The extraordinary cost of COVID-19 in human lives, social disruption, and economic distress reveals weaknesses in existing global health security architecture, the core of which are the International Health Regulations (IHRs). Agreed to as a binding treaty negotiated under the auspices of the World Health Organization (WHO), the IHRs regulate country conduct before and during global public health emergencies. The IHRs aim to “prevent, protect against, control and provide a public health response to the international spread of disease in which to avoid unnecessary interference and international traffic and trade.”
The adoption of the IHRs by the World Health Assembly in May 2005 established fundamental legal requirements for all countries, seeking to enhance international coordination in the detection of, and response to, public health risks that cross borders. Importantly, each signatory agreed to develop core capacities to detect, assess, report, and respond to disease threats. The IHRs require cooperation for early detection and mitigation of “public health events of international concern” (PHEICs) as determined by the director-general of the WHO and underscore the importance of open global communication in health crises.
Over the past 15 years, PHEICs have been declared for the 2009 H1N1 influenza, polio, Ebola outbreaks in Africa, and Zika virus in the Americas. Each emergency has revealed weaknesses in the IHRs, such as the failure of countries to comply with IHR terms, weak WHO management, inadequate support for lower-income countries, and lack of transparency. Worryingly, many countries have failed to adhere to their treaty obligations for capacity building, preparation, detection, and response to pathogens of pandemic potential.
Yet, no material modifications have been made to the text of the IHRs since they were ratified in 2005, and few changes have been made in their implementation.
A new international treaty for pandemic preparedness and response would connect countries and compel the sharing of information, technology, resources, and data in a way that makes countries accountable to one another. While a new treaty is greatly welcomed, negotiating or re-negotiating the terms of a treaty typically takes many years, and enforcing binding international agreements is challenging under any circumstances. The tension between the rights of sovereign states and the need for effective coordination in addressing a truly global threat is inherent in international law, including public health efforts to combat infectious diseases that cross national borders. The structure of the WHO as a United Nations institution necessitates cooperation with, and among, individual member states rather than the establishment of priorities that member states are expected to follow. As a practical matter, international political pressures limit the ability of the WHO to place strict requirements on its member states.
While recognizing the practical challenges for a new treaty or of revisions to the IHR treaty text, a number of scholars and public health leaders have rightfully called for important changes that could strengthen global health, including:
Such textual changes to the IHRs would be welcome, along with a renewed global commitment to international legal duties in general. But that is not sufficient. We believe the WHO and member states should take immediate steps to implement the IHRs more effectively, consistent with appropriate legal interpretations of the current text. What is more, they must reconceptualize the IHRs as a trusted, legitimate global place to turn for millions of public, private, and civil society organizations around the world as they consider how to trigger their own disease surveillance and response activities.
Immediate Actions
Given the challenges of modifying the treaty and urgency of public health action, there are action steps that the WHO can take within its current authorities that do not require amending the text of the IHRs. The WHO could also use review conferences to better guide more effective implementation of the existing treaty text.
Below are four promising opportunities for near-term actions that would encourage better preparedness, establish better warning systems, foster greater transparency, and expand funding for pandemic preparedness.
Encourage Preparedness And Action
The WHO could clarify and promulgate science-based standards to gauge country compliance with IHR obligations and call for independent reviews of country preparedness. This work could be done collaboratively with the joint evaluation reviews of the Global Health Security Agenda. By the same token, the WHO could articulate clearer and stronger guidance for countries to follow in complying with the IHRs during a crisis, such as the reporting of scientific developments and economic actions. While such guidance cannot compel country actions, it could promote norms of compliance.
Establish Better Warning Systems
While the text of the IHRs makes no provision for multilayered warnings prior to the declaration of a PHEIC, nothing prevents the WHO from developing such a system or member states from calling on the WHO secretariat to do so.
Such a nuanced system would enable governments, businesses, civil society, and other stakeholders to understand the levels of risk presented by various pathogens and outbreaks from a trusted source and to make corresponding investments and decisions regarding preparedness and response for people in their countries, communities, and organizations. There are multiple infectious disease outbreaks taking place in the world at any time, and the global community would be better served if the WHO could place them in context and guide preparedness more effectively.
Improve Transparency
Under current practice, the IHRs provide that an Emergency Committee (EC) evaluates and considers whether an outbreak constitutes a PHEIC and advises the WHO director-general accordingly. These EC decisions are often unexplained and difficult to parse, and the public is left deciphering clues from press conferences and statements on how the decision was reached.
