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Sept. 19 (Bloomberg) -- When Margaret Chan was elected to lead the World Health Organization, she said the agency’s priority was to improve the health of people in Africa.

Eight years later, the 67-year-old Chan is under attack for letting an Ebola outbreak there spiral beyond control, and this week her group found itself eclipsed as the leader of humanitarian efforts to control the epidemic.

The United Nations said it would create a separate Health Mission to coordinate care in West Africa, and the U.S. announced it would send 3,000 troops to build hospitals there. Those plans come after Chan delayed designating the outbreak as a global emergency until thousands were infected in three countries, and in the wake of complaints her agency had done too little to manage the response. Now, the WHO is in the awkward spot of being little more than a voice in the crowd, critics suggest, and Chan is seen by some as being partly to blame.

It is “so sad to see the WHO so much on the sidelines of a global heath crisis,” said Lawrence Gostin, a professor of health law at Georgetown University in Washington.

The delayed decision to recognize the outbreak as an international emergency, a declaration designed to signal to the world at large that immediate action is needed, was the WHO’s “Katrina moment,” said J. Stephen Morrison, at the Center for Strategic and International Studies in Washington. The reference is to the U.S. government’s slow response to the hurricane that flooded much of New Orleans nine years ago.

Right Timing

Chan sees it differently.

“You pull out the tool when it’s the right time to do so,” she said of the declaration during a telephone interview. “You can’t abuse it or under use it. Over or under use would compromise the credibility of the organization.”

On May 1, she met with the leader of Guinea, where the outbreak originated, and warned the government needed to take strong action, according to Chan.

“I insisted he not drop the ball,” she said.

When the disease moved into neighboring countries at the end of June, she met with those leaders as well, she said, after mobilizing WHO experts and setting up a sub-regional hub in Conakry to coordinate the response. She turned to the global emergency declaration only after these early efforts failed.

Judgment Issue

“The judgment issue is important,” Chan said. “It’s easy for people who have the benefit of hindsight to say whatever they’re saying. When you’re in the position of being the director-general of the WHO, you need to look at the evolution of the outbreak. We have taken country-level action, we have taken regional level-action and then I said to my colleagues, if these actions are still not sufficient to bring the outbreak under control, I’m going to sound an alert.”

Still, in an earlier interview, she admitted the agency “underestimated the magnitude, the complexity and the challenges. Can all of us do better? The answer is yes,” she said during an interview in Washington a week ago. “But this is too big for any organization.”

Since the start of the outbreak, the virus has infected 5,357 people, killing 2,630, according to a Sept. 18 WHO report. Now, the U.S. Centers for Disease Control and Prevention is estimating the virus could spread to hundreds of thousands more by the end of January, with a worst-case scenario of 550,000 or more infections.

The CDC report, scheduled to be released next week, isn’t yet complete and the figures may change. It assumes no additional aid or intervention by governments and relief agencies, which are now mobilizing to contain the Ebola outbreak before it spins further out of control.

Pushing Governments

Chan, meanwhile, has said she will continue to push governments to contribute to the effort.

A petite woman whose mother tongue is Cantonese, Chan is a consensus builder who tends to take her lead from the WHO’s member states rather than impose her own agenda on the agency, according to Georgetown’s Gostin. In contrast, Gro Harlem Brundtland, an earlier director who led the 7,000-person UN agency through the lethal SARS outbreak, had a more direct style that was suited to getting things done in times of crisis, he said.

Brundtland, a physician like Chan and a former prime minister of Norway, ruffled feathers politically within the organization, but won praise for her rapid response to the SARS outbreak in 2003, and for pushing through a global treaty on tobacco control during her single five-year term.

Leadership Power

As the top person at the WHO, Chan should have been more assertive against Ebola, said Laurie Garrett, a senior fellow for global health at the Council on Foreign Relations in New York. “A WHO leader has as much power as the WHO leader chooses to embrace and exert,” Garrett said by telephone.

Gostin, though, isn’t so quick to blame Chan. He argues that she was placed at the helm of an increasingly dysfunctional organization where big donors insist on growing control over how their money is used, and the leaders of regional offices are named independently of Chan.

Either way, Chan is unlikely to lose her job. No WHO director-general ever has, and the agency’s constitution doesn’t have an explicit mechanism in place for removing its leader. Instead, a hard look at the way the WHO operates may serve as a catalyst for change, according to Morrison and Gostin.

Joanne Liu, international president of Doctors Without Borders, known by its French acronym MSF, says the change may come too late to help the thousands dying of Ebola now. The decision to wait until August to seek help from the international community made the situation worse, she said.

‘Give a Signal’

The WHO’s boss “is perceived as someone who can give a signal when something happens,” Liu said. “The reality is I can be the international president of MSF, the most deployed organization in the field right now, but nobody’s listening when I say it’s an emergency. We don’t have that authority.”

Gostin, like Morrison, compared the Ebola outbreak to Hurricane Katrina, but said the blame for the WHO’s slow response lies less with Chan and more with wealthy countries who failed to support a $100 million fund for a global health emergency workforce recommended by a WHO committee in 2011.

“That was a huge myopia and could have prevented this at very little cost,” Gostin said by phone.

Chan inherited a system, he said, where three-quarters of the $4 billion budget is earmarked for specific projects -- from polio to heart disease -- cherry picked by donors including the U.S. government and the Bill & Melinda Gates Foundation.

Special Interests

Gostin is not alone in criticizing the WHO’s organization.

Nils Daulaire, the U.S. government’s representative on WHO’s executive board from 2010 until February, complains that the agency’s 194 member countries have added more special interest projects to its agenda while failing to set clear priorities, or give it adequate funding.

“It becomes a Christmas tree, with lots of bright shiny objects, and that makes it very difficult to focus,” Daulaire said.

The U.S., the WHO’s biggest donor with $115 million a year as well as even larger voluntary contributions to specific projects, is partly responsible for that imbalance as budgetary politics in Congress stymied efforts to increase unrestricted funding for the agency, Daulaire said.

Chan, who tends to do deals away from the limelight, has worked to reform the WHO and refocus it on improving basic health services and access. A meeting of the UN General Assembly she convened in 2011 resulted in a global pact to cut deaths from non-communicable diseases such as heart disease and cancer. She also led the agency through the swine flu pandemic of 2009, when the WHO was criticized for being too alarmist.

Risk Assessment

In its defense, the WHO says it increased its internal risk assessment on Ebola to the highest of four grades, or requiring a “substantial international response,” on July 26, two weeks before declaring a global health emergency.

In exposing some of the WHO’s problems, the Ebola tragedy may have made it easier to fix them, said Michael Merson, director of the Duke Global Health Institute in Durham, North Carolina.

“They still have some very talented and incredibly smart and dedicated experts,” said Merson, the author of a textbook called Global Public Health. “I’d love for this tragic outbreak to lead to a stronger WHO.”

To contact the reporter on this story: Simeon Bennett in Geneva at sbennett9@bloomberg.net To contact the editors responsible for this story: Reg Gale at rgale5@bloomberg.net; Phil Serafino at pserafino@bloomberg.net Andrew Pollack

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The citizens' meeting

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