Sunday, June 04, 2006

WHO, part II: Westphalian public health

[This is the second of several posts (Part I here) giving some background to the place of WHO in the international system. I am trying to explain some things about WHO behavior and positions I think might be useful to interpreting their actions and statements. It is not meant as a defense of either.]

In Part I we gave a brief background to the international system to which WHO is tied, the Westphalian system. When WHO was created it was the only game in town. Throughout its history, WHO has struggled to overcome the incompatibility between the legacy of a political and diplomatic world where actors are nation states and the real public health world where these actors are irrelevant.

The problem of the irrelevance of political borders (and state sovereignty) to a microbe was understood even before the germ theory. Quarantine goes back at least to the fourteenth century, and as time went on the practice and others like requiring a "bill of health" from the port of origin became an increasing source of interference to free trade and trravel between nation states. In principle one country couldn't intervene in the affairs of another to stop an epidemic, but it could prevent its ships from its shores or incarcerate its crews aand impound once landed.

As trade increased so did the costs in spoiled cargos and lost cartage times. By the middle of the nineteenth century the community of large trading nations was exploring ways to reduce the frictional loss caused by sovereignty, of each nation acting on its own. Westphalianism allowed supranational controls as long as all parties agreed. Thus began a series of international sanitary conventions from 1851 onward. They were voluntary but binding agreements negotiated by sovereign states on how to minimize interference with international trade and travel while maximizing protection from specified infectious diseases. In other words, they were rules that managed state interactions while leaving the core of sovereignty alone. The sanitary conventions didn't interfere with what went on inside borders. They covered quarantine and requirements for certain facilities at international ports and airports, the gateways for cross-border disease spread.

The classical example of a Westphalian structure in international health are the International Health Regulations (IHR), adopted by WHO in 1951 from the international sanitary conventions in force at that time. They are discussed in David Fidler's monograph, SARS, Governance and the Globalization of Disease. As he observes (p. 33), the objectives of the IHR are pure Westphalian doctrine: to ensure the maximum security against the international spread of disease with minimal interference with world traffic. At the heart of the IHR is a surveillance activity that requires notification of the international community through WHO. The IHR only covered diseases of interest to the great powers, cholera, plague and yellow fever ("Asiatic diseases"). The original IHR/1969, in force until next June when they will be succeeded by the revised IHR/2005, are Westphalian through and through:
The IHR seek to achieve minimum interference with world traffic by regulating the trade and travel restrictions WHO member states can take against countries suffering outbreaks subject to the Regulations. The IHR provide that the trade and travel measures prescribed for each disease subject to the Regulations are the most restrictive measures that WHO member states may take (IHR, 1969, Article 23). The IHR contain the maximum measures that a WHO member state may apply to address potential cross-border transmissions of cholera, plague, or yellow fever . . . . The IHR have provisions that prevent the departure of infected persons by means of transportation and that limit actions taken against ships and aircraft en route between ports of departure and arrival, against persons and means of transport upon arrival, and against cargo, goods, baggage, and mail moving in international transport . . .(Fidler, p. 34).
This is not all. The flow of epidemiologic information has also been regulated by Westphalian principles:
The [IHR] also reflect the state-centric framework, especially with regard to the flow of epidemiological information to and from WHO. Under the IHR, surveillance information that WHO can disseminate to its member states can only come from governments (IHR, 1969, Article 11). As WHO observed [cite omitted], '[t]he IHR wholly depend on the affected country to make an official notification to WHO once cases are diagnosed." WHO has no legal authority under the IHR to disclose disease outbreak information it receives from reliable non-governmental sources. (Fidler, p. 51).
This explains a great deal of WHO's seemingly irresponsible behavior regarding release of case and sequence information. It did not have the legal authority, under international law, to release information without the consent of the member state. We at Effect Measure or Henry Niman at Recombinomics might rail that WHO "must" release the Turkish sequence information, but WHO could not do so without the permission of the Turkish government. We could bemoan this restriction (as WHO did for many years) and demand WHO violate international law. But such an act could have serious consequences for WHO's position in the international system. It would be like asking the police to violate the law for a higher good. It might be justified in some circumstances, but they would have to be extraordinary and the undertaking would be fraught with difficulty and hazard. They also would not have many chances to do it again if it turned out to be unjustified.

It is clear the Westphalian IHR were inadequate to the task of safeguarding the world from pandemic disease, not only in the bird flu case but in many others where state actors have violated their obligations to notify WHO because they would suffer economic harm. WHO understood that the core principles for the Westphalian IHR were inadequate as well and by the mid nineties was undertaking to revise them. At the same time, changes were taking place in global public health, like a chrysalis developing within the Westphalian cocoon. In Part III we will take a look at them.

Correction, 6/4/06, 12:50 EDT: Inserted the word "not" to make the second sentence in the penultimate paragraph read correctly, viz., "…but WHO could not do so without the permission of the Turkish government." Sorry for any confusion. Thanks to the reader who pointed it out.