International Governance of Global Health Pandemics

COVID-19 has disrupted the world as we know it with the declaration of national disaster, imposition of strict quarantines, and economic disruptions. In order to provide some context for the role of international law in public health emergencies, this Insight provides brief history of how the international community has created institutional governance to respond to global health pandemics.

Introduction

COVID-19 is not the first pandemic to face the world and managing pandemics has not been an easy matter for sovereign States. Cholera appeared on the Southeastern edge of the Russian Empire after having traveled across India from the Asian steppes. Europe was unprepared and it quickly became apparent that different quarantine requirements by different countries were contributing to continued transmission of the disease. In 1834, a French health administrator called for an international meeting to be organized to create harmonized standards. Of particular concern to countries were the "disastrous hindrances to international commerce" that the outbreaks were having.[1] In 1851, France helped to convene the first International Sanitary Conferences designed to address the standardization of quarantine regulations aimed at preventing the importation of cholera, plague, and yellow fever.[2]

Negotiating international agreement around disease was difficult with parties disagreeing about the nature of various diseases. After 41 years of meeting and seven International Sanitary Conferences, states finally agreed in 1892 to a narrow treaty providing for maritime quarantine regulations for cholera on westbound shipping routes from the East.[3] Subsequent agreements were signed and eventually in 1909, States opened an "Office International d'Hygiene Publique" in Paris.[4] At the 13^th International Sanitary Conferences, countries that had weathered the extremely deadly 1918 Influenza Pandemic agreed in an updated International Sanitary Convention to provide immediate notification to every other government and to the Office International d'Hygiene Publique of first confirmed cases of cholera, plague, and yellow fever, as well as epidemics of small pox and typhus.[5] The term "epidemics" was never defined. Curiously, states refused to include influenza, arguing that it was impractical to quarantine for this disease.[6]

In 1943 during World War II, the United Nations Relief and Rehabilitation Administration focused on the "giving of aid in the prevention of pestilence and in the recovery of the health of the people" with a focus on displaced individuals.[7] Decisionmakers in this new body took over the work that had been done by the Office International d'Hygiene Publique and focused on additional infectious diseases, including influenza. The 1926 International Sanitary Convention was revised in 1944 to better reflect the new realities of global disease so that countries were expected to exchange epidemiological information about more diseases that would constitute "a menace to other countries."[8]

World Health Organization and Governance of Pandemics

On March 11, 2020, the Director General of the World Health Organization (WHO) announced that COVID-19 was a global pandemic. This announcement, while specific to COVID-19, emerged from multiple decades of experience of institutional efforts to cooperate and coordinate around managing the spread of infectious disease.

The World Health Organization began operation in 1948 and introduced better practices in international coordination around pandemics that are still being developed today as we react to novel health threats. In 1952, the WHO created the Global Influenza Surveillance and Response System (GISRS) to monitor the evolution of influenza viruses. The hope was to be able to identify, in a timely fashion, strains of influenza that might become pandemic and develop vaccines.

In 1969, building on the International Sanitary Regulations, countries adopted the "International Health Regulations" (IHR) requiring that WHO be notified whenever cases of cholera, plague, yellow fever, smallpox, relapsing fever, and typhus occurred within their territory.[9] The IHR was criticized for being too narrow because no attention was given to highly infectious diseases, such as influenza, in these early regulations.

In 1999, the WHO published an influenza pandemic planning framework that emphasized the need to enhance influenza surveillance, speed vaccine production and antiviral drugs (particularly to developed countries that may not have their own drug production means), and improve influenza research and emergency preparedness.[10]

