations senior system coordinator forEbola, and Dr. Keiji Fukuda, an assistant director general at W.H.O.
C M Y K Nxxx,2014-09-04,A,006,Bs-4C,E1
A6 N INTERNATIONALTHE NEW YORK TIMES THURSDAY, SEPTEMBER 4, 2014
ability to respond in parts of the worldthat need it most. Its outbreak andemergency response units have beenslashed, veterans who led previousfights against Ebola and other diseaseshave left, and scores of positions havebeen eliminated — precisely the kind ofpeople and efforts that might havehelped blunt the outbreak in West Af-rica before it ballooned into the worstEbola epidemic ever recorded.
Unlike the SARS crisis of 2003, whichstruck countries in Asia and elsewherethat had strong governments and amplemoney to spring to action, the Ebolaoutbreak has waylaid nations that oftenlack basic health care, much less theability to mount big campaigns to stampout epidemics.
The disease spread for months beforebeing detected because much of thework of spotting outbreaks was left todesperately poor countries ill preparedfor the task. Once the W.H.O. learned ofthe outbreak, its efforts to help trackand contain it were poorly led and lim-ited, according to some doctors whoparticipated, contributing to a sensethat the problem was not as bad as it ac-tually was. Then, as the extent of theepidemic became obvious, critics saythe agency was slow to declare its se-verity and come up with plans, and hasstill not marshaled the people and sup-plies needed to help defeat the diseaseand treat its victims.
“There’s no doubt we’ve not been asquick and as powerful as we might havebeen,” said Dr. Marie-Paule Kieny, aW.H.O. assistant director general.
Another W.H.O. leader agreed. “Ofcourse in retrospect I really wish thatwe had jumped much higher much ear-lier,” said Dr. Keiji Fukuda, the assistantdirector general in charge of outbreakresponse. “Of course I wish we’d pouredin more and more earlier.” But, he add-ed, “if this outbreak had been a typicaloutbreak, nobody would be saying wedid too little, too late.”
The outbreak began close to the bor-ders of three neighboring countries —Guinea, Sierra Leone and Liberia — andspread surprisingly fast. Since then, theW.H.O. has engaged more than 400 peo-ple to work on the outbreak, includingemployees of other agencies in its net-work, and in August the agency de-clared the epidemic an internationalemergency, hoping to stop it from cross-ing more borders. Dr. Chan has metwith presidents in the region, and lastweek the W.H.O. announced what itcalled a road map for a “massivelyscaled” international response.
The current outbreak has killed morethan 1,900 people and spread to thepoint that the W.H.O. warns that morethan 20,000 people could become in-fected. Sick people are dying on thestreet. Some feel the entire model theworld uses to fight outbreaks needs tobe rethought, so that an agency like theW.H.O. has the structure and mandateto take command.
But Dr. Chan said that governmentshave the primary responsibility “to takecare of their people,” calling the W.H.O.a technical agency that provides adviceand support. Still, she noted that her or-ganization, like many governments andagencies, was not prepared.
“Hindsight is always better,” Dr.Chan said. “All the agencies I talked to— including the governments — all of usunderestimated this unprecedented, un-usual outbreak.”
A Shift in EmphasisThe W.H.O., founded in 1948, is re-
sponsible for taking on a wide range ofglobal health issues, from obesity to pri-mary health care. But since the world’shealth needs far outstrip the financialcontributions of the W.H.O.’s 194 mem-ber nations, those priorities compete.
The threat of emergent infectious dis-eases jumped high onto that list 20years ago, when an outbreak of plaguein India created a panic, sending about200,000 people fleeing. The next year inZaire, now the Democratic Republic ofCongo, Ebola killed about 245 people.With fears of cross-border infectionshigh, a new urgency arose: improvingthe world’s ability to stop outbreaks.
The W.H.O. took the lead, at the re-quest of its member nations. A crew ofpassionate outbreak veterans assem-bled a unique department, using an ear-ly form of electronic crowdsourcing todetect outbreaks and dispatching ex-perts to the field. Three years after theeffort solidified, the W.H.O. played a bigrole in responding to a cluster of deadlypneumonia cases in Asia. The new virusbecame known as SARS, and it was con-tained within the year, with most casesoccurring in China.
To aid the fight, wealthy individualsoffered the W.H.O. “literally hundredsof millions because their businesseswere affected,” said Dr. Jim Yong Kim,president of the World Bank and a for-mer director at the W.H.O. “But asSARS burned out, those guys disap-peared, and we forgot very quickly.”
Soon, the global financial crisisstruck. The W.H.O. had to cut nearly $1billion from its proposed two-year budg-et, which today stands at $3.98 billion.(By contrast, the budget of the Centersfor Disease Control and Prevention for2013 alone was about $6 billion.) Thecuts forced difficult choices. More em-phasis was placed on efforts like fight-ing chronic global ailments, includingheart disease and diabetes. The whimsof donors also greatly influenced theW.H.O.’s agenda, with gifts, often to ad-vance individual causes, far surpassingdues from member nations, which ac-count for only 20 percent of its budget.
