The COVID-19 pandemic has changed many aspects of our lives, but it has not yet compelled substantial changes to the legal landscape of global health. Several proposals to revise the International Health Regulations (IHR) were put forward for discussion at the 75th World Health Assembly (WHA, May 22-28, 2022). The most ambitious revisions, proposed by the USA, included rapid sharing of pathogen genetic sequence data and introducing shorter deadlines for reporting and responding to emerging threats. However, the whole set of US amendments was not immediately adopted at the Assembly. Instead, a resolution on “a process for a process” and a shortened timeline for updating the IHR were approved. Moreover, states are invited to submit amendment proposals by September, and the debate on the IHR reform is likely to continue until the 77th WHA.
The IHR was last revised in 2005 in response to the SARS epidemic. Some key changes included the requirements for states to notify WHO of any event (infectious or not) with the potential to cause a public health emergency of international concern (PHEIC) and to develop core public health capacities. It is one of the most important legal instruments designed to “prevent, protect against, control and provide a public health response to the international spread of disease” for 196 countries. The IHR enables WHO to declare and coordinate efforts on PHEIC, including the most recent COVID-19 pandemic.
However, many have found the performance of the IHR in the current pandemic disappointing. It was unable to compel a robust, coordinated response against the PHEIC and few states showed adequate preparedness and timeliness as the IHR requires. Legal and public health experts, as well as member states themselves, have therefore begun to suggest different ways to strengthen this legal framework. Some focus on the content, asking for additional rules and textual clarity. Others believe it is less the phrasing or the spirit of the IHR that has failed, but more the inadequate implementation by member states and by WHO. Meanwhile, a global pandemic treaty has been proposed and discussed, and its development will now run parallel to the IHR reform process.
What has prevented agreement on IHR reform so far? One of the root causes is the inequality in resource, capacity, and power between high-income countries and low-income and middle-income countries (LMICs). An effective IHR must be built on the base of equity, where rights and responsibilities are well coordinated, benefits and burdens are fairly distributed, national and global interests are carefully balanced, and short-term assistance and long-term capacity-building are provided with the intention of benefiting local populations in LMICs. Fairness must manifest both on paper and in practice to facilitate trust, reciprocity, and consensus.
Take the legislative process as an example: if resource-limited countries are limited in their ability to influence such international legislation, taking into consideration their economic, social, and cultural realities, it would hardly be surprising if their enthusiasm for implementing the IHR is also limited. Moreover, considering past and present exploitative practices such as biopiracy and health colonialism, countries with more power must demonstrate their trustworthiness and accountability in the legislation process. Countries vulnerable to exploitation should be further empowered in a transparent and inclusive legislation process, so that their concerns and practical barriers in controlling global health threats can be resolved in a fair manner.
We should remember that the unanimous approval of the IHR amendments in 2005 was achieved when globalisation and cosmopolitanism were favoured. Now the political climate has changed, a consensus is ever more difficult to reach amid the rise of populism, nationalism, and geopolitical tensions. Against this backdrop, an emphasis on equity may be the only way towards trust and collaboration, and the newly agreed provision for all member states to submit amendment proposals is therefore a welcome move. If equity is not prioritised in the IHR reform, laudable principles such as global solidarity become tokenistic, or worse they are used to advance the interests of some at the expense of others. This understandably breeds mistrust, and it might be inevitable that sovereignty and national interests are prioritised over building a reciprocal and respectful partnership. The future of the IHR and global health governance lies in greater equity now; ignoring this risks another failure to respond collectively and promptly to the next pandemic.