The World Health Organization (WHO), technically responsible
for the world’s health and declaring emergencies, is actually in charge of neither.
In late July, before declaring Ebola to be a global public health crisis, WHO’s
Emergency Committee declared polio a
public health emergency of international concern. Ebola only graduated to the
same status a week later after American health care workers became infected. The
world then ignored WHO’s alarm for weeks as Ebola exploded. The other
“emergency”—polio—overshadowed an actual Ebola crisis, and makes visible WHO’s
decline to infantilized order taker and the primacy of the Gates Foundation.
Polio "Emergency"
When WHO declared polio to be a public health emergency on
May 5th, 2013, the risk of polio spreading sat near its lowest level
in human history.
Polio is more than 99% extinguished compared to 1988
when there were 350,000 cases in 125 countries. The polio “emergency” came not from
risk to public health but risk of not making the eradication schedule. To make a
2018 deadline,
polio transmission must be stopped by the end of this year. Similarly, in 2011,
the CDC declared polio to be a maximal, Level 1 crisis to
meet a now-passed 2012 deadline. Still today, the CDC Emergency Operations
Center recognizes two emergencies: polio
and Ebola.
Calls for WHO to make polio a global health emergency originated
from the Independent Monitoring Board (IMB)
of the polio eradication initiative.
Set up in 2010, IMB says
it was “convened at the request of the World Health Assembly.” However, there is no World Health Assembly resolution
that mentions or requests an independent monitoring board. “I have just had a
good look too,” said IMB spokesperson, Paul Rutter, “and can't find it either.”
Notwithstanding the unclear provenance of IMB’s authority, the
WHO Director-General in effect reports to IMB. According to IMB’s charter, the
Director-General must “immediately inform the relevant Ministry of Health and
donor or partner agency” of IMB recommendations and establish corrective action
plans “within 4 weeks of notification.”
In late 2013, the IMB expressed its desire that WHO declare polio to be a
public health emergency. However, the International
Health Regulations governing emergencies emphasize “public health
risk,” not schedule risk. But the campaign for a polio emergency
continued. At the end of January, the United States’ representative to the WHO
Executive Board, Nils Daulaire, asked
WHO to declare polio to be a public health emergency and set a deadline of mid-May,
2014.
Before being named US representative to WHO, Daulaire served
for more than a decade as president and CEO of the Global Health Council. Among
its function, the council selected the winner of the $1 million Gates Award for
Global Health. Under Daulaire, from 2000 forward, the Global Health Council
received $36 million from the Gates Foundation. In 2006, Daulaire’s wife went
to work at the foundation, continuing there until the end of 2013.
Daulaire has said
he "does not see the Gates Foundation or private entities as having a
rightful role in establishing WHO’s priorities.” He dismissed suggestions that
the foundation has an outsized role although he said: “There are member states
who believe the Gates Foundation has more influence than it ought.” Daulaire
said it is “entirely wrong” that the United States is increasing the
foundation’s role.
Polio eradication has topped the Gates Foundation’s
priorities for several years. In 2011, then foundation president, Tadataka
Yamada, answered critics of the polio-centric agenda saying: “They are right.
We are overemphasizing polio eradication.” Earlier this year, Bill Gates said
“polio is the single thing I work on the most.”
The WHO Executive Board did not vote on Daulaire’s proposal
for a polio emergency. The board, which rotates, did happen to include a number
of countries impacted by polio: Pakistan, Nigeria, India and Syria. None of
their representatives supported or mentioned the US call for a public health
emergency. The United States itself has been polio-free for more than three decades. The CDC saw no increased threat to Americans.
On May 5, just ahead of Daulaire’s deadline, WHO declared
polio a public health emergency. On the same date, WHO reported a cumulative 239
cases of Ebola and 160 deaths in three countries.
Daulaire, according to Executive Board meeting minutes,
also said “His Government attached high priority to strengthening the International
Health Regulations and had established global health security as a key issue,”
precisely where WHO would soon fail. However, according to a Reuters
report, a 2011 proposal for a $100 million epidemics task force was shot down by
member states. Also, budget cuts forced WHO’s Africa regional office to cut its
epidemic team from 12 to four staff over the past two years. As Peter Piot,
discoverer of Ebola noted, WHO budgets cuts were “approved by the USA and other
member states.”
