Global Health Systems: Ready for the Next Pandemic?
In a world traumatized by Trump’s America First agenda, many worry that nuclear conflict is around the corner. As a result, global health tends to be down at the bottom of the list of things to worry about. Yet, as we learned when Ebola struck in 2014, our lead institution, the World Health Organization (WHO), was shockingly slow on the uptake. Our global health governance was just not up to the task.
Now, Angela Merkel, the German Chancellor, has just sent a letter to WHO Director-General – a letter also signed by the heads of Norway and Ghana – asking his organization to help draft a “Global Action Plan for Healthy Lives and Well-being for All” to be discussed at the 10th World Health Summit in Berlin in October 2018.
WHO was told to do this “together with the heads of the other relevant organizations” and the letter specifically listed the main ones: UNAIDS, UNICEF, UNODC, UNDP, the World Bank, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the Global Alliance for Vaccination and Immunization (GAVI), the Global Financing Facility.
This is an important first step in the right direction. Because our whole system for global health governance, creaking and fraying at the edges, is showing its age (it was born in the aftermath of World War II). It is in urgent need of an overhaul.
WHO, the flagship of global governance, was not up to the task of tackling the Ebola epidemic: underfunded and undermanned, it didn’t have the right mandate to address the issue.
Ebola was a Wake-up Call: Pandemics are a Bigger Threat than Nuclear War
By 2016, the Ebola epidemic had killed more than 11,000 people, mostly in three West African countries (Sierra Leone, Liberia and Guinea). And it had acted as an early warning signal, forcing the global health system to respond.
The wake-up call was heard far and wide, including by the private sector and philanthropists. In 2015, Bill Gates was quick to note in a very effective and widely-viewed TED talk that pandemics are a bigger threat than nuclear weapons.
We could be facing a natural epidemic like Ebola or bio-terrorism – using a more effective means of transmission than Ebola which depends on direct contact between humans or with contaminated surfaces. For example, a weaponized pandemic might use a flu-like virus that travels through the air, with devastating results. We can’t forget the tragic 1918 flu epidemic that killed more people than World War I, an estimated 50 million people or more. As Gates pointed out, a similar flu pandemic in our crowded demographic conditions could kill 30 million people in six months.
Gates also called for military-style interventions against pandemics and, with Ebola, that is what happened. The first in West Africa was Médecins Sans Frontières that, a year into the crisis, released a widely read critical analysis of the situation. Things changed on the ground when the Obama administration intervened. With support from the CDCs, the American-led response covered four key areas – (1) emergency response, (2) laboratory capacity, (3) surveillance and (4) workforce development – and put Ebola to rest. The crisis had lasted two years.
Three years after Bill Gates’ analysis of global health, the question is: are we prepared?
The scenario Gates drew in his TED talk is chilling and three years later, he is still pessimistic. The Bill and Melinda Gates Foundation has just launched a $12 million “Grand Challenge” to encourage the development of a universal flu vaccine, one that would be effective against all strains.
Yet some lessons have been learned. The United Nations’ Agenda 2030 was unanimously adopted by its members in 2015, including SDG3 which calls for a “healthy life” for all “at all ages” and WHO has been “strengthened”.
In 2017, WHO got a new leadership team headed by Dr. Tedros Adhanom Ghebreyesus (Ethiopia), with more women (over 60%) on board. And, since July 2016, it has a new Health Emergencies programme (WHE). As noted by an independent IOAC audit report (January 2018) that reviewed it, WHE was “successfully launched” and it is “establishing a strong coordination and leadership role in health with the support of partners”, i.e. other governments, UN agencies, and NGOs.
But all is not roses: “WHO administrative systems, HR machinery and business processes are holding back the potential of the WHE Programme to excel.” Operating procedures (slow information sharing; delays in recruitment and medical procurements etc.) “require attention”. Talent acquisition and management as well as fund-raising remain critical areas.
However, WHO funding level, at some $4.4 billion, remains modest in relation to global health needs – for example, the budget of a sister UN agency, the World Food Programme which addresses hunger issues, is nearly double. And the way WHO is funded is unreliable: statutory contributions from member governments to WHO, set at less than $1 billion, cover only about a quarter of total budgetary needs. The rest has to come from voluntary contributions which are notoriously volatile and unpredictable.
