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4 Global Public Health Governance and the Revised International Health Regulations
Pages 180-230

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From page 180...
... Despite this progress, until the issues surrounding the H5N1 virus sharing are resolved, the IHR 2005 "remain a valuable but potential framework within which to address infectious diseases across international borders," Heymann asserts. Another challenge to IHR 2005 implementation involves its requirement for significant public health capacity-building, particularly with regard to infectious 0
From page 181...
... Proposals to use IHR 2005 as a means to force Indonesia to share the samples for global surveillance purposes have failed; Fidler notes that this incident highlights the important, yet ambiguous, position of health as a foreign policy issue and its broad implications for global public health governance.
From page 182...
... However, the IHR 2005 must weather far more severe crises than this epidemic to date, Fidler concludes, as well as a host of global trends that threaten to derail advances toward global public health governance. PUBLIC HEALTH, GLOBAL GOVERNANCE, AND THE REVISED INTERNATIONAL HEALTH REGULATIONS David Heymann, M.D. World Health Organization Communicating Disease Risk: Then and Now The 2003 outbreak of SARS was an event of singular importance in demon strating the need for global public health governance.
From page 183...
... represent a legally binding agreement that signifi cantly contributes to international public health security by providing a new framework for the coordination of the management of events that may constitute a public health emergency of international concerns, and will improve the capacity of all countries to detect, assess, notify, and respond to public health threats. For more information, see http://www.who.int/csr/ihr/prepare/en/index.html (accessed March 30, 2009)
From page 184...
... In the case of the IHR (and the accompanying sanitation guidelines for seaports and airports) , they attempted to strike a balance between ensuring maximum public health security against the international spread of these four infectious diseases with minimum interference in global commerce and trade.
From page 185...
... At the World Health Assembly (WHA) in May 2003, a resolution was passed by WHO member states that confirmed that WHO could receive and use infectious disease information from sources other than countries for risk assessment with the affected country in a confidential manner, and it also mandated reporting of a wider range of infec tious diseases with potential for international spread rather than just yellow fever, cholera, and plague.
From page 186...
...  FIGURE 4-1 Global Outbreak and Alert Network (GOARN) : Institutions and members of partner networks.
From page 187...
... , and of four specific dis eases even if only one case is identified: SARS, smallpox, avian influenza, and polio; • Collective, proactive global collaboration for risk assessment and risk management; and • Monitoring of implementation by the WHA. Global Governance and the Revised IHR Polio Eradication In 1988, polio was present in more than 125 countries, where it caused paralysis in approximately 1,000 children each day; and access to polio vaccine was inequitable between countries.
From page 188...
... In the first year after vaccinations ceased in northern Nigeria, it cost the Global Partnership on Polio Eradication an estimated $500 million to stop polio in reinfected African countries, as illustrated in Figure 4-4. Initial efforts to deal with this situation involved demonstrating that polio vaccines contained no impurities or hormones that could cause sterility in young girls.
From page 189...
... As an additional measure, WHO convened an ad hoc expert advisory group on polio epidemiology and public health to determine if there were any evidencebased measures that could be recommended to stop the international spread of polio. This group concluded that evidence in the scientific literature supported the fact that polio-immune adults could carry the virus in their intestines for periods up to a month, that the polio virus therefore had the potential to be carried wherever persons from polio-infected areas traveled, and that a booster dose of oral polio vaccine could decrease the period the virus was carried.
From page 190...
... Thus, while the IHR provide a useful framework that enables international coordination for the prevention and control of infectious diseases, their use is not automatic. It depends rather on the collective will of WHO member states to use them as a framework to resolve public health issues, on a case-by-case basis.
From page 191...
... Figure 4-7 presents an analysis of genetic information from the H5N1 virus collected by the Global Influenza Surveillance Network and clearly demonstrates the instability of the virus. It remains to be seen whether the H5N1 virus will undergo an adaptive mutation, such as was thought to have occurred to produce the 1918 (H1N1 influenza A)
From page 192...
... As soon as an H5N1 vaccine is licensed, WHO will also stockpile vaccine. The virus composition for H5N1 vaccine is recommended by the same risk assessment process as that used for seasonal vaccine composition, through the Global Influenza Surveillance Network.