The polio emergency, sought and won by Daulaire, had been based
on the worry that “Pakistan, Cameroon, and the Syrian Arab Republic pose the
greatest risk of further wild poliovirus exportations in 2014,” according
to WHO. Subsequently, neither Cameroon nor Syria exported polio and domestically
experienced no onset of polio-induced paralysis since before the first
declaration. Pakistan, where polio transmission has never been interrupted,
continued to export polio—as it always has, although without having prompted a
global emergency. Nonetheless, WHO concluded
on July 31st that “the international spread of polio in 2014
continues to constitute an extraordinary event and a public health risk to
other States.”
At the same time, WHO also reported a total of 1,323 Ebola cases,
729 deaths and even the export of the disease to a fourth country, Nigeria. However,
Ebola apparently did not come up at the polio meeting, according to Vice
Chair Robert Steffen: “with the targeted agendas I would not imagine that
the polio [Emergency Committee] suggested there should be an Ebola [Emergency
Committee].”
Unmentioned at the emergency meeting, Ebola had become
uncontrolled more than a month earlier. On June 23rd. Médecins Sans
Frontières (MSF) issued a press
release declaring “We have reached our limits.” An MSF spokesperson said,
“we are no longer able to send teams to the new outbreak sites,” which numbered
more than 60 across Guinea, Sierra Leone, and Liberia. MSF, which described
itself as the sole responder to the epidemic, said: “The epidemic is out of
control.” The next day, WHO Ebola expert Pierre Formenty briefed
top WHO officials in Geneva. Days later, the WHO Ebola situation report recognized “Currently,
the coverage of effective outbreak containment measures is not comprehensive,” as
Formenty’s presentation had shown. WHO updates began reporting cases and deaths
not in sentences but using a grid. The rout was
on.
The science of epidemiology should have been able to predict,
albeit tentatively, when the efforts of MSF were doomed to fail. But just as
with polio, epidemiology played no role in the timing of emergency declarations
and international response. WHO’s emergency announcement came only on August 8th
when there were 1,778 cases—including, for the first time, two Americans.
After the Ebola Emergency: No Response
Declaring polio an emergency did not unleash vast new
efforts to stamp out the disease. Most everything had already been done in the
$1 billion a year effort —except consecrating eradication as the single most
important public health issue in the world. The day after the polio
declaration, the Gates Foundation blog explained
that “The sounding of an emergency often is seen as a sign of distress, and
news of this announcement certainly communicated that.” Indeed, the supposed
emergency fueled headlines
like “Polio, Spreading Abroad, Threatens US.” Not only was there no increased threat,
the risk of spread was near historic lows. Instead “what this alarm really
signals,” continued the foundation blog, was doing “what it takes to end this
disease as quickly as possible,” that is, meeting the 2018 deadline.
When WHO declared an Ebola emergency, its declaration also did
not unleash vast new efforts to stamp out the disease. WHO lacked resources to
do anything itself while whatever heft the UN has was not applied. UN Secretary
General Ban Ki Moon was not at Margaret Chan’s side as the WHO Director-General
announced the Ebola emergency. Moon appears more frequently with Bill Gates. Gates
partnered with Moon and the UN, not WHO, for the Gates Foundation vaccine
summit that raised more than $4
billion for polio. And, as symbolized by an article co-written
by the two on vaccination, Gates and Moon author the global health agenda, not
WHO.
The world reacted to WHO’s Ebola emergency as if declared by
a clerk. The CDC dispatched
a small team to Liberia to areas that had not yet reported any cases. Its
purpose was not to assist in containment but to assess preparedness which was found
to be woeful. The CDC’s “surge” response
dispatched 50 more disease control experts to be deployed within a month.
Although issuing a travel warning
to US citizens, the CDC was “not screening passengers traveling from the
affected countries.” For the ongoing polio emergency, the CDC reported “an average
of 60-70 people” working on eradication at its Emergency Operations Center.
Gates Foundation Plays Down Ebola
For the Ebola crisis, the Gates Foundation pledged
$1 (one) million to “help address the immediate need on the ground,” according
to foundation CEO, Sue Desmond-Hellmann. But the next day, on its “Impatient
Optimists” blog, the foundation optimistically moved on. A piece
entitled “How to Prevent the Next Health Crisis,” explained how the next
threat, cerebro-spinal meningitis, “could end up being far more destructive than
the current Ebola epidemic.”
