International Development Committee

Oral evidence: Responses to the Ebola crisis: Follow-up, HC 338
Wednesday 25 November 2015

Ordered by the House of Commons to be published on 25 November 2013].

Watch the meeting – Wednesday 25 November 2015

Members present: Stephen Twigg (Chair); Fiona Bruce; Mr Nigel Evans; Fabian Hamilton; Wendy Morton; Albert Owen

Questions 63-101

Witness: Dr Bruce Aylward, Special Representative for the Ebola Response, World Health Organization, gave evidence. 

Welcome. Can I first of all say a very big thank you to you for going to such efforts to come to see us today? I know there were some issues with your flight.

Dr Bruce Aylward: I am terribly sorry to have inconvenienced you.

Chair: No, you have not at all.

Dr Bruce Aylward: I had to go to Chad and back, I’m afraid.

Chair: It is really great that you are here. We have a number of questions that we would like to explore with you. Because of this being an additional meeting, you will find that some colleagues have to leave partway through, but the aim is that we will have up to an hour for a question-and-answer session. We have eight or nine questions, so just bear that in mind, in terms of the pace of the meeting.

Q63   Wendy Morton: I am pleased to meet you, Dr Aylward. The outbreak of Ebola was declared in March. By April it had crossed the borders and by June it was the most deadly in history. Why was the response not scaled up until August and September?

Dr Aylward: If I first explain the role that I have played in this, that might help the Committee. I became involved with the response from June of last year. I manage our humanitarian crisis operations, and in June I started to follow it of my own accord and then in August I was asked to restructure the WHO response. In September I was asked to serve as the key lead strategist, I guess, for the UNMEER response and then took over the entire response subsequently. I have spent about the last six months in the field and have been in probably every infected district and town right across the three countries.

My understanding of the initial period is really hearsay. You will have heard from others who were directly involved during that period. To say one word, though, in terms of WHO’s scale‑up, some of what the public hears in the media does not quite reflect what I do understand from our people who were directly involved at the time. First, in terms of the diagnosis that was made in March, it was made by a WHO, MSF and MOH team, so our team was there. It was one of our Ebola experts who was the one who was the first to say, “This has to be tested for this.” Subsequently, immediately thereafter, it was graded as what we call a grade 2 crisis within WHO. There are only three grades; they align with the international way of grading crises. That recognises something immediately outstripping the capacity of country offices to manage it and it requires international assistance at that time.

The subsequent deployments, which were somewhere between 50 and 100 during the period through April and May—I am going just through the numbers I saw—certainly outstripped by probably fivefold, sometimes tenfold, what WHO would normally deploy to an operation like that. So I think the operation was scaled. Certainly what struck me when I first saw the data, or when I saw the data again in June, was that, with capital cities involved, you are dealing with something very different in terms of the risk of destabilising something broader than the health system. There was scaling in the earlier part of it, without a doubt—much more than ever for an Ebola response, even relative to the number of cases. However, the issue would have been around recognising that potential destabilising effect of an escalating infectious pathogen. That was not recognised to the degree it might have been.

Q64   Wendy Morton: There were also early warnings from MSF, we have been told, and calls for further resources. Do you feel that they were heeded, or could a more rapid or a greater response have followed?

Dr Aylward: They were heeded but not to the degree needed. A little of that might be in retrospect. When I look at our own organisation, this is the challenge of what we are in the midst of right now with the reform agenda that is being implemented at WHO. This is an organisation that, by mandate, is accountable for norms and standard‑setting internationally, the convening of international expertise around scientific issues related to health, et cetera. This is an operational role that we are being asked to play in Ebola, which we did eventually. When I took over in September, we went in six weeks from about 100 people on the ground to 1,300—a massive operation. It reflects the fact that a norms and standards organisation was being asked to play a technical role. Also, MSF was asking WHO to run clinical facilities and hospitals, which is not something that it does either. Their call was heeded, because WHO exceptionally ran with the governments in Sierra Leone a hospital in Kenema, which proved an incredibly difficult and dangerous thing to do—in fact, we had a number of people infected during that period. In terms of the real challenge, part of it relates to some of the issues you have highlighted, but part of it was an organisation that was not designed to be an operational field‑based organisation being asked to play such a role. Going forward, clearly that is needed and clearly the organisation needs to be reformed to play that role.

I have had two hours’ sleep on a plane, so if you need to re‑orient me please do.

Chair: No, that is fantastic. You are mentioning things that we have further questions on later on WHO reform.

Dr Aylward: I had two hours on the flight out on Monday and two hours back last night, so apologies if you need to re‑orient me a little bit.

Chair: No, not at all.