From page 193...
... but human-to-human spread still localized Pandemic period Phase 6 Increased and sustained transmission in general population. FIGURE 4-8 The current pandemic alert phaseCOthe H5N1svirus.
From page 194...
... In order to better understand the issues, WHO conducted a meeting of experts, hosted by the government of Indonesia, to understand how countries might more equitably share in the benefits associated with virus sharing. This expert group identified the following issues that needed resolution to ensure more equitable sharing of benefits: • Greater participation by developing countries in the Global Influenza Surveillance Network, through the strengthening and certification of additional national influenza centers and WHO Collaborating Centers in developing countries; • Greater transparency by WHO in the handling of influenza viruses; and • Greater access to pandemic vaccines for all countries, with an increase in developing country vaccine production capacity.
From page 195...
... CAPACITY-BUILDING UNDER THE INTERNATIONAL HEALTH REGULATIONS TO ADDRESS PUBLIC HEALTH EMERGENCIES OF INTERNATIONAL CONCERN May C Chu, Ph.D. World Health Organization Guénaël Rodier, M.D.
From page 196...
... , made up delegates of all the member states, adopted the resolution to modernize the 1969 IHR to take into consideration the evolving stage of global public health threats. Their vision was for the revised IHR to be able to accommodate a world that would be alert and be able to detect and respond to international infectious disease threats and public health events within 24 hours of its first report using the most up-to-date means of global communication and collaboration.
From page 197...
... . IHR: States Parties Must Invest in Capacity-Building The revised IHR (2005)
From page 198...
... . For instance a public health event with potential of international spread should be reported if replies to at least two of the questions are "yes." Upon notification of the event, WHO has the mandate to collect and analyze information regarding the events and to determine its potential to cause disruption in travel and trade, irrespective of the origin or source, and may share such information with countries and intergovernmental organizations following verification with the affected State Party.
From page 199...
... with permission from the World Health Organization. Figure 4-10.eps bitmap image -- not editable
From page 200...
... Each State Party shall notify WHO, by the most efficient means of communication available, by way of the National IHR Focal Point, and within 24 hours of assessment of public health information, of all events that may constitute a PHEIC within its territory in accordance with the decision instrument, as well as any health measure implemented in response to those events. Following a notification, a State Party shall continue to communicate to WHO timely, accurate, and sufficiently detailed public health information avail able to it on the notified event, including, where possible, case definitions, labo ratory results, source and type of risk, number of cases and deaths, conditions affecting the spread of the disease and the health measures employed, and report, when necessary, the difficulties faced and support needed in responding to the PHEIC (WHO, 2005)
From page 201...
... Who will be responsible to ensure a functional system and how would it be paid for? WHO's Experience in Implementing the Revised IHR Since the entry into force of the IHR (2005)
From page 202...
... Each country designated an institution to serve as the NFP and named up to three persons who would rotate the responsibility to provide all-time, all-on support. Each State Party has been requested to nominate an expert who may be called upon to serve on the Emergency Committee should a PHEIC be declared, and such expert advisory group needs to be assembled to give advice to the WHO Director-General.
From page 203...
... This information is updated in the Disease Outbreak News, which is openly shared with the public on the WHO webpage.12 The orderliness and openness of the process established under the IHR (2005) reflects how countries have utilized pandemic influenza planning and other developments to successfully and confidently report their findings.
From page 204...
... The revised IHR emphasize public health risks, irrespective of origin or source, due to naturally occurring infectious or noncommunicable diseases and the suspected intentional or accidental release of biological, chemical, or radio logical substances. The intent of the IHR is clear and unambiguous: "to prevent, protect against, control and provide a public health response to the international spread of disease, in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade" (emphasis added)
From page 205...
... For resourceconstrained countries, which attract few tourists and export minimum com modities, it is perhaps understandable that the IHR are accorded minimal priority. Rather, a large proportion of policy makers in resource-constrained countries perceive that the emphasis of the IHR on the international spread of disease evinces little concern regarding the burden of infectious diseases on the nations in which they occur.
From page 206...
