In the first days of the Ebola outbreak in West Africa, as aid workers and health authorities battled to contain the deadly virus, Mariano Lugli asked himself a simple question: where was the World Health Organization?
Lugli, an Italian nurse, was among the first responders from medical charity Medecins Sans Frontieres (MSF) to reach the remote forests of Guinea in March where the hemorrhagic fever - one of the most lethal diseases known to man - was detected.
When the epidemic spread to the capital Conakry, Lugli set up a second Ebola clinic there. He encountered a foreign medic and a logistician sent by the U.N. health agency but saw no sign of a WHO official in charge of handling the escalating outbreak.
"In all the meetings I attended, even in Conakry, I never saw a representative of the WHO," said Lugli, deputy director of operations for MSF Switzerland. "The coordination role that WHO should be playing, we just didn't see it. I didn't see it the first three weeks and we didn't see it afterwards."
The worst outbreak of Ebola on record has killed more than 3,400 people in four West African countries and spread to the United States, where the first case was confirmed in Dallas this week.
After a dire warning from the U.S. Centers for Disease Prevention and Control that the virus could infect up to 1.4 million people, many health professionals and politicians are asking how the crisis got so badly out of hand. In the past 40 years, Ebola had killed just 1,500 people in sporadic outbreaks in Africa.
Some aid workers and U.N. officials blame a lack of WHO leadership in the emergency response, particularly in the early stages when it would have been easier to contain. On several occasions, WHO officials played down the outbreak, they say.
MSF International President Joanne Liu, who warned that her organisation could not cope with the rising number of Ebola victims, has accused the WHO of failing its mandate to help member states cope with health emergencies.
Stung by the criticism, WHO officials say the organisation was overstretched by a series of health care crises. They blame weak health care systems and uncooperative populations in poor African nations still reeling from civil war in the 1990s for allowing the outbreak to explode.
Senior WHO staff, including Director General Margaret Chan, said the organisation's role was not to run Ebola clinics or campaigns but advise states how to do so.
Yet after a direct appeal from the leaders of Guinea, Liberia and Sierra Leone - the worst affected countries - for the United Nations to do more on Ebola, Secretary-General Ban Ki-moon stepped in to create a special U.N. mission last week, effectively stripping WHO of its coordination role.
"I hope the Ebola crisis will become a turning point for WHO, a needed wake-up call," said Lawrence Gostin, global health law professor at Georgetown University. "The WHO's budget and capacity to respond are in tatters, and it has become mostly a technical organisation."
"The WHO's narrow view of its role is in stark contrast to its constitutional mission as the global health leader."POLITICISED
Insiders say the WHO is amongst the most politicised of U.N. agencies, with governments holding sway over its regional operations. The director of its regional African bureau (AFRO) based in Brazzaville, Congo, is appointed by governments and has access to locally raised funds, allowing autonomy from Geneva.
"Neither donors nor WHO headquarters has a true hold on it," said one diplomat, familiar with the workings of WHO management, who said relations between Geneva and AFRO were weak.
"There was never anybody from AFRO on the coordination calls ... They were invisible throughout."
AFRO Director Dr Luis Sambo denied his bureau was slow to react, saying he immediately sent an emergency coordinator to Guinea, deployed international experts and disbursed money to help the Guinean government.
Despite some differences of opinion on conference calls, coordination remained strong with Geneva from March onwards, Sambo told Reuters.
However, experts contrasted the handling of the outbreak with the WHO's exemplary management of the 2003 SARS crisis.
During SARS, then WHO director general Gro Harlem Brundtland - a former Norwegian prime minister - gave free rein to staff in Geneva and aggressively pushed China to take greater action.
Brundtland was not re-elected and Chan, a former director of health in Hong Kong who orchestrated its fight against SARS, has taken a more low key approach in dealing with national governments since she took office in 2007.
"Dr. Chan feels that national governments need to take the lead," said Georgetown's Gostin. "But if you have governments with such fragile health systems and wide distrust among its own population, WHO needs to take the lead."
With SARS the WHO could rely on robust Asian health care systems, but when Ebola hit Liberia it had only 50 doctors, and rural clinics lacked even basic equipment like latex gloves.
When it became clear health care systems were buckling under the strain in Liberia, Sierra Leone and Guinea, the WHO declared Ebola an international public health emergency on Aug. 8.
