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* Calls for reform of U.N. health agency after mishandlingEbola
* Hit by cuts, WHO rebuffed calls to play more active role
* Crisis was complicated by weak governments, culturalfactors
* MSF coordinator says agency displayed shocking amateurism
* Calls for larger WHO budget, more powerful leadership
By Daniel Flynn and Stephanie Nebehay
DAKAR/GENEVA, Oct 5 (Reuters) - In the first days of theEbola outbreak in West Africa, as aid workers and healthauthorities battled to contain the deadly virus, Mariano Lugliasked himself a simple question: where was the World HealthOrganization?
Lugli, an Italian nurse, was among the first responders frommedical charity Medecins Sans Frontieres (MSF) to reach theremote 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 setup a second Ebola clinic there. He encountered a foreign medicand a logistician sent by the U.N. health agency but saw no signof a WHO official in charge of handling the escalating outbreak.
"In all the meetings I attended, even in Conakry, I neversaw a representative of the WHO," said Lugli, deputy director ofoperations for MSF Switzerland. "The coordination role that WHOshould be playing, we just didn't see it. I didn't see it thefirst three weeks and we didn't see it afterwards."
The worst outbreak of Ebola on record has killed more than3,400 people in four West African countries and spread to theUnited States, where the first case was confirmed in Dallas thisweek.
After a dire warning from the U.S. Centers for DiseasePrevention and Control (CDC) that the virus could infect up to1.4 million people, many health professionals and politiciansare asking how the crisis got so badly out of hand. In the past40 years, Ebola had killed just 1,500 people in sporadicoutbreaks in Africa.
Some aid workers and U.N. officials blame a lack of WHOleadership in the emergency response, particularly in the earlystages when it would have been easier to contain. On severaloccasions, WHO officials played down the outbreak, they say.
MSF International President Joanne Liu, who warned that herorganisation could not cope with the rising number of Ebolavictims, has accused the WHO of failing its mandate to helpmember states cope with health emergencies.
Stung by the criticism, WHO officials say the organisationwas overstretched by a series of health care crises. They blameweak health care systems and uncooperative populations in poorAfrican nations still reeling from civil war in the 1990s forallowing the outbreak to explode.
Senior WHO staff, including Director General Margaret Chan,said the organisation's role was not to run Ebola clinics orcampaigns 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 - forthe United Nations to do more on Ebola, Secretary-General BanKi-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 forWHO, a needed wake-up call," said Lawrence Gostin, global healthlaw professor at Georgetown University. "The WHO's budget andcapacity to respond are in tatters, and it has become mostly atechnical organisation."
"The WHO's narrow view of its role is in stark contrast toits 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 regionaloperations. The director of its regional African bureau (AFRO)based in Brazzaville, Congo, is appointed by governments and hasaccess 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 toreact, saying he immediately sent an emergency coordinator toGuinea, deployed international experts and disbursed money tohelp 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 outbreakwith 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 inGeneva and aggressively pushed China to take greater action.
Brundtland was not re-elected and Chan, a former director ofhealth in Hong Kong who orchestrated its fight against SARS, hastaken a more low key approach in dealing with nationalgovernments since she took office in 2007.
"Dr. Chan feels that national governments need to take thelead," said Georgetown's Gostin. "But if you have governmentswith such fragile health systems and wide distrust among its ownpopulation, WHO needs to take the lead."
With SARS the WHO could rely on robust Asian health caresystems, but when Ebola hit Liberia it had only 50 doctors, andrural clinics lacked even basic equipment like latex gloves.
When it became clear health care systems were buckling underthe strain in Liberia, Sierra Leone and Guinea, the WHO declaredEbola an international public health emergency on Aug. 8.
WHO headquarters took responsibility for coordination awayfrom AFRO, sending experienced staff to run country offices.
Peter Piot, a former WHO official who co-discovered theEbola virus in 1976, said the delay in doing this was a crucialfactor in allowing the epidemic to reach unprecedented levels.
"It took another five months and 1,000 deaths before the WHOdeclared this a public health emergency," said Piot, director ofthe London School of Hygiene and Tropical Medicine.