The recent renewed threat from Ebola in D.R. Congo is both a timely reminder that pandemics are always around the corner. And can have a secondary negative impact from “contagion avoidance”. People get frightened to congregate, do not go to offices, meetings, movies, restaurants, churches for fear of contracting the disease. That could adversely affect the Congolese economy, in the same ways as South Korea’s was impacted by the threat of a MERS outbreak in 2015, causing disruption in consumption expenditures and substantial economic loss.
This new Ebola outbreak, though tragic, is nevertheless a good test to verify how effective WHO is now. It is not (so far) a major pandemic. As noted by Médecins sans Frontières in an interview with French television, this time “is by no means the same magnitude as in 2014-16”. Ebola has emerged in a remote part of the country “that’s used to these small epidemics”: D.R.Congo is where Ebola first appeared in 1976 and there have been nine outbreaks of Ebola since.
Ebola is back in D.R. Congo but WHO is stronger and can (probably) handle it – for now.
As of 23 May 2018, WHO reported 58 confirmed Ebola cases and 27 deaths, including three health care workers. The WHO also signaled two “probable cases” in the Wangata health zone, heralding the arrival of the disease in the provincial port city of Mbandaka (population 1.2 million).
The worry is that when the virus reaches urban areas, it could quickly spread. As long as it is confined to distant villages and thinly populated areas, it is relatively easy to contain. This said, overall circumstances have improved. African countries also seem to have learned from the 2014 outbreak. Sierra Leone, Liberia and Guinea have set up specialized Ebola laboratories for the necessary screening tests. And the Gambia, Kenya and Nigeria have all announced that they are taking steps to prevent Ebola from spreading.
So far, WHO has released $ 2.6 million from its Contingency Fund for Emergencies to kick-start the rapid response, including for an airlift to deliver equipment to the area which suffers from poor infrastructure. More importantly, a WHO team has started an experimental vaccination campaign to inoculate people, a first of its kind, using the vaccine that had been trialed in Guinea but arrived too late to be of any use to the previous Ebola outbreak.
WHO first estimated $ 18 million are needed for a 3-month operation and then, in the light of the expanding outbreak, that request was updated to $26 million. Given the WHO financial structure, that funding will have to come from willing donor countries and private sector partners.
As usual, it is hard to raise the needed funding, and at the time of writing (17 May), only The Wellcome Trust and UK Department for International Development (DFID) have announced a commitment of up to £3 million.
UPDATE: A week later, the New York Times reported that the response now appeared to be “on track to get it”. The World Bank has contributed $12 million and will redirect another $15 million to monitor for three years the health situation in Congo. Pledges were also coming from donor countries: $8 million from the U.S. and $6 million from Germany – though pledges are not the same thing as cash in the till: it takes time to route the money to the designated recipients.
Furthermore, on 24 May 2018, WHO and the World Bank announced the creation of the Global Preparedness Monitoring Board, to be chaired by Dr Gro Harlem Brundtland, former Prime Minister of Norway and former WHO Director-General, and Mr Elhadj As Sy, Secretary General of the International Federation of the Red Cross and Red Crescent Societies. It will include political leaders, heads of UN agencies and world-class health experts, serving in their individual capacities.
This is an important step forward. The Board is tasked with providing “stringent independent monitoring and regular reporting of preparedness to tackle outbreaks, pandemics, and other emergencies with health consequences.”
All this is reassuring. Does this mean we have nothing to worry about? Unfortunately, no.
Cholera in Yemen reminds us that Global Health remains at risk
WHO and UN agencies find themselves fighting increasing threats of pandemics in the world with woefully inadequate support from donors. And the Trump administration, as pointed out by the New York Times editorial board in a recent piece, is showing a worrying “amnesia” that could seriously set back the United States’capacity to respond to future threats. In particular, the administration has dissolved the National Security Council’s biosecurity directorate that had been set up to monitor global health security threats, and it has tried to rescind $252 million in Ebola response funds left over from the earlier epidemic.
The Ebola outbreak in DR Congo is relatively small – less than 100 cases (so far). But what will happen when the world faces a “big one” or a disease that starts in a hard-to reach place?
That’s when the fund-raising story takes a turn for the worse: it is one thing to deal with limited outbreaks like Ebola, and another to address serious pandemics that affect millions of people.
