The World Health Organization and other global agencies have failed to learn sufficient lessons from the 2014 Ebola outbreak that killed more than 11,300 people in west Africa, a British doctor at the centre of the battle in Sierra Leone has said.

Although the response to the most recent Ebola outbreak in the Democratic Republic of the Congo (DRC) was swift and effective, the international community’s long-term strategies have only marginally changed, said Oliver Johnson, who in a book with Irish diplomat Sinead Walsh lifts the lid on the extraordinary behind-the-scene failures four years ago.

In Getting to Zero, the duo show how a litany of mistakes made in distant offices in New York, Washington, London and Geneva, combined with poor leadership in Sierra Leone and a weak health service, created a catastrophe that could have been prevented.

Among those coming under fire are the British army, the Department for International Development and the US Center for Disease Control.

The sharpest criticism is levelled at the WHO, which was slow to declare the Ebola outbreak an international emergency, but also failed to heed early alarm calls made by medics who were working in horrific conditions in the Kenema hospital, where British nurse Will Pooleycontracted the virus.

“WHO Kenema staff were screaming for months … but WHO leadership failed to take adequate action,” the authors note in the book.

While WHO, in the wake of Ebola, has initiated some reforms, including a roster of 75 medical teams on standby for health emergencies and changes in relation to flexibility of funding for crises, the authors say: “Despite the enormous furore over their failures on Ebola, WHO has not initiated any other significant reforms.”

Through 85 interviews with responders, politicians and witnesses, Johnson and Walsh give first-hand accounts of the world’s failure to respond to Ebola in the first few months in 2014 – inaction that ultimately cost the lives of thousands.

Walsh, who had lived in the country before the outbreak and had come from an aid background, said that even when the world did respond, plans hatched in air-conditioned offices abroad didn’t translate to local needs.

“There are people sitting around tables in Washington and London and New York, and we can all say the strategy is great, but when you are sitting in Freetown or [capital of Liberia] Monrovia it looks very different.

“When you are working in very weak health infrastructures and you put new strategies on top of them it really doesn’t look any different,” she said in an interview with the Guardian.

Neither Walsh nor Johnson had intended to write a book. But after two years they had a chance meeting and discussed their frustration with the official reports and postmortems around the world.

“I read articles, reports, often being written up by organisations, [which] presented their view of what had happened, and I didn’t recognise it,” Johnson said.

“There weren’t many people who had been there from the start to the finish … and we were frustrated by some of the stuff coming out. We decided instead of ranting about it, we should get this down on paper so it will never happen again. [In] some of these organisations, staff would come in for six weeks or two months and leave, whereas we had been there throughout and felt we had a perspective they could not offer,” said Walsh.

As Irish ambassador to Sierra Leone, Walsh was already plugged into the local politics and recalled being passed a memo that showed the WHO was reluctant to declare an international emergency and mobilise help because it was concerned local government would interpret it as a “hostile act”.

“I was livid and frustrated,” wrote Walsh. How could people on the ground be making the case for emergency funding and staffing “when the WHO were saying things were moving in the right direction?”

Johnson believes Sierra Leone would struggle to deal with another humanitarian emergency because international agencies have failed to address the fundamental cause of Ebola’s unprecedented spread.

While the new government has just pledged to put 15% of its budget into the health sector, lack of accountability, inadequate salaries and a chronic shortage of medical staff “hamper efforts to achieve meaningful reform”, the authors said.

We could not rely on WHO to sort the response out or give the international community a realistic assessment of needs

In 2014, Sierra Leone had just 136 doctors for a population of about 6 million and 12 of those died of Ebola.

“When the music stopped and the outbreak wound down, things largely returned to the way before,” Johnson writes in the book.

“When I speak to colleagues in Sierra Leone, they say that help dried up really quickly and it’s gone back not to ‘build back better’ but ‘business as usual’,” he later told the Guardian.

“I see some marginal increases in funding, marginal shifts in approach, but I don’t see the kind of shift or level of support to make a significant difference.

“At the end of the day the question is – how much do we care? … If anything I think the global appetite is less than it was two years ago. Think of some of the political shifts in the world.”