Three weeks later, on August 25, Desmond-Hellman tweeted
about how “Nigeria is using what they’ve learned battling polio to contain the
ebola outbreak.” The story was not about Nigeria as harbinger of inexorable spread
but how polio eradication investments had saved the day. And indeed, the $1.5
billion being
spent in Nigeria for polio might have contributed to extinguishing Ebola there.
Bill Gates weighed in on Ebola for the first time on
September 10, more than two months after MSF said the outbreak had become uncontrolled.
Gates tweeted about the foundation’s upcoming chat on Twitter:
The foundation now pledged $50 million; earlier in the year,
it committed
$1.8 billion to polio. The United States, now finally acting on Ebola, drew applause
from Desmond-Hellmann: “The time to act on Ebola is now,” she said with the
case count at 4,963. But just days and 2,507 cases later, Desmond-Hellman wrote of Ebola: “If the world doesn't learn from this
outbreak, one day we’ll have a real pandemic on our hands.”
It was not the foundation’s job to detect and declare
emergency outbreaks. But the foundation and Gates evaluated the Ebola threat
and publically projected the conclusion that Ebola was no emergency.
Gates Foundation Running Polio Eradication
Gates is influential. “If … I need to go to the Indian
parliament and say, ‘Let’s get serious about vaccines,’ ” said
Gates, “then yes – since I’m giving my own money [on a] large scale and
spending my life on it and I’m a technocrat – yes, that can be quite valuable.”
In 2011, Gates had gone to the World Health Assembly and said it
needed to get serious about vaccines. He explained to the assembly “how you can
provide the leadership to make this the Decade of Vaccines.” The WHA followed Gates’
leadership advice and approved his initiative. Memorably, Gates also told the
WHA: "Our priorities are your
priorities."
Not only did polio come to uniquely occupy the pinnacle
position in international public health, the Gates Foundation has come to effectively
run the eradication effort. The Director-General began answering to the
Independent Monitoring Board in 2010. In 2011, a Polio Partners Group (PPG) replaced
a meeting previously convened by WHO. WHO participates in the new group but is
barred from serving as its chair by PPG bylaws. The PPG “was not summoned into
existence per se” by act of the World
Health Assembly, according to its current chair, John Lange. As with the IMB, there is no resolution
requesting that the PPG be instantiated. Lange, now at the UN Foundation, previously
worked at the Gates Foundation from March 2009 to June 2013. He was a foundation employee when
elected PPG chair. Lange said the PPG was conceived at a meeting held not in
Geneva at WHO but the CDC in Atlanta in December 2011, at or near the time
when the CDC elevated polio to a maximum level threat.
Space for initiative-taking by WHO has been systemically
closed off, as if child-proofing a room by blocking electrical power outlets. In
2013, a new entity, the Polio Oversight Board (POB), took over operational
decision-making from WHO. According to Lange, the POB "effectively
oversees and manages" the polio eradication effort, although
“technically” the POB does not have authority over budgets, for example.
Nonetheless, said Lange: "Its decisions are implemented." The first POB
chairperson was Lange’s former boss, Chris Elias, president of global development
at the Gates Foundation.
Gates Foundation, Not WHO, Sets Global Health Agenda
The Gates Foundation’s subjugation of WHO is not new. WHO
lost its global leadership and capacity to set the world’s health agenda years
before. At the 2007 Malaria Forum, for example, the convening power of the Gates
Foundation, not WHO, brought together the world’s leading malaria researchers
and policy makers. WHO Director-General Margaret Chan sat in the audience as
Melinda Gates shocked
her invitees by proposing to eradicate malaria. Malaria eradication had been tried
and failed disastrously. However, Chan converted on
the spot, jumped up and, taking the microphone, enthusiastically supported eradication.
At the time of the Malaria Forum, the foundation had cumulatively invested $1 billion in
malaria, starting with an early, $50
million grant in 1999. By contrast, the purchasing power of WHO’s budget in
2007 had fallen
by almost 25 percent compared with 2000.
The foundation did not ask WHO, its Director-General or the researchers
it invited to the conference for their opinion about malaria eradication. For
polio, the World Health Assembly voted on and approved a resolution on eradication. But a Gates
Foundation spokesperson, asked whether there would be a vote on malaria
eradication, said: “Not as far as I know.” Arata Kochi, then the head of
malaria at WHO, fought back against what he described as a foundation “cartel.”
He was replaced after his memo leaked
to the New York Times. In 2014, the president of the American Society of Tropical Medicine and Hygiene (ASTMH) is Alan Magill, the head of malaria at the Gates Foundation. The keynote speaker for this year's ASTMH conference is Bill Gates.
