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Has Global Health Law Risen to Meet the COVID-19 Challenge? Revisiting the International Health Regulations to Prepare for Future Threats

376 journal of law, medicine & ethics
The Journal of Law, Medicine & Ethics, 48 (2020): 376-381. © 2020 The Author(s)
DOI: 10.1177/1073110520935354
Has Global Health Law Risen to Meet the
COVID-19 Challenge? Revisiting the International
Health Regulations to Prepare for Future Threats
Lawrence O. Gostin, J.D., LL.D. (Hon.), is University Professor at Georgetown
University and the Founding Linda D. & Timothy J. O’Neill Professor of Global
Health Law at Georgetown University Law Center and Director of the World Health
Organization Center on National and Global Health Law. Roojin Habibi , J.D.,
M.Sc., is a Research Fellow at the Global Strategy Lab and a Doctoral Candidate at
Osgoode Hall Law School, York University. Benjamin Mason Meier, J.D., LL.M.,
Ph.D., is an Associate Professor of Global Health Policy at the University of North
Carolina at Chapel Hill and a Scholar at the O’Neill Institute for National and Global
Health Law.
Global Health Law
Lawrence O. Gostin,
Roojin Habibi, and
Benjamin Mason Meier
Global health law is essential in
responding to the infectious disease
threats of a globalizing world, where
no single country, or border, can wall
o disease. Yet, the Coronavirus Dis-
ease (COVID-19) pandemic has tested
the essential legal foundations of the
global health system. Within weeks,
the SARS-CoV-2 coronavirus has cir-
cumnavigated the globe, bringing the
world to a halt and exposing the fra-
gility of the international legal order.
Reflecting on how global health law
will emerge in the aftermath of the
COVID-19 pandemic, it will be cru-
cial to examine the lessons learned
in the COVID-19 response and the
reforms required to rebuild global
health institutions while maintaining
core values of human rights, rule of
law, and global solidarity in the face
of unprecedented threats.
Unlike anything seen since the
Great Influenza Pandemic of 1918,
health systems have faltered under
the strain of the COVID-19 pan-
demic, with cascading disruptions
throughout the world. Borders have
closed, businesses shuttered, and
daily life brought to a standstill. In
the absence of a treatment or vaccine,
governments worldwide have sought
to ensure physical distancing across
their populations; yet, vulnerable,
marginalized, and disadvantaged
populations have faced structural
obstacles in meeting these necessary
imperatives to contain the disease.
This unequal risk of infection is exac-
erbating health inequities — within
and across nations — with weak
health systems lacking the capacity to
implement mitigation strategies, test
at-risk populations, or treat infected
individuals. As the coronavirus
sweeps across unprepared nations,
national legal responses have proven
unable to prevent, detect, or respond
to the pandemic, and the sheer scale
of human, social, and economic
upheaval has challenged global
health law as never before.
Framing global health law to con-
trol infectious disease, the Interna-
tional Health Regulations (IHR)
have established a global surveillance
and reporting system and set national
minimum mandatory controls to pre-
vent disease and maximum permis-
sible limitations on individual rights,
state sovereignty, and commercial
interests. Last revised in 2005 fol-
lowing the shortcomings in national
and global responses to the severe
acute respiratory syndrome (SARS)
epidemic, the revised IHR provide a
legal framework through the World
Health Organization (WHO) to build
national capacity for infectious dis-
ease prevention and detection and
to strengthen global governance to
address any public health emergency
of international concern. While these
IHR obligations were intended to
facilitate international coordina-
tion in the context of public health
emergencies, nationalist responses
have challenged global governance in
addressing this pandemic challenge.
Amidst challenging global health cir-
cumstances, WHO has faced increas-
ing IHR violations from states and,
as a consequence, limited influence
in the COVID-19 response.
About This Column
Lawrence O. Gostin and
Benjamin Mason Meier serve
as the section editors for Global
Health Law. Professor Gostin is
University Professor at Georgetown
University and the Founding Linda
D. & Timothy J. O’Neill Professor of
Global Health Law at Georgetown
University Law Center and Director
of the World Health Organization
Center on National and Global
Health Law. Professor Meier is an
Associate Professor of Global Health
Policy at the University of North
Carolina at Chapel Hill and a Scholar
at the O’Neill Institute for National
and Global Health Law. This column
will feature timely analyses and
perspectives on law, policy, and justice
in global health.
Gostin, Habibi and Meier
opioid controversies: the crisis — causes and solutions • summer 2020 377
The Journal of Law, Medicine & Ethics, 48 (2020): 376-381. © 2020 The Author(s)
Global health law remains cru-
cial to preventing, detecting, and
responding to COVID-19 — imple-
menting the IHR to control the rapid
spread of this novel coronavirus —
and this column explores the long
evolution and continuing limitations
of this WHO framework. Outlining
the international legal landscape,
this column examines the evolution
of global governance over infectious
disease, describing how limitations
of global health governance led to the
contemporary revision of the IHR.
This column then analyzes the imple-
mentation of the revised IHR in the
COVID-19 response, reflecting both
the promise of the IHR in promoting
global solidarity and the weaknesses
of the IHR in realizing an eective
international response to this global
threat. Given the continuing limita-
tions of the IHR, this column con-
siders reformed international legal
authorities and new international
legal instruments to bind states
together under global health law in
facing future pandemic threats.