Some diplomats suggest the WHO may have hesitated to flag upthe Ebola outbreak after it was accused of overhyping the 2009H1N1 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 ledthe fight against H1N1. "We're always having to balance, becauseif you're perceived as crying wolf it doesn't help."
BUDGET CUTS
WHO insiders say cuts to the WHO's budget after the 2008financial crisis left it ill-prepared to fight major epidemics.Its $2 billion annual spending is less than a third the size ofthe CDC budget, and smaller than that of many U.S. hospitals.
With most of WHO's funding allocated by donors to specificdiseases, such as polio or HIV-AIDS, the outbreak and crisisdepartment had its funding cut by 51 percent. Dealing withhemorrhagic fevers was increasingly left to the AFRO bureau.
Francis Kasolo, head of a WHO regional Ebola response centreset up in Guinea, said budget cuts forced AFRO to cut itsepidemic team from 12 to four staff over the past two years.
A 2011 proposal by a WHO committee for a $100 million taskforce to tackle epidemics that might have prevented Ebolaspinning out of control was not approved by member states.
When Ebola struck, WHO's international outbreak team inGeneva led by Fukuda was already swamped by outbreaks of MERSand H7N9 in China.
Kasolo said the WHO brought in hundreds of foreign expertsand health workers, paid for construction of Ebola clinics andsupplied thousands of protective suits but it did not have theskills or personnel to run the centres, as MSF was asking.
"We're a public health agency not a clinical managementagency," said Kasolo. "We don't run hospitals but we can providethe necessary guidance on how the hospital should run."
LAGGING FROM THE START
WHO officials say the epidemic raced ahead of efforts tocontrol it from the start because Guinea took more than threemonths to notify the agency of the disease.
The traditional practice of cleaning bodies by hand atfunerals spread the virus, which is transmitted by body fluids.
First detected in central Africa, Ebola had never struckWest Africa and doctors had no idea what they were seeing. Theoutbreak was initially misdiagnosed as cholera.
Only on March 13 did Guinea notify the WHO, which sent ateam to the southeast the next day. Samples dispatched to alaboratory in France showed on March 21 what many feared - Ebolahad struck a completely unprepared region.
"It was way too late," said AFRO's Sambo, "Hundreds ofunidentified people were already infected."
Once alerted to the outbreak, however, the WHO appeared tounderestimate its scale dramatically. At Geneva HQ, there was aconsensus that it was better not to cause panic.
When drug-maker GlaxoSmithKline told the WHO inMarch it had an experimental vaccine, the agency said it wasfocused on containment, only to ask the firm to fast-trackclinical trials in August as the outbreak span out of control, aGSK spokeswoman said.
At least three times in April and May, new Ebola cases inWest Africa seemed to dry up, creating a false sense that theoutbreak was contained.
By contrast, MSF warned as early as March 31 that thegeographic spread of the outbreak made it "unprecedented". Itreceived a strong rebuttal from a WHO spokesman.
"A few days or a week after our statements, there was alwaysWHO saying 'no, it's not true'," said MSF's Lugli. "Except laterthey confirmed it."
The key to defeating Ebola is tracing people who have comeinto contact with infected people, monitoring them and quicklyisolating new infections. In this too, the WHO and localgovernments struggled, partly due to popular resistance.
Communities hid their sick because of mistrust of foreigndoctors clad in plastic suits that led to attacks on aidworkers. Ebola clinics were seen as death traps, while peopleresented a ban on their traditional burial practices.
Local politics also played a role. In both Guinea and SierraLeone, regions affected by the virus were home to ethnic groupsresistant to central government and when health workers tried totrace victims in May, they were denied access.
But Michel Poncin, MSF emergency coordinator in Guinea, saidthe WHO failed to establish its own network of communitycontacts, relying instead on government officials. Teams wereoften not paid, given vehicles or fuel.
"WHO kept saying it's not our role to do it, we just advisethe health ministry," he said. "I've been really shocked by theWHO's level of amateurism in responding to this crisis." (Additional reporting by Kate Kelland; editing by PascalFletcher and Giles Elgood)
