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the street. Some feel the entire model the worlduses to fight outbreaks needs to be rethought,so that an agency like the W.H.O. has the struc-ture and mandate to take command.

But Dr. Chan said that governments havethe primary responsibility to take care of theirpeople, calling the W.H.O. a technical agen-cy that provides advice and support. Still, she

noted that her organization, like many govern-ments and agencies, was not prepared.

Hindsight is always better, Dr. Chan said.All the agencies I talked to including thegovernments all of us underestimated thisunprecedented, unusual outbreak.

A Shift in Emphasis

The W.H.O., founded in 1948, is responsiblefor taking on a wide range of global health is-sues, from obesity to primary health care. But

since the worlds health needs far outstrip thefinancial contributions of the W.H.O.s 194 mem-ber nations, those priorities compete.

The threat of emergent infectious diseasesjumped high onto that list 20 years ago, whenan outbreak of plague in India created a panic,sending about 200,000 people fleeing. The nextyear in Zaire, now the Democratic Republic ofCongo, Ebola killed about 245 people. With fearsof cross-border infections high, a new urgencyarose: improving the worlds ability to stop out-

breaks.The W.H.O. took the lead, at the request of

its member nations. A crew of passionate out-break veterans assembled a unique department,using an early form of electronic crowdsourcingto detect outbreaks and dispatching experts tothe field. Three years after the effort solidified,the W.H.O. played a big role in responding to acluster of deadly pneumonia cases in Asia. Thenew virus became known as SARS, and it wascontained within the year, with most cases oc-

curring in China.To aid the fight, wealthy individuals offered

the W.H.O. literally hundreds of millions be-cause their businesses were affected, said Dr.Jim Yong Kim, president of the World Bank anda former director at the W.H.O. But as SARSburned out, those guys disappeared, and we for-got very quickly.

Soon, the global financial crisis struck. TheW.H.O. had to cut nearly $1 billion from its pro-posed two-year budget, which today stands at

$3.98 billion. (By contrast, the budget of theCenters for Disease Control and Prevention for2013 alone was about $6 billion.) The cuts forceddifficult choices. More emphasis was placed onefforts like fighting chronic global ailments, in-cluding heart disease and diabetes. The whimsof donor countries, foundations and individu-als also greatly influenced the W.H.O.s agenda,

with gifts, often to advance specific causes, farsurpassing dues from member nations, whichaccount for only 20 percent of its budget.

At the agencys Geneva headquarters, out-break and emergency response, which wasnever especially well funded, suffered particu-larly deep losses, leaving offices that look, oneconsultant said, like a ghost town. The W.H.O.sepidemic and pandemic response department including a network of anthropologists tohelp overcome cultural differences during out-

breaks was dissolved, its duties split amongother departments. Some of the main outbreakpioneers moved on.

That shaping of the budget did affect thearea of responding to big outbreaks and pan-demics, said Dr. Fukuda, who estimated thathe now had 35 percent fewer employees thanduring the 2009 H1N1 flu pandemic more thandouble the cuts for the organization as a whole.

You have to wonder are we making theright strategic choices? he said. Are we ready

for whats coming down the pike?The entire W.H.O. unit devoted to the sci-

ence of pandemic and epidemic diseases re-sponsible for more than a dozen killers, includ-ing flu, cholera, yellow fever and bubonic plague has only 52 regular employees, includingsecretaries, according to its director, Dr. SylvieBriand, who said that could be increased duringoutbreaks. Before the Ebola epidemic, her de-partment had just one technical expert on Ebolaand other hemorrhagic diseases.

Across Africa, the ranks of the agencys re-gional emergency outbreak experts, veterans infighting Ebola, were cut from more than a dozento three. How can you immediately respondto an outbreak? said Dr. Francis C. Kasolo, aW.H.O. director. It did affect us.

And a separate section of the W.H.O. re-sponsible for emergency response was whittledto the bone during the budget cuts to 34staff members from about 94 according to Dr.Bruce Aylward, its assistant director general.

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You cant make a cut that big, that deep,and its not going to have an effect on your op-erational capacity, he said.

His group, charged with responding towars, disasters and resurgent polio, was askedin August to assist with Ebola, too. At no timethat I can think of in the recent past have webeen dealing with such a scale of human mis-

ery over such a broad geography due to such arange of hazards, he said, including enormouspopulation displacements in Syria, Iraq, theCentral African Republic and South Sudan. But,officials warn, multiple, overlapping challengesmay well be a feature of the future.

The W.H.O. hoped to balance its budget cutsby strengthening the ability of countries to re-spond to public health threats on their own. Itput out new regulations for nations to follow tohelp contain outbreaks. But by 2012, the dead-

line it set, only 20 percent of nations had enact-ed them all. In Africa, fewer than a third of coun-tries had programs to detect and stop infectiousdiseases at their borders. The W.H.O.s strategywas often more theory than reality.

There never were the resources to putthose things in place in many parts of the world,said Dr. Scott F. Dowell, a specialist formerlywith the C.D.C.

A Disease Finds Its Opening

The Ebola virus took full advantage ofthese poorly prepared nations and the holes atthe W.H.O.

Given the weakness in surveillance, the out-break was not identified until March, in Guinea,roughly three months after a villager was be-lieved to have contracted the virus from an ani-mal, possibly a fruit bat. The delay allowed doz-ens of cases to spread through villages and evento Conakry, a capital of more than one and a halfmillion people. Right away, Doctors Without

Borders declared the outbreak unprecedentedin its reach, the only group to do so.