The Legal Landscape
Drawing from the long history of
international health law described
in the opening column on “Global
Health Law,”1 the 1946 WHO Con-
stitution provided WHO with the
authority to negotiate conventions,
regulations, and recommendations
on any public health matter. With
this broad constitutional author-
ity to regulate public health, WHO
assumed governance over the IHR as
an international legal framework to
control infectious disease. The IHR
aim to structure a harmonized sur-
veillance, reporting, and response
system across WHO member states
— with these regulations automati-
cally binding on all WHO member
states unless explicitly rejected. Yet,
the applicability of the IHR was
limited to only three select diseases
(cholera, plague, and yellow fever),
and as the world faced a continuous
stream of emerging and re-emerging
diseases, the principal international
legal instrument for preventing,
detecting, and responding to infec-
tious disease outbreaks was increas-
ingly seen as inadequate.
Despite calls for the revision of the
IHR, it took an outbreak of a novel
coronavirus to prompt international
action. SARS emerged in Guangdong,
China in late 2002, but China did not
inform WHO of this emerging threat
— as SARS was not one of the three
diseases covered by the IHR. China’s
delay in accurately reporting the
SARS outbreak — compounded by
the use of domestic legal restrictions
inconsistent with public health prac-
tice — drew widespread international
condemnation, raising calls for WHO
action.2 With SARS highlighting the
weaknesses of international law to
control for infectious disease, the
international community committed
with remarkable speed to updating
the breadth, scope, and notification
obligations under the IHR.
The 2005 revision of the IHR
provides the contemporary legal
framework to prevent, detect, and
respond to public health emergen-
cies of international concern. The
IHR were revised to achieve a higher
level of global health security while
avoiding unnecessary interference to
international trac and safeguard-
ing human rights in the public health
Looking beyond specific infec-
tious diseases, IHR (2005) codified
the versatile and encompassing cat-
egory of a Public Health Emergency
of International Concern (PHEIC),
which includes any extraordinary
event that:
1. constitutes a public health risk to
other states through the interna-
tional spread of disease (broadly
defined as “any illness or medical
condition, irrespective of ori-
gin or source, that presents or
could present significant harm to
humans”) and
2. potentially requires a coordinated
international response.4
Through National IHR Focal Points,
states bear an obligation to notify
WHO within 24 hours of all detected
events within their territory which
may constitute a PHEIC.5 Based upon
information received from both state
and non-state sources (e.g., media
and online sources, civil society, and
other states), the WHO Director-
General has the ultimate authority to
determine whether an event consti-
tutes a PHEIC, considering:
1. information provided by the State
Party within whose territory an
event is occurring;
2. advice from an ad hoc technical
expert group known as the Emer-
gency Committee;
3. scientific principles, available sci-
entific evidence, and other related
information; and
4. an assessment of the risk to
human health, of the risk of inter-
national spread, and of the risk
of interference with international
This PHEIC declaration has since
been employed by WHO six times to
control the international spread of
infectious disease: polio, Zika, Influ-
Reflecting on how global health law will emerge
in the aftermath of the COVID-19 pandemic, it
will be crucial to examine the lessons learned
in the COVID-19 response and the reforms
required to rebuild global health institutions
while maintaining core values of human rights,
rule of law, and global solidarity in the face of
unprecedented threats.
378 journal of law, medicine & ethics
The Journal of Law, Medicine & Ethics, 48 (2020): 376-381. © 2020 The Author(s)
enza H1N1, Ebola (in West Africa and
then in the Congo), and most recently
in the ongoing global struggle against
Beyond the international declara-
tion of a PHEIC, the IHR bind states
to build their domestic capacities
to prevent, detect, and respond to
infectious disease. Using the nor-
mative power of global health law
to frame national eorts to contain
disease, the IHR set concrete obliga-
tions for governments to strengthen
national public health capacities and
improve global health security. States
retain sovereign authority to develop
national health legislation, but this
domestic legislation “should uphold
the purpose” of the IHR, reinforc-
ing international commitments.7
These international health commit-
ments extend to human rights law,
with the IHR requiring that domes-
tic implementation “shall be with the
full respect for the dignity, human
rights and fundamental freedoms of
persons.8 Thus, national measures
under the IHR must be based on sci-
entific risk assessment and must not
be more restrictive of international
traffic, or more intrusive to indi-
viduals, than reasonably available
alternatives.9 Where nations lack the
capacity to meet these commitments,
the IHR provide a path for interna-
tional collaboration and assistance
in the development, strengthening,
and maintenance of national public
health capacities.10
Under this international legal
framework for global health secu-
rity, WHO plays a coordinating role
in supporting member states to
strengthen health systems and build
public health capacities. However,
states were slow to reform their pub-
lic health capacities following IHR
(2005), pushing WHO to work with
states in 2016 to develop monitoring
mechanisms to facilitate accountabil-
ity for public health law reforms. The
resulting Joint External Evaluation
(JEE) has provided a monitoring and
evaluation tool to assess IHR imple-
mentation at the country-level, cre-
ating an independent expert review
process to: assess national progress
in meeting IHR core capacities, find
gaps in implementation, and iden-
tify best practices.11 This voluntary,
collaborative, multisectoral process
seeks to help countries strengthen
their capacities to prevent, detect,
and rapidly respond to public health
threats. Yet despite these evolving
eorts to support states in building
public health capacities and meet-
ing IHR responsibilities, many states
continue to shoulder weak health sys-
tems with inadequate legal capacity.12
Implementing the IHR in the
COVID-19 Response
The COVID-19 pandemic has brought
into sharp focus the limitations of the
IHR in (1) notifying WHO of public
health risks; (2) declaring a PHEIC
where necessary in the international
response; (3) coordinating national
responses commensurate with public
health risks; and (4) fostering global
solidarity for infectious disease pre-
vention, detection, and response.