The lack of transparency in the current process leaves the public without critical information leading to mistrust and confusion—a crucial failure during a pandemic. It also leaves open the possible accusation that the decision has been made for political reasons, rather than based on science and public health information.
For the sake of clear communication, the WHO should disclose full minutes of meetings, including access to documents and evidence that will help countries better understand the EC’s decision-making process and increase the credibility of a final decision.
Expand Funding
The WHO and many of its low-income member states require additional resources to undertake their obligations pursuant to the IHRs. The lack of resources reflects a lack of political commitment by member states, particularly by high-income countries. Member states should prioritize funding the WHO’s Emergency Program and Contingency Fund and ensure that the WHO’s health security budget is protected from the overall WHO budget process. In addition, they should insist that WHO regional bodies coordinate effectively with the Geneva headquarters on all emergency preparedness and response activities.
Whether through the WHO or other global initiatives, such as the Global Health Security Agenda, wealthier countries should take the lead in offering technical assistance and international financing to close capacity gaps in individual countries that need external support.
Supporting Global Surveillance And Response
The profound global impact of the ongoing COVID-19 pandemic cannot be overstated. As noted by the Global Preparedness Monitoring Board in July 2020, “procedures and mechanisms for rapid and comprehensive global cooperation and collective action were absent, inadequate or unused, including protecting and ensuring global supply chains for personal protective equipment and other essential items.”
Moving forward, we recommend reimagining the IHRs, at least in part, as more than simply the rulebook for cooperation among countries seeking to manage a global infectious disease outbreak. The IHRs could also serve as a backbone resource for synchronizing and synergizing response efforts from all corners of society. One similar model is the Inter-Agency Standing Committee (IASC) that brings together the executive heads of 18 United Nations (UN) and non-UN organizations to ensure coherence of preparedness and response efforts, formulate policy, and agree on priorities for strengthened humanitarian action. The IHRs could become a trusted, evidence-based mechanism for automatically triggering preparation and response by other international organizations, governments, civil society, private companies, faith communities, and others that have felt the impact of COVID-19. Public-sector, private-sector, and non-governmental organization leaders need a reliable global source of scientific information, with international political legitimacy, to provide relevant public health information about potential and actual threats posed by various pathogens of pandemic potential and trigger actions required to prepare and respond to health emergencies.
Revising the IHRs will require coordinated cooperation with other international bodies. For example, the IHRs could provide automatic triggers for action in organizations such as: the World Trade Organization by coordinating with the WHO in collecting and reporting trade-restrictive measures adopted in response to infectious disease outbreaks; the World Bank, by aligning the Pandemic Emergency Financing Facility to enable countries to access funds before a formal PHEIC is declared; the International Civil Aviation Organization by planning and managing disruptions to global air travel; the International Maritime Organization by developing mechanisms to ensure safe ship crew changes and travel during pandemics; or the Food and Agriculture Organization of the United Nations by supporting its One Health Agenda to accelerate biomedical research discoveries, enhance public health efficacy, expedite expanding the scientific knowledge base, and improve medical education and clinical care.
Beyond international organizations, leaders in private sector, civil society, religious communities, and governments at all levels could be invited to use the IHRs as the basis for triggering preparedness and response within their own institutions and networks. Such triggers would necessarily vary across different types of organizations, but all would rely on the same baseline information. Although not everyone has typically viewed these groups as stakeholders in international-level guidelines for pandemic preparedness and infectious disease response, COVID-19 clearly demonstrates the need for involvement from all sectors of society.
Conclusion
The COVID-19 pandemic may be a watershed moment in global health, for the WHO, its member states, and other stakeholders to mobilize and secure a robust international disease surveillance and outbreak response system for future pandemics. A properly funded, transparent WHO could make the IHRs the centerpiece of global health architecture, expanding the role of the treaty in building a coordinated and participatory system.
While revising IHRs is vitally important, it will take time. In the near-term, we encourage the WHO and member states to use current authorities to ensure transparency, expand funding, and improve preparedness. We also urge the WHO to position the IHRs, and the public health recommendations made under its auspices, as an anchor instrument on which public, private, and civil society organizations can rely in making their own plans to prepare and respond to the next pandemic.
