At the forefront - getting to zero
Bruce Aylward, Assistant Director-General, Polio and Emergencies, leads the Ebola response at WHO, spending 90% of his time away from headquarters working with our regional and country offices and our partner agencies to manage and coordinate the response to the Ebola crises.
Q: What makes you tick?
A: I am driven by a sense of fairness – I think that we live in an era when we can get minimum health services to every single person, everywhere in the world and make their lives better.
I also believe that we now have the possibility to mobilize and move populations on an unbelievable scale to improve the health of children and their families. I work with eradication and in crises because they force us to reach populations that are easily forgotten. My job is to make sure that we do not forget these people.
Q: What is your role in the Ebola response?
A: As the Director-General’s Special Representative on Ebola, I focus on analyzing the evolving epidemiology and using that to drive the response priorities across civil society, governments, humanitarian organizations and the United Nations agencies. I work within UNMEER to help provide the technical direction required for the overall operation. It is a unique role.
I also represent WHO on issues related to Ebola so I spend a significant amount of time meeting with partner agencies and donors, to explain what we are doing, and to advocate for additional resources.
Q: What are the things that keep you up at night during the Ebola response?
A: When I first got involved in August, the stark realization that the classic Ebola strategy was not going to work kept me awake at night. We had to try a new approach to slow down this outbreak, the one that we laid out in the WHO Ebola Response Roadmap on 28 August (2014). After that, it was “can we slow down and reverse the exponential growth in cases through the rapid scale-up of a combination of three Bs: beds, burials and behavioural change?”. We – the governments and their partners – had to scale these interventions up really really fast if this was going to work. It turned out that, working collectively, we could and by October/November (2014) it was clear that the three Bs could take some of the heat out of this outbreak.
What keeps me up at night now is worrying that the world will shift its gaze from this crisis and forget the importance of finishing Ebola. We have already seen that risk: this year the only thing that fell more rapidly than the number of new cases was the new financing needed to fight Ebola. The world made a mistake once by not getting on top of the response fast enough with the huge resources and assets that were needed in these countries. We have to make sure that the world does not make this mistake again just because the number of cases has fallen to relatively low numbers. Will the world fail to understand the complexity of finishing the tail end of an outbreak like this? We have the strategy, we have the infrastructure in place, we have the commitment of the people. The question now is: will we have the resources to finish the job?
Q: As you mentioned, you have worked with vaccine preventable diseases, polio eradication and humanitarian health emergencies for the past twenty years. What have you learnt from those areas that you can apply to this response?
A: I think that a few of things from the polio programme have been incredibly important. The most important thing was that when you empower and inform populations, they can do incredible things to improve their own health and the health of their children. If you look at polio, at the peak of the operation we had about 20 million people involved in the vaccination of over 600 million children across 75 to 80 countries, and the vast majority of these people had never even seen polio!
Second, I learned the challenges to achieving what I call ‘programmatic perfection’ in a public health initiative. We usually think that “if we get 80% immunization coverage that would be great”, but to achieve polio eradication in certain areas of India, for example, they had to achieve over 98% coverage. If people had really known that in their hearts at the beginning of the polio eradication, they might never even have started. But having seen countries achieve the programmatic perfection needed to eradicate polio in some really tough places like Somalia, northern Nigeria and northern India, I had a sense of what would be needed – and what could be achieved – when I went into the Ebola outbreak.
Thirdly, from our humanitarian work, I learned what large scale crisis management was and what it took to run multi-agency operations on that scale with governments and across a huge number of partners and UN entities. I knew the actors in the humanitarian field, how they work and interact, and how we could use this to our advantage, and to the disadvantage of the Ebola virus. I had also learned from polio eradication what it takes to engage and mobilize populations on a huge scale.
Finally, from all of these programmes I learned how to work on a large scale using WHO’s systems and processes. The reality is that, through 20 years of building the polio programme and implementing health programmes in many complex emergency settings, you learn how to get things done in such areas. We took a lot of that to the Ebola programme. In fact, we’ve used a lot of talent from both the humanitarian emergency and polio programmes in this Ebola response.
I guess I’ve spent my entire carrier training to do something like this. It brings together years and years of my experience in everything from disease eradication to humanitarian response.
Q: How do you envision WHO’s future role vis-a-vis emergency response efforts?
A: This outbreak has shown, along with other crises such as the Nepal earthquake and the Syria crisis, that when populations are struck by emergencies the first thing they often worry about is their health. In many crises, however, the emergency health response has not been commensurate with the scale of the crisis. Coming out of Ebola, and all the other crises of the past 24 to 36 months, there is finally a very strong international recognition of the need for an even stronger international agency to coordinate and drive the health response in crises.
There is now a strong consensus forming that the agency to do this should and must be WHO. Unfortunately, people sometimes still ask: “can you really put such an emergency culture into WHO?” When I look at just the Ebola crisis, I am convinced that the answer is a resounding ‘yes’. We have had over 950 staff working on this emergency for prolonged periods of time over the last 12 months. That includes a third of the staff from our Africa region and almost a third of the staff in headquarters. All of these people have been deeply involved in this crisis. This tells me that we already have a health agency that has a deep culture of emergency response. When you get a third of your staff working on a crisis, it means that you have an agency that sees emergency response as a central part of its work.
Although people often say that changing the culture of an organization is the hardest part, what we’ve seen in WHO is a lot of staff who want to be very relevant in major crises. As the role of the Organization in emergencies expanded, I think that this culture will also change even more and very, very quickly. We have seen so much courage, so much dedication and so much generosity from WHO staff in this crisis. I have absolutely no doubt that there is a very strong culture of emergencies in WHO. This is a great foundation on which to build an even stronger WHO capacity to deliver truly effective health relief to the people and populations who suffer catastrophes, irrespective of the cause.