In March, a Blurry photograph appeared on a news website in the West African nation of Guinea. The image showed two women in a remote village lying on grass mats, while several men stood over them wondering what illness had struck their loved ones. The women were dying. The news site quoted the village nurse as saying the mystery killer was “extremely serious.”
But the mystery was soon solved. Officials working for the United Nations’ World Health Organization (WHO) in the Guinean capital of Conakry announced that tests had shown the women in the village had become infected by the deadly Ebola virus. It took more than a week for the news of the re-emergence of Ebola to make its way from the dirt-poor African village to Guinea’s health officials, then to the local WHO office and finally to the Swiss city of Geneva, in the foothills of the Alps, where it reached WHO Director-General Margaret Chan.
By then, Ebola had been spreading for at least three months and had already killed dozens of people in Guinea. The virulent infectious disease was on its way to crossing into Sierra Leone, Liberia, Senegal and Nigeria before jumping continents for the first time ever, to the Spanish capital of Madrid and then the U.S. cities of Dallas and New York. It was the kind of nightmare scenario that until then had been the stuff of Hollywood thrillers.
Seven months later, Ebola has killed at least 4,922 people. The true figure could be even higher–experts say many deaths from Ebola go unreported–and new outbreaks could be just a plane flight away. “There have been some very big public-health emergencies in recent years,” Chan tells Time, sitting in her sunlit office with a view of WHO’s wooded gardens. “But Ebola has got to be the biggest of them all.”
Tracing Ebola from that grainy photo in Guinea in March to the burst of action in Washington this fall, when President Barack Obama deployed troops to West Africa, it’s tempting to see a world united against the disease. But it hasn’t always been this way. The virus was able to cross oceans and worm its way into big cities thanks in good part to entrenched bureaucracy in West Africa and abroad, years of rich countries penny-pinching on global health spending and a failure of leadership at WHO. Ebola struck in three near destitute countries, two of them struggling to recover from years of brutal war, at a time when the very people tasked with preventing disease epidemics had cut crucial staff and funds. “Outbreak control is our bread and butter,” Chan says. Yet this one, she says, “outstripped WHO’s capacity to respond.”
Ultimately, leaders at WHO and the governments and institutions that fund it will have to wrestle with the challenge of better controlling future epidemics. Rich donors like the U.S. and the European Union will then have to decide whether to reinforce the network of existing high-profile institutions–U.N. organizations like WHO, plus some well-funded national bodies like the U.S. Centers for Disease Control and Prevention (CDC)–or start afresh with new agencies and new plans. Only one thing seems clear today: retaining the status quo will only leave the world vulnerable to further outbreaks. “We should not be where we are today,” says Christopher Stokes, general director of the Ebola operations center of Doctors Without Borders/Médecins Sans Frontières (MSF) in Brussels. The international aid agency has been at the forefront in tackling the outbreak in West Africa, where 13 of its staff have died of the disease since March. “From Day One, this epidemic has not been under control. And nobody is on top of the epidemic, even today.”
If WHO is getting the bulk of the blame, that’s because its very purpose is to prevent catastrophes like this from happening. That failure seems even more glaring now, since the Ebola outbreak was WHO’s “moment to shine,” says Lawrence Gostin, professor of global health law at Georgetown University in Washington, who believes the world needs a strong WHO and has drafted extensive plans for how to overhaul it. Yet WHO laid off 1,000 staff members in 2010–including some of the same people who might have helped stop Ebola from spreading–and halved its budget for outbreak and response to a meager $114 million this year.
WHO was founded in 1948 and tasked with collecting data, setting international health policies and standards and responding when it sees trouble. And for decades the organization did just that, including responding to past brushes with Ebola in Africa. For a major eruption in 1995, WHO coordinated a tight-knit campaign in the Congolese rain forest, stopping the outbreak after it had claimed 254 lives. “The WHO had such a high reputation, it was like the voice of God had arrived,” recalls Laurie Garrett, senior fellow for global health at the Council on Foreign Relations in New York City, who witnessed the Congolese epidemic as a journalist.
In the following years, WHO swung into action time and again, coordinating the strategy for Hong Kong’s avian-flu outbreak in 1997 and for the respiratory syndrome called SARS that first erupted in southern China in late 2002 before spreading to more than 25 countries and killing 774 people. During both those epidemics, WHO officials watched the televised briefings out of Hong Kong from the city’s health director, Margaret Chan. They were impressed by what they saw.
Born just a year before WHO’s founding, Chan had stumbled into studying medicine in her 20s, mostly so that she could follow her boyfriend (now husband) to medical school in Canada. Back home, she worked her way up in Hong Kong’s health department before WHO hired her in 2004 as a midlevel official based at the Geneva headquarters. In 2006 she became the first Chinese ever to head a U.N. organization. In her acceptance speech she said one of her priorities during her tenure would be preparing for unexpected epidemics, which she called “global threats to health that also bring shocks to economies and societies.” Ebola has turned those words into a painful prophecy.