Q65   Wendy Morton: Just coming back on the point that WHO was not really geared to deliver things on an operational level, if that is the case, has that always been the case in terms of WHO? If it was, who else could have taken on that role? Is it something that has been lacking in the international sphere for some time?

Dr Aylward: WHO has played that role on some exceptional operations. For example, in the polio eradication programme, which I ran previous to doing this, we have 3,000 or 4,000 people in the field. It is a big field-based operation, but it really operates a little bit outside of the normal operating procedure of the organisation. It has also, for certain smaller outbreaks, gone out and operationalised this way, and in some humanitarian crises. To be frank, there has been a certain ambivalence among the membership of the organisation—the member states and the organisation itself—as to the degree to which it should play an operational role. Over the last five to 10 years, the recognition that infectious pathogens almost uniquely among the hazards we face toward health have the potential to cause large‑scale destabilisation at national and international levels has led people to the recognition that there needs to be a capacity to do this. I believe that should be in WHO.

Q66   Fiona Bruce: You say there might be limitations on the operational remit of WHO. Presumably you would agree that certainly it should act as an international alert to other organisations to engage? Yes. The Director-General of WHO would announce that there was a public health emergency of international concern and then the procedure would be that other organisations would immediately start to engage in an accelerated way. That is how it should happen. Am I right?

Dr Aylward: I feel differently about that; perhaps I might explain for the Committee. A public health emergency of international concern is declared under the treaty known as the International Health Regulations, as the Committee is aware. That treaty has two purposes: the first is to prevent the international spread of the disease, and the second is to prevent the application of unnecessary restrictions on travel and trade. You might remember it grew out of the SARS epidemic back in the 2000s, when there was a feeling that inappropriate travel advisories were issued—the people that received them felt that—that led to impacts on economy, et cetera. This led to the revision of the IHR treaty, which put in place, among other things, the declaration of a PHEIC, which would happen when something escalated to the point, for example, that Ebola did.

I feel that because a PHEIC is something that is grounded in a treaty whose purpose is to prevent inappropriate restrictions on travel and trade, there is almost by definition a reticence to declare until absolutely necessary that something is a public health emergency of international concern. Maintaining travel and trade is the purpose. In the emergency management world I work, in we work differently. When something escalates, you go with a no-regrets approach and you declare early, based on the complexity, severity, scale, et cetera, of a crisis. The IHR and PHEIC are not well designed.

WHO has a separate process under what is called our Emergency Response Framework. Under that, we would look at how something is evolving and grade it 1, 2 or 3. This was declared a grade 3 crisis by WHO before it was even declared a PHEIC, which means we felt it had outstripped the ability of the country and even the regional system to manage it. The problem was that was not a trigger for the international community. As we look going forward, what we need to do is ensure that there is international consensus around the grading of infectious pathogens as they evolve from an outbreak to a health emergency to a health crisis to truly a destabilising security crisis, as this one did. That should be what triggers the involvement, because a PHEIC may be too late; it is not designed to grade an escalating crisis.

Q67   Fiona Bruce: I take it that you are saying that the procedures regarding the declaration of an international emergency really need to be improved.

Dr Aylward: Absolutely.

Q68   Fiona Bruce: Have they been improved?

Dr Aylward: You have put it more succinctly. That is part of the reform process that has to be agreed. Right now in the disaster management world we have what is called an L3 declaration. When that is declared by the principals of the major humanitarian agencies it signifies a system‑wide crisis—like the Nepal earthquake, for example, or something where everyone has to surge in on it. That system is mainly used in the context of natural disasters and conflicts, but as we go forward the recognition now has to be infectious pathogens have to be managed the same way as part of the broader disaster management world. Frankly, that is not unlike how the UK responded in this crisis and the mechanisms you used.

Q69   Fiona Bruce: Can I just go back? The PHEIC was not announced until August.

Dr Aylward: 8 August.

Q70   Fiona Bruce: But you are saying that you had issued this other declaration even before then.

Dr Aylward: There was a grade 2 declaration back in March, if I remember correctly, and there was a grade 3 declaration probably in the July/August period when it started to escalate. I cannot remember the date exactly; I was not involved at that point, I’m sorry.

Q71   Fiona Bruce: I am just wondering why WHO did not make more of a noise, if it knew that this outbreak constituted a serious public health danger to other states and required a co-ordinated international response, when the response to that grade 3 announcement did not seem to be the kind of response that was obviously needed from the international community.

Dr Aylward: Again, I was not involved in the day-to-day at that point. As I have gone back and looked at the record, there is a number of points at which WHO said, “This is an extraordinary event. It requires a greater international response.” However, it was unable to leverage that. At the same time, there was the Syria crisis, and various other ones unfolding, such as the MERS crisis. You are absolutely right, though: as part of the reform going forward, there has to be a mechanism or an instrument to more effectively and urgently grade, assess, communicate and then manage infectious threats.

