One year after the United Nations Security Council declared the Ebola outbreak to be a threat to international peace and security, senior World Health Organization (WHO) officials are now projecting that the goal of zero transmission of the Ebola virus by the end of 2015 appears “very possible.” The number of Ebola cases has fallen to single digits for six consecutive weeks in Guinea and Sierra Leone (Liberia was declared Ebola free in May).
As the prospect of an Ebola-free world becomes more likely, public health experts are taking stock of the crisis and examining lessons learned in order to prevent a catastrophic epidemic on this scale from re-occurring. A notable effort in this regard is a new WHO panel, tasked by the World Health Assembly to assess the effectiveness of the International Health Regulations (IHR), the international treaty regulating how countries should detect, report and respond to global pandemics.
The panel met for the first time on August 24-25 and is expected to focus on three major areas related to IHR performance, including communications and flow of information, country capacities, and compliance and governance. Its findings, to be presented at the 69th World Health Assembly in May 2016, could have major implications for global health security. Indeed, the time may be ripe to push through reforms aimed at changing the way international health norms are understood, monitored and enforced.
The Ebola outbreak revealed many of the shortcomings of the current framework. As David Fidler observes in an article for Chatham House, several countries violated the IHR when they banned trade with Guinea, Liberia, and Sierra Leone, closed their borders, denied visa requests from the region, or cancelled flights to West Africa (in the case of commercial airline providers). These include both African nations and developed nations such as Australia and Canada (around 45 in all).
Not only did this make it more difficult to deliver vital supplies to the region, WHO and the UN Security Council were powerless to respond other than to offer strong condemnatory statements. “The Ebola outbreak illustrated how inconsequential an IHR breach is, even by countries like Canada who argued against travel bans during SARS yet enacted them during Ebola,” said Amesh Adalja, Senior Associate at the Center for Health Security at the University of Pittsburgh Medical Center.
Already records from the panel’s first meeting point to a widespread feeling that the IHR should be strengthened and given “teeth.” In a departure from the status quo, the committee has said it will explore the possibility of enforcement measures, such as sanctions and on-site inspections akin to the arms control regime, for countries that restrict trade and travel, fail to report disease outbreaks, or take other steps in contravention with WHO’s recommended measures.
Other mechanisms to be explored include a systematic review of national health systems (perhaps similar to the universal periodic review of the human rights law regime) as well as social pressures, such as publically naming-and-shaming countries which violate the regulations. All in all, these measures could amount to a new norm of “responsibility to detect” requiring nations and the international community to detect and respond to deadly outbreaks.
However, it’s worth noting that compliance measures have been called for by previous review panels to no avail. Thus, this panel will need to develop a carefully-considered list of recommendations to the World Health Assembly next May, as well as learn the lessons of previous review panels, if it is to generate momentum for reform. Below is a short list of dilemmas it will need to reconcile when it meets to deliberate a second time in October.
First, striking a balance between empowering the IHR and WHO on the one hand, and appeasing member states on the other, will prove to be a decisive challenge. Since implementation of the IHR relies on buy-in from its member states, anything but incremental changes could result in opposition from countries concerned about giving up their sovereignty. Being subject to critical review could also produce a backlash. For instance, a proposal to rank countries on a graded scale based on their level of risk and susceptibility to disease outbreaks could lead to undesirable stigmatization.
Second, because implementation of the IHR is the responsibility of WHO as well as member states, the committee will need to possess a keen understanding of what the organization can tolerate by way of reform. Any proposals to expand the jurisdiction of WHO to include monitoring measures may require major internal restructuring. As Dr. Bruce Aylward, a senior WHO official is quoted as saying, changes on this scale could lead to “revolt” within the organization; the health body already must contend with a list of 21 reforms from the Ebola Interim Assessment Panel report in July.
Third, any recommendation will need to weigh the role of enforcement measures with the need to shore up IHR core capacity requirements. As Sara E. Davies, Adam Kamradt-Scott, and Simon Rushton argue in their new book, the greatest challenge to implementing the IHR is not willful non-compliance by member states but lack of capacity. Only one third of states have met their IHR core capacity requirements. If this is true, it may be counterproductive to offer sticks when what is needed are carrots, such as incentives for establishing better disease alert systems.
Fourth, there is the question of whether reforms should be made to the text of the IHR or be interpreted in light of the current framework. According to Sara E. Davies, David Fidler and others, the current framework is sufficient; what is needed is a “WHO director-general not afraid to test the limits of the instrument.” Instead of calling for textual revisions to the IHR – a process that has been fraught with difficulty in the past – the committee may seek to propose options that would expand the scope of the current document.
No matter how prudent the panel’s recommendations, it remains to be seen whether the “shock” of the Ebola crisis will be enough for its recommendations to be taken seriously. Still, the fact that enforcement measures such as sanctions are being considered could indicate a dramatic shift in the normative climate, one in which reforming the system of global health security is actually possible.
Michael R. Snyder is an independent analyst and frequent contributor to the Global Observatory.