Hastening the spread, hospitals lackedbasic infection-control essentials like runningwater, protective gowns and gloves. Manydoctors and nurses caught the virus from theirpatients, passed it to others, and died. The vul-nerability and collapse of medical facilities re-vealed how far there is to go in achieving theW.H.O.s top priority ensuring basic globalhealth care.

This kind of outbreak would not have de-veloped in an area with stronger health sys-tems, Dr. Fukuda said.

In the crucial weeks after the discovery, dai-ly meetings brought together national authori-ties and foreign responders at the W.H.O. officein Conakry. But an absence of strong leadershipand professionalism was notable from the be-

ginning, participants said.Its purely improvisation, said Marc

Poncin, the emergency coordinator for DoctorsWithout Borders in Conakry. There is no one totake responsibility, absolutely no one, since thebeginning of the crisis.

Stopping previous Ebola outbreaks had re-quired meticulous tracking: monitoring peoplewho had close contact with infected individu-als and isolating them if they developed symp-toms. Previously, if we missed a case, said

Dr. Simon Mardel, a British emergency doctordeployed by the W.H.O. to help with the effort,it was like a failure.

This time, the number of contacts beingfollowed was disastrously low from the begin-ning, only 8 percent in the epicenter of Guck-dou, Guinea, in early April, according to an-other doctor sent by the W.H.O. That meantthe disease was silently spreading. Dr. Mardelsaid he thought the more experienced W.H.O.leaders who had left the agency would have

been very vocal, and they would have soughtto put it right quickly, as a matter of urgency.A single person who traveled and became sickcould touch off a conflagration.

It was not that responders were not try-ing. Victims contacts were spread acrossa wide area, hours away on bad roads. Thepayment of local workers had somehow beenoverlooked, so they stopped doing vital, risky

jobs. Essential protective equipment was notdelivered to many who needed it. Bottles of

bleach were given out without buckets. TheW.H.O. lacked relationships with some long-standing organizations with large networks ofhealth workers in the region.

Traditions that contributed to Ebolasspread, including funerals where mournerscame into contact with corpses, were not fullyrecognized or confronted, said Dr. Pierre Rol-lin, an outbreak specialist at the Centers forDisease Control and Prevention who workedwithin the W.H.O. umbrella.

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Some villagers blocked roads with treetrunks and drove Ebola workers away withstones, accusing them of bringing in the disease.Adding to the tension, only bare-bones clinicalcare was provided to try to treat patients, reduc-ing the chances of yielding survivors who couldact as ambassadors for the cause. Some doctorsdeployed by the W.H.O. said it should have given

them more tools to care for patients.Institutional and personal tensions flared.

Everyones working at a fevered pace, Dr. Dow-ell said. Theres confusion and chaos. It arguesfor a system thats organized as much as possibleahead of time so people know their roles.

One consultant thought it strange that theW.H.O. would not send Twitter messages withlinks to the C.D.C.s Ebola prevention informa-tion, part of a policy not to promote materialfrom other agencies. Various offices within the

W.H.O.s balkanized hierarchy also jockeyedfor position.

The difficulties in tracking cases and gain-ing access to villages led many to think the out-break was burning out. I came home sort ofthinking, with a little luck, thats wrapped up,said Dr. Daniel Bausch, an Ebola outbreak vet-eran from Tulane University, who returned inMay from a W.H.O. mission in Guinea.

The outbreak was not gone, just hidden. Anherbalist in Sierra Leone contracted the virus

treating Guinean patients. More than a dozenmourners at her funeral fell ill and seeded Sier-ra Leone. Some of them traveled back to Guineaand rekindled the outbreak there. After a lull ofseveral weeks, cases re-emerged in Liberia, too,and reached the capital, Monrovia.

Dr. Bausch flew to Sierra Leone in July. Iwas like, where is everybody? referring to

the shortage of health workers fighting the dis-ease. We all recognized we were really under-staffed. We needed more people in the field.

In some treatment centers, two or threedoctors, wearing stifling gowns and masks inthe heat, were caring for up to 90 patients. Withthe only W.H.O. logistician in the country work-ing elsewhere, Dr. Bausch did not have anyoneto accompany him and manage supplies of pro-tective equipment, he said.

Dr. Bausch worked in Kenema, Sierra Le-

one, where he had helped set up a researchprogram for another hemorrhagic fever, Lassa,which was common in the region. He knewsome of the nearly two dozen health workersthere who died after Ebola hit.

It would be a logical question to ask, sinceLassa was there, why was it so hard to switchgears to Ebola?, Dr. Bausch said. But researchinstitutes provided money for science, he said,not for disease surveillance and treatment.Those tasks had been left to the government of

MICHAEL APPLETON FOR THE NEW YORK TIMES

Dr. Margaret Chan, the director general of the W.H.O., with Dr. Da-vid Nabarro, left, the United Nations senior system coordinator for

Ebola, and Dr. Keiji Fukuda, an assistant director general at W.H.O.

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Sierra Leone, one of the poorest countries onearth, he said. I always felt bad about this.

In late July in Liberia, two Americans work-ing at a missionary hospital fell sick and weresoon evacuated home. A Liberian-Americanbrought the virus by plane to Nigeria, Africasmost populous nation. Suddenly, the worldseemed to understand the threat.

The question now, experts wonder, is wheth-er the leaner, retooled W.H.O. heavy on tech-nical know-how, light on logistical muscle

can surge in a way that will help lead the worldin bringing one of the most challenging healthcrises in recent history to a close. W.H.O.s roadmap calls for $490 million from donors, andthousands of foreign and local health workersto contain the outbreak. Yet few foreign medi-cal teams have answered the call so far.

It is incumbent on the international com-

munity to really respond now, said Dr. Kasolo,a W.H.O. director in Africa. Otherwise historywill judge us badly. n