Q72   Fiona Bruce: What was the difference or the trigger later in the autumn that suddenly caused the international community to sit up and think, “We really have a problem here”? Where were WHO in this?

Dr Aylward: If you look first at the trigger for the PHEIC, what happened was, you will remember, that a person with Ebola boarded an aeroplane and flew into Nigeria, and then we had the case there and the outbreak there, which clearly demonstrated the international risk and led to that declaration. It was subsequent to that declaration, as you saw, that responders left the country, airlines left the country, businesses left the country, borders were closed and the operation became incredibly complex. After that, we had the further escalation of the outbreak, especially in Monrovia, where we had the terrible events of West Point in August. It was that that led, when we were seeing this exponential growth of the virus, the Secretary‑General, in consultation with Dr Chen, to go to the Security Council and establish the United Nations emergency mission for Ebola.

Q73   Fiona Bruce: In a sentence, how would you describe the WHO’s response to this issue between, say, July and October?

Dr Aylward: It was brave, it was courageous and it was scaled up rapidly during that period from July. That was when there was the real change.

Q74   Fiona Bruce: Was it adequate? Was it early enough?

Dr Aylward: In hindsight, everything should have been scaled up more rapidly than that. What is interesting is I have spent so much time on the ground now over the last months and, looking back, my perception of some of the drivers of the epidemic are changing, I must say, with the more time I have spent on the ground. The fundamental problem with this outbreak was the lack of community trust and engagement in the response and in the belief in the response strategies. That was the ultimate problem. People would not report cases. The communities would not report cases. They would not bring sick people for treatment, et cetera. That proved to be the main driver and continues to be the main problem. So if anything was not scaled up, it was not so much the medical side, but that community engagement and trust building that was really going to be fundamental to stopping this thing.

Q75   Fiona Bruce: What you are saying is that people did not have confidence in the message that WHO was putting out.

Dr Aylward: Not that WHO, or the government, or the local leaders were giving out. This was because what we were asking these communities to do was so fundamentally different or at odds with some of the things that were so close to their societies, it became very, very difficult. You cannot perform your normal funeral rights; you cannot bury your dead. If you are sick, you cannot be cared for at home; you must be brought to a treatment centre, and if they die you do not get the body back. Remember that this is a society that is grounded on a belief in most of these areas—it is a fantastic thing to see when you are in the villages—that their ancestors are part of day-to-day life. Anything that compromises that relationship is worth dying for, quite frankly. It was a fundamental part of trying to engage the communities. This is still a problem today.

Q76   Fiona Bruce: This is very interesting because Tearfund and a number of other charities have put in evidence saying that they believe that there was inadequate involvement of organisations like them. There was an inadequate understanding of the role of faith and faith bodies in responding to the epidemic. Would you say that is right?

Dr Aylward: There were inadequacies on so many sides. What I would like to ask is: is the counterfactual—that if they had been involved, it would have been different—correct? Again, there are so many of them involved now. When a new area gets infected now, you see the exact same pattern that you saw almost six, nine, 12 months ago. This is what is so challenging. As we look forward, it just teaches us risk communications and engagement in the communities have to be a big part of this. Again, I am in no way trying to defend the behaviours of anyone, but my job is to make a safer world going forward, which means having a really hard look at this one.

Chair: Thank you very much. That moves us nicely on to the next set of questions. In a moment we will have some questions around longer‑term reform and funding of WHO, but before that we have some more operational‑type questions, starting with Albert.

Q77   Albert Owen: Good afternoon. Just to follow on the questioning of my two colleagues, you acknowledged in your answers that systems needed to improve. You also acknowledged what we have been told in written evidence: that communication gaps did exist. Does the WHO have the operational capacity to respond to public health emergencies like this? Is there a capacity issue?

Dr Aylward: We have built the capacity for the Ebola response. When I took over the day-to-day operation in September, there were some key gaps around things like operations planning, operations management and crisis management on the ground. There were another couple of notable gaps in capacities. We have built those capacities during this response. There is a danger that, if there is not the momentum to maintain reform and to sustain those pieces, it will unravel; we will have a reform process and then we will try to build them again. Right now we have managed to run quite a large operation. We now have, as I mentioned, about 1,300 people operating in 73 sites right across these countries. We have the largest geographic distribution of any organisation operating on the crisis today, so it is a large-scale operation. You can get there, but a lot of this was done ad hoc, so now you have to build this into the system, which means the member states of WHO need to charge this with, “You are an operational organisation accountable for the management of such risks.”