From the initial outbreak in China,
notification delays significantly ham-
pered WHO’s ability to understand
the scope of the threat and coordinate
the international response. Although
China first reported a case of novel
coronavirus to WHO on December
31, 2019, retrospective analyses have
demonstrated that SARS-CoV-2 was
already circulating in Wuhan for sev-
eral weeks prior to the first WHO
notification.13 One of the principal
IHR reforms in 2005 sought to allow
WHO to take account of non-state
(“unofficial”) sources of informa-
tion, recognizing that governments
are often reluctant to notify WHO
of novel pathogens within their bor-
ders; however, this innovation was
ineffective in the early days of the
COVID-19 outbreak, as Chinese
authorities repressed health work-
ers, scientists, and civil society in
December 2019 — keeping them
from sharing timely concerns about
a novel coronavirus in Wuhan.14 (As
the IHR does not provide WHO with
the authority to investigate events
independently, the IHR requirement
for WHO to verify reports received
from non-state sources with the rel-
evant state dismantled an additional
channel through which WHO could
have received the necessary informa-
tion.15) Legitimate questions remain
as to what Chinese authorities knew,
when they learned it, and whether
they notified WHO in a “timely, accu-
rate and suciently detailed” manner
in accordance with the IHR16 — or
whether, as with SARS, the response
was impeded by the information poli-
tics of autocratic governance, leaving
WHO with insucient information
to promptly declare a PHEIC.17
Even after China notified WHO
about this coronavirus outbreak, the
IHR failed to facilitate WHO’s rapid
declaration of a PHEIC, delaying
global preparations for a pandemic
response. With inadequate reporting
and a split in expert opinion, WHO
Director-General Tedros Adhanom
Ghebreyesus convened an Emer-
gency Committee on three occasions
in late January 2020 to advise on the
declaration of a PHEIC, as the Com-
mittee continued to find that it was
“too early” and that there were “a lim-
ited number of cases abroad.18 (The
definition of a PHEIC may have been
misapplied at this critical juncture,
as neither the timing of the threat
nor the actual international spread
of disease are constitutive elements
of a PHEIC — on the latter question,
there need only be the “potential” for
international spread.19) A PHEIC
was finally declared on January 30th,
by which point the coronavirus was
well on its way to becoming a pan-
demic – something WHO would not
formally acknowledge until March
11th.20 Global health law scholars
have long questioned WHO’s tenta-
tive approach to declaring a PHEIC,
arguing that where the IHR defini-
tion is met, a PHEIC declaration can
spur action, investment, and soli-
darity from the international com-
munity.21 Yet, WHO has remained
diplomatically hesitant to exercise its
authority to declare a PHEIC, appre-
hensive of a declaration that could
devastate the economies of aected
states and spur nationalist measures
that hamper global coordination.22
Following this PHEIC declara-
tion, states have responded with
overwhelming restrictions on inter-
national traffic, individual rights,
and global commerce — with these
nationalist restrictions taken in direct
contravention of WHO recommenda-
Gostin, Habibi and Meier
opioid controversies: the crisis — causes and solutions • summer 2020 379
The Journal of Law, Medicine & Ethics, 48 (2020): 376-381. © 2020 The Author(s)
tions. In responding to PHEICs under
the IHR, state responses are expected
to adhere to WHO’s temporary recom-
mendations and other IHR parame-
ters.23 Where states apply other health
measures, such measures are required
under the IHR to achieve equal or
greater health protection than WHO
recommendations and be:
1. based on scientific principles,
and available scientific evidence,
or where such evidence is insuf-
ficient, on advice from the WHO
and other relevant intergovern-
mental organizations;
2. not more invasive to persons or
more restrictive of international
trac than reasonably available
alternatives; and
3. implemented with full respect
for the dignity, human rights
and fundamental freedom of
Although states have disregarded
WHO recommendations in the past
by enacting travel and trade restric-
tions, the sheer scale of violative state
actions — including travel bans, flight
suspensions, visa restrictions, and
border closures — has brought inter-
actions within and between countries
to a grinding halt.25 Governments
rapidly instituted domestic Stay-
at-Home orders, closed businesses,
banned public gatherings, and even
erected cordon sanitaires (guarded
areas where individuals may not
enter or leave).26 (WHO praised
China’s containment eorts as “ambi-
tious, agile and aggressive,27 yet it
has since tempered its enthusiasm for
such restrictions on individual liber-
ties.28) Even as evidence increasingly
points to the need for widespread
testing, contact tracing, and physi-
cal distancing,29 with transparent
governance and public participation
in health decision-making, govern-
ments are increasingly using such
states of emergency as pretext for
widespread abuses of human rights
and subversive attacks on democratic
Finally, the rise of nationalism has
undercut the global solidarity envis-
aged under the IHR, which requires
states to adopt a common and shared
responsibility to “collaborate…to the
extent possible.31 While IHR duties
of international “collaboration and
assistance” are intentionally unspe-