At the agency’s Geneva headquar-ters, outbreak and emergency re-sponse, which was never especially wellfunded, suffered particularly deeplosses, leaving offices that look, one con-sultant said, like a ghost town. TheW.H.O.’s epidemic and pandemic re-
sponse department — including a net-work of anthropologists to help over-come cultural differences during out-breaks — was dissolved, its duties splitamong other departments. Some of themain outbreak pioneers moved on.
“That shaping of the budget did affectthe area of responding to big outbreaksand pandemics,” said Dr. Fukuda, whoestimated that he now had 35 percentfewer employees than during the 2009H1N1 flu pandemic — more than doublethe cuts for the organization as a whole.
“You have to wonder are we makingthe right strategic choices?” he said.“Are we ready for what’s coming downthe pike?”
The entire W.H.O. unit devoted to thescience of pandemic and epidemic dis-eases — responsible for more than adozen killers, including flu, cholera, yel-low fever and bubonic plague — hasonly 52 regular employees, includingsecretaries, according to its director, Dr.Sylvie Briand, who said that could be in-creased during outbreaks. Before theEbola epidemic, her department hadjust one technical expert on Ebola andother hemorrhagic diseases.
Across Africa, the ranks of the agen-cy’s regional emergency outbreak ex-perts, veterans in fighting Ebola, werecut from more than a dozen to three.“How can you immediately respond toan outbreak?” said Dr. Francis C. Kaso-lo, a W.H.O. director. “It did affect us.”
And a separate section of the W.H.O.responsible for emergency responsewas whittled “to the bone” during thebudget cuts — to 34 staff members fromabout 94 — according to Dr. Bruce Ayl-ward, its assistant director general.
“You can’t make a cut that big, thatdeep, and it’s not going to have an effecton your operational capacity,” he said.
His group, charged with responding
to wars, disasters and resurgent polio,was asked in August to assist with Ebo-la, too. “At no time that I can think of inthe recent past have we been dealingwith such a scale of human misery oversuch a broad geography due to such arange of hazards,” he said, includingenormous population displacements inSyria, Iraq, the Central African Republicand South Sudan. But, officials warn,multiple, overlapping challenges maywell be a feature of the future.
The W.H.O. hoped to balance itsbudget cuts by strengthening the abilityof countries to respond to public healththreats on their own. It put out new reg-ulations for nations to follow to helpcontain outbreaks. But by 2012, thedeadline it set, only 20 percent of na-tions had enacted them all. In Africa,fewer than a third of countries had pro-grams to detect and stop infectious dis-eases at their borders. The W.H.O.’sstrategy was often more theory than re-ality.
“There never were the resources toput those things in place in many partsof the world,” said Dr. Scott F. Dowell, aspecialist formerly with the C.D.C.
A Disease Finds Its OpeningThe Ebola virus took full advantage
of these poorly prepared nations andthe holes at the W.H.O.
Given the weakness in surveillance,the outbreak was not identified untilMarch, in Guinea, roughly three monthsafter a villager was believed to havecontracted the virus from an animal,possibly a fruit bat. The delay alloweddozens of cases to spread through vil-lages and even to Conakry, a capital ofmore than one and a half million people.Right away, Doctors Without Bordersdeclared the outbreak unprecedented in
its reach, the only group to do so.Hastening the spread, hospitals
lacked basic infection-control essentialslike running water, protective gownsand gloves. Many doctors and nursescaught the virus from their patients,passed it to others, and died. The vul-nerability and collapse of medical facili-ties revealed how far there is to go inachieving the W.H.O.’s top priority —ensuring basic global health care.
“This kind of outbreak would nothave developed in an area with strongerhealth systems,” Dr. Fukuda said.
In the crucial weeks after the dis-covery, daily meetings brought togethernational authorities and foreign re-sponders at the W.H.O. office in Cona-kry. But an absence of strong leader-ship and professionalism was notablefrom the beginning, participants said.
“It’s purely improvisation,” said MarcPoncin, the emergency coordinator forDoctors Without Borders in Conakry.“There is no one to take responsibility,absolutely no one, since the beginningof the crisis.”
Stopping previous Ebola outbreakshad required meticulous tracking: mon-itoring people who had close contactwith infected individuals and isolatingthem if they developed symptoms. Pre-viously, “if we missed a case,” said Dr.Simon Mardel, a British emergencydoctor deployed by the W.H.O. to helpwith the effort, “it was like a failure.”
This time, the number of contacts be-ing followed was disastrously low fromthe beginning, only 8 percent in the epi-center of Guéckédou, Guinea, in earlyApril, according to another doctor sentby the W.H.O. That meant the diseasewas silently spreading. Dr. Mardel saidhe thought the more experiencedW.H.O. leaders who had left the agency“would have been very vocal, and theywould have sought to put it right quick-ly, as a matter of urgency.” A single per-son who traveled and became sick couldtouch off a conflagration.
