The International Health Regulations (IHR) have long been considered to be an inadequate tool for policing international public health. As far back as 1969 the then WHO Deputy Director-General pronounced the IHR's legal duties “a dead letter”. Now in the process of revision, and the subject of six regional WHO meetings in mid-June, can the IHR keep pace with modern global public health governance?
The IHR started out in 1951, 3 years after the creation of the WHO, as the International Sanitary Regulations (ISR), in an attempt to consolidate various international sanitary conventions that had been in place since before World War II. In view of this fact, the ISR—renamed the IHR in the late 1960s—have historically been based on national sovereignty and sought to achieve “maximum security against the international spread of disease with minimal interference with world traffic”. This central, rather diplomatic, tenet and focus on just four notifiable diseases-smallpox, cholera, yellow fever, and plague (smallpox was removed from the list in 1981)-have proved to be the weak points of the IHR.
Focusing solely on the horizontal movement of infectious diseases between countries, the IHR had no hold over the prevention and control of disease within individual member states. This proved to be a problem when countries routinely ignored their obligation to report disease outbreaks for fear of an economic backlash. And it seemed that countries were right to worry about the imposition of strict trade and travel measures by other countries since there are many instances of such unnecessarily excessive sanctions. At the dawn of the HIV/AIDS era, for example, many states began to demand “AIDS-free certificates” from international travellers. However, the application of stringent measures to newly emerging diseases pointed up another weakness of the IHR-any step taken by a WHO member state to address the threat of a new disease not subject to the IHR was on legally shaky ground, simply because the measure was not provided for by the IHR.
The key proposed change for the revised IHR is a departure from the list of, now three, notifiable diseases. Member states would be required to report “events potentially constituting a public health emergency of international concern”, a rather loose term that has been a sticking point for attendees at regional meetings.
If this represents the key change to the IHR, then why is it so vague? While it would not be especially helpful for the revised IHR to be based solely on an extended, or continuously amended, list of diseases, one might expect greater clarity in this definition. Particularly in relation to emergent infectious diseases, one can imagine a public health event going unreported, either because its significance is not realised until too late, or because a country has deliberately loosely interpreted these regulations for its own ends.
The revised IHR will have the status of an international treaty, but this fact has not historically produced compliance, nor seen action brought in the wake of non-compliance. However, during the severe acute respiratory syndrome (SARS) outbreak of 2003 all affected member states, with the exception of China, openly reported outbreaks and cooperated with WHO despite having no legal obligation to do so. This remarkable situation signified that a fundamental change had taken place in global public health governance-the shift in the political, economic, and technological climate had brought about new ways of thinking for public health.
Moreover, post-SARS, the World Health Assembly 2003 officially recognised the collection and dissemination of non-governmental sources of information. Since the mid 1990s WHO had openly used such sources of information as part of its Global Outbreak Alert and Response Network, but this move was not made policy until 2001.
An increased role for non-state actors will be pivotal in the future of the IHR, or rather the future of global public health governance, since it is clear that the revision of the IHR has not brought about these changes but is responding instead to underlying political, economic, and technological revolutions in infectious diseases epidemiology. The IHR is not needed to shape these global changes in reporting but it will provide a valuable legal framework on which the new public health world order can rest. Most importantly, the revised IHR will be able to take advantage of such changes for the benefit of global public health, and this is where its future power will lie.