cific, states have taken advantage
of these ambiguities to limit their
actions to national frontiers, shirk-
ing international responsibilities and
undermining WHO governance. The
international community’s failure to
ensure the equitable global distribu-
tion of “sta, stu, space and systems”
has already twice created the perfect
storm for the resurgence of Ebola.32
Instead of now coming together to
confront the COVID-19 pandemic
through global governance, states
have reverted to isolationist policies,
geopolitical competition, and global
neglect. This shortsightedness amidst
the COVID-19 pandemic, neglect-
ing WHO guidance and threatening
WHO support when global gover-
nance is needed most, has exposed
the world to staggering humanitar-
ian upheaval, economic instability,
and health insecurity.33
The world is now paying in immea-
surable human suffering for these
compounding IHR violations, with
COVID-19 presenting a lasting threat
to health security, human rights,
and the rule of law.34 Where states
fail to uphold global health law, the
world loses the ability to mitigate
common threats through collective
action. The future of global health
must have international law at its
foundation, and the WHO Director-
General has already advocated for
strengthening the IHR to reflect
an independent assessment of the
COVID-19 response. When the pan-
demic recedes, WHO must mobilize
its member states to undertake this
major review of international legal
authorities, including WHO’s institu-
tional structure, to realize the prom-
ise of global health law in addressing
future infectious disease threats.
Revising Global Health Law to
Meet Future Threats
Global health law has proven unable
to mitigate the threat of COVID-19,
raising an imperative for interna-
tional legal reforms to clarify state
obligations, facilitate legal account-
ability, and realize global health secu-
rity. Such holistic reforms of global
health law will require either the
undertaking of fundamental revi-
sions to the IHR framework or the
development of a new international
legal instrument to structure global
health governance.
Strengthening global governance,
it will be necessary to ensure that
WHO is amply funded and politically
supported, empowering it to “speak
truth to power” in confronting gov-
ernments that do not comply with
science-based recommendations.
This will require critical reforms of
The future of global health must have
international law at its foundation, and the WHO
Director-General has already advocated for
strengthening the IHR to reflect an independent
assessment of the COVID-19 response. When
the pandemic recedes, WHO must mobilize its
member states to undertake this major review of
international legal authorities, including WHO’s
institutional structure, to realize the promise of
global health law in addressing future infectious
disease threats.
380 journal of law, medicine & ethics
The Journal of Law, Medicine & Ethics, 48 (2020): 376-381. © 2020 The Author(s)
global health law, including revisions
to provide authority for:
Enhanced Surveillance and Man-
datory Reporting — allowing for
unocial data sources, including
civil society and academic experts,
and the independent collection of
public health data where necessary
by WHO sta;35
Transparency in PHEIC Delib-
erations — allowing for open and
independent EC decision-making36
and shifting from a binary trigger
to a tiered system of multiple levels
of public health emergency to spur
commensurate state responses;37
Rapid & Public Monitoring of
State Measures — allowing for
scrutiny of state decisions that
do not comply with WHO guid-
ance, with monitoring and review
in global economic governance,
under international trade law, and
through the human rights system;
Global Funding Mechanisms
allowing for the development of
new or reformed global governance
institutions to pool international
funding and bolster technical
support for the development of
sustainable national public health
systems to prevent, detect, and
respond to outbreaks.38
Developed through global health law
reforms, WHO has authority under
its constitution to negotiate conven-
tions (art. 19), regulations (art. 21),
and recommendations (art. 23), and
all of these authorities should be con-
sidered in either:
Revising the IHR architecture to
reflect the imperative for reforms
— with built-in and ongoing pro-
cesses to amend the IHR in accor-
dance with the changing nature of
future public health emergencies
and evolving scientific knowledge;
Drafting a Framework Convention
on Infectious Disease — with bind-
ing obligations and accountability
mechanisms under a newly-nego-
tiated legal instrument, supported
by compliance mechanisms, peri-
odic meetings of states parties, and
dispute settlement processes;39 or
Providing standing WHO recom-
mendations on necessary state
responses — with detailed WHO
guidance on appropriate national
policies and regular empirical anal-
ysis of the impact of public health
laws on public health outcomes.
States will be the ultimate deci-
sionmakers in these next steps, yet
these reforms must recognize the
ongoing struggle that states have
faced in preventing, detecting, and
responding to infectious disease.
Where the COVID-19 pandemic has
presented an unprecedented threat
to global health, impacting every
country throughout the world, it will
be urgently necessary at the earli-
est appropriate moment to reshape
the global health law landscape to
respond collectively to the common
threat of future pandemics.
The authors have no conflicts to disclose.