It was not that responders were nottrying. Victims’ contacts were spreadacross a wide area, hours away on badroads. The payment of local workershad somehow been overlooked, so theystopped doing vital, risky jobs. Essen-tial protective equipment was not deliv-ered to many who needed it. Bottles ofbleach were given out without buckets.The W.H.O. lacked relationships withsome longstanding organizations withlarge networks of health workers in theregion.
Traditions that contributed to Ebola’sspread, including funerals wheremourners came into contact withcorpses, were not fully recognized orconfronted, said Dr. Pierre Rollin, anoutbreak specialist at the Centers forDisease Control and Prevention whoworked within the W.H.O. umbrella.
Some villagers blocked roads withtree trunks and drove Ebola workersaway with stones, accusing them of
bringing in the disease. Adding to thetension, only bare-bones clinical carewas provided to try to treat patients, re-ducing the chances of yielding survi-vors who could act as ambassadors forthe cause. Some doctors deployed bythe W.H.O. said it should have giventhem more tools to care for patients.
Institutional and personal tensionsflared. “Everyone’s working at a fe-vered pace,” Dr. Dowell said. “There’sconfusion and chaos. It argues for a sys-tem that’s organized as much as pos-sible ahead of time so people know theirroles.”
One consultant thought it strangethat the W.H.O. would not send Twittermessages with links to the C.D.C.’s Ebo-la prevention information, part of a pol-icy not to promote material from otheragencies. Various offices within theW.H.O.’s balkanized hierarchy also jock-eyed for position.
The difficulties in tracking cases andgaining access to villages led many tothink the outbreak was burning out. “Icame home sort of thinking, with a littleluck, that’s wrapped up,” said Dr. DanielBausch, an Ebola outbreak veteranfrom Tulane University, who returned inMay from a W.H.O. mission in Guinea.
The outbreak was not gone, just hid-den. An herbalist in Sierra Leone con-tracted the virus treating Guinean pa-tients. More than a dozen mourners ather funeral fell ill and seeded Sierra Le-one. Some of them traveled back toGuinea and rekindled the outbreakthere. After a lull of several weeks,cases re-emerged in Liberia, too, andreached the capital, Monrovia.
Dr. Bausch flew to Sierra Leone inJuly. “I was like, ‘where is everybody?’”referring to the shortage of health work-ers fighting the disease. “We all recog-nized we were really understaffed. Weneeded more people in the field.”
In some treatment centers, two orthree doctors, wearing stifling gownsand masks in the heat, were caring forup to 90 patients. With the only W.H.O.logistician in the country working else-where, Dr. Bausch did not have anyoneto accompany him and manage suppliesof protective equipment, he said.
Dr. Bausch worked in Kenema, SierraLeone, where he had helped set up a re-search program for another hemor-rhagic fever, Lassa, which was commonin the region. He knew some of the near-ly two dozen health workers there whodied after Ebola hit.
“It would be a logical question to ask,since Lassa was there, why was it sohard to switch gears” to Ebola?, Dr.Bausch said. But research institutesprovided money for science, he said, notfor disease surveillance and treatment.Those tasks had been left to the govern-ment of Sierra Leone, “one of the poor-est countries on earth,” he said. “I al-ways felt bad about this.”
In late July in Liberia, two Americansworking at a missionary hospital fellsick and were soon evacuated home. ALiberian-American brought the virus byplane to Nigeria, Africa’s most populousnation. Suddenly, the world seemed tounderstand the threat.
The question now, experts wonder, iswhether the leaner, retooled W.H.O. —heavy on technical know-how, light onlogistical muscle — can surge in a waythat will help lead the world in bringingone of the most challenging health cri-ses in recent history to a close. W.H.O.’sroad map calls for $490 million from do-nors, and thousands of foreign and localhealth workers to contain the outbreak.Yet few foreign medical teams have yetanswered the call.
“It is incumbent on the internationalcommunity to really respond now,” saidDr. Kasolo, a W.H.O. director in Africa.“Otherwise history will judge us badly.”
Cuts at W.H.O. Hurt Response to Ebola Crisis, Officials Say
PHOTOGRAPHS BY DANIEL BEREHULAK FOR THE NEW YORK TIMES
From Page A1
Health workers, above, prepared toenter a high-risk ward at an Ebolatreatment center in Monrovia, Li-beria, run by Doctors Without Bor-ders. At left, relatives of a man whodied of what appeared to be Ebolawaited outside their home in Mon-rovia while a team of workerssprayed and disinfected the area.
MICHAEL APPLETON FOR THE NEW YORK TIMES
Dr. Margaret Chan, the director general of the W.H.O., with Dr. Da-vid Nabarro, left, the United Nations senior system coordinator forEbola, and Dr. Keiji Fukuda, an assistant director general at W.H.O.
C M Y K Nxxx,2014-09-04,A,006,Bs-4C,E1
the street. Some feel the entire model the world uses to fight outbreaks needs to be rethought, so that an agency like the W.h.O. has the struc-ture and mandate to take command.
But Dr. Chan said that governments have the primary responsibility “to take care of their people,” calling the W.h.O. a technical agen-cy that provides advice and support. Still, she noted that her organization, like many govern-ments and agencies, was not prepared.
