This week, an annual meeting of the world's most powerful global health players is taking place in Geneva. It's called the World Health Assembly, and ministers of health, heads of state, and civil society leaders are gathered at the United Nations' Palace of Nations to set health priorities and policies for the entire world.
At the moment, they're focused on whether we're prepared for future deadly disease outbreaks — a question that's particularly urgent in the wake of the Ebola epidemic in West Africa. More than a year and 25,000 cases later, it's clear the World Health Organization and the countries involved weren't ready for that crisis. The world took too long to act, leading to avoidable suffering and long-term devastation.
The Ebola outbreak should have been predictable — in the sense that we know the next outbreak is always around the corner. Yet as Dr. Margaret Chan, the WHO boss, said in her opening remarks this week, "The Ebola outbreak shook this organization to its core."
It wasn't just Ebola. We know the WHO has done a less than stellar job at responding to outbreaks in the past. The organization was set up in 1948 with the ambitious mission of rallying countries around health problems. It's supposed to be the key player for health around the world. But the organization has been struggling of late as it loses funding and influence relative to other disease-focused groups (like UNAIDS, which was set up in the wake of the WHO's failure to deal with the HIV crisis) and public-private health partnerships (like Gavi, which is focused on financing vaccines).
In theory, the WHO still has a crucial role to play in responding to deadly disease epidemics; it's the only global body that can declare a pandemic and mobilize internationally in the face of health threats such as Ebola. But to do so, it will have to change radically.
Why the WHO is struggling to respond to deadly outbreaks
Development assistance for health 1990 to 2013. You can see WHO's relative influence in the global health landscape shrink over the past two decades. (IHME)
Some of the most detailed explanations for why the WHO struggled to act on Ebola can be found in this interim Ebola response assessment, released this month from an independent panel of experts convened by WHO's director general. The panel makes clear that the problem with the Ebola response actually mirrors problems with the WHO itself — how it's funded and organized.
Take the organization's financing. The WHO is supported by its 196 member states, each of which pay in for membership and gain a seat at the decision-making table. This structure is part of what makes the WHO special: every country has a seat, no matter how rich or poor.
Yet only one-quarter of the WHO's funding comes from these membership dues. That means the other 75 percent is voluntary, from wealthy countries and contributions of other players, most prominently the Bill and Melinda Gates Foundation. Essentially, the organization relies on donors to come forward and fund the bulk of its budget and projects.
And that's created problems. When pandemic threats emerge, the organization scrambles, waiting for the money to trickle in from donors before action can be taken. "That's not the way to run an agency," said Dr. Julio Frenk, dean of the Harvard T.H. Chan School of Public Health. "WHO should be seen as the instrument for member states to exercise their collective action in the face of common threats and to realize common opportunities."
The WHO's culture is also problematic. The organization favors hiring health professionals over other types of skilled labor. As this 2014 study points out: "While an impressive 43.8% of WHO's professional staff are medical specialists, only 0.1% are economists and only 1.4% and 1.6% are lawyers and social scientists, respectively." That makes the WHO a valuable source of health knowledge, but it can be an obstacle when it comes to navigating the informal rules of international diplomacy to get things done in an emergency.
Meanwhile, critics have pointed out that the WHO suffers from a bit of an identity crisis. While it considers itself a technical body that provides expert advice, it's also a political body that works with world governments and helps coordinate other global health actors. And, at times, politics can trump scientific expertise. The WHO took months to call the Ebola a public health emergency of international concern in part due to political wrangling.
There are plenty of ideas for fixing the WHO...
At this year's World Health Assembly, there's been lots of talk of learning the lessons of Ebola to fix the WHO. One idea that's been bandied about involves increasing the WHO's mandatory membership payments from countries. These payments have been frozen since the 1990s, not even fully keeping in step with inflation.
There's also talk of creating a well-funded emergency response unit within the WHO that would be ready to act when another outbreak sparks. Many attendees here in Geneva have pointed out that we have a humanitarian system that can kick into action in the face of natural disasters like the recent earthquake in Nepal, but no similar system for health emergencies.
Meanwhile, experts have wondered whether innovative insurance mechanisms could help countries respond more quickly to outbreaks. Right now, many countries have incentive to cover up diseases early on — for fear that announcing a health emergency would lead to trade or travel restrictions. So a special insurance program for countries to help compensate them for these losses might make them more willing to come clean about outbreaks. The problem? This sort of scheme could easily be abused.
The challenge is that any of these changes would require an overhaul to the structure of the WHO, or at least to the way in which it has always worked. And sweeping changes may be tough to make, especially now that the Ebola threat is fading.
"Once the media stops talking about pandemics, the pressure on politicians to do something goes down, and we forget until the next pandemic," says Harvard's Julio Frenk. "That's exactly what happened after H1N1 in 2009." Frenk knows: he was Mexico's minister of health from 2000 to 2006, and in the middle of his term he led that country's response to the global SARS pandemic.
This helps explain why in Geneva, along with the urgency around Ebola, there's also a distinctive lack of confidence that anything will actually change this year. As a senior member of the US delegation here told Vox, "Are we sure [the WHO] can do better next time? No."
Why the WHO is still crucial to public health
What's clear is that the WHO in its current form isn't set up to act fast in the face of a health emergency. And yet, as that same US official said, "The WHO fills a function no one else can."
The WHO is the guardian of global public health. It's the one international authority that can enact quarantines, declare pandemics, and coordinate disease responses. It remains the body the world looks to in times of health crisis. However imperfect the WHO may be, there is simply no other body that gives all countries an equal place at the table to rally around health.
Ebola will not be the last global epidemic the world faces. MERS, leishmaniasis, and plague are just a few possibilities on the horizon.
That's why everyone in Geneva seems to want to see a stronger WHO. As another delegate noted, creating a new organization from scratch would simply be too difficult, and it's not clear it wouldn't suffer from the same challenges the WHO faces.
"What people realized this time with Ebola is that people do want the WHO," said Barbara Stocking, who led the independent review of the Ebola response. "It can't be dissipated. It [would be] bad for all of us in the world."