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opioid controversies: the crisis — causes and solutions • summer 2020 381
The Journal of Law, Medicine & Ethics, 48 (2020): 376-381. © 2020 The Author(s)
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... Global health law is essential in responding to the infectious disease threats of a globalizing world, such as the Covid-19 pandemic where no single country, or border, can prevent the epidemic of the disease and it has proven the essential legal foundations of the global health system (Gostin et al., 2020). As the Covid-19 spread across unprepared nations, national legal responses have demonstrated unable to prevent, detect, and respond to the pandemic. ...
... The ultimate purpose of such declaration is to catalyze timely evidence-based action, to limit the public health and societal impacts of emerging and re-emerging disease risks while preventing unwarranted travel and trade restrictions (Wilder-Smith and Osman, 2020). Gostin et al. (2020) argued that: ...
... To strengthen global governance, it will be necessary to ensure that WHO will be able to confront governments that do not comply with science-based recommendations. Gostin et al. (2020) suggest that it will require critical reforms of global health law, including revisions to provide authority of WHO for: (1) enhanced surveillance and mandatory reporting which is allowing to use unofficial data sources, including from civil society and academic experts, and the independent collection data by WHO staff as recently guided by WHO (2021); (2) transparency in PHEIC deliberations which is allowing for open and independent emergency committee's (EC) decision-making and shifting from a binary trigger to a tiered system of multiple levels of public health emergency; (3) rapid and public monitoring of state measures with allowing for scrutiny of state decisions that do not comply with WHO guidance; and (4) global funding mechanisms through the development of new or reformed global governance institutions which able to pool international funding and bolster technical support for the development of sustainable national public health systems to prevent, detect, and respond to outbreaks. It is important to establish policymaking across sectors to improve the health of all communities and people (Health in All Policies or HiAP) (Green et al., 2021). ...
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As a compilation of research and scholarly articles under the auspices of Dewan Guru Besar (Board of Professors) of Universitas Gadjah Mada, this volume is expected to contribute for the Sherpa Track of G20 forum. We believe that multi-disciplinary approach among university scholars would provide a comprehensive understanding on what to be considered by the G20 country leaders who are scheduled to meet in Bali, indonesia, in 2022. Parallel to the three prioritized agendas for G20, critical reviews on health system after the Covid-19 global pandemic, changing activities and lifestyle under digitalized economy, and transition towards sustainable energy are presented. Cases are mostly taken from the Indonesian experience. We would argue that interdependency and partnership among countries are inevitable and that we must understand and acknowledge it more than ever. All the critical global issues—health, poverty, climate change—can only be addressed with collective actions of a II individuals in developed as well as developing countries. The collective awareness of the new world order for healthy, smart, and green lifestyle is essential to the future living in the planet. The G20 forum is crucial as it represents 65 percent of the world population and 80 percent of the world economy. We hope that G20 leaders have a full commitment and capacity to conduct an orchestra of global community which enable and empower citizens while acknowledging cultural diversity in their respected countries. It is a high time for aIl of collective and concerted actions.
... In particular, the inadequacies of an existing mechanism-the international health regulations (IHRs)-in coordinating nation-states and ensuring equitable access to medical countermeasures (MCMs) during emergencies. 1 The IHRs require states to put in place core capacities to detect as well as notify the WHO of a potential threat in their vicinity. However, when COVID-19 struck, the IHRs did not contain specific binding provision for equitable access to MCMs, and have been described as 'a specialism that has largely retained a 19th century colonial framework of international cooperation for disease control'. ...
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The COVID-19 pandemic has underscored significant shortcomings in the global governance of health emergencies, particularly within the existing framework of the International Health Regulations (IHRs), which have failed to ensure fair and equitable access to medical countermeasures during crises. As a result, efforts are underway to transform pandemic prevention, preparedness, and response. Key proposals include revising the IHRs, establishing a pandemic treaty, and designing a platform for medical countermeasures under the guidance of the World Health Organization (WHO). The initial draft of the pandemic treaty emphasizes concerns regarding equity. However, the precise incentives that could encourage political leaders and pharmaceutical companies to adopt more favourable behaviours during future outbreaks remain uncertain. Furthermore, the COVID-19 crisis has shed light on the necessity to enhance domestic production of biotechnology solutions, strengthening access and supply chains for all pandemic-related products during emergencies and periods between outbreaks. To effectively tackle epidemics wherever and whenever they occur, WHO's platforms for medical countermeasures must prioritize national and regional ownership. These platforms should facilitate locally and regionally driven solutions, which can be adapted to meet specific health needs and contextual requirements. Addressing the deep-rooted flaws in global health governance demands a comprehensive approach that emphasizes equitable access to medical countermeasures, the establishment of a robust pandemic treaty, and the promotion of localized solutions driven by national and regional actors. By implementing these measures, the international community can better prepare for and respond to future health emergencies while safeguarding the well-being of all nations.
... Once WHO declared an emergency, states imposed overwhelming restrictions on international traffic, individual rights and global commerce, contravening WHO recommendations and undermining global solidarity. 58 Governance gaps in social protection resulted in widening inequalities both within and among countries. The Access to COVID-19 Tools Accelerator (ACT-A) became the signature initiative to promote equitable access to medical resources. ...
