June 19, 2015

Ebola: Back to the Future of Health Diplomacy

A relative grieves as a Red Cross burial team prepares to remove the body of Ofori Gweah, who died of Ebola's telltale symptoms, in a riverside area called Rock Spring Valley in central Monrovia, Liberia, September 18, 2014.
A relative grieves as a Red Cross burial team prepares to remove the body of Ofori Gweah, who died of Ebola's telltale symptoms, in a riverside area called Rock Spring Valley in central Monrovia, Liberia, September 18, 2014.

Global Health Responses

History is critical if we want to understand some of the failures of the present. A review of over 160 years of international health diplomacy and cooperation shows the constant tension between a vision of health where disease knows no borders and the continuous difficulty in overcoming national interest. At regular intervals, a global health crisis like the Ebola outbreak in 2014 reminds the world that there is a need to act together because the health of one part of the globe is inextricably linked to the health of another. But the crisis mode rarely turns into long-term action, which requires states to act together consistently for the health of all. This is a threat to the world’s health security.
Health was one of the first trans-border issues to employ multilateral diplomatic mechanisms during the 19th century.1 Increasing globalisation brought with it the more rapid and extensive spread of infectious diseases. As major cholera pandemics hit big cities in Europe between 1821 and 1851, and the fear of contagion began to affect trade though quarantine measures, it was recognised that international cooperation was necessary. Nation-states subsequently “invented” a new way of working together in health:

  • In the first phase, international conferences were convened with the object of enabling nations to reach agreements on “non-political” subjects such as health. The first International Sanitary Conference took place in 1851 in Paris and the first international convention on health was agreed in 1892. It was negotiated in a joint effort between diplomats and medical experts.
  • In a second phase, 1919 marked the beginning of a new stage of diplomatic endeavour to address problems “common to all”, and health was included in the Covenant of the League of Nations. The League established a health office in Geneva, which was very active, for example, in the typhus epidemic in Eastern Europe that broke out in 1919.
  • Finally, in a third phase following World War II, the World Health Organization (WHO) was created in Geneva to “act as the directing and co-ordinating authority on international health work”.

There was much optimism at the time that the creation of this agency would help eliminate most diseases, and indeed one of its historic achievements was the victory over the scourge of smallpox; in 1980, the WHO could declare the eradication of this disease. Major successes have been achieved with the control of measles and polio, but today—70 years after the founding of the WHO—the world still faces major old and new infectious disease threats, many of them of a trans-border nature. Yet, 160 years after the first engagement, the political commitment to invest significantly in common health security—which includes the need to build strong health systems in all countries—and in health as a global public good has not manifested itself sufficiently.