A case in point is the cholera crisis in Yemen. It is amply reported in the press, for example, the UK Guardian recently highlighted UNICEF’s warning that Yemen would be hit by an “another outbreak of deadly cholera” in the coming months when the rainy season starts. A dramatic statistic was circulated: In Yemen, every ten minutes one child dies from preventable diseases.
Dramatic statistics evidently don’t work anymore. The global health effort in Yemen has been woefully underfunded. UN fund-raising in March-April of this year obtained nearly $2 billion in pledges, with about half of it from Saudi Arabia and UAE, but an estimated $3 billion was needed. And pledges are not the same as actual payments, the funds often don’t show up or are delayed. Overtime, the UN’s constant calls for funds appear to fall on increasingly deaf ears.
Why? The reasons are several.
First, the explosion in the number of humanitarian crises. In a world where conflict situations are on the increase together with the number of failed states, causing unprecedented flows of people migrating within countries and across borders, pandemics are far more likely. And far harder to control.
Second, we are facing an unprecedented resistance from Western donor countries to the UN’s repeated appeals for financing. The world is simply not responding. This listlessness has deep roots: (1) in the general withdrawal of OECD countries from the aid and development game and (2) in the shift to reliance on the private sector. Official Development Assistance (ODA) is dwarfed by the vast flows of private money to the developing world, especially to strong “emerging” economies like India’s. Not to mention the rise of China with its new Asian Infrastructure Investment Bank and its Belt and Road Initiative that many see as a threat to human rights and the environment.
The private sector might fill the gap for a while (Bill Gates, Mark Zuckerberg and others) but not for long. The pandemics are likely to be larger than all their billions put together could ever handle.
Solutions to the global health crisis: Fix what we have or start over?
More is needed, both in terms of funding and institutions, we can all agree on this.
At one extreme, you could try and fix the current system, as Merkel has done, asking WHO et al. to propose a draft “Global Action Plan” for health. At the other extreme, you could start over and design a system from scratch, building on a thorough diagnostic of what is wrong with the system as it now stands.
The latter solution was recently put forward in an article for The Lancet by two highly respected global health experts, Richard Seifman and OK Pannenborg, both with over 45 years of international experience in the field, working for various major organizations, including the World bank. Titled “The Need for a Geopolitical Shift in Global Health”, they make their point with a striking analogy: Our global health system is like a house, think of it as the “House of Global Health”, originally built for the industrialized democracies. Overtime, it has added too many rooms (too many health actors) “without connecting doors or even windows”.
Seifman and Pannenborg argue that the House of Global Health is ready to collapse under its own weight. And to support their argument, they make an important additional point: While the growing number of players may not be a problem per se, the “changing power structure” certainly is, particularly the rise of China. For now, they note, “the United States is still by far the largest global health funder in absolute amounts but the Trump Administration’s turn inward, and its proposals to slash spending on global health, is another crack in the foundation of the Global Health House.”
Their solution? A “Bretton Woods-style Conference on Global Health in the 21st Century”. What the world needs, they argue, is a new global health system. Even radical restructuring measures, like creating one financial fund and one global health implementation agency instead of the many we have now and restricting WHO to a regulatory policy-guiding role, would not be enough.
This is ambitious and does not appear to fit easily with Ms. Merkel’s plans.
Proposal: A Bellagio-style Meeting of Experts to nudge the world in the right direction
In my view, one needs to let the ball run its course within the UN – and it is now set for examining a “Global Plan of Action” at the 10th World Health Summit. But that doesn’t mean nothing can be done to improve the chances of adopting reforms that are “fit for purpose”, that really work.
A nudge in the right direction could be given from the outside. In this regard, in a recent conversation I had with Mr. Seifman, he suggested that a Bellagio-style conference could be just what is needed to do the job.
The suggestion is convincing: A Bellagio-style conference is a special kind of international meeting, informal, one that pulls together top experts and leaders in their field. They often attend in their own personal capacity, which means they come without mandates or hidden agendas. This creates the best conditions for open debates and free exchanges of ideas. Bellagio conferences have historically sparked innovations, notably the Green Revolution, the Forum for African women educationalists, impact investing and GAVI.
New ideas are exactly what the Global Health system needs.
Editors Note: The opinions expressed here by Impakter.com columnists are their own, not those of Impakter.com