“hindsight is always better,” Dr. Chan said. “All the agencies i talked to — including the governments — all of us underestimated this unprecedented, unusual outbreak.”
A Shift in Emphasisthe W.h.O., founded in 1948, is responsible
for taking on a wide range of global health is-sues, from obesity to primary health care. But since the world’s health needs far outstrip the financial contributions of the W.h.O.’s 194 mem-ber nations, those priorities compete.
the threat of emergent infectious diseases jumped high onto that list 20 years ago, when an outbreak of plague in india created a panic, sending about 200,000 people fleeing. the next year in Zaire, now the Democratic Republic of Congo, Ebola killed about 245 people. With fears of cross-border infections high, a new urgency arose: improving the world’s ability to stop out-breaks.
the W.h.O. took the lead, at the request of its member nations. A crew of passionate out-break veterans assembled a unique department, using an early form of electronic crowdsourcing to detect outbreaks and dispatching experts to the field. three years after the effort solidified, the W.h.O. played a big role in responding to a cluster of deadly pneumonia cases in Asia. the new virus became known as SARS, and it was contained within the year, with most cases oc-curring in China.
to aid the fight, wealthy individuals offered the W.h.O. “literally hundreds of millions be-cause their businesses were affected,” said Dr. Jim Yong Kim, president of the World Bank and a former director at the W.h.O. “But as SARS burned out, those guys disappeared, and we for-got very quickly.”
Soon, the global financial crisis struck. the W.h.O. had to cut nearly $1 billion from its pro-posed two-year budget, which today stands at
$3.98 billion. (By contrast, the budget of the Centers for Disease Control and Prevention for 2013 alone was about $6 billion.) the cuts forced difficult choices. More emphasis was placed on efforts like fighting chronic global ailments, in-cluding heart disease and diabetes. the whims of donor countries, foundations and individu-als also greatly influenced the W.h.O.’s agenda, with gifts, often to advance specific causes, far surpassing dues from member nations, which account for only 20 percent of its budget.
At the agency’s Geneva headquarters, out-break and emergency response, which was never especially well funded, suffered particu-larly deep losses, leaving offices that look, one consultant said, like a ghost town. the W.h.O.’s epidemic and pandemic response department — including a network of anthropologists to help overcome cultural differences during out-breaks — was dissolved, its duties split among other departments. Some of the main outbreak pioneers moved on.
“that shaping of the budget did affect the area of responding to big outbreaks and pan-demics,” said Dr. Fukuda, who estimated that he now had 35 percent fewer employees than during the 2009 h1N1 flu pandemic — more than double the cuts for the organization as a whole.
“You have to wonder are we making the right strategic choices?” he said. “Are we ready for what’s coming down the pike?”
the entire W.h.O. unit devoted to the sci-ence of pandemic and epidemic diseases — re-sponsible for more than a dozen killers, includ-ing flu, cholera, yellow fever and bubonic plague — has only 52 regular employees, including secretaries, according to its director, Dr. Sylvie Briand, who said that could be increased during outbreaks. Before the Ebola epidemic, her de-partment had just one technical expert on Ebola and other hemorrhagic diseases.
Across Africa, the ranks of the agency’s re-gional emergency outbreak experts, veterans in fighting Ebola, were cut from more than a dozen to three. “how can you immediately respond to an outbreak?” said Dr. Francis C. Kasolo, a W.h.O. director. “it did affect us.”
And a separate section of the W.h.O. re-sponsible for emergency response was whittled “to the bone” during the budget cuts — to 34 staff members from about 94 — according to Dr. Bruce Aylward, its assistant director general.
“You can’t make a cut that big, that deep, and it’s not going to have an effect on your op-erational capacity,” he said.
his group, charged with responding to wars, disasters and resurgent polio, was asked in August to assist with Ebola, too. “At no time that i can think of in the recent past have we been dealing with such a scale of human mis-ery over such a broad geography due to such a range of hazards,” he said, including enormous population displacements in Syria, iraq, the Central African Republic and South Sudan. But, officials warn, multiple, overlapping challenges may well be a feature of the future.
the W.h.O. hoped to balance its budget cuts by strengthening the ability of countries to re-spond to public health threats on their own. it put out new regulations for nations to follow to help contain outbreaks. But by 2012, the dead-line it set, only 20 percent of nations had enact-ed them all. in Africa, fewer than a third of coun-tries had programs to detect and stop infectious diseases at their borders. the W.h.O.’s strategy was often more theory than reality.
“there never were the resources to put those things in place in many parts of the world,” said Dr. Scott F. Dowell, a specialist formerly with the C.D.C.
A Disease Finds Its Openingthe Ebola virus took full advantage of
these poorly prepared nations and the holes at the W.h.O.