Q78   Albert Owen: Going forward and coming on to the reform stages, if there was another outbreak of this nature, do you think you have the capacity now to deal with it much quicker?

Dr Aylward: Yes, but it is still an ad hoc capacity. It is not institutionalised in the organisation.

Albert Owen: Okay, so that is what needs reforming.

Q79   Fabian Hamilton: Dr Aylward, after the response was scaled up and everything got up and running, what were the major challenges in co-ordination and what was the turning point in the epidemic?

Dr Aylward: When I was first on the ground in September, I was struck by the number of agencies—and this includes a lot of the NGOs and other organisations—whose programmes, in the face of an Ebola crisis, were being called Ebola programmes. We had the Ebola “Paint Trees Yellow” programme, the Ebola this—I am just using something facetious, but any programme was being called that. There was a real challenge trying to orient the system and all of the capacities on the ground around what needed to be done to stop Ebola. You needed a burial cluster; you needed a communications cluster and behaviour change cluster; you needed a case management cluster. These do not normally exist. They are very specific to stopping Ebola. Certainly as late as September there were still a lot of agencies doing a wide range of things that were not directly focused on stopping the outbreak.

The launch of UNMEER was a turning point. I remember very, very clearly a workshop in October in Accra, which brought in the UN agencies and other partners from the three countries and sat down and said, “Who is going to bury the dead? Who is going to do this?” and really laid out and set accountabilities across the agencies for that. That was the turning point—a major turning point. Other turning points are epidemiologic and problematic, but in terms of the operation, that was one of the key ones when we got the planning right really deeply across the entire initiative. Other turning points were later in that year as we hit what we call the 70‑70 target of UNMEER.

Q80   Fabian Hamilton: Are there lessons that could be learnt for the future on how to manage a co-ordinated response with a large number of NGOs—especially international NGOs?

Dr Aylward: Absolutely. When you speak to the humanitarian agencies and others that we work with on the ground in this crisis, what you hear from them repeatedly is that in a crisis you look for the familiar, so work with the crisis management systems that exist for other kinds of crises, which are usually driven by the OCHA and humanitarian system. We have learnt a lot of lessons.

Coming back to the point that I made to Mrs Bruce, first of all we need a new system for grading these crises and communicating so everybody knows what we are dealing with. The second thing that we need is to be able to escalate the leadership mechanism and co-ordination mechanisms to bring in eventually OCHA on health crises, and then, when something truly has a destabilising effect nationally or internationally, bring in the Secretary-General’s office to be able to manage the political pieces necessary. On the ground, mechanisms like OCHA are absolutely essential for that NGO engagement. NGOs are used to working through that system. They are not used to work through UNMEER, which is a UN mission that really has authority only over the UN frankly. Did that answer the question?

Q81   Fabian Hamilton: Yes, it did. Thank you for that. Do you think that the UN emergency health mission model could be followed again in the future, or does it need amending?

Dr Aylward: I believe that parts of that were necessary and would be necessary in future were we dealing with a rapidly escalating infectious pathogen or high-threat pathogen that has the capacity to destabilise on a multi‑country level, or even a regional or global level. We have to look very carefully at what parts of the architecture internationally already exist that we should have been using much earlier and more effectively and then, when we do bring in something like a Secretary-General‑led mechanism, we should be very, very clear that that role is going to be really around leveraging the political assets and support needed for this, as well as having executive authorities over the agencies that would play a role going forward. That would really only be in the extraordinary circumstances, as Ebola was.

You will need a mechanism that goes beyond our usual humanitarian ones. Usually you have an earthquake or a conflict, and it is affecting a very circumscribed area and it will stay generally within that area. With an infectious hazard that can escalate like this—to steal a phrase from my child, go viral—these things can truly destabilise on a large scale, and there you need to be able to get above the usual humanitarian mechanisms because they are not acceptable or appropriate to many circumstances that could be affected by an infectious hazard, but would not need, frankly, the usual humanitarian approaches on some other hazards.

Q82   Chair: You made brief reference to this, Dr Aylward. Late last week a small number of new cases were reported in Liberia. Are you able to give us an update on these cases and the efforts to keep them under control?

Dr Aylward: First, I might just mention to the Committee what distinguishes these cases from most of what we have seen. As everyone in the Committee is aware, Ebola is a disease that is driven by person-to-person contact with infected body fluids and the disease does not naturally persist in human populations. It is the animal population from where it re‑enters. Almost all of the cases that we have seen are related to the original infection of an adult or a child probably way back nearly two years ago.

