At the very least, the Ebola outbreak in West Africa provides dramatic proof of the importance of having minimum capacities and infrastructures in place before a severe disease becomes established in a population.

Ebola in Guinea, Liberia, and Sierra Leone was an extreme stress test that saw the virtual collapse of health services.

The national responses in Nigeria, Senegal, and Mali show the good results possible when health officials are on high alert and the health system is well-prepared. But overall, national and international responses show how far the world is from achieving global health security. Overall, these experiences provide a stunning example of all that was missing, all that can go wrong.

The IHR call for national capacity "to detect events involving disease or death above expected levels for the particular time and place in all areas within the territory".

But how can countries that routinely experience deaths from diseases like malaria, Lassa fever, yellow fever, typhoid fever, dengue, and cholera recognize an unusual event in the midst of all this background noise from difficult and demanding diseases?

Maybe this is another truly fundamental problem that keeps the IHR from working as intended.

The Ebola virus circulated in Guinea for three months, undetected, off every radar screen, with no alarms sounding, misdiagnosed as cholera, then thought to be Lassa fever.

Even in Sierra Leone, where health officials were on high alert, the virus spread undetected for at least a month, sparking numerous chains of transmission that rapidly multiplied.

The earliest cases to reach the health system were managed as gastroenteritis, again with a diagnosis of cholera presumed.

Within six weeks, three hotspots of intense virus transmission were firmly established.

As we learned, cases at the start of an outbreak, when containment has the best chance of success, will be missed in the absence of sensitive surveillance, rapid laboratory support, and good information systems shared by the public health and clinical sectors. If the two arms of the health system are not talking or sharing information to raise awareness and take rapid action, we have seen what can happen

As I always say, what gets measured gets done. What can't be seen can't be measured or managed.

As we learned, when new cases occur that cannot be linked to a known chain of transmission, an outbreak is out of control.

Ladies and gentlemen,

As a second weakness, many countries imposed measures, such as restrictions on travel or trade, that went well beyond the temporary recommendations issued by the Emergency Committee last August.

These measures isolated the three countries and vastly increased economic hardship for some of the world's poorest people. All three ran short of food and fuel.

Just as important, travel restrictions, including the many airlines that suspended flights to West Africa, impeded the arrival of desperately needed response teams and equipment.

If countries are punished in this way, where is the incentive for rapid and transparent reporting?

Whether and under what circumstances countries should be permitted to implement health measures beyond those recommended by WHO was a politically charged issue when the IHR were negotiated.

At present, WHO does not have a mechanism for enforcing compliance with its recommended measures. This has to change.

A third weakness is the absence of a formal alert level of health risk other than the declaration of a public health emergency of international concern, or PHEIC. This is a recommendation from the Stocking report for you to consider.

Establishing a formal intermediate level of alert of health risk would require an amendment to the IHR.

Another option is illustrated by the Emergency Committee convened to assess the MERS situation.

Although many meetings under this Committee were held, none declared a PHEIC, yet their reports consistently set out advice aimed at reducing the number of cases and preventing further international spread.