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Seven things we now know about how the world has handled Ebola

Masked customs officers look on during a screening area for international passengers from United flight 998 from Brussels at Newark airport in Newark, N.J., Saturday, Oct. 4, 2014.  (Viorel Florescu/ via AP)

As the Great Ebola Freak Out continues in the United States, inveterate Africa reporter Howard French tweeted something pretty trenchant:

This is an excellent suggestion!  But as a follow-up, I’d note that there already has been some outstanding journalistic and scholarly work on this very question over the past few months or so.  And a perusal of this literature reveals the following seven observations:

1)  The World Health Organization (WHO) is not terribly centralized, and it’s not going to be anytime soon.  The traditional stereotype of international organizations is that of a bloated secretariat based in Geneva, far removed from local field knowledge.  In the case of the WHO, however, that stereotype needs to be turned on its head.

Two recent articles in the European Journal of International Relations stress that the WHO might be unique among international governmental organizations.  Erin Graham analyzed why the WHO has failed to achieve its stated goals despite strong pushes by major national donors. Her conclusion was that the WHO is too decentralized to be held to account.

Like a weakened government in a failing state, WHO headquarters in Geneva did not control its regional or country office hinterlands. As a result, country programing in health systems was not well connected to goals espoused at headquarters, and control mechanisms exercised by member states to hold agents accountable were of limited use.

Tine Hanrider goes even further in his article:

One of the most peculiar features of the WHO — its division into six quasi-autonomous regional organizations — seems to be inalterable….
The WHO’s federal structure is extraordinary when compared to other international organizations. Its six regional bureaus are not merely implementing offices, but quasi-separate organizations. The regional committees–the WHO’s regional member-state forums–parallel the policymaking functions of the World Health Assembly. Moreover, the six regional offices are headed by the independently elected Regional Directors iand enjoy close to operative autonomy in administering the WHO’s country-level activities….  the level of autonomy granted to the WHO’s regions is unique in the
universe of UN organizations.

Can the WHO reform itself?  Hanrider is deeply pessimistic.  As he notes, the history of reform efforts at the WHO is one in which, “regionalizing transformations succeed and stick, while centralizing transformations are consistently defeated.”

2)  The WHO is kinda sorta funded like a decentralized state university.  While major donors can’t necessarily get the WHO’s regional bureaus to do exactly what they want, their funding can determine the overall focus.  In her explanation of why it seemed to be underperforming, the New York Times’ Sherri Fink notes that 2008 hit the WHO hard:

Soon, the global financial crisis struck. The W.H.O. had to cut nearly $1 billion from its proposed two-year budget, which today stands at $3.98 billion. (By contrast, the budget of the Centers for Disease Control and Prevention for 2013 alone was about $6 billion.) The cuts forced difficult choices. More emphasis was placed on efforts like fighting chronic global ailments, including heart disease and diabetes. The whims of donor countries, foundations and individuals also greatly influenced the W.H.O.’s agenda, with gifts, often to advance specific causes, far surpassing dues from member nations, which account for only 20 percent of its budget (emphasis added).

If the WHO is that reliant on major donors, then it has very little ability to prioritize pandemics that affect the least developed parts of the world.

3)  You can’t depoliticize global health governance.  Why not just create a new health body free from the WHO’s archaic structure?  Actually, that’s what has been done since the turn of the century, as Carlos Bruen and Ruairi Brugha note in their June 2014 article for the International Journal of Health Policy Management.  They point out that recent global health initiatives, such as the GAVI Alliance to fund child vaccines or the Global Fund to Fight AIDS, Tuberculosis and Malaria, were created in part to bypass the WHO.  At the same time, they were also deeply political acts.  Indeed, Bruen and Brugha conclude:

Politics is treated as distinct from policy, an unwelcome ghost that causally interacts with the policy machine, disturbing rational decision-making and technical intervention. However, political and institutional factors are central to global health policy processes, down to and including the development and use of health evidence. Politics is of fundamental importance to public health researchers and requires at least a willingness to analyse, even where there is a reluctance to engage in, the politics of public policy.

Just to be clear, you can’t depoliticize national health governance either.  Exhibit A:  Adam Nossiter’s depressing New York Times explainer for why a really valuable container of medical aid remains uncleared, just sitting on the dock in Freetown, Sierra Leone.

4)  There’s something going on between the CDC and the WHO’s African bureau. According to Fink, “the W.H.O. would not send Twitter messages with links to the C.D.C.’s Ebola prevention information, part of a policy not to promote material from other agencies.”  According to the Washington Post’s Lena H. Sun, Brady Dennis, Lenny Bernstein, and Joel Achenbach, “[The WHO’s] Africa office, which oversees the region, initially did not welcome a robust role by the CDC in the response to the outbreak.” I have no idea what the backstory is here, but it’s one that’s definitely worth pursuing.

5)  Gosh, it looks like social scientists can be kinda important in coping with global pandemics. According to Fink, the post-2008 budget cuts hit some parts of the Geneva office harder than others:

[O]utbreak and emergency response, which was never especially well funded, suffered particularly deep losses, leaving offices that look, one consultant said, like a ghost town. The W.H.O.’s epidemic and pandemic response department — including a network of anthropologists to help overcome cultural differences during outbreaks — was dissolved, its duties split among other departments. Some of the main outbreak pioneers moved on (emphasis added).