Given the weakness in surveillance, the out-break was not identified until March, in Guinea, roughly three months after a villager was be-lieved to have contracted the virus from an ani-mal, possibly a fruit bat. the delay allowed doz-ens of cases to spread through villages and even to Conakry, a capital of more than one and a half million people. Right away, Doctors Without Borders declared the outbreak unprecedented in its reach, the only group to do so.
hastening the spread, hospitals lacked basic infection-control essentials like running water, protective gowns and gloves. Many doctors and nurses caught the virus from their patients, passed it to others, and died. the vul-nerability and collapse of medical facilities re-vealed how far there is to go in achieving the W.h.O.’s top priority — ensuring basic global health care.
“this kind of outbreak would not have de-veloped in an area with stronger health sys-tems,” Dr. Fukuda said.
in the crucial weeks after the discovery, dai-ly meetings brought together national authori-ties and foreign responders at the W.h.O. office in Conakry. But an absence of strong leadership and professionalism was notable from the be-ginning, participants said.
“it’s purely improvisation,” said Marc Poncin, the emergency coordinator for Doctors Without Borders in Conakry. “there is no one to take responsibility, absolutely no one, since the beginning of the crisis.”
Stopping previous Ebola outbreaks had re-quired meticulous tracking: monitoring people who had close contact with infected individu-als and isolating them if they developed symp-toms. Previously, “if we missed a case,” said Dr. Simon Mardel, a British emergency doctor deployed by the W.h.O. to help with the effort, “it was like a failure.”
this time, the number of contacts being followed was disastrously low from the begin-ning, only 8 percent in the epicenter of Guéck-édou, Guinea, in early April, according to an-other doctor sent by the W.h.O. that meant the disease was silently spreading. Dr. Mardel said he thought the more experienced W.h.O. leaders who had left the agency “would have been very vocal, and they would have sought to put it right quickly, as a matter of urgency.” A single person who traveled and became sick could touch off a conflagration.
it was not that responders were not try-ing. Victims’ contacts were spread across a wide area, hours away on bad roads. the payment of local workers had somehow been overlooked, so they stopped doing vital, risky jobs. Essential protective equipment was not delivered to many who needed it. Bottles of bleach were given out without buckets. the W.h.O. lacked relationships with some long-standing organizations with large networks of health workers in the region.
traditions that contributed to Ebola’s spread, including funerals where mourners came into contact with corpses, were not fully recognized or confronted, said Dr. Pierre Rol-lin, an outbreak specialist at the Centers for Disease Control and Prevention who worked within the W.h.O. umbrella.
Some villagers blocked roads with tree trunks and drove Ebola workers away with stones, accusing them of bringing in the disease. Adding to the tension, only bare-bones clinical care was provided to try to treat patients, reduc-ing the chances of yielding survivors who could act as ambassadors for the cause. Some doctors deployed by the W.h.O. said it should have given them more tools to care for patients.
institutional and personal tensions flared. “Everyone’s working at a fevered pace,” Dr. Dow-ell said. “there’s confusion and chaos. it argues for a system that’s organized as much as possible ahead of time so people know their roles.”
One consultant thought it strange that the W.h.O. would not send twitter messages with links to the C.D.C.’s Ebola prevention informa-tion, part of a policy not to promote material from other agencies. Various offices within the W.h.O.’s balkanized hierarchy also jockeyed for position.
the difficulties in tracking cases and gain-ing access to villages led many to think the out-break was burning out. “i came home sort of thinking, with a little luck, that’s wrapped up,” said Dr. Daniel Bausch, an Ebola outbreak vet-eran from tulane University, who returned in May from a W.h.O. mission in Guinea.
the outbreak was not gone, just hidden. An herbalist in Sierra Leone contracted the virus
treating Guinean patients. More than a dozen mourners at her funeral fell ill and seeded Sier-ra Leone. Some of them traveled back to Guinea and rekindled the outbreak there. After a lull of several weeks, cases re-emerged in Liberia, too, and reached the capital, Monrovia.
Dr. Bausch flew to Sierra Leone in July. “i was like, ‘where is everybody?’ ” referring to the shortage of health workers fighting the dis-ease. “We all recognized we were really under-staffed. We needed more people in the field.”
in some treatment centers, two or three doctors, wearing stifling gowns and masks in the heat, were caring for up to 90 patients. With the only W.h.O. logistician in the country work-ing elsewhere, Dr. Bausch did not have anyone to accompany him and manage supplies of pro-tective equipment, he said.
Dr. Bausch worked in Kenema, Sierra Le-one, where he had helped set up a research program for another hemorrhagic fever, Lassa, which was common in the region. he knew some of the nearly two dozen health workers there who died after Ebola hit.
“it would be a logical question to ask, since Lassa was there, why was it so hard to switch gears” to Ebola?, Dr. Bausch said. But research institutes provided money for science, he said, not for disease surveillance and treatment. those tasks had been left to the government of
A6 N INTERNATIONALTHE NEW YORK TIMES THURSDAY, SEPTEMBER 4, 2014
ability to respond in parts of the worldthat need it most. Its outbreak andemergency response units have beenslashed, veterans who led previousfights against Ebola and other diseaseshave left, and scores of positions havebeen eliminated — precisely the kind ofpeople and efforts that might havehelped blunt the outbreak in West Af-rica before it ballooned into the worstEbola epidemic ever recorded.
