On December 31, 2019 the World Health Organization (WHO) received the first report of a suspected novel coronavirus (2019-nCoV) in the city of Wuhan, China: forty-four cases of pneumonia with a suspected link to a large seafood and live animal market. On January 9, 2020, the WHO confirmed the suspicion and announced that a novel coronavirus had been detected in patient samples from Wuhan. By the end of January there had been 213 deaths, 9,682 confirmed cases (1,527 “severe” cases) and over 15,000 suspected cases across thirty-one provinces in China. The disease spreads by human-to-human transmission, and self-isolation is recommended for fourteen days for all persons who may have come into contact with persons infected with the virus or who had traveled in the affected area. Over twenty countries had reported coronavirus cases and the Philippines had reported the first death from the virus outside of China. On January 30, 2020, the WHO Director-General declared the outbreak a Public Health Emergency of International Concern (PHEIC) under the International Health Regulations. How do we assess the response of the WHO and major states?
In 2005, states agreed to the aforementioned international legal framework, the International Health Regulations (IHR), to govern situations like this. The IHR aimed to achieve greater international cooperation in response to public health emergencies of international concern (PHEIC) through three initiatives: build countries’ capacities to detect, assess, and report public health events; grant the WHO the coordinating role to build this capacity; and, in the event of a PHEIC, agree to specific measures at ports, airports, and ground crossings to limit the spread of health risks, while also preventing unnecessary and punitive trade and travel restrictions. The revised IHR provide “rules and processes designed to increase compliance” with trade and travel measures that the WHO Director-General could recommend on the basis of scientific evidence regarding the outbreak. The process laid out by the IHR is unambiguous. What is ambiguous is the willingness of states to comply.
Fast forward to 2020 and we see that many states, corporations, and universities have not heeded the WHO’s public health advice and scientific recommendations on the coronavirus. Prior to the WHO Director-General declaring the outbreak a PHEIC, many states and organizations took matters into their own hands, quarantining people arriving from China, suspending flights to Wuhan (and in some cases all of China), and denying Chinese students entry into school. The WHO Director General and the IHR Emergency Committee took pains to stress that China was cooperating and that the WHO did not support the trade and travel measures taken by these states and corporations. Rather than being a show of support for such measures, the declaration of a PHEIC was made due to the “many unknowns” concerning the virus and because, “in line with the need for global solidarity, the Committee felt that a global coordinated effort is needed to enhance preparedness in other regions of the world that may need additional support for that.”
This will not be the last time that a global coordinated effort is necessary to address a novel infectious disease in the twenty-first century, and no country is immune. The IHR process, built on the principle of mutual trust, was specifically designed to facilitate cooperation among states, corporations, civil society, and individuals in the event of a PHEIC. The unique dependency feature of the revised IHR means that implementation depends on the voluntary compliance of the states from which the PHEIC originates. Each time a potential public health emergency is reported the WHO Director-General decides how to respond according to a decision instrument attached to the IHR (Annex 2). The Director-General may receive a suspected outbreak report from either a state or a non-state actor, but they must receive information from the state in question that either confirms or denies the presence of a potential PHEIC. After receiving this information, the Director-General must decide whether to convene an Emergency Committee from a roster of public health and infectious disease experts—including health officials from the affected country—which then deliberates and makes a recommendation. Ultimately, however, it is the Director-General who makes the call on whether the event constitutes a PHEIC. This delicate balance of WHO leadership and deference to sovereignty was reached after careful diplomacy at the 2005 World Health Assembly.