The Ebola Epidemic

The Ebola epidemic of 2014–5 in some of the poorest countries in the world—concentrated in Liberia, Sierra Leone and Guinea—provided a wake-up call: neither the countries nor the international agencies were able to respond with the required speed and expertise to this complex health emergency. Over 10,000 people have died of the highly contagious disease for which there is no vaccine and no treatment, and probably at least the same number have died of other diseases because the health services were overwhelmed in the face of the crisis. Initially it was mainly non-governmental actors that responded on the ground, in particular Medicins Sans Frontières, which was subsequently pushed to the limit of its capacity.2 But others must be mentioned, such as local volunteers, especially from the Red Cross and NGOs such as Save the Children. Severe criticism has been levelled at the WHO—both of its work at country and regional level and of the fact that it took much too long to make use of the provisions of the International Health Regulations (IHR)3—available to the WHO as an international legal instrument—to declare a Public Health Emergency of International Concern (PHEIC).4
Ebola is not yet over—but as the outbreak is being contained, a number of evaluation panels have been established with the task to explore “what went wrong”. An interim assessment panel established by the Executive Board of the WHO issued its first report for the 68th World Health Assembly (WHA68) in May 2015 and highlighted the need to consider the structural and political shortcomings that lie at the root of the crisis and the failures of the response.5 Some of the questions being asked include: Why did the established mechanisms of humanitarian and health response not work? Why were countries so badly prepared? Why was community engagement not prioritised from the start? Why do we not have a functioning global emergency health workforce? Why is it still so difficult for UN agencies to work together? Why are there no diagnostics, vaccines or treatments? Why was this area of the WHO’s work so underfunded? Why did the different levels of the organisation not work together better? Why did the UN agencies not work more efficiently?
The WHO underlines that “good outbreak control relies on applying a package of interventions, namely case management, surveillance and contact tracing, a good laboratory service, safe burials and social mobilisation. Community engagement is key to successfully controlling outbreaks.”6 All of these are critical at country level and are usually not in place in fragile states. We also have to face the fact that the Ebola outbreak was a failure of the global emergency and response system. At present there is much lip service paid to acting and to supporting countries to move from a crisis mode to one that addresses the long-term requirements to build sustainable health systems.
In a resolution to take the Ebola work forward, WHA68 underlined the need to engage in international cooperation and collective action and to revisit the IHR, the need for a contingency fund and a global health emergency workforce, and the urgent need to build in-country capacity.7 Yet, while the Ebola outbreak crisis reinforced the point that countries must work to implement their responsibilities under the IHR and that poorer countries will need support to do this, many countries still insisted on self-assessment of their capacities on a voluntary basis only, rather than establishing a peer-review process and/or external evaluation that allows for mutual learning and joint health security.
The experience with outbreaks shows that countries are rightly worried about declaring an outbreak because of the severe economic consequences that can come in its wake, as borders are closed and planes stop flying. Trade bans in particular are much debated.8 Of course, this is short-sighted, since the economic costs of the outbreak can be much greater if the response begins late. Current calculations by the World Bank Group show that Liberia, Guinea and Sierra Leone will lose at least US$1.6 billion between them in forgone economic growth in 2015 as a result of the epidemic.9 Challenges include job losses, smaller harvests and food insecurity.
The crisis also showed that, despite the agreement in the IHR to follow WHO advice on travel bans and trade restrictions, many countries acted unilaterally—frequently to appease their populations, respond to media hysteria or gain political points in an election period. At present there are neither incentives nor sanctions to counteract such behaviour by countries; this too must be explored in the future. Despite the fact that the IHR is a legally binding treaty mechanism, it lacks “teeth”. It is a key health-diplomacy challenge to develop a global health-security framework that will ensure both higher investment and compliance.

Can There Be Change?

If Ebola was a global systems failure, then the response has to be at system level. There has been action following other global health crises, which has led to new institutions and approaches in global health governance. Three can be mentioned here.
· The threat of HIV/AIDS led to the creation of new organisations such as UNAIDS and financing mechanisms such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) and UNITAID, as well as to a wide range of very proactive civil-society organisations.
· The SARS outbreak of 2002–3 led to the revision of the IHR in 2005, broadening their scope and redefining the powers assigned to the WHO as well as the responsibilities of countries.
· The H5N1 influenza outbreak led to the Pandemic Influenza Preparedness (PIP) Framework in 2011, which introduced a multi-stakeholder approach to pandemic influenza preparedness and response.
Ebola is the second disease (after HIV/AIDS) to be taken to the United Nations Security Council and declared a threat to peace and security worldwide. As in the case of HIV/AIDS, the Ebola crisis has led to proposals for new health agencies and new financing mechanisms; the World Bank Group has been very prominent in this debate, for example suggesting a new kind of insurance mechanism for countries through a Pandemic Emergency Facility.10 This time round, WHO member states have said very clearly that there must be no proliferation of agencies, and responsibility for outbreaks needs to stay with the WHO. Given the historical phases of international disease control outlined above, it seems obvious that the response to public-health emergencies of international concern must be the core business of the organisation. However, it is exactly this key insight that has eluded the member states and the secretariat over recent years, as they cut back funds and staffing in this area of the WHO’s work in response to an overall budgetary crisis in the organisation.
Global challenges can only be resolved jointly, and they need reliable financial resources to enable the agencies tasked to address them. But countries are normally not very willing to provide such resources for global public goods or to agree to instruments and mechanisms that might challenge their sovereignty. Yet, sometimes there is hope. The sociologist Ulrich Beck has developed the concept of cosmopolitan moments, meaning that a crisis can become a prism that brings collective action into focus.11 Cosmopolitan moments also open up new political spaces and new actors to join the global governance effort. Many argue that Ebola might be such a critical point in time that kick-starts a new dynamic in global health security that will also bring in other actors such as the private sector, which is highly dependent on safe global environments.
Apart from being discussed at the UN Security Council, Ebola also led to other new approaches: the UN Secretary-General established the first-ever UN emergency health mission, UNMEER—modelled on peacekeeping—to provide support to the Ebola response by redeploying financial, logistical and human resources. Ebola is also the subject of a High-Level Panel on the Global Response to Health Crises, established by the UN Secretary-General to analyse the overall UN system response and make proposals for the whole UN system. The global Ebola response is also prominent in the G7’s deliberations and the German Chancellor, Angela Merkel, current chair of the G7, addressed WHA68, reinforcing the need for the global community to act together on health security.12

