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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.

Emerging norms for the control of emerging epidemics