Trust in the WHO’s advice regarding public health and scientific measures reached a peak in 2003 in the wake of the effective response to SARS and the looming threat of the H5N1 bird flu. Nevertheless, it was predicted at the time that states might not so readily cede their sovereignty in the next emergency, and might not always trust the WHO to coordinate their response to the next outbreak. This diplomatic wisdom proved correct. In the case of the H1N1 swine flu, the first PHEIC declared under the revised IHR in 2009, WHO’s actions saved lives. However, some questioned whether the organization’s advice was in the interest of public health. There was suspicion that some on the IHR Emergency Committee wanted to profit from the sale of antivirals, and others questioned whether the WHO was accruing too much authority for itself. In the years that followed, the circumstances in which an Emergency Committee would be convened became more ambiguous. No PHEIC was called in response to the Middle East Respiratory Syndrome (MERS) in 2012, but one was called for polio in 2014. No PHEIC was called in the early onset of the Ebola outbreak in West Africa in 2014, but an immediate one was announced for the Zika outbreak in 2016. Then again, there were unexplained delays in calling the second Ebola outbreak a PHEIC in the Democratic Republic of Congo in 2019, and no Emergency Committee ever convened for one of the worst health crises in recent years: the cholera outbreak in Yemen from 2016–2019. Most damning for the WHO is that even when Emergency Committees decided to declare a PHEIC, most states had already enacted their own trade and travel measures, thus negating much of the added value theoretically supplied by the WHO’s coordinating efforts. With 2019-nCoV there was a difference of one week between the first convened meeting where a PHEIC was not declared and the second meeting where the IHR Emergency Committee convened to discuss the spread of the outbreak and WHO Director-General declared a PHEIC. Despite the relative swiftness of the Committee this time, states, much like in 2014, 2016, and 2019, did not wait for WHO’s advice. In practice, these decisions are not driven primarily by scientific advice on the basis of a decision instrument attached to the IHR. Rather, they are political decisions. The WHO Director-General must navigate through difficult political and legal terrain, pushing states to comply without alienating them and risking division.
This ambiguity matters because states takes matters into their own hands when they do not trust that this international process is capable of protecting their interests. In theory, cooperation in areas of technical endeavors—for example, science, mapping, weather, and health—are meant to be functional pursuits that enhance international cooperation in spite or because of the differences among the political actors. The benefits of cooperation should outweigh self-interest. The task before WHO is for cooperation to benefit the collective. When it comes to coordinating containment, the state that adopts unjustified trade and travel bans is as dangerous as the rogue state who may risk it all with failure to report.
Cooperation depends upon regular channels of communication among vastly different political regimes and health systems. With 2019-nCoV, there is a real fear among the international community that China has no internal system that demands trust and fidelity to the IHR process. Fair or unfair, correct or incorrect, there is significant mistrust of China’s reporting transparency. This is linked to the SARS experience, but it goes deeper. China is an undemocratic, closed regime with a history of abusing civil and political rights. Even with prompt reporting and sharing of genomic sequences (both of which the Chinese government did this time around), overcoming this image is difficult. In the early stages of the outbreak, Wuhan police arrested a medical doctor for reporting information about the novel virus on a medical blog. While the information proved incorrect, the desire to communicate the risk was brave and, as the Supreme People’s Court noted when they threw out the arrest warrant, the actions of the police increase suspicion about the willingness of the government to be transparent and to release accurate information concerning the outbreak. For the IHRs to work, member states must trust each other to adhere to the process, something that is more likely when they have transparent communication practices that permit free flow of information to the international community but also within their own society.
A decade or so of ambiguous practice and contestation in the implementation of the IHR process has weakened the WHO’s influence over key states. Some have responded by calling for further revisions to the IHR, but changing the rules will not strengthen the instrument unless steps are taken to address these underlying political challenges. The WHO (including the regional offices) and the foreign ministries in states need to communicate more during “peacetime.” The IHR needs to recognize the equal value of diplomacy compared to law and health advisories. States need to see the value in strengthening transparent communication, domestically and internationally. German Health Minister Jens Spahn has recently suggested that the Group of Seven should “seek a unified procedure” to respond to the crisis, saying that independent, isolated approaches will not work. In this spirit, China must be invited to such discussions among the G7. The solution to this crisis and future health crises will not come from isolation. The IHR provides a process for diplomatic cooperation. What is needed is more communication, more information, and more efforts to build trust between states, the WHO, and the citizenry.
Sara E. Davies is professor of international relations at the School of Government and International Relations, Griffith University, Australia and adjunct associate professor at the Gender, Peace and Security Centre, Monash University, Australia. Sara was an Australian Research Council (ARC) Future Fellow 2014–2018 and recently authored Containing Contagion: The Politics of Disease Outbreaks in Southeast Asia (Johns Hopkins University Press, 2019).