... In many African countries, the infectious disease surveillance system functions vertically, having been established to monitor specific vaccine-preventable diseases such as poliomyelitis, cerebrospinal meningitis, cholera, or yellow fever. This ad hoc system of disease-specific surveillance programs has resulted in a lack of integration of disease surveillance and control, a disdain for developing and building local capacity, and a penchant for acquiring imported technologies.
From page 207...
... However, for reasons of territorial integrity and an absence of formal collaborative agree ments, health officials may be reluctant to share information on priority commu nicable diseases with their counterparts in other countries. Regulatory Constraints Donor agencies impose inflexible regulatory constraints that hamper maximum utilization of human and financial resources for integrating disease surveillance systems.
From page 208...
... employed under a donor-funded project dealing with measles may not be allowed to place his expertise at the service of his government during an epidemic of yellow fever. Enabling Implementation of the IHR 2005 in Resource-Constrained Countries If the revised IHR are to be successfully implemented in resource-limited countries, there will be a need to correct the misperception that the emphasis of the revised IHR is on the international spread of disease, while the issue of the burden of infectious diseases on the resource-constrained nations is of secondary priority.
From page 209...
... should be provided for establishing and maintaining disease surveillance systems at the national level. Sustainable Surveillance: National Capacity-Building The polio eradication initiative in Africa has enabled the establishment of a reliable acute flaccid paralysis (AFP)
From page 210...
... In fulfilling this mandate, I explore why the H5N1 virus sharing contro versy raises hard questions about the IHR 2005 and its future. This exploration involves: • Reviewing the IHR 2005's importance as an innovative global governance regime; • Examining how the H5N1 virus sharing controversy represents a significant problem for the IHR 2005 and the future of global health governance; • Considering what the virus sharing controversy reveals about the nature of public health as a foreign policy issue; 14 JamesLouis Calamaras Professor of Law and Director, Center on American and Global Security, Indiana University, Bloomington.
From page 211...
... From the epidemiological perspective, the IHR 2005's scope has increased in three ways: • Unlike the IHR 1969, which applied to a short list of specified infectious diseases (cholera, plague, and yellow fever) , the IHR 2005 apply to a list of specific communicable disease threats and any communicable disease event that may represent a public health emergency of international con cern (IHR 2005, Annex 2)
From page 212...
... In addition, this power permits the WHO Director-General to declare such an emergency over the opposition of WHO member states directly affected by the disease event in question. Fifth, the IHR 2005 incorporate human rights concepts and require WHO member states to apply their public health powers in conformity with the prin ciples of international human rights law.15 The IHR 1969 contained no such effort to bring human rights concepts to bear on cooperation on infectious disease control.
From page 213...
... The H5N1 Virus Sharing Controversy and the Revised IHR Indonesia's Exercise of Viral Sovereignty Those who supported the adoption of the IHR 2005 knew that, sooner or later, this new regime would face serious tests in the context of disease outbreaks. The first real test of the IHR 2005 emerged, however, in a context most experts did not predict -- the refusal of a WHO member state to share samples of the H5N1 avian influenza virus with WHO.
From page 214...
... In sum, the first attempt to apply the IHR 2005 in the context of a serious global health crisis ended with the IHR 2005 being marginalized legally and politically. Deeper Implications for Global Health Governance The H5N1 virus sharing controversy has deeper implications for global health governance than an unsuccessful application of the IHR 2005.
From page 215...
... The virus sharing controversy has, however, seen national interests diverge sharply, which has produced a fragmented, divisive political context. The trajec tory toward more effective global health governance observable in the handling of
From page 216...
... Health has risen in importance as a foreign policy and diplomatic concern over the past 10-15 years, but the relationship between health and foreign policy still remains ambiguous and contested. The virus sharing controversy is a good case study in this context because it helps highlight characteristics of health within the realm of foreign policy.18 Agenda Expansion One feature of health as a foreign policy issue is the tendency for healthrelated agendas to expand.
From page 217...
... Forum Shifting Another feature of the health-foreign policy relationship that appears in the virus sharing controversy is the tactic of "forum shifting." States and nonstate actors often try to shift the negotiating forum of diplomatic disputes into forums more conducive or receptive to their particular interests. Forum shifting has been prominent in the diplomatic maneuvering over intellectual property rights and access to essential medicines.
