International institutions are poised to make one of the most momentous decisions about the future of global health security since the formation of the World Health Organization (WHO) in 1948.
By the end of this year, 5 global commissions will have published major critiques of global health preparedness, all spurred by the Ebola epidemic, which exposed deep flaws in the international system.
These commissions include the WHO’s independent Ebola Interim Assessment Panel, which reported in July that senior leaders failed to respond effectively during the crisis in West Africa, calling for “significant transformation” of the agency (http://bit.ly/1JS5lQe); the WHO Review Committee on the International Health Regulations (IHR), which held its first meeting in Geneva late August (http://bit.ly/1E5thKN); the Harvard/London School of Hygiene and Tropical Medicine Independent Panel on Ebola; the Global Health Risk Framework Commission of the National Academy of Medicine (formerly the Institute of Medicine); and the United Nations (UN) secretary-general formed a High-Level Panel, which includes sitting heads of state to provide political support for major reforms of the global health system (http://bit.ly/1PgRHIk).
All the reports will feed into the January meeting of the WHO executive board, with the final decisions taken by the World Health Assembly in May 2016. There are concerns that 5 commissions will prove to be costly and duplicative. Moreover, there is no assurance that their recommendations will lead to the meaningful and enduring changes now so badly needed in the global health landscape.
The Sovereignty Challenge
Although infectious diseases transcend borders, requiring international cooperation and collective action, states assert national sovereignty as a justification for flaunting international norms (http://bit.ly/1lUq9aZ). The IHR requires states to report emerging threats and to share information. Governments, however, have hidden vital information. Saudi Arabia, for example, hasn’t openly shared information about Middle East respiratory syndrome (http://bit.ly/1JfD60q), which, with the Hajj pilgrimage imminent, is alarming. West African states also did not fully report suspected cases of Ebola virus disease until the crisis escalated (http://bit.ly/1PrWhSG).
As required by the IHR, the WHO issues temporary recommendations after declaring a public health emergency of international concern. Yet, state and national governments flouted WHO recommendations during the influenza A(H1N1) and Ebola epidemics by restricting travel and trade and instituting inhumane quarantines. Quarantines in New York and New Jersey, for example, dissuaded health workers from volunteering in West Africa because of the prospect of confinement on their return home. These actions impeded the international response, making it harder for health workers and essential equipment to move to and from the affected regions.
Most importantly, the IHR requires states to develop core health system capacities. Yet, less than 35% of countries have met core capacities, and 48 countries have failed even to report (http://bit.ly/1NA3mms). WHO doesn’t even independently evaluate how countries perform, relying instead on unreliable self-assessments. High-income countries have not devoted sufficient resources to build health systems in lower-income countries—although the US Global Health Security Agenda is now investing in capacity building (http://bit.ly/1KoU33o).
The Challenge of International Cooperation
Closely related to the sovereignty problem is the challenge of international cooperation. The international landscape is diverse and complex, with more than 175 initiatives, funds, agencies, and donors (http://bit.ly/1KsNeCr). The UN has formed a health cluster led by the WHO (http://bit.ly/1FkxD1u), with 32 partner institutions (both inside and outside the UN), national governments, and civil society. Beyond the health cluster are multiple actors, including public/private partnerships (such as Gavi and the Global Fund), private industry, international charities (such as Médecins Sans Frontières) and health ministries, among many others. And, of course, public health goes well beyond the health sector, spanning agriculture, migration, trade, climate change, and much more.
Coordination is vital in health emergencies to ensure that all actors understand their roles and work cooperatively, without duplicating efforts or erecting bureaucratic hurdles. Yet, there has been a patent lack of harmony in international humanitarian operations, ranging from responses to earthquakes in Haiti and Nepal to the Ebola epidemic. The failure of effective leadership, for example, spurred the UN secretary-general to establish the first emergency health mission, the UN Mission for Ebola Emergency Response, to scale up the response on the ground and create a unity of purpose (http://bit.ly/15qg8l5). The United States, the United Kingdom, and France all sent in military assets.
The WHO is constitutionally mandated to “act as the directing and co-ordinating authority on international health work” (http://bit.ly/VFrPAj). Yet, it was either unwilling or unable to effectively lead the international response to Ebola. WHO Director-General Margaret Chan at one point stated that the WHO was not an implementing organization, implying that it did not have a central role in leading activities on the ground. More importantly, WHO country offices reportedly hindered international efforts to send health workers and medical supplies.
There are 2 central questions in any international emergency response. The first is “Who’s in charge?” The second is “Does an effective command and control structure exist to deliver all essential functions, including human resources, training, medical supplies, and logistics?” As the Haitian crisis demonstrated, even a massive scale-up of international aid cannot work without a coherent and complementary approach, in which actors work collectively to achieve the common good.
The “Good Governance” Challenge
Good governance is essential to ensure that multiple actors operate openly, effectively, and with accountability, including international organizations and national governments. It requires setting targets, creating indicators to measure progress, monitoring and evaluating outcomes, freedom of information and transparency, stewardship and honesty, civil society engagement, and accountability—critical features often lacking at the national and international levels.
WHO offers a clear illustration of ineffective governance (http://bit.ly/1I9oY7d), even though it is among the most democratic organizations in the international system, with virtually all countries represented at the Health Assembly, each with an equally weighted vote. Despite this, a few powerful donors, such as the United States, the European Union, and the Gates Foundation, heavily influence the organization. Major donors drive the global health agenda by funding the agency with earmarked funds, which account for nearly three-quarters of its overall budget.
In addition the WHO’s policies on open information and conflicts of interest are broadly criticized (http://bit.ly/1KjvtEd). Unlike UNAIDS, the Global Fund, and Gavi, the WHO does not include civil society or other nonstate actors in its governance structures.
Many low- and middle-income states similarly exhibit major governance deficits. Often, their decisions are closed to public scrutiny, they shun or even punish civil society organizations, and resist accountability mechanisms. The health sector, moreover, is among the most corrupt of all government sectors (http://bit.ly/1fQ7kX2). Corruption not only siphons critical resources intended to improve local and national health, but also undermines social cohesion and fosters public distrust. Monopoly power, unchecked authority, unaccountability, and weak enforcement create opportunities for corruption.
I’ve had the privilege of being a member of 2 Commissions and advising 3 others, and I have little doubt that each will expose major gaps in global health security and offer radical solutions. But the window of political opportunity following the West African Ebola epidemic is rapidly closing, as memories fade and as new daunting threats loom—ranging from ISIS and the refugee crisis in Syria to energy and climate change.
The question remains whether the entrenched interests of powerful states will block meaningful reforms. If this historic moment passes with only tepid reforms, we ought to hold our political leaders fully accountable.
Corresponding Author: Lawrence O. Gostin, JD (gostin@law.georgetown.edu).
Published online: September 16, 2015, at http//:newsatjama.jama.com/category/the-jama-forum/.
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