Mark J. Siedner of Harvard Medical School and John D. Kraemer of the O’Neill Institute for National and Global Health Law, Georgetown University, discuss the impact of the delayed global response to the Ebola epidemic.
On August 8, twenty weeks after the first suspected cases in what has become the worst hemorrhagic fever outbreak in history, the World Health Organization’s (WHO) Director-General declared the epidemic a public health emergency of international concern (PHEIC). The announcement, which signals that an epidemic constitutes a sufficient public health risk to member WHO States through the spread of disease, will ideally motivate financial and logistic support to the countries most affected. But after nearly 1,000 deaths, and for a disease where a relatively simple and coordinated public health response has extinguished prior epidemics, many are left wondering, “what took so long?”
An integral part of the WHO mission, mandated by the International Health Regulations (IHR), is to protect member states from international public health threats. The IHR were revised in 2005 after the SARS outbreak to improve responses to epidemics in an increasingly globalized world. Among the IHR’s central components is commitment from high-income countries to build capacity to prevent public health emergencies, and to provide assistance during active ones. The IHR task WHO with promptly identifying emergencies by declaring PHEICs to sound the proverbial alarm.
By most accounts, the criteria to declare a PHEIC were met months ago (Figure 1). The outbreak quickly made public health impact with its rapid pace and case fatality rates above 50% and by disproportionately affecting healthcare workers. It became an international epidemic five days after the first cases were reported when it spread from Guinea to Liberia. The epidemic is also unusual because it represents the first hemorrhagic fever epidemic in urban areas, where poverty and population density exacerbate disease spread. Only nine days after Guinea notified the WHO of the outbreak, Senegal closed its land borders with Guinea. By the end of May – 10 weeks before the PHEIC declaration – the epidemic raged on in Guinea, gained speed in Sierra Leone, and reemerged in Liberia.