From page 218...
... The mantra of public health is, however, to prevent health harms and protect populations from unusual levels of morbidity and mortality. The virus sharing controversy highlights the elasticity of health in foreign policy.
From page 219...
... The virus sharing controversy reflects growing frustration in parts of the developing world that improvements in global health gov ernance, such as the IHR 2005, actually do little to help them deal with their public health problems, which will be exacerbated by the anticipated population growth in the years ahead. Thus, the "demographics of dis cord" could erode incentives for developing countries to cooperate with developed countries in global health governance.
From page 220...
... The lack of any clearly identifiable strategy, supported by funding, to help developing countries meet their minimum core surveillance and response obligations under the IHR 2005 has also been made more glaring by the virus sharing controversy. These political problems point to a harsh message for global health policy -- surveillance as the "center of gravity" for global health governance cannot hold without more robust efforts to address the "benefits" imbalance emphasized by the virus sharing controversy.
From page 221...
... This section analyzes this gap by contrasting critical aspects of the intent behind the IHR 2005 with the lack of effective strategies to implement the regu lations globally. The IHR 00 as Health in Foreign Policy Those crafting the IHR 2005 intended this new regime to have the kind of foreign policy significance for countries that global health policies rarely achieve.
From page 222...
... Thus, the IHR 2005 hooked into the foreign policy priority of national security. The express purpose of the IHR 2005 speaks to the foreign policy interest in maintaining economic power and well-being by stating that the regulations seek to address international disease threats in ways that do not unnecessarily interfere with international trade and travel.
From page 223...
... The IHR 00 and "Great Debates" in Global Health Another way to sense the intent behind the IHR 2005 is to consider how this radically new global health governance regime relates to some of the "great debates" taking place in global health policy circles, including: • Naturally occurring infectious diseases versus bioterrorism: The IHR 2005 recognize both threats as real and contain provisions that move countries toward building public health capabilities to handle both types of threats. • Vertical versus horizontal programs: With their emphasis on the need to develop and sustain core public health capabilities, the IHR 2005 support the need to craft more policies and initiatives that move toward building horizontal, systemic capabilities.
From page 224...
... These implementation problems include the impact of the H5N1 virus sharing controversy and more general worries about the lack of any robust and funded strategy to assist devel oping countries to implement the IHR 2005 by the 2012 compliance deadline. I have also raised the concern that other global problems and crises, such as the global energy, food, climate change, and economic crises, have overshadowed the policy challenge of IHR 2005 implementation.
From page 225...
... The United States has expended a great deal of foreign policy and diplomatic effort on addressing pandemic influenza and bioterrorism, and, in the event either of these threats emerges, the President of the United States and his national security and foreign policy teams would have to confront such developments. Yet, the committee never directly mentions either threat or provides any recommendations for the Obama Administration to improve how the United States addresses these global health challenges.
From page 226...
... to advise the WHO Director-General on whether the H1N1 virus and outbreak constituted a public health emergency of international concern; -- the Emergency Committee's recommendation that the H1N1 outbreak did constitute a public health emergency of international concern; -- the WHO Director-General's declaration under the IHR 2005 (Arti cle 12) that a public health emergency of international concern existed; and -- the WHO Director-General's issuance, with the advice of the Emer gency Committee, of temporary recommendations under the IHR 2005 (Article 15)
From page 227...
... The HN Outbreak's Impact on the Virus Sharing Controversy During the H1N1 outbreak, affected countries shared samples of the H1N1 virus with WHO and other countries (e.g., Mexico shared virus samples with Canada and the United States) without controversies.
From page 228...
... Conclusion The virus sharing controversy sparked by Indonesia has been a body blow to the trajectory of global health governance, and in particular the IHR 2005. This controversy has not been fatal to the prospects of the IHR 2005, as the H1N1 outbreak demonstrates.
From page 229...
... 2008. Regional infectious disease surveillance networks and their potential to facilitate the implementation of the International Health Regulations.
From page 230...
... Paper presented at the Workshop on Globalization, Movement of Pathogens (and Their Hosts) , and the Revised International Health Regulations, hosted by the Forum on Microbial Threats, Washington, DC.


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