Despite the rapidly mounting Ebola cases in the Democratic Republic of Congo, experts at the World Health Organization on Friday decided not to declare a global health emergency.
Because the outbreak, which has been ongoing since August, hasn’t spread beyond the DRC, “we considered there would be no added benefit by declaring [an emergency], particularly as excellent work is being done on the ground by WHO and many partner organizations,” said Robert Steffen, chair of the WHO-convened committee of external experts that deliberated over the emergency declaration.
A “public health emergency of international concern,” or PHEIC (pronounced “fake”) is an official designation the WHO can give to an outbreak in order to sound the international alarm. It can galvanize attention and trigger the release of resources — money and personnel — to help stop a disease from spreading globally. The decision to trigger an emergency ultimately rests with WHO Director General Tedros Adhanom Ghebreyesus, but it’s informed by the expert panel’s recommendations.
Friday’s determination marks the second time the WHO decided against declaring Ebola in DRC an emergency. In October, the health agency’s expert panel offered similar reasoning. Then the WHO noted that not a single Ebola case has been exported beyond the borders of the DRC, and that an international response was already well underway. The panel was confident the DRC had plenty of experience responding to the virus.
But this year, the outbreak has continued to spiral. It’s the first known Ebola outbreak to happen in an active war zone (located in DRC’s northeastern provinces, North Kivu and Ituri). And flare-ups in violence have frequently interrupted the efforts of Ebola responders, leading to more cases. That’s why some health experts think the WHO is acting too timidly and that an emergency declaration is overdue.
Why some say it’s time to call Ebola in the DRC a global health emergency
In the past week alone, there were 74 new cases — the most of any week since the outbreak was identified in August. And to date, at least 740 people have died out of more than 1,100 cases. That makes the DRC’s outbreak the second-largest known Ebola outbreak in history, following only the 2014-2016 epidemic in West Africa.
And while Ebola hasn’t yet spread across international borders, cases were recently identified at an airport in the DRC.
“The Ebola outbreak in DRC is serious,” Tom Frieden, the president of Resolve to Save Lives and former director of the Centers for Disease Control and Prevention, told Vox. “Cases are increasing, and there’s decreasing ability to stop spread because of insecurity. It’s hard to see how you can make a strong argument about this not being a PHEIC.”
Lawrence Gostin, Georgetown Law’s chair in global health law, also believed it’s time to trigger the emergency declaration and rethink the response. “The WHO can’t expect to play by the old public health rulebook and expect to succeed in the context of persistent violence and community distrust.”
Tom Inglesby, director of the Center for Health Security of the Johns Hopkins Bloomberg School of Public Health, was also surprised by the negative decision. “We’ve reached a new moment of seriousness in this outbreak and WHO has not gotten the resources it needs to respond to this outbreak in full capacity,” he said.
And it’s not just that this is the worst week in terms of new cases since the outbreak started, Inglesby continued. “It’s what’s behind the numbers. We have a high percentage of people who are appearing with Ebola after they’ve died. We have a lot of people who have Ebola but are invisible to the response community. That’s why those numbers are going up.”
Why global health emergencies are rare
But there are reasons WHO experts might opt against triggering the PHEIC alarm, even in serious outbreaks.
A PHEIC is defined as “an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response.”
Despite all the dangerous outbreaks in recent years, the WHO has only declared a public health emergency four times since the International Health Regulations, which govern global health emergency responses, were enacted in 2007.
The first time was in 2009, with the outbreak of the H1N1 swine flu pandemic. The second time was in May 2014, when polio seemed to surge again, threatening the eradication effort. The third time, in August 2014, came as the Ebola outbreak in West Africa was growing out of control. And the fourth: In February 2016, the Zika outbreak across South and Central America was declared a PHEIC.
And that’s because these decisions are not taken lightly. First, the PHEIC is a political tool used to focus the world’s attention on a health crisis. Using this declaration too often would weaken its significance. Second, one of the key considerations in declaring a PHEIC is whether the disease threat is dire enough for countries to be forced into enacting travel and trade restrictions. These can be devastating to local economies.
Health emergency declarations are often associated with economic losses, even when the WHO only warns people to limit or delay travel to affected regions (instead of outright travel restrictions).
If this outbreak continues to spiral, however, the WHO risks reputational damage for not declaring an emergency sooner.
“Whether the Ebola outbreak in the DRC technically is or is not a [PHEIC] is beside the point,” said America’s former Ebola response coordinator, Ron Klain. “The response is failing to get the disease under control.” And unlike the 2014-2016 West Africa outbreak, DRC responders have an Ebola vaccine to work with, he added.
“The WHO has decided that this is not a PHEIC. But that does not change the grim reality that it is an emergency, and the international community,” said Klain, “needs to get a lot more concerned, right away.”