Christopher McDougall

The New International Health Regulations and the Federalism Dilemma

The recent revision of the International Health Regulations, say Wilson and colleagues, is both long overdue and eminently necessary to face the challenges of an increasingly globalized world.

Protecting global health security through the International Health Regulations: requirements and challenges

The International Health Regulations, the principle document governing the response to public health emergencies that pose an international threat, were revised in 2005 and became binding international law on June 15, 2007.[1][1] These new regulations, unanimously approved by the World Health

Strategies for implementing the new International Health Regulations in federal countries

The International Health Regulations (IHR), the principal legal instrument guiding the international management of public health emergencies, have recently undergone an extensive revision process. The revised regulations, referred to as the IHR (2005), were unanimously approved in May 2005 by all Member States of the World Health Assembly (WHA) and came into effect on 15 June 2007. The IHR (2005) reflect a modernization of the international communitys approach to public health and an acknowledgement of the importance of establishing an effective international strategy to manage emergencies that threaten global health security. The success of the IHR as a new approach to combating such threats will ultimately be determined by the ability of countries to live up to the obligations they assumed in approving the new international strategy. However, doing so may be particularly challenging for decentralized countries, specifically those with federal systems of government. Although the IHR (2005) are the product of an agreement among national governments, they cover a wide range of matters, some of which may not fall fully under the constitutional jurisdiction of the national government within many federations. This tension between the separation of powers within federal systems of government and the requirements of an evolving global public health governance regime may undermine national efforts towards compliance and could ultimately jeopardize the regimes success. We hosted a workshop to examine how federal countries could address some of the challenges they may face in implementing the IHR (2005). We present here a series of recommendations, synthesized from the workshop proceedings, on strategies that these countries might pursue to improve their ability to comply with the revised IHR.

Emerging norms for the control of emerging epidemics

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 influenza2 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. Table 1 The normative continuum from principle through actions during SARS to new international law Normative themes/principles Representative interview extracts with regard to responses to SARS Representative IHR (2005) articles1 International solidarity to control EIDs is a public good “We’ve essentially created a commons… wealthy countries need to understand that they’re at risk for everything in the poor countries… And so it is in their own self interests, beyond the obvious humanitarian concerns, to get very involved and very concerned about allowing all countries to defend their own populations, and the global population, against the emergence of new infections.” The purpose of the IHR is to “prevent, protect against, control and provide a public health response to the international spread of disease” (Article 2 p.9) and the goal of the universal application of the agreement is the “protection of all people of the world from the international spread of disease” (A3.3 p.10) Responsibility of the WHO as a supranational public health authority “Every new emerging infectious disease that has the potential for rapid global spread is not only an opportunity, it is a mandate for effective and aggressive WHO action… it would have been a failure of leadership had they [WHO] not acted; SARS was crying for that kind of leadership.” The WHO Director-General retains ultimate authority on the determination of a public health emergency of international concern (A12.3 p.14), the issuance of temporary recommendations (A49.5 p.33) and their modification, termination or extension at any time (A15 pp.15-16). Coercion global interventionism, proportionate to the threat, is justifiable “What makes [epidemics] dangerous... is when information is not flowing freely... travel advisories [should be used] as more of a stick that will be applied when there’s good evidence that information is not coming out.” If an affected State Party “does not accept the offer of collaboration” from WHO in assessing the urgency of the event, the WHO Director-General is authorized to share information with other States Parties, “when justified by the magnitude of the public health risk” (A10.4 p.13), as appropriate and necessary to enable them to respond to a public health risk or prevent the occurrence of similar incidents (A11.1 p.13). Security, equity and reciprocity support enhancing access and assistance “...it’s the responsibility of the international community to make sure [developing] countries develop the ability to comply with the new laws, but… I think there is a real sense of complacency in the wealthier countries about the state of health in the world...” Improved international “collaboration and assistance” (A44 p.31) is urged. States Parties are to “undertake to collaborate” with each other, particularly for “the mobilization of financial resources to facilitate implementation” (A44.1.c). They are also engaged by the obligation to provide “technical cooperation and logistical support, particularly in the development, strengthening and maintenance of the public health capacities required” (A44.1.b). Open in a separate window EID, epidemic-prone infectious disease; IHR, International Health regulations; SARS, severe acute respiratory syndrome.

Establishing public health security in a postwar Iraq: constitutional obstacles and lessons for other federalizing states.

The public health consequences of the conflict in Iraq will likely continue after the violence has subsided. Reestablishing public health security will require large investments in infrastructure and the creation of effective systems of governance. On the question of governance, the allocation of powers in the new constitution of Iraq is critical. Given the ease with which public health threats cross borders, the constitution needs to grant to the federal government the legal authority to manage such threats and simultaneously meet international requirements. Unfortunately, the draft constitution does not accomplish this objective. If politically possible, the constitution should be amended to provide the federal government with this authority. If not possible, the Iraqi federal government would have two options. It could attempt to use alternative constitutional powers, such as national security powers. This option would be contentious and the results uncertain. Alternatively, the federal government could attempt to establish collaborative relationships with regional governments. Residual sectarian tensions create potential problems for this option, however. Reflecting on the Iraqi situation, we conclude that other federalizing countries emerging from conflict should ensure that their constitutions provide the federal government with the necessary authority to manage threats to public health security effectively.

“With Human Health It’s a Global Thing”: Canadian Perspectives on Ethics in the Global Governance of an Influenza Pandemic

We live in an era where our health is linked to that of others across the globe, and nothing brings this home better than the specter of a pandemic. This paper explores the findings of town hall meetings associated with the Canadian Program of Research on Ethics in a Pandemic (CanPREP), in which focus groups met to discuss issues related to the global governance of an influenza pandemic. Two competing discourses were found to be at work: the first was based upon an economic rationality and the second upon a humanitarian rationality. The implications for public support and the long-term sustainability of new global norms, networks, and regulations in global public health are discussed.

Amantes Sunt Amentes: Pathologizing Love and the Meaning of Suffering

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