In 2002, WHO had a chance to put new theories about effective global pandemic containment into practice with a coronavirus. In 2003, the Global Outbreak Alert and Response Network formed in 2000 provided a tip about an unusual clustered outbreak of respiratory illness in Guangdong China. This Global Network was a new WHO-facilitated multi-stakeholder response to controlling pandemics that collected and disseminated information not just from national governments but from a broad array of additional public health surveillance networks. On February 14, 2003, the Chinese government reported 305 unusual cases, but indicated that the outbreak was "coming under control." The World Health organization called upon its network of influenza laboratories to identify any novel influenza viruses that might have pandemic potential. On February 19, 2003, the WHO Global Influenza Surveillance Network reported that a 33-year-old Hong Kong man and his nine-year-old son had contracted the H5N1 virus after travelling through Guangdong Province to Fujian Province—where the family's 8-year-old daughter had developed a severe respiratory illness, died, and was buried. After an outbreak report in Hong Kong, the WHO called for heightened global surveillance as cases began emerging in Canada, Vietnam, and Singapore. By March 15, the number of cases had exploded and WHO declared a worldwide health threat of "sudden acute respiratory disease" and declared need to control air travel. On March 27, scientists in the WHO network identified the novel coronavirus causing SARS. Through a combination of vigorous and relatively aggressive national containment activities put into place through national emergency regulations (including case identification, case isolation, contract tracing, surveillance, closing of international borders, and quarantine of contacts) as well as well-publicized international travel recommendations, human-to-human transmission of SARS was remarkably contained within four months by July 5, 2003. The rapid sharing of information across networks of experts and decisionmakers was key; the good faith participation of states in containment efforts was essential.

In 2005, WHO updated the International Health Regulations focused on establishing and improving the global capacity to prevent, detect, and respond to infectious disease threats such as pandemic influenza. Under the revised IHR, countries were required to improve international surveillance and reporting mechanisms for disease outbreaks and to strengthen their national surveillance and response capacities.[11] Where historic international agreements limited what types of events were to be shared, the revised IHR called upon states upon to report any event that: (1) has a serious public health impact; (2) is unusual or unexpected; (3) might be internationally virulent; and (4) is likely to trigger a significant risk of international travel or trade restrictions.[12] National IHR Focal Points report to regional WHO IHR Contact Points, and someone must be available as a contact point around the clock. Under the revised regulations, WHO can make a combination of temporary emergency recommendations combined with standing recommendations for ongoing health risks.[13] Under the regulations, an Emergency Committee advises the Director-General of WHO on temporary recommendations during a public health emergency of international concern."[14]

In 2011, WHO introduced a Pandemic Influenza Preparedness (PIP) Framework for the Sharing of Influenza Viruses and Access to Vaccines and Other Benefits. The pandemic framework operates through the sharing of influenza viruses, genetic sequence data from these viruses, reagents, and risk assessments, all though the GISRS.

WHO International Health Regulations and COVID-19

Will the COVID-19 situation be more like SARS where technical cooperation and aggressive national public health actions eventually achieved containment, or will the situation generate conflict between states? As COVID-19 continues to spread to far more countries than SARS spread to,[15] cooperative prevention and preparation in the context of international public health law becomes essential to prevent the pandemic from becoming a borderless disaster.

For the COVID-19 outbreak, key states have been responding in compliance with the International Health Regulations. The WHO China office reported the initial cluster in December 2019, isolated the virus on January 7, 2020, and then shared the genetic sequence of COVID 19 on January 12, 2020, to ensure proper diagnostic kit developments.[16] Appealing to the object and purpose of the International Health Regulations, the WHO has continued to remind countries of the need for proportionality in applying measures that are "restricted to public health risks, and which avoid unnecessary interference with international traffic and trade."[17] Meanwhile, travel bans have been, and continue to be, imposed that are questioned by public health law experts.[18]

As this Insight is written, there is a great deal of uncertainty regarding the direction of the pandemic, but the WHO has played a key role as a facilitator in managing transmission of epidemiological information and sharing of effective national strategies across global networks. There are many difficult decisions ahead for individual governments but there is strength in affirming international solidarity to contain the disease equitably without damaging long-term State reputations or creating conditions for future unwarranted discrimination.

Anastasia Telesetsky is Professor of Law at the University of Idaho College of Law and is a member of the Insights Editorial Board.