The
Gates Foundation isn’t on the sidelines haphazardly supporting good causes but
actively architecting global health policy. The “overemphasis” on polio comes
from foundation plans for malaria eradication. As Bill Gates recently explained: “Polio we hope
to get done by 2018. Then the credibility, the energy from that we will allow
us to take the new tools we’ll have then and go after a malaria plan.” The
current malaria plan was paid
for by the Gates Foundation. A year after shifting malaria policy to
eradication, in 2008, the foundation became and has remained the largest
funder of polio eradication.
Absent this link to malaria eradication, the foundation’s
overemphasis of polio makes little sense. Even Gates acknowledges that, among eradication efforts, polio is borderline. Smallpox he said, “was a good choice. Polio is a hard but reasonable choice." Much better is malaria, which he characterized as "a very reasonable choice.” At no time in the past or present has
polio merited the world’s sole focus—unless for symbolic reasons. Other
diseases, like diarrhea, are more prevalent and deadly. Polio, for all its
awfulness, rarely causes death.
The Gates Foundation has also hived off childhood
immunization from WHO. The cleaving began in in 1998 with the introduction
of the Bill & Melinda Gates Children’s Vaccine Initiative. The creators of
this early initiative worried that WHO “might consider that we are trying to
pre-empt their responsibility,” and worked to “find a way to present ourselves
that avoids all presumption of a challenge to WHO." (Quoted in Muraskin, Crusade to Immunize the World's Children.) The program eventually
became what is known today as GAVI. The money for immunization goes to GAVI and
no longer directly to WHO and UNICEF. By
2008, any challenge to WHO was over. A GAVI governance change submerged WHO on
a board
with 28 other members, its vote counting as much as a representative from the
vaccine industry.
WHO is no longer even in charge of global health
statistics. The 2013 Global Burden of Disease was assembled and published by
the Institute for Health Metrics and Evaluation (IHME). IHME was created by a
$105
million grant from the Gates Foundation. Located at the University of
Washington, IHME threw down the gauntlet years before, publishing papers on
maternal and child mortality that publically contradicted figures from WHO on
the
front page
of the
New York Times. At a related
2010
conference,
IHME chief Chris Murray said bodies like WHO were “not the definitive
producers” of global health metrics. He proposed that WHO become a “disengaged
guide,” like Consumer Reports or that WHO present comprehensive results without
judging them, a model which Murray likened to Kayak.com. A third, unmentioned
alternative is for IHME to simply replace WHO as definitive producer of the world’s
global health statistics.
Bill Gates as Global Health Visionary
Seizing control from WHO could be explained, perhaps applauded, given serious questions about its competence and serial, unsuccessful reform
efforts. Gates, who made his career trouncing another anachronistic
three-letter acronym, IBM, seems not to have considered trying to shore up
international global health governance. Not global health but population
control had been Gates’ initial focus in the 1990s. As he
explained
earlier this year "It was only when we found out about this phenomenal
connection between improved health and reduced population growth that we felt:
Great, let’s just make the foundation as big as possible to go after these
health problems.” He courted and, in 2006, won the fortune of Warren Buffett
for his foundation’s endowment,
explaining at
the time: "If you want to deal with billions of people, you need
scale."
Institutions of civil society were inadequate. “We must be
willing to look at the failure of collective action and see how we can change
it,” Bill and Melinda Gates wrote
in 2007. More recently, regarding democratic processes, Gates said:
“The closer you get to it and see how the sausage is made, the more you go, oh
my God!” He questioned whether in the United States, “can complex,
technocratically deep things…can that get done?” It was unclear that democracy was
equal to complicated modern problems. According to Gates: “The idea that all
these people are going to vote and have an opinion about subjects that are
increasingly complex – where what seems, you might think … the easy answer [is]
not the real answer. It’s a very interesting problem. Do democracies faced with
these current problems do these things well?”
How well has Gates done in the face of important global
health problems? Prior to Ebola, AIDS represented the greatest global health
crisis of the present era. Although AIDS is far from solved, the epidemic has
been controlled by the free provision of anti-retroviral therapy (ART). Free
ARTs saved lives and reduced
transmission of the disease. The PEPFAR program, unexpectedly initiated and
signed into law by George W. Bush, made ARTs free in the world’s hardest hit
regions. Even Bono credited Bush and American taxpayers: “…10 million people
owe their lives to the U.S…George Bush started it,” the U2 frontman said
last year.