WHO headquarters took responsibility for coordination away from AFRO, sending experienced staff to run country offices.
Peter Piot, a former WHO official who co-discovered the Ebola virus in 1976, said the delay in doing this was a crucial factor in allowing the epidemic to reach unprecedented levels.
"It took another five months and 1,000 deaths before the WHO declared this a public health emergency," said Piot, director of the London School of Hygiene and Tropical Medicine.
Some diplomats suggest the WHO may have hesitated to flag up the Ebola outbreak after it was accused of overhyping the 2009 H1N1 swine flu epidemic and pandering to pharmaceutical firms.
Could it have declared earlier? Sure," said Keiji Fukuda, WHO assistant director-general for health security, who had led the fight against H1N1. "We are always having to balance, because if you're perceived as crying wolf it doesn't help."
WHO insiders say cuts to the WHO's budget after the 2008 financial crisis left it ill-prepared to fight major epidemics. Its $2 billion annual spending is less than a third the size of the CDC budget, and smaller than that of many U.S. hospitals.
With most of WHO's funding allocated by donors to specific diseases, such as polio or HIV-AIDS, the outbreak and crisis department had its funding cut by 51 percent. Dealing with hemorrhagic fevers was increasingly left to the AFRO bureau.
Francis Kasolo, head of a WHO regional Ebola response centre set up in Guinea, said budget cuts forced AFRO to cut its epidemic team from 12 to four staff over the past two years.
A 2011 proposal by a WHO committee for a $100 million task force to tackle epidemics that might have prevented Ebola spinning out of control was not approved by member states.
When Ebola struck, WHO's international outbreak team in Geneva led by Fukuda was already swamped by outbreaks of MERS and H7N9 in China.
Kasolo said the WHO brought in hundreds of foreign experts and health workers, paid for construction of Ebola clinics and supplied thousands of protective suits but it did not have the skills or personnel to run the centres, as MSF was asking.
We're a public health agency not a clinical management agency," said Kasolo. "We don't run hospitals but we can provide the necessary guidance on how the hospital should run."
LAGGING FROM THE START
WHO officials say the epidemic raced ahead of efforts to control it from the start because Guinea took more than three months to notify the agency of the disease.
The traditional practice of cleaning bodies by hand at funerals spread the virus, which is transmitted by body fluids.
First detected in central Africa, Ebola had never struck West Africa and doctors had no idea what they were seeing. The outbreak was initially misdiagnosed as cholera.
Only on March 13 did Guinea notify the WHO, which sent a team to the southeast the next day. Samples dispatched to a laboratory in France showed on March 21 what many feared - Ebola had struck a completely unprepared region.
"It was way too late," said AFRO's Sambo, "Hundreds of unidentified people were already infected."
Once alerted to the outbreak, however, the WHO appeared to underestimate its scale dramatically. At Geneva HQ, there was a consensus that it was better not to cause panic.
When drug-maker GlaxoSmithKline told the WHO in March it had an experimental vaccine, the agency said it was focused on containment, only to ask the firm to fast-track clinical trials in August as the outbreak span out of control, a GSK spokeswoman said.
At least three times in April and May, new Ebola cases in West Africa seemed to dry up, creating a false sense that the outbreak was contained.
By contrast, MSF warned as early as March 31 that the geographic spread of the outbreak made it "unprecedented". It received a strong rebuttal from a WHO spokesman.
"A few days or a week after our statements, there was always WHO saying 'no, it's not true'," said MSF's Lugli. "Except later they confirmed it."
The key to defeating Ebola is tracing people who have come into contact with infected people, monitoring them and quickly isolating new infections. In this too, the WHO and local governments struggled, partly due to popular resistance.
Communities hid their sick because of mistrust of foreign doctors clad in plastic suits that led to attacks on aid workers. Ebola clinics were seen as death traps, while people resented a ban on their traditional burial practices.
Local politics also played a role. In both Guinea and Sierra Leone, regions affected by the virus were home to ethnic groups resistant to central government and when health workers tried to trace victims in May, they were denied access.
But Michel Poncin, MSF emergency coordinator in Guinea, said the WHO failed to establish its own network of community contacts, relying instead on government officials. Teams were often not paid, given vehicles or fuel.
"WHO kept saying it's not our role to do it, we just advise the health ministry," he said. "I've been really shocked by the WHO's level of amateurism in responding to this crisis."