Unlike the SARS crisis of 2003, whichstruck countries in Asia and elsewherethat had strong governments and amplemoney to spring to action, the Ebolaoutbreak has waylaid nations that oftenlack basic health care, much less theability to mount big campaigns to stampout epidemics.
The disease spread for months beforebeing detected because much of thework of spotting outbreaks was left todesperately poor countries ill preparedfor the task. Once the W.H.O. learned ofthe outbreak, its efforts to help trackand contain it were poorly led and lim-ited, according to some doctors whoparticipated, contributing to a sensethat the problem was not as bad as it ac-tually was. Then, as the extent of theepidemic became obvious, critics saythe agency was slow to declare its se-verity and come up with plans, and hasstill not marshaled the people and sup-plies needed to help defeat the diseaseand treat its victims.
“There’s no doubt we’ve not been asquick and as powerful as we might havebeen,” said Dr. Marie-Paule Kieny, aW.H.O. assistant director general.
Another W.H.O. leader agreed. “Ofcourse in retrospect I really wish thatwe had jumped much higher much ear-lier,” said Dr. Keiji Fukuda, the assistantdirector general in charge of outbreakresponse. “Of course I wish we’d pouredin more and more earlier.” But, he add-ed, “if this outbreak had been a typicaloutbreak, nobody would be saying wedid too little, too late.”
The outbreak began close to the bor-ders of three neighboring countries —Guinea, Sierra Leone and Liberia — andspread surprisingly fast. Since then, theW.H.O. has engaged more than 400 peo-ple to work on the outbreak, includingemployees of other agencies in its net-work, and in August the agency de-clared the epidemic an internationalemergency, hoping to stop it from cross-ing more borders. Dr. Chan has metwith presidents in the region, and lastweek the W.H.O. announced what itcalled a road map for a “massivelyscaled” international response.
The current outbreak has killed morethan 1,900 people and spread to thepoint that the W.H.O. warns that morethan 20,000 people could become in-fected. Sick people are dying on thestreet. Some feel the entire model theworld uses to fight outbreaks needs tobe rethought, so that an agency like theW.H.O. has the structure and mandateto take command.
But Dr. Chan said that governmentshave the primary responsibility “to takecare of their people,” calling the W.H.O.a technical agency that provides adviceand support. Still, she noted that her or-ganization, like many governments andagencies, was not prepared.
“Hindsight is always better,” Dr.Chan said. “All the agencies I talked to— including the governments — all of usunderestimated this unprecedented, un-usual outbreak.”
A Shift in EmphasisThe W.H.O., founded in 1948, is re-
sponsible for taking on a wide range ofglobal health issues, from obesity to pri-mary health care. But since the world’shealth needs far outstrip the financialcontributions of the W.H.O.’s 194 mem-ber nations, those priorities compete.
The threat of emergent infectious dis-eases jumped high onto that list 20years ago, when an outbreak of plaguein India created a panic, sending about200,000 people fleeing. The next year inZaire, now the Democratic Republic ofCongo, Ebola killed about 245 people.With fears of cross-border infectionshigh, a new urgency arose: improvingthe world’s ability to stop outbreaks.
The W.H.O. took the lead, at the re-quest of its member nations. A crew ofpassionate outbreak veterans assem-bled a unique department, using an ear-ly form of electronic crowdsourcing todetect outbreaks and dispatching ex-perts to the field. Three years after theeffort solidified, the W.H.O. played a bigrole in responding to a cluster of deadlypneumonia cases in Asia. The new virusbecame known as SARS, and it was con-tained within the year, with most casesoccurring in China.
To aid the fight, wealthy individualsoffered the W.H.O. “literally hundredsof millions because their businesseswere affected,” said Dr. Jim Yong Kim,president of the World Bank and a for-mer director at the W.H.O. “But asSARS burned out, those guys disap-peared, and we forgot very quickly.”
Soon, the global financial crisisstruck. The W.H.O. had to cut nearly $1billion from its proposed two-year budg-et, which today stands at $3.98 billion.(By contrast, the budget of the Centersfor Disease Control and Prevention for2013 alone was about $6 billion.) Thecuts forced difficult choices. More em-phasis was placed on efforts like fight-ing chronic global ailments, includingheart disease and diabetes. The whimsof donors also greatly influenced theW.H.O.’s agenda, with gifts, often to ad-vance individual causes, far surpassingdues from member nations, which ac-count for only 20 percent of its budget.
At the agency’s Geneva headquar-ters, outbreak and emergency re-sponse, which was never especially wellfunded, suffered particularly deeplosses, leaving offices that look, one con-sultant said, like a ghost town. TheW.H.O.’s epidemic and pandemic re-
sponse department — including a net-work of anthropologists to help over-come cultural differences during out-breaks — was dissolved, its duties splitamong other departments. Some of themain outbreak pioneers moved on.