The Larger Question

As a consequence, health security has become highly political, with heads of state and government being involved in many different ways, both in the affected countries and in the countries providing support. Maybe this level of political involvement will finally address the much larger question at hand: how will nation-states deal with the issues of sovereignty in relation to health security challenges in the early 21st century? “In the past, it was enough for a nation to look after itself. Today, it is no longer sufficient,” said a leading diplomat.13 Indeed, my health can no longer be separated from your health when a virus is just a plane ride away—health diplomacy implies the double responsibility to represent the interests of a country as well as the interests of the global community.
For example, cases of Ebola were exported to Nigeria, Senegal, the USA, Spain, Mali and the United Kingdom. SARS travelled on aircraft from China initially to Hong Kong, Hanoi and Toronto, and then infected thousands of people around the world. The Spanish flu pandemic of 1918–9 probably killed 50–100 million people worldwide.14 Bill Gates has drawn attention to the danger of complacency: “The world lost time in the current epidemic trying to answer basic questions about combating Ebola. In the next epidemic, such delays could result in a global disaster.”15
While the world was focused on Ebola, China was dealing with H7N9; the Middle East with the MERS Corona virus; South Sudan, Benin and Ghana with cholera; DRC with yellow fever; Benin with Lassa fever; Madagascar with plague; Niger and Nigeria with meningitis; and Uganda with Marburg virus and typhoid fever. The world faced more than 90 outbreaks of infectious disease between March 2014 and April 2015. There were also a range of ongoing grade-3 events under the Emergency Response Framework of the WHO: these included natural disasters in the Philippines and Nepal, as well as conflicts in Syria, the Central African Republic, South Sudan and Iraq. In addition, the world is dealing with the re-emergence of polio and increasing anti-microbial resistance. However, no priority is given to health security in the context of the WHO’s work, or in the Sustainable Development Goals due to be adopted in September at the UN General Assembly in New York.16
The problem relates to the narrow and outdated understanding of what countries consider to be a domestic health issue. Today, no health minister can ensure population health “at home” without a concern for the regional or global context. Each national health system is now a core component of the global health system. In order to ensure health security, health investments need to be made both at home and abroad—and particularly in the “weakest link”. One is the extension of the other, not a separate field of activity. This means that countries need to invest in the implementation of the IHR as a global public good, both domestically and in other countries, as well as in regional and global mechanisms to prevent, detect and respond.
One such important health diplomacy initiative is the Global Health Security Agenda (GHSA), which brings together countries, international organisations and civil society to promote health security as a national and international security priority.17 Twenty-nine countries, the FAO, the WHO and the World Organisation for Animal Health (OIE) are committed, as are Interpol, the African Union, the European Union, ECOWAS and the World Bank Group; the G7 has endorsed the initiative. Countries have committed to action packages to prevent avoidable epidemics, contribute to the early detection of threats and ensure a rapid and effective response against infectious disease outbreaks.