However, in the last few months it has become clear to us that there is another phenomenon happening against the background of the bigger epidemic. What that is is little flares of the disease. What we are seeing is, in male survivors of the outbreak, they will have persistent virus in their semen for anywhere up to nine months or longer, and rarely that virus can be reintroduced into the population, either directly, possibly through sexual contact, or from coming into contact with the semen otherwise. That can give rise to a little flare‑up. We have seen three of these in Liberia. The one happening right now is probably due to that. We have seen one of these in Sierra Leone, and we have seen it happen three times that we know of in Guinea. They are very, very rare events, but until the virus has died out of the human population altogether, they will continue to happen. That is probably going to be most of 2016, so we may continue to see the odd flare.

What is happening in Liberia is that as of today there are still three cases concerned. There are a number of suspected cases that are being tested to see whether or not they may have Ebola. We do not know exactly how this virus re-emerged. We are still trying to do the investigation looking at who had contact with whom in this family. Also we will have genetic sequencing of the virus to try to tell us whether this is a virus that has survived all along or if it links back to someone who was infected the previous year, so the investigation is very much ongoing. There is still a real risk that this could get out of control. Not all of the contacts are well identified and being followed. The vast majority are, but with Ebola we have learned to be very, very careful in predicting when something is under control. You will remember, sir, that this has a 21-day incubation period, so the virus tricks you into thinking, “Okay, it has gone quiet,” and then it pops up 10 days later. Therefore, we are right in the high‑risk period right now where we will know how much more of a problem we are going to have.

Q83   Chair: More broadly, in a sense leaving that aside and in particular looking at the situation in Sierra Leone, there is a sense of moving into a recovery stage now where countries are free of Ebola. What sort of role would you see the WHO playing alongside the governments of those countries in the recovery stage?

Dr Aylward: The WHO in the recovery phase would be playing more to its traditional strengths, which are more about looking at health systems, health system strengthening and how you put in place the mechanisms needed to ensure you have a resilient zero when you hit zero with Ebola, helping strengthen surveillance systems, and helping ensure rapid response capacity, et cetera, to manage infectious threats. However, at the same time it needs to work at a district level to help strengthen those district management teams, so they can get their hospitals functioning again safely, so that they are planning the right public health services, and so on. For the next two years we have planned to maintain a capacity in the case of Sierra Leone at the district level, to work with those district management teams to try to get those hospitals functional again, keep them safe again and get the trust of the communities back in that system. It is that on the clinical side, and then helping ensure they get the vaccination programmes and malaria programmes—the things that are more traditionally WHO strengths—functional again.

Q84   Chair: We are going to move now to look at some of these issues around reform and funding of WHO moving forward. As you will be aware, the London School of Hygiene and Tropical Medicine and Harvard have released a report this week that is very critical of the World Health Organization and recommends some fairly radical reforms. Could you give your reaction to your report and then more broadly your views on reform?

Dr Aylward: It was a good report. It was very critical of WHO’s ability to operate as an operational agency in crises. As we talked about earlier in this conversation, there are valid concerns in part because of mandate and in part because of expectations of member states and so on. We have an opportunity to address those collectively. If you look at the diagnoses or the issues raised by that report and its 10 recommendations, these are similar issues that have been raised by the Stocking commission and others.

What distinguishes this report a little bit is perhaps the extent to which they have proposed really novel and in some ways far‑reaching solutions perhaps, like tougher medicine or more radical surgery than some of the others. Others would say, “Here is the issue. Propose this.” These ones are saying, “Go even further.” Among those recommendations is the establishment of a UN accountability mechanism for health emergency status, a global health committee under the Security Council. In terms of the recommendations that WHO would have the authorities and ability to address, we are already planning to move in that direction, such as on the restructuring of the organisation emergency work, establishing lines of accountability authority right across the organisation, and capacitating it operationally. Those things are being done. It would be the remit of others to speak to some of the proposals—to the Secretary-General’s office and others.

I would be a little bit surprised—and this goes beyond my station and authority—to put in place a mechanism for managing infectious threats on a day-to-day basis that you would not have for other hazards, like natural disasters, et cetera. There is a very special issue around that destabilising potential of high-threat pathogens and new emerging pathogens that do require a different level of, if not oversight, at least cognition that they are there and that they are being managed. Again, one would ask whether the establishment of standing mechanisms like that is the most effective way to do it. I am not sure. I have just seen the report on Monday. That is why I was here on Monday; I went through it then.

Q85   Chair: One of the issues we explored this morning with David Nabarro, which has come up both in evidence but also in broader media discussion and commentary on this issue, relates to the current method of appointing directors of WHO regional offices. I think I am right in quoting from the Associated Press an internal WHO document from a year ago that says the heads of WHO country offices in Africa are “politically motivated appointments made by the regional director”. Is this an issue that WHO is taking seriously and where we might see change?

