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PTEMBER 4, 2014

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seasonably warm, humid, high 88.

Weather map appears on Page C8.

VOL. CLXIII . . . No. 56,614

2014 The New York Times

Late Edition

Today, sun and clouds, warm, high

87. Tonight, clear to partly cloudy,
low 70. Tomorrow, partly sunny, unseasonably warm, humid, high 88.
Weather map appears on Page C8.

$2.50

NEW YORK, THURSDAY, SEPTEMBER 4, 2014

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AHEAD OF NATO MEETING

Agency Says It Lacked
Staff and Resources AHEAD OF NATO MEETING

BRYAN DENTON FOR THE NEW YORK TIMES

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Survived an ISIS Massacre

SIS Massacre

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DAMON WINTER/ THE NEW YORK TIMES

W.H.O. Hurt Response to Ebola Crisis, Officials Say

THE NEW YORK TIMES INTERNATIONAL THURSDAY, SEPTEMBER 4, 2014

W.H.O. Hurt Response to Ebola Crisis, Officials Say

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eases at their borders. The W.H.O.s

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, including 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

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 structure 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 agency that provides advice and support. Still, she
noted that her organization, like many governments 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 Emphasis
The W.H.O., founded in 1948, is responsible
for taking on a wide range of global health issues, from obesity to primary health care. But
since the worlds health needs far outstrip the
financial contributions of the W.H.O.s 194 member 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 worlds ability to stop outbreaks.
The W.H.O. took the lead, at the request of
its member nations. A crew of passionate outbreak 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 occurring in China.
To aid the fight, wealthy individuals offered
the W.H.O. literally hundreds of millions because 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 forgot very quickly.
Soon, the global financial crisis struck. The
W.H.O. had to cut nearly $1 billion from its proposed 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, including heart disease and diabetes. The whims
of donor countries, foundations and individuals 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 agencys Geneva headquarters, outbreak and emergency response, which was
never especially well funded, suffered particularly 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 outbreaks 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 pandemics, 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 whats coming down the pike?
The entire W.H.O. unit devoted to the science of pandemic and epidemic diseases responsible for more than a dozen killers, including 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 department had just one technical expert on Ebola
and other hemorrhagic diseases.
Across Africa, the ranks of the agencys regional 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. responsible 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 cant make a cut that big, that deep,

and its not going to have an effect on your operational 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 misery 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 respond to public health threats on their own. It
put out new regulations for nations to follow to
help contain outbreaks. But by 2012, the deadline it set, only 20 percent of nations had enacted them all. In Africa, fewer than a third of countries 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 Opening

The Ebola virus took full advantage of
these poorly prepared nations and the holes at
the W.H.O.
Given the weakness in surveillance, the outbreak was not identified until March, in Guinea,
roughly three months after a villager was believed to have contracted the virus from an animal, possibly a fruit bat. The delay allowed dozens 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 vulnerability and collapse of medical facilities revealed 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 developed in an area with stronger health systems, Dr. Fukuda said.
In the crucial weeks after the discovery, daily meetings brought together national authorities and foreign responders at the W.H.O. office
in Conakry. But an absence of strong leadership
and professionalism was notable from the beginning, participants said.
Its 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 required meticulous tracking: monitoring people
who had close contact with infected individuals and isolating them if they developed symptoms. 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 beginning, only 8 percent in the epicenter of Guckdou, Guinea, in early April, according to another 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 trying. 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 longstanding organizations with large networks of
health workers in the region.
Traditions that contributed to Ebolas
spread, including funerals where mourners
came into contact with corpses, were not fully
recognized or confronted, said Dr. Pierre Rollin, an outbreak specialist at the Centers for
Disease Control and Prevention who worked
within the W.H.O. umbrella.

cause their businesses

said Dr. Jim Yong Kim,
e World Bank and a forat the W.H.O. But as
out, those guys disapforgot very quickly.
global financial crisis
H.O. had to cut nearly $1
proposed two-year budgy stands at $3.98 billion.
he budget of the Centers
ntrol and Prevention for
s about $6 billion.) The
ficult choices. More emced on efforts like fightobal ailments, including
nd diabetes. The whims
greatly influenced the
a, with gifts, often to adal causes, far surpassing
mber nations, which ac0 percent of its budget.
cys Geneva headquark and emergency rewas never especially well
red particularly deep
offices that look, one conike a ghost town. The
mic and pandemic re-

His group, charged with responding

declared the outbreak unprecedented in

MICHAEL APPLETON FOR THE NEW YORK TIMES

Dr. Margaret Chan, the director general of the W.H.O., with Dr. David Nabarro, left, the United Nations senior system coordinator for
Ebola, and Dr. Keiji Fukuda, an assistant director general at W.H.O.

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, reducing 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.
Everyones working at a fevered pace, Dr. Dowell said. Theres confusion and chaos. It argues
for a system thats 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 information, 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 gaining access to villages led many to think the outbreak was burning out. I came home sort of
thinking, with a little luck, thats wrapped up,
said Dr. Daniel Bausch, an Ebola outbreak veteran 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

would have been very

would have sought to pu
ly, as a matter of urgency
son who traveled and bec
touch off a conflagration.
It was not that respon
trying. Victims contact
across a wide area, hour
roads. The payment of
had somehow been over
stopped doing vital, risk
tial protective equipmen
ered to many who neede
bleach were given out w
The W.H.O. lacked rela
some longstanding orga
large networks of health
region.
Traditions that contrib
spread, including fu
mourners came into
corpses, were not fully
confronted, said Dr. Pie
outbreak specialist at t
Disease Control and P
worked within the W.H.O
Some villagers block
tree trunks and drove
away with stones, acc

treating Guinean patients. More than a dozen

mourners at her funeral fell ill and seeded Sierra 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 disease. We all recognized we were really understaffed. 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 working elsewhere, Dr. Bausch did not have anyone
to accompany him and manage supplies of protective equipment, he said.
Dr. Bausch worked in Kenema, Sierra Leone, 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

Sierra Leone, one of the poorest countries on

earth, he said. I always felt bad about this.
In late July in Liberia, two Americans working at a missionary hospital fell sick and were
soon evacuated home. A Liberian-American
brought the virus by plane to Nigeria, Africas
most populous nation. Suddenly, the world
seemed to understand the threat.
The question now, experts wonder, is whether the leaner, retooled W.H.O. heavy on technical 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 medical teams have answered the call so far.
It is incumbent on the international community to really respond now, said Dr. Kasolo,
a W.H.O. director in Africa. Otherwise history
n
will judge us badly.