The men behind the curtain.

Monday was the fifth anniversary of the earthquake that shattered Port au Prince, Haiti. A hundred thousand people were killed, and a great deal of local healthcare infrastructure was destroyed. The scale of the crisis, in the heavily populated capital city of a low resource country, one already decimated by decades of violent conflict, was immense. The international humanitarian response was fragmented, inefficient, and ultimately inadequate.

The Haitian earthquake hinted at something that Ebola has brought home with force – the international community does not, at present, contain a single organisation capable of responding comprehensively to massive humanitarian crises in low-resource settings. Many people during the Ebola outbreak have either asked me if I think, or or told me that they believe, that the WHO has failed in its response to the epidemic. This position belies an understandable, but profound, misconception about what WHO is and what it is for.

The World Health Organisation does not, to the surprise of many people, directly provide healthcare, just as the UN Agriculture agency does not grow food. The WHO’s purpose is to guide and support national governments and humanitarian organisations in designing health programs and structuring health systems. It advises on responses to emergency situations, as it did for SARS, but countries and organisations themselves have to carry out its instructions.

The major direct providers of health care during humanitarian crises are Médecins Sans Frontières (Doctors Without Borders), the Red Cross, and other major international NGOs, but their capacity is limited. Port au Prince was already far too large for a small number of organisations to provide everything that was needed, and Port au Prince is a city of less than 1 million people. Liberia, Sierra Leone, and Guinea have a combined population of over 20 million. Guinea alone covers an area ten times the size of Haiti.

NGOs are not in a position to co-ordinate and mediate between five affected governments in the way that WHO can, and although they may send technical support staff to Departments of Health, WHO are not in a position to provide healthcare on the scale that NGOs do. Both types of work are needed. So the idea that the failure to control this epidemic can be blamed solely on WHO, even if there were no mitigating circumstances, is simply mistaken. WHO is only one player in humanitarian crises of this type, even when the cause is a disease.

Beyond this, as I’ve written before, Ebola was previously unknown in this part of Africa, and an outbreak in a major city had never previously occurred. Like Haiti before the earthquake and unlike Hong Kong during SARS, these countries lacked the healthcare infrastructure to respond to the magnitude of the threat. WHO could tell Hong Kong what to do with the hospitals, doctors, nurses, and quarantine facilities they already had, but they could not snap their fingers and provide all those resources to Liberia. Before the outbreak began, Liberia had 50 doctors to treat a population of 4.4 million people. Many of them have died during the epidemic. WHO called repeatedly on well-resourced UN member states to contribute health care workers and supplies – few responded with the speed and volume required.

The reality in West Africa, and in Haiti, and in many other low-resource, conflict-affected settings, is that there is simply not enough of anything: not enough doctors, not enough hospitals, not enough beds,not enough supporting infrastructure, not enough education, not enough money, not enough food. Some of these things can be flown in on short notice, but they tend to leave the same way they arrive. Ultimately, they all need to be built up and sustained locally. If disasters like this are to be prevented, rich countries need to reform the policies currently crippling the economies and health care systems of poor countries. They need to commit meaningfully to foreign aid, not just in moments of crisis, but for as long as such measures are needed.

It is always tempting to try to find the single fork in the road, or the single actor, to blame for a catastrophe. Mistakes have been made, without question. They always are. Nonetheless, WHO is a bit like the wizard of Oz – they appear all powerful, but behind the curtain, there are simply a few hundred human beings trying to hold everything together.

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