Dr Aylward: The current Director-General has taken that issue quite seriously. Previously these positions were appointed, frankly. In her tenure she has put in place a new mechanism by which any candidate for WHO representative has to go through a rigorous vetting that is done independent of the organisation, and is a multi‑day written and oral testing process done by professionals. If they do not meet those criteria they cannot be rostered, and if they are not rostered they cannot serve as a representative. It tests quite seriously a number of parameters they would need to be able to operate properly in their positions. A significant number of people who are candidates for those positions and some serving when this was put in place were not able to pass. They were removed from office and reassigned to technical roles or something better suited to their abilities, so there is quite an intent to do that. You can imagine that when you have 147 offices around the world, it will take time to fully apply that and get the calibre of people you want. There is a very deep recognition that they have to meet the standard to be in those jobs going forward.

Q86   Chair: Thank you. In terms of the reform programme as a whole, do you have a sense of how long is it going to take? At what point will reform have been achieved? Is it in a year’s time or two years’ time?

Dr Aylward: In what context?

Chair: The broader reform that we have been talking about at WHO.

Dr Aylward: There is the broader reform of WHO, which kicked off in 2009, if I remember correctly, which was a function of financing challenges at that time that drove it. Now there is something new being called a reform process. I like to call it a new programme process because frankly you have to put a new programme in place for the emergency work. I am most familiar with the latter. With the latter, the intent is to go very quickly. There has been frustration with people because there was a charge to our Director‑General last December past to undertake a reform process, but then she was also told that there should be this evaluation and that evaluation, et cetera. As you know, David Nabarro’s group has just provided a set of recommendations. The Stocking report came out some months ago. The London School has just come out last week. We have the International Health Regulations review coming out in the next months, and then we have the high-level panel of the Secretary‑General coming out.

The Director-General has signalled the direction she is going with her reforms. She has set up an internal consultative process, and she has followed these external and internal evaluations, which are all coming to fruition now. Now is the time to move very, very fast on implementation and actioning those. The goal will be, by the time of our executive board meeting in January, to have the organisational design for the new programme, platform and processes in place, to have the build of that programme in place between then and May, and then be implementing from then. This Director-General has 20 months left in her term, and she is intent that the changes she puts in place are there long enough and are deep enough to survive this mandate, so I anticipate it will move fast at this point.

Q87   Fabian Hamilton: So the World Health Organization does accept the need to establish a new body to deal with outbreak control, such as the Centre for Emergency Preparedness and Response. That is a fact, presumably.

Dr Aylward: Yes. The Director-General received Dr Nabarro’s report on Monday past, if I remember correctly, and with the senior management endorsed the major recommendations including that it would be a programme that would reach right across the organisation with directing authority, one budget, one HR and so on.

Q88   Fabian Hamilton: Can you see any disadvantages in that model? The advantages are obvious, are they not?

Dr Aylward: Yes, as always it is about the challenges to putting it in place. I have been charged, as of Friday night, with moving forward with the design. There will be some formidable challenges. There is a risk that the sheer number of small outbreaks and earthquakes with health implications and so on could lead to this programme getting mired down if it is not careful enough in its centralisation of some authorities that it does not leave enough decentralised to be able to manage everything. That might be one potential downside to it. Again, I come from a disaster management world, which is much more directive, so it fits that world.

Chair: We are now going to move on to the question of funding. Fiona—

Fiona Bruce: In the sense it is a dangerous question to ask someone.

Dr Aylward: I am having a hard time telling if I am being helpful or not.

Chair: You are being very helpful and wonderfully concise as well.

Dr Aylward: Now you are being polite.

Chair: That is real praise. That is not fake praise.

Q89   Fiona Bruce: What level of funding does the World Health Organization need to properly deliver its mandate, and where should this come from?

Dr Aylward: In the context of its work on emergencies?

Q90   Fiona Bruce: On the reformed WHO.

Dr Aylward: The new programme. Again, before I took this over I ran the polio eradication programme for WHO—that partnership. At the peak of our operations, we had nearly 6,000 people working on various types of contracts around the world, our total expenditure was about $1 billion, and about a quarter of that was just in people and equipment and supplies to keep the operation functional. When I look at what WHO has today for managing its health emergencies work, we did a mapping across the organisation last year. Before I was in this job I wanted to know how many people do this if we have something big we have to draw on. It was about 500 people across the organisation. There is a huge gap in the basic capacities needed to be able to maintain early warning capacity, surveillance capacity, risk verification capacity in highly vulnerable countries as well as technical expertise at the global and regional levels.

