Since its establishment in 1948, the World Health Organization (WHO) has sought to establish and create a global health network that is “trusted to serve public health at all times.[1]” This essay will examine the Middle Eastern Respiratory Syndrome (MERS) epidemic in 2013 and look at how the response to MERS highlights a significant gap in the WHO’s global health network plan – chiefly the implementation of WHO’s standardized Ports of Entry (PoE) protocol during Public Health Emergencies of International Concern (PHEIC). In 2018, only 52% of all participating countries in the WHO have a PoE protocol for infectious disease – and all follow their national protocols for diagnosing diseases.[2] This stems from a fear that signing a WHO standardized protocol on infectious diseases at PoE, member-states would be giving up their autonomy.[3] I argue that efforts to modernize the WHO’s global health response measures have always been under fire by member-states because of a belief that they are giving up the autonomy of their borders. In order to ensure the safety of the international community, I suggest the UN Security Council (UNSC) enact the creation of a harmonized port of entry protocol during PHEIC. I will also point out revisions that must be made to the International Health Regulation in order to fulfil this task.
To lay the groundwork, I will first discuss the WHO’s PoE guidelines for infectious diseases and why this has only allowed for 52% of all WHO member-states to have a PoE protocol for infectious diseases. Created in 2005, the International Health Regulation (IHR) was designed to cover all the glaring issues that arose from the SARS epidemic of 2002, including the issue of screenings at all PoE’s to ensure traveller safety and reduce the risk of spreading disease.[4] The new IHR’s regulations revolved around the WHO’s declarations of PHEIC. To summarize, a PHEIC is called by the WHO when a disease: “constitutes a public health risk to other countries through the international spread and potentially requires a coordinated international response.[5]” The IHR’s criteria for the creation of safe PoE are as follows: national legislation that has policies to ensure surveillance of diseases, communications between government and the WHO, and preparation for responding to diseases communications.[6] As many policymakers have noted, however, the varying levels of health and socio-economic development across countries hinder development. The 52% of countries that do follow this guideline tend to be those in the global north.[7] Because the WHO has no previsions to help set up specified regulations, many countries have no way of creating PoEs that follows WHO’s recommendations. The most vulnerable locations identified by the WHO being Africa and the Middle East, with only 30% of all PoEs having implemented acceptable measures for disease response.[8]
The WHO has uncovered resistance in imposing surveillance systems at PoEs. In 2007, the WHO push forward revisions to Articles 20 and 21 in the IHR, which state that the WHO can establish their independent surveillance and monitoring systems, as well as standardization on screening procedures for infectious diseases in the port of entries of its member-states. However, member-states argued that any development of a standardized PoE protocol would violate Article 2 of the IHR, which stipulates that any protocol to be introduced must “avoid unnecessary interference with international traffic and trade.[9]” Of 194 states in the WHO, only 64 supported the creation of a standardized response to infectious disease at PoE. As a result, the WHO’s current policy is to allow autonomy of member-states. States are “recommended” to follow the WHO’s guidelines on PoE safety precautions. There are no checks to see that these PoE follow WHO standards; more often, the WHO differs this responsibility to the national health agency of the member-state.[10]
In the example of MERS, Saudi Arabia came under fire for not allowing the WHO to examine its PoE in a PHEIC. Then Director-General Margaret Chan strongly urged the Saudi government to allow the WHO to establish quarantine zones in its PoE. However, the Saudi government was adamant that the WHO should not tamper with its “internal affairs.[11]” Saudi Arabia argued the WHO has no authority in its borders due to Article 2 of the IHR at the time since Saudi Arabia was preparing for the Hajj pilgrimage, which it argued was economical as much as it was religious.[12] As millions poured into Saudi Arabia, the WHO was unable to enforce the IHR. Since a vast majority of pilgrims were coming from Africa, they were returning to home PoE that most likely did not follow WHO regulations on infectious disease, spreading MERS into their home states. As a result, over 2,000 homegrown cases of MERS appeared in many African countries following the Hajj pilgrimage.[13]
To counter Saudi Arabia’s point that quarantine would be averse to its economy, I would like to bring up the example of MERS spreading to South Korea and how other countries feel the blow when ports do not follow WHO recommendations. Because Saudi Arabia never enacted quarantine and surveillance measures at its own PoE, it has been exporting MERS since the 2013 epidemic, leading to a new, violent outbreak of the virus in 2015.[14] South Korea received a little over a hundred cases of MERS in 2015, and it damaged their tourism business by shutting down many hotels and tourist destinations. Even though Korea established WHO measures at its airports, it was unable to stop the development of homegrown cases. It is estimated that over 2.1 million noncitizen visitors to Korea were lost due to the virus scare. Estimates suggest that over USD 2 billion in losses came as a result of the imported disease.[15] It also damaged the Saudi economy since fewer countries were willing to trade with them because of their negligence to stopping the spread of disease.[16] Thus, quarantine would have been the more profitable option to dealing with MERS.
