Abstract
The International Health Regulations are a legally binding instrument which should support WHO in coordinating pandemic control. Covid-19 has demonstrated the limits of international cooperation in pandemics. An even broader Global Health approach would be needed that focusses not only on controlling outbreaks, but acknowledges societal expectations and implements Health in All Policies.
Zusammenfassung
Die internationalen Gesundheitsvorschriften sind ein rechtlich bindendes Instrumentarium, mit dessen Hilfe die WHO die Bekämpfung von pandemisch auftretenden Erkrankungen koordinieren soll. Covid-19 zeigt die begrenzte Bereitschaft zur internationalen Kooperation im Pandemiefall auf. Tatsächlich erforderlich wäre ein Global-Health-Ansatz, der nicht nur auf Ausbruchskontrolle fokussiert, sondern auch gesellschaftliche Erwartungen berücksichtigt und Gesundheit in allen Politiken umsetzt.
International health regulations
The International Health Regulations (IHR; named so since 1969) and their predecessors comprise coordinating measures to control infectious diseases which spread across national borders and continents. The first such regulations stem from the mid-19th century. Initially, their focus was on the “classical” communicable diseases such as cholera, smallpox, and yellow fever.
WHO and the IHR
When the World Health Organization (WHO) was founded after World War II, it was given via the IHR the responsibility for implementing a global regime of epidemic control. The World Health Assembly (WHA), representing all WHO member states, has the authority to adopt regulations designed “to prevent, protect against, control, and provide a public health response to the international spread of disease in ways that […] avoid unnecessary interference with international traffic and trade” [1]. In 1995, the scope of the IHR was expanded to cover emerging and re-emerging infectious diseases. The current IHR, which entered into force in 2007, are a binding instrument of international law [1] (with the International Convention on Tobacco Control being WHO’s only other instrument of this kind). Underlying the IHR was the vision of a world community that was increasingly interconnected and willing to cooperate on disease control [2]. This vision was reinforced by the G20 (Group of Twenty) leaders as recently as 2017 [3]: “We support the WHO’s central coordinating role, especially for […] response to health emergencies”. Thus, a Global Health institution with a mandate, appropriate legal instruments, and the necessary political support seemed to have been in place to thwart off a pandemic, should one arise.
Political power play
And it did arise, in the shape of the Covid-19 pandemic, whose onset was first noted in China in late 2019 [4]. Instead of demonstrating the strengths of WHO and the IHR, however, it laid bare the weaknesses of the purportedly multilateral vision of Global Health. In particular, the pandemic showed how national interests quickly superseded global public health requirements. In the first few weeks of the pandemic, WHO played a crucial and successful role. It defined the need for world-wide, non-medical preventive measures such as physical distancing in the report of the WHO-China mission [4]. By mid-March, however, WHO was criticized for not maintaining global leadership in controlling the pandemic [5]. This criticism disregards that WHO member states were already starting to act unilaterally, and implementing measures such as closing national borders that were not in line with the IHR [6]. Such measures became convenient instruments to exacerbate existing conflicts such as the trade war between the US and China, and to withdraw from inconvenient international agreements. A blatant example was provided by US president Trump who, while bungling the Covid-19 crisis at home, accused China of having caused the pandemic, and WHO of mismanaging it, announcing that he would withdraw US funding [7]. Multilateralism, an already endangered precondition of Global Health [8], suffered another blow. In several countries, power politics and jingoistic economic interests quickly overrode global public health concerns in spite of the universally endorsed and legally binding IHR.
Central institutions but decentral interventions
Not only WHO, but also other institutions such as the European Centre for Disease Control (ECDC) were criticised in a comparable way [9]. This could be conceived as an indication of another underlying political crisis, here of the EU. Yet, critique launched against institutions such as WHO and ECDC is to be expected in an outbreak of a new disease of which knowledge is limited. With Covid-19, interventions had to be developed “on the go”, unlike in the classical communicable diseases. In addition, the Covid-19 pandemic actually comprises of a mosaic of various regional epidemics, with different starting points in time and different regional severity, as the global Covid-19 Dashboard shows [10]. Thus, measures which may be vital in one place could be overly restrictive in another (and vice versa). Ultimately, preoccupation with real or perceived national concerns quickly superseded multilateral institutions and their function in pandemic control.
Societal concerns
The IHR stipulate that implementation should “be with full respect for the dignity, human rights and fundamental freedoms of persons” [1]. Societies with different political systems, however, may have substantially different ideas how preventive interventions and individual freedom should be balanced. Drastic quarantine measures at population level were implemented without much societal debate in Wuhan/China. They were broadly accepted by the population and successful in reducing local transmission to few instances [11]. When these measures were strongly recommended by the WHO-China Joint Mission [4], it quickly became clear that they were not acceptable to all societies in the same way. In countries where they are primarily perceived as restricting freedoms, every prolongation kindles renewed debate [12], [13]. Evidence-based public health measures prescribed by the IHR may thus be constrained by fundamental societal concerns.
Pandemics as combined crises
Pandemics are perceived as being caused by an infectious agent, frequently a virus. This is an over-simplified view: pandemics are combined crises [14], as the political and societal aspects discussed above show. Covid-19, in addition, has a strong environmental component. The pandemic virus has a zoonotic origin and was presumably spread on a market dealing in wild animals for human consumption [15]. Global Health thus needs to go far beyond the IHR and take responsibility for the broader determinants of health [16], [17], in line with current debate in public health [18]. The combined crisis also demonstrates the need for institutional reform of the multilateral governance system [19]. While being supported by Germany [8], this reform is stalling, in spite of the challenges identified during previous epidemics such as Ebola [20]. Germany presents itself as a supporter of multilateralism and WHO reform [8]. To fulfill this role, Germany urgently needs to update and revise its global health policy [21], taking into account concerns about the present policy’s narrow view of Global Health [22], [23].
What this means for Global Health
Global Health needs more than IHR, as the Covid-19 pandemic demonstrates. Global Health comprises all elements of public health, in particular its concern about social determinants of health, health systems, and the need to reflect health in all policies. The pandemic also confirms that there is no “local” or “regional” public health. Unsurprisingly, even health maps for the “local” human habitat delineate the role of macroeconomic and political global forces, as well as of the global environment, on health [18]. Health in All Policies thus inevitably extends to policies at global level. To take this argument further, the delimitation between Global health and public health that some authors uphold [23] seems increasingly artificial. In today’s world, even with recurring nationalism, Global Health is public health, and vice versa.
Author Declaration
Author contributions: All authors have accepted responsibility for the entire content of this submitted manuscript and approved submission. Funding: Authors state no funding involved. Conflict of interest: Authors state no conflict of interest. Ethical statement: Primary data for humans or for animals were not collected for this research work.
Autorenerklärung
Autorenbeteiligung: Alle Autoren tragen Verantwortung für den gesamten Inhalt dieses Artikels und haben der Einreichung des Manuskripts zugestimmt. Finanzierung: Die Autoren erklären, dass sie keine finanzielle Förderung erhalten haben. Interessenkonflikt: Die Autoren erklären, dass kein wirtschaftlicher oder persönlicher Interessenkonflikt vorliegt. Ethisches Statement: Für die Forschungsarbeit wurden weder von Menschen noch von Tieren Primaärdaten erhoben.
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