With denial at home when Ebola struck, no one in command abroad and a near non-existent health service, the disease had a perfect host.

Chaotic meetings with local ministers and health officials coupled with a dysfunctional local government and complacency in the west engendered a hellish downward spiral.

Johnson had been helping to improve management systems in Freetown’s main government hospital, the Connaught, as part of the King’s Sierra Leone Partnership. Suddenly, he found himself leading the team’s Ebola response when the head of the hospital’s team died of the disease in the early days of the outbreak.

He felt out of his depth. But with an emergency and riots at the hospital gates, he had little option but to get stuck in.

The team turned the A&E unit into an isolation ward, buying yards of plastic from the local market, providing buckets for bedside toilets and getting a local welder to build a water-tight metal box on top of a gurney to take infected sewage away for incineration in a structure that looked like a coffin.

Against this background, Johnson and his team hit the buffers again and again.

NGOs fled the city and the international community was “deaf” to what was going on.

In the book, Johnson tells how he approached DfID for a donation of $12,500 (£9,500) to create desperately needed isolation units in six hospitals in Freetown, in a bid to avert the spread.

DfID refused. “$12,500 is too small,” Johnson was told by an adviser. They suggested he try the United Nations and WHO, with no success.

“I ended up asking my mother for a donation,” said Johnson.

Slightly fewer than 1,000 patients went through the Connaught, were triaged, blood-tested, and discharged Ebola-free, or sent to another hospital for treatment.

“In my naivety in those early Ebola days I thought, ‘Right, health crisis – WHO are here. They know what to do … I soon found out that not only could we not rely on WHO to sort the response out or give the international community a realistic assessment of needs, but that we donor partners could barely get a meeting with them,” said Johnson. “We got none of what we needed or asked for from WHO.”

Walsh had worked in Asia and central Africa before coming to Freetown. Unlike her British embassy neighbours, she had responsibility for the Irish equivalent of DfID and had freedom to disburse money.

She recalls how the lack of transparency and coordination in the early days led to deadly missteps.

Three weeks into the outbreak in June, 90 people had been confirmed dead in Kailahun, where Ebola had entered the country from Guinea.

A Ugandan epidemiologist arrived to lead the response for WHO and drew up a plan, costing $286,000, which included 16 cars for a surveillance team. He reckoned this would be enough to kill the outbreak.

He got $86,000 and one car. “It was not nearly enough,” Walsh said.

She had been sitting in the WHO offices at the beginning of the outbreak in June 2014 pleading with the organisation to tell her how Irish Aid and other donors could help. Had she known she could have “quickly have produced far more”, she believes she could have helped stop Ebola in its tracks.

Perhaps the biggest mismatch was Kerry Town, an ambitious British hospital designed and conceived in London, which took months to open. When it did it was so constrained by its own protocols that it treated relatively few patients. In all, it is estimated to have cost DfID around £80m.

As one local doctor told the authors: “They wanted to get everything perfect before they started receiving patients,” while other clinics were having to turn away patients, who were likely to go on to die as well as infect others.

Walsh, however, is clear in the book that the UK ultimately played a critical role. “No matter what criticisms I and others had of some of the ways the UK operated during the response, there was absolutely no doubt in my mind that they had turned the response around and invested enormous resources which had been central to getting to zero.”

There are many heroes in the book – not least the 221 local health workers who died – and Foday Sahr, now the surgeon general of the Sierra Leonean army, who ran one of the military’s Ebola units. But of organisations, it is the Sierra Leonean army that Johnson and Walsh single out for praise. “A week after the government-run Hastings Ebola treatment unit had opened, they had 120 beds compared with the four they had managed in Kerry Town,” wrote Johnson.

If there was one overall message the authors said they wanted to impart, it is is that international agencies must “work with communities – not do something to them”.

The book, published on Monday, is a compelling read, full of compassion, grief, ingenuity and stories of courage and unstinting commitment of local nurses, cleaners and others who remain unsung heroes of Ebola. But it is also full of tales of denial, extraordinary lapses in leadership and awkward truths that will make uncomfortable reading for many, locally and internationally.

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Lisa O’Carroll

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