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The World Health Organisation (WHO) was inaugurated in 1948 to bring the world together to ensure the highest attainable standard of health for all. Establishing health governance under the United Nations (UN), WHO was seen as the preeminent leader in public health, promoting a healthier world following the destruction of World War II and ensuring global solidarity to prevent disease and promote health. Its constitutional function would be ‘to act as the directing and coordinating authority on international health work’. Yet today, as the world commemorates WHO’s 75th anniversary, it faces a historic global health crisis, with governments presenting challenges to its institutional legitimacy and authority amid the ongoing COVID-19 pandemic. WHO governance in the coming years will define the future of the Organisation and, crucially, the health and well-being of billions of people across the globe. At this pivotal moment, WHO must learn critical lessons from its past and make fundamental reforms to become the Organisation it was meant to be. We propose reforms in WHO financing, governance, norms, human rights and equity that will lay a foundation for the next generation of global governance for health.
... However, COVID-19 exposed the limitations of the IHR reporting systemand in particular, its limited power to ensure states' compliance or report accurately on their core response and preparedness capacities. 3 These limitations led to a call for reform in the form of a legally binding pandemic instrument to strengthen global response to pandemics-the Pandemic Treaty. ...
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The call to strengthen global health governance against future outbreaks through a binding treaty on pandemics has attracted global attention and opinion. Yet, few of these perspectives have reflected the voices from early career global health professionals in Africa. We share our perspectives on the Pandemic Treaty, and specifically our scepticism on the limitations of the current top-down approach of the treaty, and the need for the treaty to centre equity, transparency and fairness to ensure equitable and effective cooperation in response to global health emergencies. We also highlight the challenges intergovernmental organisations for health faced in coordinating nation states during the COVID-19 crisis and how a Pandemic Treaty would address these challenges. We argue that lessons from the COVID-19 pandemic provide a critical opportunity to strengthen regional institutions in Africa—particularly in a multipolar world with huge disparities in power and resources. However, addressing these challenges and achieving this transformation may not be easy. Fiscal space in many countries remains constrained now more than ever. New tools such as the Pandemic Fund should be designed in ways that consider the specific needs and capacities of countries. Therefore, strengthening countries’ capacities overall requires an increase in domestic investment. This paper calls for wider structural reforms such as debt restructuring among other tools to strengthen countries’ capacities.
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Resumo O artigo aborda a resposta do governo brasileiro à pandemia da covid-19, enfatizando o sistema de vigilância em saúde e de inteligência epidemiológica. Retoma a evolução da vigilância em resposta às normas do Regulamento Sanitário Internacional, no contexto da saúde global. Analisa os atos do Executivo publicados no Diário Oficial da União e se detém nos atores e grupos formados para o enfrentamento da pandemia da covid-19 de janeiro de 2020 até março de 2022. Parte da premissa de que a inteligência epidemiológica deve estar a serviço da saúde pública. Constata-se que certo tensionamento burocrático e a transferência de protagonismo entre grupos marcam o desmonte dos mecanismos de inteligência.
Policy Points Global health institutions and instruments should be reformed to fully incorporate the principles of good health governance: the right to health, equity, inclusive participation, transparency, accountability, and global solidarity. New legal instruments, like International Health Regulations amendments and the pandemic treaty, should be grounded in these principles of sound governance. Equity should be embedded into the prevention of, preparedness for, response to, and recovery from catastrophic health threats, within and across nations and sectors. This includes the extant model of charitable contributions for access to medical resources giving way to a new model that empowers low‐ and middle‐income countries to create and produce their own diagnostics, vaccines, and therapeutics—such as through regional messenger RNA vaccine manufacturing hubs. Robust and sustainable funding of key institutions, national health systems, and civil society will ensure more effective and just responses to health emergencies, including the daily toll of avoidable death and disease disproportionately experienced by poorer and more marginalized populations.
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Background Covid-19 is not the first pandemic to challenge GHG. Preceding outbreaks and epidemics were sources of continuous debate on GHG leadership and structure resulting in its current structure. However, Covid-19 proved the presence of many deficits in the current GHG. The response to the Covid-19 pandemic is a cumulative result of all policies and actions of different governments and agencies active in global health. Assessing how Covid-19 is being handled globally provides lessons for ensuring better performance in facing upcoming outbreaks. This study has three main objectives: first, to evaluate the performance of GHG during Covid-19 in general and in relation to Covid-19 vaccine equity in particular. Second, to identify the reasons behind this performance; and third, to propose prospective changes in GHG for better performance. Methods A cross-sectional research design using the Delphi method was applied. A panel of experts participated in the three-round Delphi surveys. Their scores were used to perform consensus, performance and correlation analysis. Results GHG performance limited the achievement of Covid-19 vaccines’ global equity. GHG performance is a product of the existing GHG system, its actors and legal framework. It is a collective result of individual GHG actors’ performance. The most influential actors in decision-making regarding Covid-19 vaccine are the vaccine manufacturers and governments. While the most invoked power to influence decision are economic and political powers. Covid-19 decisions underlying value, although had human right to health at the base, overlooked the concept of health as a global public good and was skewed towards market-oriented values. GHG mal-performance along with its underlying factors calls for four main changes in GHG structure: assigning a clear steward for GHG, enhanced accountability, centralized authority, more equitable representation of actors, and better legal framework. Conclusion GHG structure, actors’ representation, accountability system, and underlying priorities and value require future modification for GHG to achieve better future performance and higher health equity levels.
