Ebola: what lessons for the International Health Regulations?

With more than 3000 deaths since the first case was confirmed in March, 2014, and after months of slow, fragmented responses, the international community has recognised Ebola as a public health emergency of international concern and a clear threat to global health security. It is the subject of a high-level UN Security Council resolution, and has triggered the creation of a UN Mission for Ebola Emergency Response. Despite these efforts, Ebola is staying ahead of efforts to contain it. In such a situation, although it is understandable to focus on urgent actions, it would be a mistake not to reflect on how we arrived at this situation and what we need to do to prevent it from happening again.

The International Health Regulations (IHR) represent the system designed to prevent national public health emergencies from becoming international crises. WHO's historic responsibility has been to control the spread of disease. The IHR were adopted in 1969 (IHR 1969) and focused on smallpox, plague, cholera, and yellow fever. In 1995, in the wake of plague in India and Ebola in DR Congo, a resolution was passed in the World Health Assembly (WHA) to revise and update the IHR. In the late 1990s a new way of working within WHO was created to detect and respond to infectious disease outbreaks using sources of information other than countries as prescribed under the IHR, and creating a network of over 120 partners to respond—called the Global Outbreak Alert and Response Network. The severe acute respiratory syndrome epidemic in 2003 gave great impetus to the revision process. In 2005, a revised IHR (IHR 2005) was adopted by the WHA, to come into force in 2007. The IHR 2005 are not limited to any specific diseases and they oblige countries to notify WHO of “events that may constitute a public health emergency of international concern” and to develop “core public health capacities”. They also offered flexibility to countries to develop core capacities by 2012, with a possible 2-year extension. Although all WHO member states have agreed to the IHR principles, countries were left to self-report their progress on core capacity development, such as surveillance, diagnostic, and containment demands.

With no additional financing in place and no proper accountability mechanism to ensure independent monitoring, this laudable vision has become a huge missed opportunity. Today, every person newly infected with Ebola reminds us of this lost opportunity. Whereas most developed countries certainly have the capacities to implement such a framework, many low-income and middle-income countries, and especially fragile states, do not. It was only on Aug 8, after a meeting of the International Health Regulations Emergency Committee, that WHO declared the outbreak a “public health emergency of international concern”. Such delays have probably enabled the outbreak to spread rapidly.

Several commentators have questioned the capability of WHO to address international threats, such as Ebola. Acknowledging gaps in global governance, and with its distinctive interest in global security, the USA has taken the lead and launched its Global Health Security Agenda earlier this year “to accelerate progress toward a world safe and secure from infectious disease threats and to promote global health security as an international security priority”. On Sept 26, a meeting took place in the White House to discuss the implementation of this new security agenda, together with the delivery of commitments to assist west Africa.

In view of the seriousness of the crisis, US leadership should be welcomed. However, the US Government is not a multilateral health agency. The final responsibility to prevent the international spread of disease rests with WHO and its IHR. But WHO has been poorly served by its member states and governing bodies. Member states have failed to invest in WHO to ensure the agency has full capacity to address its global mandate. And WHO's Executive Board and WHA failed utterly to keep the promise they made in 2005 to scale-up attention and investment in crucial surveillance and reporting systems so necessary to prevent the kind of epidemic that is Ebola today.

Two priorities stand out. First, an urgent donor conference must be convened to discuss the implications of the Ebola epidemic and the international community's failure to invest in the IHR. That conference must end with substantial financial commitments to strengthen delivery of core IHR public health capacities. Second, a robust mechanism must be put in place to guarantee independent monitoring and review of country implementation of the IHR. Self-reporting is an unreliable way to protect the world's peoples from new and dangerous epidemics.