Scanning electron micrograph of the virus growing on a kidney epithelial cell from the African green monkey. Flickr / NIAID. Some rights reserved.

The Ebola outbreak in west Africa has brought to light important issues and tensions in global health, ranging from the institutions created to service the international community—such as the World Health Organisation (WHO)—to the roles of governments, politics and ideas in determining how, where and what health issues are addressed. Failings in the management of, and response to, the outbreak have sparked a debate about the efficacy of global health governance.

This is a necessary debate for the global health community to have. When the time comes, we believe that analysts of global health politics and international relations have several valuable insights to draw, to help learn the lessons.

Exceptional

First, on institutional reform: the outbreak has been an exceptional event. It should not be assumed that lessons drawn from this single event can provide a template for redesigning the everyday workings and agenda of an institution such as the WHO.

The WHO has certainly made mistakes in the Ebola response, and these need to be recognised and addressed. This is not the only metric by which this institution should be judged, however. Nor should Ebola be used politically as an opportunity further to undermine the WHO.

Secondly, on institutional innovation: we have observed recent calls for the creation of a new international ‘rapid-response’ agency for health emergencies. Clearly in some cases rapid response is of the utmost importance, and enhanced rapid-response co-ordination and capacity is needed.

Emphasising rapid response to the detriment of other solutions is problematic, however, inasmuch as it is by its nature ill-suited to building long-term solutions to deep-seated problems. The international community must also be careful that creating such a body may be counterproductive, by shifting attention away from the important task of strengthening in-country health systems, which are best placed to be first-line responders to health emergencies.

Nor should Ebola be used politically as an opportunity further to undermine the WHO.

Thirdly, on the relationship between global health governance and national health systems: any investigation into institutional failings in the response to Ebola in 2014 must be cognisant of the wider system of global health governance which has dominated questions of African health reform since 2000. A knee-jerk ‘blame game’ of ‘who did not do what when they should’ will only provide a veneer of accountability. Instead, we need a systematic unravelling of why health systems were so poorly developed in Guinea, Liberia and Sierra Leone.

Here, reflecting on the impact of the goal-oriented mentality underpinning the Millennium Development Goals agenda cannot be avoided. We must also consider the roles of the actors (state and non-state) that have supposedly been responsible for supporting these health systems, and what they could have done better. The results of such analyses could go some way to providing the basis for thinking about how to build a more sustainable model of global health governance.

Politics

Fourthly, on the centrality of politics to all institutions: attempting to separate politics from the technical workings of institutions is a useless exercise—and a potentially dangerous one. All global health institutions are engaged in the management of resources, expectations and the interests of myriad state and non-state actors. They have to engage in political brokering, negotiation, leadership and policy design and implementation.

The idea that international institutions can or should be ‘apolitical’ has only contributed to limiting their agency, whilst obscuring the real politicking that occurs within and between these institutions. ‘Politics’ is not the problem, and it must be part of the solution.

Frail institutions: this health centre in Sierra Leone depends on a range of stakeholders. Flickr / European Commission DG ECHO. Some rights reserved.

Fifthly, on power and inequalities: contrary to a much-repeated refrain, disease does know borders. These borders may be those that separate nation-states from one another, but they can also be cultural, racial, economic or gendered.

Access to information and adequate healthcare, as well as exposure to health risk, is not equally shared but rather dependent on a multitude of local, national and international divisions—not least inequalities in power and wealth. These need to be acknowledged, understood and deconstructed if we are to finally make good on the promise of delivering ‘health for all’.

The recent Ebola outbreak in west Africa—the latest in a depressing series of outbreaks in this region in recent decades—has highlighted the extent to which global health policy has become reactive rather than proactive. A failure to take bold political action in addressing the concerns we have highlighted in this letter will mean that the global health community will remain ill-equipped to respond to future outbreaks, still less to prevent them occurring.