Die Corona-Krise hat zu einer deutlichen Zunahme staatlicher Interventionen in die Wirtschaft geführt, sowohl in der nationalen Wirtschaftspolitik, als auch in den internationalen Wirtschaftsbeziehungen. Diese Tendenz – und die damit verbundene Hinwendung zum organisierten Kapitalismus – setzt sich auch nach der Corona-Krise fort, insbesondere aufgrund der russischen Invasion der Ukraine und der Entkopplung zwischen den Wirtschaftsräumen Chinas und der USA.
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Objectives: Sarcopenia is an important metabolic disorder associated with end-stage liver disease and is an independent predictor of mortality in liver transplant candidates. We evaluated effects of pretransplant muscle mass, muscle quality, and visceral adipose tissue on mortality after liver transplant. Materials and methods: For 2015-2020, we included 65 liver transplant recipients whose records contained pretransplant liver computed tomography images. We calculated skeletal muscle mass index (muscle tissue area in centimeters squared divided by height in meters squared), visceral-to-subcutaneous fat ratio (visceral adiposity indicator), and intramuscular adipose tissue content ratio (muscle quality indicator). Results: Median age was 55 years (IQR, 45-63 years), and 48 (73.8%) patients were men. During follow-up, 53 (81.5%) study group patients survived; mean survival time was 71.73 ± 3.81 months. The deceased patient group had a statistically higher pretransplant visceral-to-subcutaneous fat ratio than the survival group (P = .046). Survival was 100% for 1 positive indicator, 86.2% for 2 positive indicators, and 70.4% for 3 positive indicators (P = .096). Positive correlation was confirmed between pretransplant skeletal muscle mass index and age (P = .043) and pretransplant body mass index (weight in kilograms divided by height in meters squared) (P < .001). There was a moderate positive correlation between pretransplant intramuscular adipose tissue content ratio and age (R = 0.529, P ≤ .001) and a weak positive correlation with pretransplant body mass index (R = 0.361, P = .003). Furthermore, pretransplant visceral- tosubcutaneous fat ratio showed a weak positive correlation with age (R = 0.306, P = .013) and a weak negative correlation with the Model for End-Stage Liver Disease score (R = -0.301, P = .016). Conclusions: Pretransplant sarcopenia is an important indicator to predict mortality and morbidity in posttransplant follow-up. Visceral-to-subcutaneous fat ratio is an important parameter to evaluate sarcopenia in liver transplant patients.
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Effective response to and rapid, reliable detection of infectious disease outbreaks require successful coordination of countries' border policies early on. As threats from diseases are highly salient to the public, researchers agree that a better understanding of domestic politics is crucial. This study investigates a key piece of this question: public demands for border closures. Our experiments in the United Kingdom and the United States show that a greater pandemic threat mildly increases support for border closures, but the World Health Organization's (WHO) guidance against border closures and reminders about international legal obligations to follow the guidance substantially weaken support for border closures. However, during the COVID-19 pandemic, many countries flouted WHO's recommendations and restricted their borders. Examining media attention suggests people's lack of knowledge of the WHO guidance as a crucial reason for those border closures. Our study produces insights into the design of effective global health governance.
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Policymakers have come to look to human rights law in framing national health policy and global health governance. Human rights law offers universal frameworks to advance justice in public health, codifying international standards to frame government obligations and facilitate accountability for realising the highest attainable standard of health. Addressing threats to individual dignity as ‘rights violations’ under international law, health-related human rights have evolved dramatically to offer a normative framework for public health.
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On March 11, 2020, the World Health Organization declared COVID-19 a pandemic1. The outbreak containment strategies in China based on non-pharmaceutical interventions (NPIs) appear to be effective2, but quantitative research is still needed to assess the efficacy of NPIs and their timings3. Using epidemiological and anonymised human movement data4,5, here we develop a modelling framework that uses daily travel networks to simulate different outbreak and intervention scenarios across China. We estimated that there were a total of 114,325 COVID-19 cases (interquartile range 76,776 - 164,576) in mainland China as of February 29, 2020. Without NPIs, the COVID-19 cases would likely have shown a 67-fold increase (interquartile range 44 - 94) by February 29, 2020, with the effectiveness of different interventions varying. The early detection and isolation of cases was estimated to have prevented more infections than travel restrictions and contact reductions, but combined NPIs achieved the strongest and most rapid effect. The lifting of travel restrictions since February 17, 2020 does not appear to lead to an increase in cases across China if the social distancing interventions can be maintained, even at a limited level of 25% reduction on average through late April. Our findings contribute to an improved understanding of NPIs on COVID-19 and to inform response efforts across the World.
