By K Srinath Reddy
Even as the world mostly refers to the Covid-19 pandemic in the past tense, the threat of future pandemics is presently engaging the attention of all countries through two major international initiatives convened by the World Health Organisation (WHO). International Health Regulations (IHRs) are being revised to increase the speed and efficiency of global health alerts. A new Pandemic Treaty is being negotiated to provide a more efficient and equitable response to a pandemic than witnessed recently. Both these initiatives will draw on the experiences of the Covid-19 pandemic to enhance global capabilities for responding to a new microbial threat.
IHR is the most important multi-lateral treaty that regulates the global architecture for health emergency preparedness, response, and resilience (HEPR). It commenced in 1969, for reporting on six infectious diseases. By 1973, the focus was on three diseases—cholera, yellow fever and plague. In 1995, the World Health Assembly (WHA) called for extending the scope to many sources of risk to human health (biological, chemical, radiological, and nuclear). The SARS-I pandemic catalysed a major revisit of IHR in 2005, calling on countries to assess and improve their national capacities for surveillance and response, and was to be accomplished by 2012. IHR 2005 required countries to notify WHO of any event which can potentially cause a ‘public health emergency of international concern’ (PHIEC) and to develop core public health capacities to investigate and control such threats. It enabled WHO to declare a PHIEC and coordinate a global response.
Despite this, the Covid-19 pandemic response revealed several weaknesses—both at several national levels and in global coordination. Many national health systems were inadequately prepared to recognise, report and respond to the escalating threat. Global sharing of information was neither uniformly prompt nor reliable. WHO’s assessments and national reports were at variance and global technical assistance had to be provided through filters of negotiated national government consent. Calls for revision of IHR mounted, both to expand its scope and to strengthen its implementation.
Proposals for revision of IHR were placed before the 75th WHA in 2022, were debated in the 76th WHA this year and are being steered towards the adoption of a new-age IHR in the 77th WHA. A total of 307 amendments to the existing IHR have been tabled by member states. They will be debated to develop consensus on revisions.
The most radical amendments have been proposed by the US, which has been very wary of bioterrorism and pandemic threats from other countries. The US’s Centers for Disease Control (CDC) work closely with WHO to monitor global trends. Covid-19 pandemic raised concerns about loopholes in timeliness, completeness and accuracy of outbreak reporting and speed of response, which the US proposals seek to plug. Amendments tabled by the US include proposals for rapid sharing of pathogen genetic sequence data and shorter deadlines for reporting and responding to emerging threats. An amendment to Article 12 proposes to remove the need for WHO to consult and find agreement with the country, which is seen to be the origin of a potential threat. This will be done through the mechanism of an ‘intermediate public health alert’ that requires ‘heightened international awareness’.
An amendment also proposes to give the six regional directors of WHO powers to declare a ‘public health emergency of regional concern’ (PHERC), avoiding delays of a global review and expediting coordinated regional responses. The US proposals allow WHO to rely on ‘outside’ information received from non-official channels, with only 24 hours given to the national government to respond before the information is made public. This is intended to overcome the tardiness or inaccuracy of national reporting but critics question whether third parties may use this channel to damage the reputation of countries. Consultation with countries is also not required before an PHEIC or PHREC is declared. Amendments propose to make deployment of WHO’s technical assistance missions to countries mandatory, by replacing ‘may’ with ‘shall’. This is supported further by amendments to Article 15, allowing WHO’s Director General and Expert Committees to recommend the deployment of expert teams to a country experiencing a PHIEC.
Critics of the proposed amendments are concerned about the erosion of national sovereignty, if many of the decisions are taken by WHO on the basis of expert committees which consist of non-officials and are often dominated by scientists from high income countries. There is concern that declaration of a PHIEC will provide a fast track to emergency use authorisation of drugs and vaccines with curtailed scrutiny of evidence on efficacy and safety. Annex 2 of the current IHR calls for declaration of a PHIEC when a SARS virus is detected. Should that be done even if the virus has a low infection fatality rate (IFR)? This has implications for people’s mobility and livelihoods.
There is a compelling need to strengthen global surveillance systems for timely detection of serious threats to public health which not only pose danger to lives but also undermine economic security and social stability. WHO needs to be strengthened to act with speed, technical competence, objectivity, and capacity to coordinate global responses, whenever a PHEIC arises. It should do so without unduly undermining national sovereignty in making assessments and deciding on locally appropriate responses. The ongoing negotiations on IHR will have to find a fine balance between these goals. Alongside this effort to make IHR a ‘fit for purpose’ instrument, the new Pandemic Treaty which is being negotiated in parallel should usher in a new era of cooperation in global health
The author is Cardiologist, epidemiologist, and distinguished professor of public health, PHFI