On August 8, the World Health Organization (WHO) Director-General Margaret Chan declared the West Africa Ebola crisis a “public health emergency of international concern,” saying “our collective health security depends on urgent support for containment in the affected countries”, triggering powers under the 2005 International Health Regulations (IHR). The IHR requires countries to develop national preparedness capacities, including the duty to report internationally significant events, conduct surveillance, and exercise public health powers, while balancing human rights and international trade. Until last year, the director-general had declared only one such emergency—influenza AH1N1 (in 2009). Earlier this year, she declared poliomyelitis a public health emergency of international concern and now again for Ebola.
“This is the largest, most severe, most complex outbreak in the nearly four decades history of this disease,” said Dr. Chan. Secretary-General Ban Ki-moon convened a United Nations system-wide coordination meeting in response to the current Ebola outbreak in West Africa, which is now affecting more than 1 million people in the so-called “hot zone of disease transmission” on the borders of the three countries most impacted by the disease: Guinea, Sierra Leone and Liberia. According to the latest update issued on 13 august by the World Health Organization, between 10 and 11 August, 128 new cases of Ebola virus disease, as well as 56 deaths, were reported from Guinea, Liberia, Nigeria, and Sierra Leone, bringing the total number of cases to 1,975 and deaths to 1,069.
Ebola is a highly virulent pathogen causing severe hemorrhagic fever with a high case fatality rate in humans and non-human primates. Lawrence Gostin (a professor of Global Health Law, Georgetown University) writes that the Ebola virus disease (EVD) has 3 species of human significance: Zaire, Sudan, and Bundibugyo. The West Africa outbreak is from a new strain of the Zaire species, with a reported case-fatality rate of 55%. The incubation period can be as short as 2 days or as long as 21 days. Infection can cause fever, vomiting, diarrhea, and generalized bleeding as well as death. Fruit bats likely carry Ebola virus, with humans infected by close contact with infected body fluids and “bushmeat” of primates, forest antelope, wild pigs, and bats. Human-to-human transmission occurs only by close contact with infected body fluids, so it is hard to contract (no airborne transmission between humans has been demonstrated).
The Ebola outbreak raises a number of questions. Has the WHO responded to Ebola as swiftly as it should have? Under the International Health Regulations, any human cases of Ebola must be reported to WHO within 24 hours, which should then trigger a response from the WHO. This did not happen. WHO received its first report about an Ebola case in Guinea on March 22, but it took more than three months for it to act. Since 1976 more than 15 Ebola outbreaks have erupted in sub-Saharan Africa, so why hasn't it been stamped out already? One reason, Charles Kenny, a senior fellow at the Center for Global Development observes, is that extremely poor countries with crumbling health systems simply don't have the ability to monitor outbreaks and isolate and care for victims of an epidemic or to provide cheap and effective tools to protect people from major killers. Also, Abby Norman, A USA based writer and patient advocate notes, the spread of this disease has become prolific at least partially because many of those who are infected are resisting treatment – they believe that the western medical professionals have brought the disease with them and are systematically killing off entire families. Another reason that Ebola seems to spread so virulently in African countries is due to their penchant for eating “bushmeat” which are most likely to harbor the Ebola virus, she writes. Although WHO deserves criticism for its tardiness, we also need to understand the contraints placed on it. It is woefully underresourced (in personnel and funds) and has direct control over very little of its budget, so the international community has to be willing to support the WHO, J. Youde notes (associate professor of political science at the University of Minnesota Duluth).
Ethical questions could also be raised. Lawrence Gostin writes: "Fueling disquiet about global justice, 2 US aid workers infected in Liberia were treated with an experimental anti-Ebola antibody prior to being transported to Atlanta. This serum had been previously used only in nonhuman primates. Even though the serum’s safety and efficacy remain unknown, it sparked an international controversy. Should US workers receive a drug in extremely scarce supply when Africans are affected in far greater numbers? Should you give an experimental drug at all to African patients that has not undergone any safety testing in humans? and who should have priority access?" On August 12, a 12-member ethics panel convened by WHO announced that it is ethical to treat Ebola patients with experimental drugs to counter the largest, most severe and most complex outbreak of Ebola virus disease in history. Related is the question if you should transport infected persons to non-affected countries. There is the potential that the actual movement of the patient could do more harm than the benefit from more advanced supportive care outside of the country, although in the case of Ebola the risk seems minimal.
BACKGROUND: INTERNATIONAL HEALTH REGULATIONS
The global community has long recognized the need for international collaboration and governance to contain the spread of infectious diseases. In the 1800’s, international agreements and discussion focused on a select subset of diseases (primarily cholera, and later plague and yellow fever) and quarantine regulations necessary to prevent the shipping trade from transporting these diseases across international borders. The discussions and negotiations were codified into the First International Sanitary Convention of 1892, later to become the International Sanitary Regulations. Through many revisions, the structure of these agreements remained fairly static until after World War II, with the establishment of the World Health Organization (WHO). In 1951, WHO adopted the existing conventions and related agreements as the International Sanitary Regulations, which became binding on WHO member states. In 1969, the regulations were revised and renamed the International Health Regulations. Over time, compliance with the regulations (focusing tightly on the control of a short list of diseases) diminished, in part because countries saw limited national benefits from the disease reporting requirements; the global surveillance system under the IHR (1969) gradually faded in relevance and effectiveness.By the 1990s the tools available to govern the international response to cross-border outbreaks had clearly become inadequate. Although a resolution was adopted at the 1995 World Health Assembly to revise the International Health Regulations to better address contemporary realities and aid in global governance of disease reporting and responses, nothing much happened until the emergence of the Sars virus in 2003. On 23 May 2005, the World Health Assembly adopted the Revised International Health Regulations, known as IHR (2005). Katz, R. and and J. Fischer, "The Revised International Health Regulations", Global Health Governance, 3(2010), No. 2, pp. 1-18.
A selection of relevant publications from the Peace Palace Library collection
- Fidler, D.P., and L.O. Gostin, "The New International Health Regulations: an Historic Development of International Law and Public Health", in J.J. Kirton (ed.), Global Health, Farnham, Ashgate, 2009, pp. 489-498.
- Fleming, M., "Combating the Spread of Disease : the International Health Regulations", Columbia Journal of Transnational Law, 50 (2012), No. 3, pp. 805-825.
- Gostin, L.O., Global Health Law, Cambridge, Massachusetts, Harvard University Press, 2014.
- Gostin, L.O. , D. Lucey, and A.Phelan, "The Ebola Epidemic: A Global Health Emergency", Journal of the American Medical Association, published online 11 August 2014.
- Gostin, L.O., “Influenza A (H1N1) and Pandemic Preparedness Under the Rule of International Law,” Journal of American Medical Association, 301 (2009), No. 22, pp. 2376-2378.
- Katz, R. and and J. Fischer, "The Revised International Health Regulations", Global Health Governance, 3(2010), No. 2, pp. 1-18.
- Tambo, E., E. Chidiebere Ugwu and J. Yonkeu Ngogang, "Need of surveillance response systems to combat Ebola outbreaks and other emerging infectious diseases in African countries", Infectious Diseases of Poverty, 29 (2014), No. 3, pp.1-7.