“That shaping of the budget did affectthe area of responding to big outbreaksand pandemics,” said Dr. Fukuda, whoestimated that he now had 35 percentfewer employees than during the 2009H1N1 flu pandemic — more than doublethe cuts for the organization as a whole.
“You have to wonder are we makingthe right strategic choices?” he said.“Are we ready for what’s coming downthe pike?”
The entire W.H.O. unit devoted to thescience of pandemic and epidemic dis-eases — responsible for more than adozen killers, including flu, cholera, yel-low fever and bubonic plague — hasonly 52 regular employees, includingsecretaries, according to its director, Dr.Sylvie Briand, who said that could be in-creased during outbreaks. Before theEbola epidemic, her department hadjust one technical expert on Ebola andother hemorrhagic diseases.
Across Africa, the ranks of the agen-cy’s regional emergency outbreak ex-perts, veterans in fighting Ebola, werecut from more than a dozen to three.“How can you immediately respond toan outbreak?” said Dr. Francis C. Kaso-lo, a W.H.O. director. “It did affect us.”
And a separate section of the W.H.O.responsible for emergency responsewas whittled “to the bone” during thebudget cuts — to 34 staff members fromabout 94 — according to Dr. Bruce Ayl-ward, its assistant director general.
“You can’t make a cut that big, thatdeep, and it’s not going to have an effecton your operational capacity,” he said.
His group, charged with responding
to wars, disasters and resurgent polio,was asked in August to assist with Ebo-la, too. “At no time that I can think of inthe recent past have we been dealingwith such a scale of human misery oversuch a broad geography due to such arange of hazards,” he said, includingenormous population displacements inSyria, Iraq, the Central African Republicand South Sudan. But, officials warn,multiple, overlapping challenges maywell be a feature of the future.
The W.H.O. hoped to balance itsbudget cuts by strengthening the abilityof countries to respond to public healththreats on their own. It put out new reg-ulations for nations to follow to helpcontain outbreaks. But by 2012, thedeadline it set, only 20 percent of na-tions had enacted them all. In Africa,fewer than a third of countries had pro-grams to detect and stop infectious dis-eases at their borders. The W.H.O.’sstrategy was often more theory than re-ality.
“There never were the resources toput those things in place in many partsof the world,” said Dr. Scott F. Dowell, aspecialist formerly with the C.D.C.
A Disease Finds Its OpeningThe Ebola virus took full advantage
of these poorly prepared nations andthe holes at the W.H.O.
Given the weakness in surveillance,the outbreak was not identified untilMarch, in Guinea, roughly three monthsafter a villager was believed to havecontracted the virus from an animal,possibly a fruit bat. The delay alloweddozens of cases to spread through vil-lages and even to Conakry, a capital ofmore than one and a half million people.Right away, Doctors Without Bordersdeclared the outbreak unprecedented in
its reach, the only group to do so.Hastening the spread, hospitals
lacked basic infection-control essentialslike running water, protective gownsand gloves. Many doctors and nursescaught the virus from their patients,passed it to others, and died. The vul-nerability and collapse of medical facili-ties revealed how far there is to go inachieving the W.H.O.’s top priority —ensuring basic global health care.
“This kind of outbreak would nothave developed in an area with strongerhealth systems,” Dr. Fukuda said.
In the crucial weeks after the dis-covery, daily meetings brought togethernational authorities and foreign re-sponders at the W.H.O. office in Cona-kry. But an absence of strong leader-ship and professionalism was notablefrom the beginning, participants said.
“It’s purely improvisation,” said MarcPoncin, the emergency coordinator forDoctors Without Borders in Conakry.“There is no one to take responsibility,absolutely no one, since the beginningof the crisis.”
Stopping previous Ebola outbreakshad required meticulous tracking: mon-itoring people who had close contactwith infected individuals and isolatingthem if they developed symptoms. Pre-viously, “if we missed a case,” said Dr.Simon Mardel, a British emergencydoctor deployed by the W.H.O. to helpwith the effort, “it was like a failure.”
This time, the number of contacts be-ing followed was disastrously low fromthe beginning, only 8 percent in the epi-center of Guéckédou, Guinea, in earlyApril, according to another doctor sentby the W.H.O. That meant the diseasewas silently spreading. Dr. Mardel saidhe thought the more experiencedW.H.O. leaders who had left the agency“would have been very vocal, and theywould have sought to put it right quick-ly, as a matter of urgency.” A single per-son who traveled and became sick couldtouch off a conflagration.
It was not that responders were nottrying. Victims’ contacts were spreadacross a wide area, hours away on badroads. The payment of local workershad somehow been overlooked, so theystopped doing vital, risky jobs. Essen-tial protective equipment was not deliv-ered to many who needed it. Bottles ofbleach were given out without buckets.The W.H.O. lacked relationships withsome longstanding organizations withlarge networks of health workers in theregion.
Traditions that contributed to Ebola’sspread, including funerals wheremourners came into contact withcorpses, were not fully recognized orconfronted, said Dr. Pierre Rollin, anoutbreak specialist at the Centers forDisease Control and Prevention whoworked within the W.H.O. umbrella.