Bill Gates opposed free AIDS drugs, because of the “harsh
mathematics of the epidemic,” as he wrote
in The Independent. “[F]or each
person who starts getting treatment today, 10 more people will need treatment
tomorrow.” Gates cited cost estimates as high as $40 billion a year by 2020.
Instead, prices were forced down, anti-retrovirals saved lives and turned the
tide of the epidemic.
Aversion to Short-term Crises and Outbreaks
“The battleground is disease prevention, not treatment,”
according to an early advisor to the foundation, Bill Foege. His philosophy might have
informed Gates’ opposition to free AIDS treatment. Gates named a $60 million building
on the University of Washington campus after Foege,
saying: “On so many issues, from
the importance of disease prevention to the details of how to get partnerships
right… Bill [Foege] has pointed the way,” Foege replied: “I’m grateful for the vision that not only
worries about how to get vaccine into a child but is not diverted by the
tyranny of the acute from changing the future.”
The Gates Foundation, shaped by Foege, is constitutionally
averse to short term crises. When the foundation at last pledged a modest $50
million for Ebola, it made much of how it was its largest
ever grant for a humanitarian
emergency. The foundation might have viewed Ebola as an acute need potentially competing
for resources needed for vaccination efforts or perhaps to rid the world of polio and
malaria forever.
The foundation presumably made assessments of the Ebola threat, but it is not clear how and by whom. The foundation does not appear to have a section or person dedicated to outbreaks. The portfolio of the foundation's Lance Gordon, neglected tropical diseases, perhaps comes closest to Ebola. Gordon did not reply to an email asking how the foundation assessed the Ebola outbreak.
The foundation prioritized meningitis vaccination above
Ebola. Gates, perhaps uniquely, audaciously defended the slow response to
Ebola, saying “I think it is amazing how the United States has responded to this.” He warned “it’s
easy to forget just how much has been done” in response to what he called a
“short-term crisis,” although he would not forecast when it would end. The
unprecedented deployment of the military he attributed
not to the exponentially expanding scale of the disaster but “the president who
said let’s get the Department of Defense involved because they’re the ones who
can do logistics and get people in and out and get things built.” In contrast to Gates,
President Obama has emphasized
that "the world is not doing enough" to fight Ebola.
The US response, according to Gates wasn’t late. "Was
there some other government who took decisive action before we did?” he asked.
“Was there a CDC equivalent who flew in and personally toured [the affected
countries]?” WHO did not figure in his world. However, looking to the CDC as
global sentinel—waiting for Tom Frieden’s trip report—further delayed the international response several
weeks. Frieden recently said
"Speed is the most important variable here.” But for Gates, only Frieden’s
trip revealed
that: “even though the US and we had given money,” a reference to the
foundation’s $1 million pledge, “that seeing the urban impact, that we really
all needed to step up.” Frieden, unlike Gates, has said
of the outbreak “this was preventable." But the trigger for Gates was
anecdote from a top official, not epidemiology, reports from those on the ground, nor a WHO emergency.
It is not the CDC’s job to be the first-line monitor of
international disease outbreaks, being neither not suited nor designed for it. Pointing
out the obvious, a Lancet editorial
noted “the US Government is not a multilateral health agency.” WHO, not the
CDC, has an international surveillance network tied into national ministries of
health in nearly every country. “The final responsibility to prevent the
international spread of disease rests with WHO and IHR [the International
Health Regulations],” the editorial concluded.
But whether one looks to the CDC or WHO, as the polio
emergency demonstrates, both agencies toe the line set by the Gates Foundation.
The foundation has downplayed Ebola, with Gates defending the timing and
strength of the international response.
Gates’ “Big idea”
on Ebola is to circumvent WHO to speed approval of experimental drugs: He
asked: “Who decides that if there’s some slight increased risk of a side effect
the benefits here outweigh that?” Legal authority and responsibility lie with
WHO. A WHO panel of ethicists has already approved
untested treatments. But according to
Gates, “It’s very tricky because really the world is not very practiced at what
resources should come in and how these decisions should be made.”
Gates’ consistent answer to the world’s health problem remains:
take away the functions served by the World Health Organization. He has been
successful. Today WHO is timorous, enfeebled, and incapacitated, playing a
mostly ceremonial, subservient role. Gates is protagonist. Ebola is out of
control.