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Background The COVID-19 outbreak containment strategies in China based on non-pharmaceutical interventions (NPIs) appear to be effective. Quantitative research is still needed however to assess the efficacy of different candidate NPIs and their timings to guide ongoing and future responses to epidemics of this emerging disease across the World. Methods We built a travel network-based susceptible-exposed-infectious-removed (SEIR) model to simulate the outbreak across cities in mainland China. We used epidemiological parameters estimated for the early stage of outbreak in Wuhan to parameterise the transmission before NPIs were implemented. To quantify the relative effect of various NPIs, daily changes of delay from illness onset to the first reported case in each county were used as a proxy for the improvement of case identification and isolation across the outbreak. Historical and near-real time human movement data, obtained from Baidu location-based service, were used to derive the intensity of travel restrictions and contact reductions across China. The model and outputs were validated using daily reported case numbers, with a series of sensitivity analyses conducted. Results We estimated that there were a total of 114,325 COVID-19 cases (interquartile range [IQR] 76,776 - 164,576) in mainland China as of February 29, 2020, and these were highly correlated (p<0.001, R2=0.86) with reported incidence. Without NPIs, the number of COVID-19 cases would likely have shown a 67-fold increase (IQR: 44 - 94), with the effectiveness of different interventions varying. The early detection and isolation of cases was estimated to prevent more infections than travel restrictions and contact reductions, but integrated NPIs would achieve the strongest and most rapid effect. If NPIs could have been conducted one week, two weeks, or three weeks earlier in China, cases could have been reduced by 66%, 86%, and 95%, respectively, together with significantly reducing the number of affected areas. Results suggest that the social distancing intervention should be continued for the next few months in China to prevent case numbers increasing again after travel restrictions were lifted on February 17, 2020. Conclusion The NPIs deployed in China appear to be effectively containing the COVID-19 outbreak, but the efficacy of the different interventions varied, with the early case detection and contact reduction being the most effective. Moreover, deploying the NPIs early is also important to prevent further spread. Early and integrated NPI strategies should be prepared, adopted and adjusted to minimize health, social and economic impacts in affected regions around the World.
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Background: A recent cluster of pneumonia cases in Wuhan, China, was caused by a novel betacoronavirus, the 2019 novel coronavirus (2019-nCoV). We report the epidemiological, clinical, laboratory, and radiological characteristics and treatment and clinical outcomes of these patients. Methods: All patients with suspected 2019-nCoV were admitted to a designated hospital in Wuhan. We prospectively collected and analysed data on patients with laboratory-confirmed 2019-nCoV infection by real-time RT-PCR and next-generation sequencing. Data were obtained with standardised data collection forms shared by the International Severe Acute Respiratory and Emerging Infection Consortium from electronic medical records. Researchers also directly communicated with patients or their families to ascertain epidemiological and symptom data. Outcomes were also compared between patients who had been admitted to the intensive care unit (ICU) and those who had not. Findings: By Jan 2, 2020, 41 admitted hospital patients had been identified as having laboratory-confirmed 2019-nCoV infection. Most of the infected patients were men (30 [73%] of 41); less than half had underlying diseases (13 [32%]), including diabetes (eight [20%]), hypertension (six [15%]), and cardiovascular disease (six [15%]). Median age was 49·0 years (IQR 41·0-58·0). 27 (66%) of 41 patients had been exposed to Huanan seafood market. One family cluster was found. Common symptoms at onset of illness were fever (40 [98%] of 41 patients), cough (31 [76%]), and myalgia or fatigue (18 [44%]); less common symptoms were sputum production (11 [28%] of 39), headache (three [8%] of 38), haemoptysis (two [5%] of 39), and diarrhoea (one [3%] of 38). Dyspnoea developed in 22 (55%) of 40 patients (median time from illness onset to dyspnoea 8·0 days [IQR 5·0-13·0]). 26 (63%) of 41 patients had lymphopenia. All 41 patients had pneumonia with abnormal findings on chest CT. Complications included acute respiratory distress syndrome (12 [29%]), RNAaemia (six [15%]), acute cardiac injury (five [12%]) and secondary infection (four [10%]). 13 (32%) patients were admitted to an ICU and six (15%) died. Compared with non-ICU patients, ICU patients had higher plasma levels of IL2, IL7, IL10, GSCF, IP10, MCP1, MIP1A, and TNFα. Interpretation: The 2019-nCoV infection caused clusters of severe respiratory illness similar to severe acute respiratory syndrome coronavirus and was associated with ICU admission and high mortality. Major gaps in our knowledge of the origin, epidemiology, duration of human transmission, and clinical spectrum of disease need fulfilment by future studies. Funding: Ministry of Science and Technology, Chinese Academy of Medical Sciences, National Natural Science Foundation of China, and Beijing Municipal Science and Technology Commission.
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This introductory column examines the development of the field, detailing the evolving scope and content of global health law. Beginning in the early history of international health law, national governments have long sought to address infectious disease threats through international regulations. This focus on international health law structured global governance for health in the aftermath of World War II, with the establishment of the World Health Organization (WHO) bringing states together to respond to common public health threats. Yet, WHO’s early efforts to stem the international spread of infectious diseases have proven too narrow to meet the expanding legal challenges faced by a globalizing world. This column ends by framing the new field of global health law and outlining the leading global health threats that will be explored in future columns, demonstrating the power of this emerging field in conceptualizing the legal response to global health.