For Chan, 67, life at the top hasn’t been easy. Alone in Geneva, with her husband and grown son back in Hong Kong, she has seen her early hopes as WHO chief–of shaking up an aging institution and improving the lives of desperately poor African women–hit a wall of obstacles. The agency’s 194 member states–including the U.S., its biggest financial backer–have not raised their voluntary contributions in decades. That has forced Chan to solicit more donations, largely from rich governments, individuals and deep-pocketed charities, almost all of which set preconditions on how their money is spent. Even the funding for WHO’s most crucial work, like tackling emerging epidemics, depends largely on donors’ generosity. After the global financial crisis hit in 2008, WHO saw its funding drop by more than $1 billion. WHO’s budget covering 2013 and 2014 is just $3.98 billion, about one-third of the CDC’s budget.
Despite facing one of the gravest global health crises in years, WHO’s Geneva complex feels eerily unpeopled and becalmed. “There has been zero nominal growth in many, many years,” Chan says. After accounting for all the locked-in donations, Chan has few funds that she can allocate as she chooses. “The real money is about 20%” of the budget, she says.
Yet funding is not Chan’s only challenge. Under the organization’s decentralized structure, WHO regional offices have great autonomy. Officials at the headquarters in Geneva have regularly butted heads with some of them, according to Garrett at the Council on Foreign Relations. “In some cases the regional offices have ignored policies from Geneva and openly contested headquarters’ budgets,” she says. Regional directors have virtually unchecked authority in their domains, and while some are very effective, others can do more harm than good in a crisis.
The consequences of that loose chain of command became apparent in March, when WHO officials in Conakry were apparently slow in telling Geneva how serious the Ebola outbreak was. WHO officials in Geneva declined to tell TIME the exact dates the Conakry and Geneva offices knew about the outbreak, saying it would be part of a postepidemic internal review. Several seasoned aid workers and health experts told TIME that the performance of WHO’s local offices was often inadequate, although most of these workers were reluctant to be named for fear of damaging relationships in the midst of the epidemic. “The incompetence of the WHO’s local team has led to a lot of casualties,” said a veteran of international relief organizations, speaking from one of the Ebola-hit countries in West Africa.
WHO in Geneva did not shine either. Although Chan first learned in March about the outbreak in Guinea, she told TIME it was not until she was given an in-house presentation on its scale in June that the true dimensions of the crisis struck her. And even then it took until Aug. 8 for Chan to declare the epidemic a “Public Health Emergency of International Concern”–a rarely used WHO designation meant to signal that a disease needs urgent worldwide attention. By then at least 961 people had died of Ebola. Chan admits that Ebola caught her off guard. “With the benefit of hindsight, all of us realize that cases of Ebola were spreading in a hidden manner,” she tells TIME. “Looking back, the scale of the response did not match the scale of the epidemic.”
Chan says she cannot be “a one-issue director-general.” She tells TIME that as serious as Ebola is, she is also currently dealing with many other infectious outbreaks, including Middle East Respiratory Syndrome and the Marburg virus in Uganda. Chan flew to Moscow in October to attend a conference on smoking and told a journalist there, “Ebola is important, but there are other important issues, like tobacco control.”
Deep in the basement of who’s Geneva headquarters, the organization’s top epidemiologists and logisticians are racing to make up for lost time. In a large strategic-operations room on Oct. 28, about 60 senior WHO officials and staff members track Ebola cases on large screens as they try to determine the course of the epidemic and how to deploy more doctors, nurses and experts to the Ebola zone. Many of the staff are jammed up against the walls, seated on the floors and around the long conference table as top WHO officials present slides showing that day’s statistics from West Africa; also present are experts from MSF and Save the Children. Chan looks across the room and shakes her head. “Many of you are exhausted,” she says. “You have been in this game for six or nine months.”
Chan’s kind words for her staff are understandable, but there is precious little sympathy from some aid workers in Africa who say WHO is out of touch with the grim realities within African communities. “WHO is centered in government offices,” says Stokes of MSF. “They are quite disconnected.”
In West Africa and in global capitals, those who have suffered the ravages of Ebola and those who fund WHO and other major organizations will ask why the world failed this time–and how it should prepare for the next deadly outbreak. Health experts say they already feel anguish about the past months and stress that everyone, from WHO to Western governments to local officials on the ground, was tragically slow to act. “It’s unconscionable,” Gostin says. “It never should have happened. The U.S. was very late to the game. If Ebola is not a reflection point where we learn and change, it will be a very sad state of affairs.”
Chan, much like Gostin, believes true change will require billions more dollars from governments to establish a permanent emergency fund to fight unexpected health crises like Ebola. She’d like to set up an army of trained doctors and nurses to deploy at short notice, much like U.N. Peacekeeping, which deploys soldiers from various countries in crises across the world. Chan makes the case for bolstering WHO, saying climate change and mass migration could make outbreaks of deadly epidemics like Ebola more frequent. “Countries will need to ask themselves, Are we prepared to invest in global security?” Chan says. “Ebola has to be a turning point.”
Chan insists the Ebola disaster is the perfect moment to push through reforms within WHO. “I won’t waste this crisis,” she says. But true reform–dismantling power structures, reordering priorities–is tough, and for the eight years Chan has been in charge, it has proved elusive. The world had better hope those changes happen before the next deadly infectious epidemic strikes.
–WITH REPORTING BY ARYN BAKER/CAPE TOWN, DAVID STOUT/HONG KONG AND MASSIMO CALABRESI/WASHINGTON
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