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Lawrence O. Gostin
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The West African Ebola epidemic was a clarion call to transform global health security. Why? After all, more people die every week from enduring diseases such as HIV/AIDS, tuberculosis, and malaria—not to mention noncommunicable diseases—than died throughout the Ebola epidemic. In 1948 the United Nations created the World Health Organization (WHO) precisely to lead the global response to novel infectious diseases with the potential for rapidly spreading across borders. Yet, the WHO and the entire international community were so focused on other priorities (and many countries, like the United States, so self-absorbed with isolated Ebola cases) that they turned their backs on the suffering of the world’s poorest people. The result was an unconscionable amount of illness and death, most of which was entirely preventable.
The Ebola epidemic spurred no fewer than 4 global commissions: the WHO Ebola Interim Assessment Panel (July 2015), the Harvard–London School of Hygiene and Tropical Medicine Independent Panel on the Global Response to Ebola (November 2015), the National Academy of Medicine’s Global Health Risk Framework Commission (January 2016), and the United Nations High-Level Panel on the Global Response to Health Crises (February 2016). In addition, the WHO commissioned an independent assessment, which is ongoing, of the functioning of the International Health Regulations during the Ebola epidemic. All 4 reports had striking similarities. Here I examine the reports’ major themes and what it will take to safeguard the future of global health security. This is also a matter that global leaders plan to discuss at the G7 (May 2016 in Japan) and G20 (September 2016 in China) summits.
World Health Organization Reform: A Center for Global Health Security
All the commissions were scathing in their criticism of the WHO, and even the agency’s own independent panel concluded that “urgent warnings either did not reach senior leaders or senior leaders did not recognize their significance.”1 The Harvard–LSHTM Commission wrote, “Confidence in the organization’s capacity to lead is at an all-time low.”2 The failures of the WHO’s governance are well understood: unsustainable funding, dysfunction between headquarters and regional offices, and lack of transparency and accountability. A common theme in these panels was a proposal to create a dedicated WHO center for preparedness and response that would report to the director general and/or an independent governing board. The WHO has also announced internal reforms, but these are well short of the panels’ accountability measures.
The WHO will elect a new director general in 2017, offering an opportunity to install a leader with the integrity and political will to challenge the most powerful governments and donors. Above all, the WHO requires good governance: freedom of information, to foster transparency; participation of non-state actors and the ability to harness the ingenuity of civil society and businesses; human resource reforms, with a focus on effective performance; and an inspector general to ensure accountability.3
International Health Regulations
The WHO oversees the International Health Regulations 2005 (IHR), the governing framework for global health security. Yet, member states flouted their legal obligations during the 2014 Ebola crisis, including a failure to fund and build core health system capacities, late reporting, travel and trade restrictions, and unnecessary quarantines. The director general declared a Public Health Emergency of International Concern (PHEIC) 4 months after the outbreak spilled across borders. The WHO currently permits countries to “self-assess” their core capacities, with all commissions demanding independent, transparent external assessments. The director general, moreover, must promptly convene an IHR emergency committee and, if necessary, promptly declare a PHEIC. The 4 commissions proposed enhanced IHR compliance, such as early reporting and avoiding travel and trade recommendations.4 One straightforward reform would be to publish lists of member countries’ compliance or nonadherence, given that transparency is a vital pathway to accountability.
During the financial crisis, the WHO cut its biennial budget by $1 billion, 35% of which came from funds dedicated to epidemic preparedness and response. That decision cost lives, as resources were mobilized painfully slowly. Sustainable financing must address both the WHO’s capacity to respond as well as each nation’s preparedness. Several funding mechanisms are intended to close capacity gaps: WHO’s Emergency Contingency Fund, the Global Health Workforce Reserve, and the World Bank’s Pandemic Finance Facility. Regional banks, such as the African and Asian Development Banks, also have a role. The National Academy of Medicine panel estimated the annual cost of pandemic preparedness at $3 billion to $5 billion, which is well beyond current financing but a “best buy” if one considers the massive costs of uncontrolled epidemics.
Knowledge Production: Research and Development
The Ebola epidemic underscored both the failures of information and technology—including health information systems, community mobilization strategies, health worker protective equipment, rapid diagnostic tests, vaccines, and therapeutics—and their limited availability in lower-income countries. Part of the problem in West Africa was simply financial and logistical, the failure to move key resources to affected countries. But a more systemic problem is the perverse market incentives for research and development. Epidemics in impoverished regions offer the perfect storm for inadequate technological investments. The private sector won’t invest heavily in diseases that are periodic and unpredictable, that affect primarily countries and populations too poor to pay for their products, and that have no long-term prospect for recouping development costs.
It is in the collective security interests of all countries to overcome these perverse market incentives. The Global Risk Framework Commission proposed a WHO pandemic product development committee focused on diseases with pandemic potential. The committee would guide national and international R&D investments. The commission also proposed that R&D stakeholders invest $1 billion annually on innovations to combat episodic diseases with pandemic potential that often disproportionately affect poor countries.
The United Nations: Shoring Up the Political Will and Stepping Up the Global Action
Even if the foregoing reforms come to pass, major pandemics will occasionally overwhelm even a well-prepared WHO. At some point, the United Nations machinery will have to respond forcefully to ramp up surge capacity, coordinate an international, multistakeholder response, and stiffen political resolve. Certainly, the UN “Health Cluster” (more than 40 health and humanitarian organizations) will bring a multiagency/multistakeholder response. Beyond this standing cluster, though, the UN secretary-general may have to assume responsibility for coordinating the response. The Harvard–LSHTM panel, for example, recommended a standing health committee within the Security Council. That panel also called for a permanent UN “accountability commission” providing systemwide assessments of international responses to major epidemics. The Risk Framework Commission proposed a trigger point at which operational control would be shifted to the secretary-general. Perhaps less boldly, the UN High-Level Panel foresees a role for a coordinated UN response, modeled, for example, on the UN Mission for Ebola Emergency Response (UNMEER).
A Political Window Closing
The political window opened by Ebola, however, is rapidly closing, and with global attention now focused on the Islamic State and the Paris attacks, this window might have closed. Global health advocates cannot allow that to happen because Ebola may well prove to be the defining event of a generation. And in the next contagious crisis, we will not be so fortunate if a novel influenza or corona virus spins out of control, and, unlike Ebola, it cannot be contained.
Author(s): Lawrence O. Gostin
Read on Wiley Online Library
Volume 94, Issue 1 (pages 34–38) DOI: 10.1111/1468-0009.12176 Published in 2016
Lawrence O. Gostin is University Professor in Global Health Law at Georgetown University, faculty director of the O’Neill Institute for National and Global Health Law, and director of the World Health Organization (WHO) Collaborating Center on Public Health Law and Human Rights. He has chaired numerous National Academy of Sciences committees, proposed a Framework Convention on Global Health endorsed by the United Nations Secretary General, served on the WHO Director’s Ad Hoc Advisory Committee on Reforming the WHO, drafted a Model Public Health Law for the WHO and the Centers for Disease Control and Prevention, and directed the National Council of Civil Liberties and the National Association for Mental Health in the United Kingdom, where he wrote the Mental Health Act and brought landmark cases before the European Court of Human Rights. In the United Kingdom, he was awarded the Rosemary Delbridge Prize for the person “who has most influenced Parliament and government to act for the welfare of society.”
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