By early June of last year, the Ebola epidemic in West Africa was the deadliest ever recorded. There weren't enough beds to treat patients and many were refusing to seek treatment, driving the outbreak underground.
Senior staffers in Africa at the World Health Organization raised the prospect of declaring an international emergency. The answer from WHO's Geneva headquarters: Wait.
According to internal e-mails and documents obtained by Associated Press, the UN health agency resisted sounding the international alarm until August, a two-month delay that some argue may have cost lives. More than 10,000 are believed to have been killed by the virus since WHO announced the outbreak a year ago.
WHO has acknowledged acting too slowly to control the Ebola epidemic. In its defence, the agency says the virus's spread was unprecedented and blames several factors, including lack of resources and intelligence from the field. Internal documents obtained by AP, however, show WHO's top leaders were informed of how dire the situation was. But they held off on declaring an emergency in part because it could have angered the countries involved, interfered with their mining interests or restricted the Muslim pilgrimage to Mecca in October.
Declaring an emergency was "a last resort," Dr. Sylvie Briand, who runs WHO's pandemic and epidemic diseases department, said in a June 5 e-mail to a colleague who floated the idea. "It may be more efficient to use other diplomatic means for now."
Five days after Briand's e-mail, WHO Director-General Dr. Margaret Chan was sent a memo that warned cases might soon appear in Mali, Ivory Coast and Guinea Bissau. But it went on to say that declaring an international emergency or even convening a committee to discuss it "could be seen as a hostile act."
Critics and former WHO staff dismiss that reasoning.
"That's like saying you don't want to call the fire department because you're afraid the trucks will create a disturbance," said Michael Osterholm, a prominent infectious diseases expert at the University of Minnesota.
The signs this was no ordinary outbreak – the panic, the health workers' deaths, and the urban spread of the virus – were there from the beginning. Many are recorded in a memo sent to WHO's Africa director on March 25.
In mid-April, an experienced Ebola expert with WHO's Africa office wrote to Geneva, with disturbing news that many staffers at a leading hospital in Guinea had been exposed to the virus.
"What we see is the tip of an iceberg," Jean-Bosco Ndihokubwayo wrote in an e-mail, writing in all caps: "WE NEED SUPPORT."
The Ebola outbreak erupted at a difficult time for the agency. WHO was also struggling to contain polio outbreaks – which it had declared an international emergency in May – and Middle Eastern Respiratory Syndrome. At a June 2 meeting, one senior scientist warned the agency was "overwhelmed."
Declaring an international emergency might not necessarily have fixed all those problems – some argue it can create new ones – but it acts as a global distress signal. Dr. Joanne Liu, the international president of Doctors Without Borders, said she had been lobbying Chan to sound the alarm.
"I told her, 'Dr. Chan, the Ebola epidemic in West Africa is out of control,' " Liu recalled telling Chan in a July 30 meeting in Geneva. "And she looked at me and she said, 'Dr. Liu, I'm not that pessimistic.' And I just said, 'Dr. Chan, I'm not being pessimistic, I'm just being realistic.' " The emergency was eventually declared on Aug. 8, by which point nearly 1,000 people had already died from Ebola.
WHO's Ebola response leader, Bruce Aylward, couldn't say whether an earlier declaration would have made a difference, noting that "the overall response slowed down" after the emergency was declared. "Had we declared it earlier, it is very, very difficult to say how perceptions would have affected the response."
Dr. Matthieu Kamwa, a former WHO scientist, describes that kind of reasoning as contradictory. If emergencies don't work, why declare them at all?
The declaration triggered a global deployment to contain the virus. U.S. President Barack Obama ordered up to 3,000 troops to West Africa and promised to build more than a dozen 100-bed field hospitals. Britain and France also pledged to build Ebola clinics; China sent a 59-person lab team and Cuba sent more than 400 health workers.
Kamwa says it's clear the alarm should have been sounded sooner.
"People died because things were not done," he said.