Going forward, you are looking at a programme that would probably need about 1,200 people at the combination of global, regional and country levels. A lot of those would be nationals, and that would have an operating budget of somewhere around $250 million to $350 million a year, but, on top of that, for other events it would probably run to $500 million, I would imagine. That is a fraction of what something like the World Food Programme or another UN agency with a large mandate in one particular area would need to do.

In terms of where it comes from, about half of the money would come from existing WHO expenditures on outbreaks and emergencies—other things that are spread across the organisation—so there would be a certain amount from consolidating it. Another proportion of it may come from a decision—one of the recommendations of the London School report was to really streamline what the organisation does. It is doing everything in the world right now. It probably did that painting behind you. It is doing too many things. With that, there should be efficiencies within the organisation that could finance part of it. These are tough decisions member states would have to make and give up pet projects.

Then, a certain proportion will require additional financing. Many people say, “Why can you not just do it with what you have?” There was no operations planning expertise. The first thing a military send into a war is your planners. It has no operations management expertise. It has a lot of technical experts but nobody to really manage them and translate it into an operation. It is what I had to bring into the organisation to do it. You do have to build as well, and that would probably be somewhere in the region of an additional $150 million, I would anticipate, to do it at that scale. Frankly, for global health security, that is not a lot of money.

Chair: $150 million.

Dr Aylward: Additional to what is already spent, which is probably about $250 million. With that what you get is a global capacity to be able to scan the horizon for emerging pathogens and problems, verify alerts that you hear about in different places, and launch an initial risk assessment when one needs to be done. It does not pay for managing those crises when they come. That would be additional.

Chair: Of course.

Fiona Bruce: May I revert back to an earlier question?

Q91   Chair: You can but let me just pursue the finance. How confident are you that we can raise $150 million from donors?

Dr Aylward: It is going to be extremely difficult in the current environment. As we look at the rollout of the reform programme, my goal, having been charged with that this year, is to spend this year looking at those internal efficiencies and restructuring, et cetera, of it, filling some of the relatively small gaps. You would then build proof of principle and the operation over time. We are not in a financing environment, especially with many of the donors in northern Europe right now, in which there is a lot of money to plan an expansion. I have had to have some very tough conversations internally in managing expectations. We are going to have to do a lot with marginally more. I would hope in the current year we would have 15% to 20%, or more, of what we would need, but it would be unrealistic in the current environment.

Q92   Chair: Is that including UK and DFID? Do you have a sense of where DFID will be with regard to that request or is it too early to say?

Dr Aylward: It is too early to say. I should have caveated my comments at the beginning. I am trying to be as helpful as possible. Ballpark figure: I hear people using numbers like $10 million and $30 million, and they have never run a big operation. If you want to put people on the ground and manage a big operation across three levels of an organisation in 130 countries, many of which are fragile or vulnerable, you need substantive standing capacity. In the current security environment we operate in, it costs money to keep them safe as well. Our operating costs are 15% or 20% above what they would have been five years ago.

Q93   Fiona Bruce: I would just like to go back to one of my earlier questions. Am I correct in understanding that the International Health Regulations, which set down the PHEIC procedure, also set down the grade 2 and the grade 3 alerts?

Dr Aylward: No. The International Health Regulations provide obligations on all of those who are signatory to that treaty to establish and maintain a certain minimum capacity to be able to prevent, detect and respond, basically, to infectious diseases. I then puts obligations on WHO to verify, when things happen, whether or not they constitute a substantive risk, and then to convene an emergency committee that would make recommendations to the Director-General as to whether something constitutes a PHEIC and what might be done to help manage that PHEIC.

Again, I come back to the original point I made. That treaty is really designed to ensure that there are no inappropriate restrictions on travel and trade in the event of these kind of hazards. That is different than what you would do to manage a crisis, in my mind. At WHO we have this IHR treaty that governs our work with our member states, but then internally we have something called an Emergency Response Framework, and in that framework we grade emergencies. Ebola is graded under that thing. That Emergency Response Framework then tells us how much we have to, as an organisation or with our partners, invest in a particular crisis for its management, so it is different than the PHEIC declaration.

Q94   Fiona Bruce: So the grading is something you had control over.

Dr Aylward: Yes.

Q95   Fiona Bruce: Why did you not grade this disaster as more serious earlier on?

Dr Aylward: The Emergency Risk Framework is a relatively new thing. In 2011 I was put in charge of WHO’s crisis management work, as well as what I did on polio. One of the things I recognised was that the organisation did not have standard procedures on its assessment and grading of emergencies and then the accountabilities and responsibilities as they evolve. We established the Emergency Response Framework, and it is exactly the same across the organisation from managing these things. I operate in one part of the organisation. Outbreaks operate in another, and sometimes they would grade things but they would not then implement the processes the way we normally would on the crisis management side. Again, coming back to your question earlier, Chair, when I was brought into the operation in August it was to restructure the operation along those crisis management principles and procedures that we have, because finally an infectious disease had arisen to a point where it needed to be managed that way. One of the things, as part of the reform going forward, is that any infectious threat now, the Director‑General has said, will have to be graded and managed through that same mechanism.