As it turns out, these anthropologists might have been useful in West Africa, since the emergency response failed to inspire trust among the locals:

Traditions that contributed to Ebola’s spread, including funerals where mourners came into contact with corpses, were not fully recognized or confronted, said Dr. Pierre Rollin, an outbreak specialist at the Centers for Disease Control and Prevention who worked within the W.H.O. umbrella.
Some villagers blocked roads with tree trunks and drove Ebola workers away with stones, accusing them of bringing in the disease. Adding to the tension, only bare-bones clinical care was provided to try to treat patients, reducing the chances of yielding survivors who could act as ambassadors for the cause. Some doctors deployed by the W.H.O. said it should have given them more tools to care for patients.

6)  Even halfway decent levels of health governance and civic trust can stop Ebola in its tracks. Hey, remember when Laurie Garrett was freaking out about Ebola spreading uncontrollably in Lagos and I suggested that this was an overblown concern? Well, a few months later, we have a definitive answer, courtesy of the New York Times’ Donald McNeil Jr. “With quick and coordinated action by some of its top doctors, Nigeria, Africa’s most populous country, appears to have contained its first Ebola outbreak.”

Nigeria was fortunate because its disease vector came from a single airport case. But as McNeil notes, it’s also because not all West African states are as bad off as Liberia, Guinea or Sierra Leone:

Nigeria has significant advantages over poorer countries where the outbreak is out of control.
It has many more doctors per capita, some educated abroad at top medical schools.
It has standing teams of medical investigators, with vehicles and telephones, who normally trace outbreaks of other ills like cholera or Lassa fever.
Lagos University Teaching Hospital was able to do Ebola tests in six hours.
The hospitals where patients were isolated were equipped to do tests for electrolytes and blood proteins, both of which must be kept in balance as patients are fed orally or intravenously to replace fluids lost to diarrhea and vomiting.
And air-conditioned hospitals let people wearing protective gear work longer without overheating.

So it turns out that countries that can muster a level of functionality on par with Nigeria stand a fighting chance against Ebola.  Indeed, even though Nigeria’s national government has just a bit of a corruption problem, even corrupt governments have an incentive to take health aid and use it effectively.

7)  It is not clear if the United States has sufficient levels of civic trust to handle Ebola. After the first Ebola patient was diagnosed in the United States in Dallas, Tex., both the Obama administration and the Perry administration stressed a similar “don’t panic” message.  As Politico’s David Nather notes, however, the GOP’s non-Perry 2016 hopefuls have been less supportive:

Sen. Rand Paul of Kentucky declared on “The Laura Ingraham Show” that “this could get beyond our control” and worried, “Can you imagine if a whole ship full of our soldiers catch Ebola?”
Sen. Ted Cruz — Perry’s Texas colleague — raised the prospect of restricting or banning flights to the West African countries that are hardest hit by the disease, noting in a letter to the Federal Aviation Administration that some African nations and certain airlines have already imposed their own flight bans.
Rep. Paul Ryan of Wisconsin floated the idea of quarantining airline passengers in the affected African countries before they could fly out. “We’re learning a lot about how it’s spread but the question is ‘How can a person just jump on a plane and get here without a quarantine period of 21 days,’ which I believe is recommended,” he said on a radio talk show Wednesday. A spokesman for Ryan says the congressman misspoke and was referencing a recommendation to be monitored for 21 days.
And Louisiana Gov. Bobby Jindal says the United States should cut off flights from those countries. “President Obama said it was ‘unlikely’ that Ebola would reach the U.S. Well, it has, and we need to protect our people,” he said in a statement Friday.
In fact, of the 2016 Republican hopefuls who have commented on the Ebola crisis, Perry is the only one who has been a reassuring voice.

As bad as the 2016 hopefuls have been, much of the conservative political discourse on this has been even worse. To be fair, asking the question about quarantine is the first thought all of us have. But as conservative health care wonksdevelopment experts, and the head of the CDC have observed, it’s a really bad idea and would make the epidemic worse. Indeed, the only thing worse than the conservative rhetoric on this has been Naomi Wolf’s rhetoric.

These arguments on the left and right feed a millenarian fear of social chaos that sounds awfully familiar. The initial screw-ups in handling the Dallas case of Ebola feed into already high levels of social distrust.  Over at the National Journal, Ron Fournier articulates — and stokes — the slightly more respectable version of this argument:

Is the Obama team right about Ebola? The fact is, nobody knows whether the disease will spread or mutate. Crises are, almost by definition, unpredictable—which is why we have institutions and leaders whom we must trust to adapt to what comes.
Trust. There’s that word again. How much faith can the public summon toward an administration that used incompetence as a defense in scandals involving the IRS, Benghazi, and Obamacare; that lied about its surveillance of Americans; and that just recently acknowledged dangerous misjudgments regarding the Secret Service and ISIS?

The one glimmer of good news is that the CDC still retains high degrees of bipartisan trust. My hunch is that the CDC’s still-sterling reputation, the United States’ superior health infrastructure, and the continued failure of rumored Ebola cases to pan out, will cause the more responsible tone to win out over the crazies of the left and right. But it’s going to be a near-run thing.