Academic journal article Bulletin of the World Health Organization

Emerging Norms for the Control of Emerging Epidemics

Academic journal article Bulletin of the World Health Organization

Emerging Norms for the Control of Emerging Epidemics

Article excerpt

Introduction

Recent WHO initiatives, including the revised International Health Regulations (IHR), (1) the final report on Ethical considerations in developing a public health response to pandemic influenza (2) and the interim protocol on Rapid operations to contain the initial emergence of pandemic influenza, (3,4) are representative of a new strategy for multilateral cooperation on emerging and epidemic-prone infectious disease (EID). These initiatives together define emerging legal, ethical and operational norms for the global prevention and management of outbreaks and other public health emergencies. Each one also reflects a revolutionary willingness of the international community to accept new forms of supranational authority and to abide by the principle that national sovereignty can in some circumstances be subordinate to public health protection. (5) As such, they are integral parts of the evolution of international health governance towards a global public health security regime. (6)

A significant but underexamined normative shift lays behind this dramatic change in strategy. Following the 2002-2003 severe acute respiratory syndrome (SARS) epidemic, before the approval of the revised IHR, we explored the concordance between the values and norms that guided global health authorities during the former and those subsequently elaborated as the core principles of the latter (Table 1). We identified four substantive themes that characterize the normative shift: (i) the effectiveness of global solidarity in providing the public good of EID surveillance and response; (ii) the responsibility of WHO to act as a supranational public health authority; (iii) the justifiability of necessary and proportionate coercive global public health measures to control outbreaks; and (iv) the imperative to reduce inequalities in capacities and access to resources across countries in the service of security, equity and reciprocity. We discuss these observations and their implications for future development of efforts to establish global public health security.

International solidarity

SARS solidified the case for considering collective responses to outbreaks as a "public good", the provision of which requires heightened international collaboration and resource pooling. The determinants of individual and population health status increasingly circumvent the territorial boundaries of countries and thus lie beyond the capacity of countries to address effectively through national action alone. Efforts to protect the health of the population of any single nation can no longer be effectively pursued in isolation from genuine efforts to promote the health of populations elsewhere. Given WHO's mandate to protect global health, combined with evidence that containment of outbreaks where they emerge can be achieved through timely detection and response, a strategy to manage, if not prevent, pandemics has become a possibility for the first time in history. This elevates international cooperation for EID control to the level of a public good with a global scope akin to previous efforts to eradicate smallpox and current ones to eradicate polio.

WHO as a supranational authority

Recognizing the increasingly global scope of EIDs, and the inherent global necessity and responsibility to respond to them, WHO assumed an expanded mandate and exercised new powers during the SARS epidemic. The enhanced role and authority of WHO, although not uncontroversial, were not publicly challenged by the international community and were, in fact, formally recognized and entrenched in the revised IHR. This affirms the authority of WHO as global leader and direct coordinator of responses to epidemics and pandemics. Impediments to the solidarity required to mount effective global responses to outbreaks, however, include concerns for local or national economic interests, a lack of assurance for equity and reciprocity, and the institutional and budgetary constraints of WHO. …

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