WHO member states have underlined that they continue to see the WHO as the key agency to ensure global health security, but they have not committed the financial resources that the organisation would need to play this role responsibly and effectively. There is no common understanding yet that assessed contributions to the WHO’s pandemic preparedness and response, as well as to emergency mechanisms, are not contributions to foreign aid but are (by extension) investments that ensure domestic health. We cannot wait for an airborne outbreak to scare the world into responsible action.
Health security and health diplomacy are as challenging and as important today as 160 years ago, even though we have so much more knowledge and so many more mechanisms and instruments to address the challenges at hand. It is irresponsible not to apply them. Health security must again be recognised as a political priority to be addressed at the highest level of government and the United Nations. It requires access to universal health coverage and reliable public health systems that can prevent, detect and respond. And it demands the investment in collective mechanisms—a global warning-and-response system—that serve all countries through a strong WHO. That is the key lesson to be drawn from the Ebola outbreak.
1 Kickbusch I. and Ivanova M. “The history and evolution of global health diplomacy” in: Kickbusch I., Dragger N., Lister G., Told M. and Kanth P. (eds) Global Health Diplomacy. New York: Springer (2012) pp. 11–26.
2 Medicins Sans Frontières. “Ebola: Pushed to the limit and beyond”. www.msf.org/article/ebola-pushed-limit-and-beyond. 23 March 2015, accessed 30 May 2015.
3 World Health Organization. “International Health Regulations” (2005). www.who.int/ihr/publications/9789241596664/en/. Accessed 30 May 2015.
4 “Ebola: a failure of international collective action”. The Lancet 384(9949) (23 August 2014) p. 1181. www.thelancet.com/pdfs/journals/lancet/PIIS0140-67…. Accessed 30 May 2015.
5 World Health Organization. “Ebola Interim Assessment Panel” (2015). apps.who.int/gb/ebwha/pdf_files/WHA68/A68_25-en.pd… Accessed 30 May 2015.
6 World Health Organization. “Ebola Virus Disease”. www.who.int/mediacentre/factsheets/fs103/en/. Fact sheet No. 103, updated April 2015. Accessed 30 May 2015.
7 World Health Organization. “2014 Ebola virus disease outbreak and follow-up to the Special Session of the Executive Board on Ebola” (23 May 2015)
apps.who.int/gb/ebwha/pdf_files/WHA68/A68_ACONF5-e…. Accessed 30 May 2015.
8 Langton, D. “Avian Flu Pandemic: Potential Impact of Trade Disruptions” (9 June 2006)
fpc.state.gov/documents/organization/68827.pdf. Accessed 30 May 2015.
9 World Bank. “World Bank Group Ebola Response Fact Sheet” (18 May 2015). www.worldbank.org/en/topic/health/brief/world-bank… 30 May 2015.
10 World Bank. “Pandemic Emergency Facility: Frequently Asked Questions” 21 May 2015. www.worldbank.org/en/topic/pandemics/brief/pandemi…. Accessed 30 May 2015.
11 Beck, U. “Critical theory of world risk society: a cosmopolitan vision”. Constellations 16(1) (2009).
12 World Health Organization. “Statement by Federal Chancellor Angela Merkel at the 68th session of the WHO World Health Assembly in Geneva on 18 May 2015”. www.who.int/mediacentre/events/2015/wha68/merkel-s…. Accessed 30 May 2015.
13 Cooper, R. The Breaking of Nations: Order and Chaos in the 21st Century. Revised and updated edition. London: Atlantic Books. 2004.
14 “Historical Estimates of World Population”. en.wikipedia.org/wiki/1918_flu_pandemic. Accessed 25 May 2015.
15 Gates, B. “The Next Epidemic: Lessons from Ebola”. New England Journal of Medicine 372 (9 April 2015) pp. 1381–4.
16 Kickbusch, I., Orbnski, J., Winkler, T. and Schnabel, A. “We need a sustainable development goal 18 on global health security”. The Lancet 385(9973) (21 March 2015) p. 1069.
17 Global Health.gov (US Department of Health and Human Services). “The Global Health Security Agenda”. www.globalhealth.gov/global-health-topics/global-h…. Accessed 31 May 2015.

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