International Health Regulations Must Overcome Perceptions of Double Standard

Prospective students sit for their admission exams at the Midwifery school in Masuba, Sierra Leone. In the wake of Ebola and recovering from a long civil war, Sierra Leone now has the highest maternal mortality rate in the world. Photo by Getty Images.
Prospective students sit for their admission exams at the Midwifery school in Masuba, Sierra Leone. In the wake of Ebola and recovering from a long civil war, Sierra Leone now has the highest maternal mortality rate in the world. Photo by Getty Images.

The Ebola outbreak has cast a light on the International Health Regulations (IHR) – the legally binding instrument designed to protect the world from unnecessary risk of a catastrophic outbreak and spread of infectious disease. The reports of the WHO’s IHR Review Committee − of which I was a part − and of the panel commissioned by the UN secretary-general, along with numerous additional studies, have made it clear that the IHR remain technically fit for purpose. The problem is that almost 50 per cent of states have yet to fully comply, even after being given the maximum extensions allowed in the treaty, exposing the world to unnecessary risk.

Besides a lack of resources, one reason for non-compliance is the split between low- and middle-income countries (LMICs) and high-income countries (HICs) over the focus of, and priority for, compliance. There is a perception among LMICs that HICs are selective in their call for full compliance, being primarily interested in those aspects which protect themselves from the health risk posed by LMICs while ignoring those aspects of the IHR which are beneficial to LMICs.

At the Munich Security Conference, I spoke with several senior ministers from LMICs, who pointed out that while they were being criticized by HICs for non-implementation of the IHR, the very same HICs, contrary to the IHR, imposed unreasonable restrictions ‘that quarantined Africa’. They also pointed out that it was only when Zika was considered to have the potential to affect the success of the Olympic Games and spread to the US that the world took notice. Meanwhile, significant outbreaks of other infectious diseases, such as yellow fever, they claimed, are ignored as they do not affect HICs. The fact that all the major academic reports on Ebola were released in the UK or US rather than in the affected countries also drew unfavourable comment.

The point is not whether these observations are accurate or justified; it is the fact that they are the perception of at least some LMICs and taken together they undermine the will to implement the IHR. While it is true that universal implementation of the IHR will protect HICs, implementation is equally a safeguard against health risks in LMICs, and a better job needs to be done to promote this message to heads of state, foreign and finance ministers from LMICs.

There is also the issue of priorities for funding, and specifically where health sits in the long list of areas that LMICs need urgently to address. One LMIC official in Munich told me ‘it is not for you to tells us what should be the priority for using our resources’, while another explicitly stated: ‘yes, health is important, but education is even more important and that guides our funding decisions.’

Getting to full compliance

Given these attitudes, in my view the only way for the poorest countries to achieve compliance is via the 10-year funded strategic plan as recommended by our committee.  This needs to take account of the current funding available from all sources, the integration of the numerous vertical programmes and, critically, the provision of additional funding.  The funding needs to be aligned to specific milestones and with the Sustainable Development Goals.

Using a 10-year time frame was the subject of much debate during the IHR Review Committee’s deliberations.  The UN panel chose a 5-year time table and some within the IHR committee argued that as member states had signed up to full implementation by 2015, an even shorter timetable was required.  For a high-income country, a short timetable is preferable, as without full implementation, they are at increased risk of uncontrolled infectious disease arising and spreading from those countries that have not implemented the IHR.  However, full compliance needs the development of and/or strengthening of a comprehensive health system and needs to take account of the current reality facing the least-resourced countries, which lack both financial and human resources.  This is especially true for those emerging from conflict, and imposing an unreasonable and unachievable time scale is, in my opinion, counterproductive.  Of course this does not preclude earlier implementation for better-resourced states, nor the earlier and universal adoption of specific capabilities, such as systems for the identification of an outbreak.

Both reports also call for a better process of assessment of compliance, given the actual difference between self-declarations of compliance and the reality exposed by the Ebola outbreak. The IHR Review Committee has recommended independent assessment of, or progress towards, compliance with IHRs. We recognize the sensitivity of this recommendation, which could be seen as an infringement of a state’s sovereignty, but were encouraged by the experience of most of the states in the eastern Mediterranean region who during the outbreak submitted themselves to external independent assessments. States apparently found these appropriate and helpful, even where the outcome demonstrated gaps in compliance. In order not to reinforce perceptions of discrimination against LMICs, our committee took care to recommend that all states, and not just those considered at greatest risk of non-compliance, were exposed to independent assessment.

Tying the milestones in the 10-year plan with the results of an independent review of progress and the provision of external financial assistance should facilitate and encourage progress towards full compliance, while independent reviews will also enable an assessment of where outbreaks of infectious diseases pose the greatest risk, pointing to where the WHO should focus its efforts on mitigation.

But the bottom line is this: until the IHR are fully implemented the risk to the world from catastrophic infectious disease remains higher than is ideal or achievable.

Louis Lillywhite retired as surgeon general of the UK Armed Forces in 2010. His 42-year career in the Army included medical appointments as a consultant occupational physician, operational deployments, and command and staff appointments in the Ministry of Defence and in various army and NATO Headquarters.

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