Q96   Fiona Bruce: I am trying to understand whether you saw this crisis as being as serious as, say, Médecins Sans Frontières did at that stage. Are you saying you were inhibited by your own internal procedures from communicating the gravity of it? Is that what happened?

Dr Aylward: To be absolutely clear, I was not involved, as I say, in the management, because there are different clusters—

Q97   Fiona Bruce: Speaking about WHO as a corporate body, had WHO grasped the gravity of this but the procedures, which you are saying caused the communication problems, inhibited it from communicating? Why did somebody in WHO not say, “Never mind all of these procedures and this grading; this is serious. We must do something about this.”

Dr Aylward: A number of people did.

Q98   Fiona Bruce: Why did the world not hear then?

Dr Aylward: The challenge was that it was such a new thing. Ebola had occurred so many times up until then. We had the two dozen outbreaks in DR Congo and Uganda and various other places. They had all been managed within a number of weeks or months at most, and they had all led to relatively small flares. So there was a certain sense of, “This is Ebola. We know Ebola. This will be manageable.” Those proved wrong assumptions, but they proved to be the wrong assumptions by everybody. MSF caused an alarm about this, but it was about, “We want you to make more hospitals.” If you look carefully at what they said it was not clear. It was out of control in terms of what they could manage, very definitely.

I hear other agencies—some in this country—but I keep going back to the end of March, when the diagnosis was made; you had four major towns in Guinea infected. You had the virus in the capital city and you had the virus shortly thereafter on the other side of the border. That had never happened before. The whole world saw the exact same data. The whole world—“Listen, WHO. Say it is grade 2 or it is a grade 3,” and people did not react.

Q99   Fiona Bruce: You did not issue a PHEIC at that stage?

Dr Aylward: No. Again, I was not involved, quite frankly, in the discussions around that. I have, by the way, seen the discussions around people being concerned about the political implications or the impact on travel and trade, and this sort of thing influencing decisions about declaring a PHEIC. I am close enough that I would have heard those things. I never heard that about anything in terms of an infectious disease threat, certainly among the level of WHO that normally deals with that centrally. Regarding the idea that we should not do this because it may have this effect or that effect, it tends to be much more, “Is this is a public health emergency or not?”

Q100   Fiona Bruce: Why was a PHEIC not issued six months earlier, or at least four months earlier?

Dr Aylward: I do not know. If you go back to four months earlier and look at the data in May, you will see a curve that was going up a little bit, and down and up, and then it would go down again. They had three peaks and valleys before finally it took off. People were getting a sense that, “We have nearly got it. Now we will just push a bit harder and this time we will go right to zero.” If something started, and started going like that immediately, people would have called it a PHEIC. It was when it started going like that that they declared it a PHEIC, but before that the thing had gone like this. During this period everyone says, “Why did you not call it a PHEIC there?” Everybody knew it was a PHEIC here. WHO called it a PHEIC down here. All of the airports were closed. All of the planes stopped flying, etc. This is before the end of this.

These are absolutely great questions. As one goes forward, you have to be thinking very hard about the triggers not for declaring these PHEICs so much as declaring them a grade 3 or potentially grade 4 crises.

Q101   Chair: Dr Aylward, thank you very much indeed. That completes our questions for today. I am really grateful to you, as I said at the beginning, for coming to talk to us today. Your evidence will be very helpful in our follow‑up inquiry, both in terms of looking at what happened and learning lessons from it, but also moving forward on the whole agenda of reform of the architecture, including WHO itself. Thank you very much indeed for coming today.

Dr Aylward: Thank you, Chair. Can I just express my appreciation for you giving your time to this? I have worked in these villages and these communities and with the presidents, from the presidents to the children in these places, and this was a really a horrific event. The attention that people at your level are giving to this and really digging into these issues is important. As we go forward, these things will happen. It was an exceptional thing, and there will be mistakes when exceptional things that we have never seen before happen. That will happen. They should never happen a second time, but unless bodies like this give it this kind of attention they will. I am sure no one thanks you for this role, but for someone who has been out there trying to manage it, we need a different organisation and a different system going forward, and this kind of attention will hopefully help get it there. Thank you.

Chair: Thank you very much indeed.

              Oral evidence: Responses to the Ebola crisis: Follow-up, HC 338                            15