For an effective policy to be allowed in efforts to control infectious diseases, the WHO must revise the IHR. Specifically, Article 2’s loophole of allowing states to negate the involvement of the WHO due to trade and economic concerns. As some policy analysts and economists have pointed out, the damages for allowing diseases to spread because of PoEs being kept open at the status quo can be brutal to the global economy – more so than if proper quarantine measures were put in place by all countries. Experts at the University of Adelaide have pointed out that in the worse cases, a global loss of 30% GDP could potentially be seen in the event of mass infection with no quarantine being issued, assuming the current amount of PoEs following WHO guidelines stay at 52%. However, if proper quarantine procedures were kept, the loss would be reduced to 10%.[17] For this reason, I would also argue that the WHO must also revise Article 2 of the IHR to include a clause that states excludes PHEIC from its statement to “avoid unnecessary interference with international traffic and trade.[18]”
The WHO needs to press forward an agenda that global health during a PHEIC is an issue of international security and should present a motion to the UNSC to consider the issue of PoEs as an issue that the WHO has legal jurisdiction over, on the technicality that PoEs are international zones in which infectious disease is an international security threat. Currently, the 5 permanent council members follow recommended WHO’s recommended PoE protocol, so it would not be unrealistic to see it pass a UNSC motion. A harmonized protocol that WHO member-states would need to abide by would need to be enacted in cases of PHEIC, with funding drawing from the UN Central Emergency Response Fund to establish proper quarantine infrastructure in low WHO PoE integration areas.
Looking forward to the current COVID19 outbreak in China, the issue remains that the WHO still is grappling with the issue of asserting its IHR mandate on PoEs during a PHEIC. While China has taken steps to allow WHO officials to collaborate in the surveillance of COVID19, other countries, such as Italy, were far too slow to adopt any protocol until it was far too late, and now many new cases in Italy are being reported as homegrown cases.[19] Austerity measures must be taken going forward to truly create a global health network that incorporates all PoE.
Notes:
1. “Vision.” World Health Organization. World Health Organization. Accessed March 11,
2020. https://www.who.int/dg/vision.
2. “IHR Core Capacities Implementation Status: Points of Entry.” World Health
Organization. World Health Organization, May 13, 2019.
https://www.who.int/gho/ihr/monitoring/points_of_entry/en/.
3. Ibid.
4. Arie, Sophie. "Would Today's International Agreements Prevent Another Outbreak like
SARS?" BMJ: British Medical Journal 348 (2014). Accessed March 11, 2020.
www.jstor.org/stable/26515393.
5. “IHR Procedures Concerning Public Health Emergencies of International Concern
(PHEIC).” World Health Organization. World Health Organization, October 4, 2017.
https://www.who.int/ihr/procedures/pheic/en/.
6. Ibid.
7. "Revised International Health Regulations." Morbidity and Mortality Weekly Report 55,
no. 53 (2006): 3-4. Accessed March 11, 2020. www.jstor.org/stable/23317324.
8. Ibid.
9. Youde, Jeremy. “MERS and Global Health Governance.” International Journal 70, no. 1
(March 2015): 117-136. doi:10.1177/0020702014562594.
10. Ibid., 126.
11. Ibid., 130.
12. Ibid.
13. Ibid., 136
14. Joo, Heesoo, Brian A. Maskery, Andre D. Berro, Lisa D. Rotz, Yeon-Kyeng Lee, and
Clive M. Brown. “Economic Impact of the 2015 MERS Outbreak on the Republic of
Koreas Tourism-Related Industries.” Health Security 17, no. 2 (2019): 100–108.
https://doi.org/10.1089/hs.2018.0115.
15. Ibid.
16. Selvey, Linda A., Catarina Antão, and Robert Hall. “Evaluation of Border Entry
Screening for Infectious Diseases in Humans.” Emerging Infectious Diseases 21, no. 2
(2015): 201. https://doi.org/10.3201/eid2102.131610.
17. Peng, Xiaoming. “The Economic Cost of Quarantine.” Business Wire, February 15,
Quarantine.
18. Ibid.
19. “Coronavirus: Italy Extends Strict Quarantine Measures Nationwide.” BBC News. BBC,
March 9, 2020. https://www.bbc.com/news/world-europe-51810673.
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