Some villagers blocked roads withtree trunks and drove Ebola workersaway with stones, accusing them of
bringing in the disease. Adding to thetension, only bare-bones clinical carewas provided to try to treat patients, re-ducing the chances of yielding survi-vors who could act as ambassadors forthe cause. Some doctors deployed bythe W.H.O. said it should have giventhem more tools to care for patients.
Institutional and personal tensionsflared. “Everyone’s working at a fe-vered pace,” Dr. Dowell said. “There’sconfusion and chaos. It argues for a sys-tem that’s organized as much as pos-sible ahead of time so people know theirroles.”
One consultant thought it strangethat the W.H.O. would not send Twittermessages with links to the C.D.C.’s Ebo-la prevention information, part of a pol-icy not to promote material from otheragencies. Various offices within theW.H.O.’s balkanized hierarchy also jock-eyed for position.
The difficulties in tracking cases andgaining access to villages led many tothink the outbreak was burning out. “Icame home sort of thinking, with a littleluck, that’s wrapped up,” said Dr. DanielBausch, an Ebola outbreak veteranfrom Tulane University, who returned inMay from a W.H.O. mission in Guinea.
The outbreak was not gone, just hid-den. An herbalist in Sierra Leone con-tracted the virus treating Guinean pa-tients. More than a dozen mourners ather funeral fell ill and seeded Sierra Le-one. Some of them traveled back toGuinea and rekindled the outbreakthere. After a lull of several weeks,cases re-emerged in Liberia, too, andreached the capital, Monrovia.
Dr. Bausch flew to Sierra Leone inJuly. “I was like, ‘where is everybody?’”referring to the shortage of health work-ers fighting the disease. “We all recog-nized we were really understaffed. Weneeded more people in the field.”
In some treatment centers, two orthree doctors, wearing stifling gownsand masks in the heat, were caring forup to 90 patients. With the only W.H.O.logistician in the country working else-where, Dr. Bausch did not have anyoneto accompany him and manage suppliesof protective equipment, he said.
Dr. Bausch worked in Kenema, SierraLeone, where he had helped set up a re-search program for another hemor-rhagic fever, Lassa, which was commonin the region. He knew some of the near-ly two dozen health workers there whodied after Ebola hit.
“It would be a logical question to ask,since Lassa was there, why was it sohard to switch gears” to Ebola?, Dr.Bausch said. But research institutesprovided money for science, he said, notfor disease surveillance and treatment.Those tasks had been left to the govern-ment of Sierra Leone, “one of the poor-est countries on earth,” he said. “I al-ways felt bad about this.”
In late July in Liberia, two Americansworking at a missionary hospital fellsick and were soon evacuated home. ALiberian-American brought the virus byplane to Nigeria, Africa’s most populousnation. Suddenly, the world seemed tounderstand the threat.
The question now, experts wonder, iswhether the leaner, retooled W.H.O. —heavy on technical know-how, light onlogistical muscle — can surge in a waythat will help lead the world in bringingone of the most challenging health cri-ses in recent history to a close. W.H.O.’sroad map calls for $490 million from do-nors, and thousands of foreign and localhealth workers to contain the outbreak.Yet few foreign medical teams have yetanswered the call.
“It is incumbent on the internationalcommunity to really respond now,” saidDr. Kasolo, a W.H.O. director in Africa.“Otherwise history will judge us badly.”
Cuts at W.H.O. Hurt Response to Ebola Crisis, Officials Say
PHOTOGRAPHS BY DANIEL BEREHULAK FOR THE NEW YORK TIMES
From Page A1
Health workers, above, prepared toenter a high-risk ward at an Ebolatreatment center in Monrovia, Li-beria, run by Doctors Without Bor-ders. At left, relatives of a man whodied of what appeared to be Ebolawaited outside their home in Mon-rovia while a team of workerssprayed and disinfected the area.
MICHAEL APPLETON FOR THE NEW YORK TIMES
Dr. Margaret Chan, the director general of the W.H.O., with Dr. Da-vid Nabarro, left, the United Nations senior system coordinator forEbola, and Dr. Keiji Fukuda, an assistant director general at W.H.O.
C M Y K Nxxx,2014-09-04,A,006,Bs-4C,E1
Sierra Leone, “one of the poorest countries on earth,” he said. “i always felt bad about this.”
in late July in Liberia, two Americans work-ing at a missionary hospital fell sick and were soon evacuated home. A Liberian-American brought the virus by plane to Nigeria, Africa’s most populous nation. Suddenly, the world seemed to understand the threat.
the question now, experts wonder, is wheth-er the leaner, retooled W.h.O. — heavy on tech-nical know-how, light on logistical muscle —
can surge in a way that will help lead the world in bringing one of the most challenging health crises in recent history to a close. W.h.O.’s road map calls for $490 million from donors, and thousands of foreign and local health workers to contain the outbreak. Yet few foreign medi-cal teams have answered the call so far.
“it is incumbent on the international com-munity to really respond now,” said Dr. Kasolo, a W.h.O. director in Africa. “Otherwise history will judge us badly.” n