International health emergencies in failed and failing states.

Author:Giorgetti, Chiara
  1. INTRODUCTION II. HEALTH EMERGENCIES AS GLOBAL SECURITY ISSUES III. HEALTH SYSTEMS IN FAMED AND FAMING STATES IV. THE ROLE OF WHO IN ADDRESSING GLOBAL HEALTH EMERGENCIES A. The 2005 International Health Regulations Framework 1. The Original International Health Regulations 2. The 2005 International Health Regulations B. The Global Outbreak Alert and Response Network 1. Key Features of the Global Outbreak Alert and Response Network 2. GOARN's Effectiveness in Global Health Emergencies V. OTHER INTERNATIONAL EFFORTS TO ADDRESS GLOBAL HEALTH EMERGENCIES IN SITUATIONS OF HUMANITARIAN CRISES VI. CONCLUSION: LESSONS LEARNED AND THE WAY FORWARD I. INTRODUCTION

    Globalization and the spread of disease have made public health a matter of international concern. This is particularly true in situations of trans-boundary health emergencies, as demonstrated by the Severe Acute Respiratory Syndrome (SARS) and Ebola epidemics, and more recently by the cholera outbreak in post-earthquake Haiti and the outbreaks of H1N1 and H3N2 influenza. (1) Often, these emergencies cannot be addressed exclusively by one State, but must instead be addressed by the international community as a whole. The difficulties of successfully addressing trans-boundary health emergencies are compounded in situations of failed and failing States, where governments lack the power to control their territories and populations. (2)

    This Article explores mechanisms available to respond to public health emergencies in failed and failing States, with the goal of assessing their effectiveness and identifying existing challenges. First, the Article defines health emergencies and State failure. Next, it examines the role played by the World Health Organization (WHO) in controlling global health emergencies, in particular through the International Health Regulations (IHR) and the Global Outbreak Alert and Response Network (GOARN). Finally, it discusses the role of other international organizations, including the United Nations Children's Fund (UNICEF) and the UN Office for the Coordination of Humanitarian Affairs (OCHA), in global health emergencies in failed or failing States. While no comprehensive and mandatory action plan exists to deal with global health emergencies, the tools developed by WHO and other international organizations have often proven to be effective in dealing with global health emergencies. The lack of binding enforcement measures seems to have been compensated by voluntary activities and cooperation by Member States and non-State actors. The question that still needs to be resolved, however, is how to ensure that actions are taken in a timely and comprehensive manner in all global health emergencies, even when the State at the center of the crisis is reluctant or unable to provide assistance. In these situations, IHR 2005 and GOARN can be used symbiotically to ensure a coordinated response to health emergencies in failed and failing States. In this way, WHO can play a fundamental role to ensure that health emergencies are detected and temporary recommendations are approved and implemented. It is important to ensure that WHO acts within its given powers and is provided the appropriate support and tools to carry out its mandate.


    Health has become a central topic of international law. Its importance is recognized in several international and regional instruments, such as the Universal Declaration on Human Rights and the UN Convention on the Rights of the Child. (3) The UN Charter cites the need to collaborate on health issues in several articles, (4) and several international organizations now include health-related mandates, including WHO and UNICEF. (5)

    Public health has increasingly become a global issue. Faster, easier, and cheaper transportation methods have resulted in a phenomenal increase in the movement of people and goods, (6) and new conservation technologies have improved the international trade of perishable goods. (7) These developments have made it easier for diseases to spread faster and to more distant locations. (8) Indeed, easier movement of people and goods has facilitated not only the spread of infectious diseases, but also their emergence and reemergence in both humans and animals. (9) Accordingly, global health (10) has become an important concern for the international community. Globalization has, to a certain extent, undermined the ability of one State, acting alone, to protect its people from the spread of infectious diseases. As a result, it has become clear that only collective efforts can efficiently address

    public health emergencies.

    Deadly diseases like tuberculosis, malaria, and cholera are still widespread in many regions of the world. (11) Some of their pathogens are becoming drug-resistant, and thus more difficult to cure and isolate. (12) Some diseases are spreading into previously disease-free regions. (13) Moreover, new infectious diseases, such as SARS and Ebola hemorrhagic fever, (14) typically have trans-boundary effects, and thus can only be properly handled by the coordinated actions of multiple national and international actors. As global health expert Professor David Fidler concludes, "most public health experts agree that the distinction between national and international public health is no longer relevant because globalization has enabled pathogenic microbes to spread illness and death globally." (15)

    Finally, the connection between national security and health has also become apparent. (16) Significantly, States have begun to identify certain diseases as national security threats and have developed measures to halt and control the spread of these diseases as part of their foreign policies. (17) For example, in 2000, the Clinton administration for the first time declared AIDS a threat to the United States' national security and global stability (18) and mandated the U.S. National Security Council to develop an appropriate response. (19) President Obama shared the same understanding of the HIV/AIDS epidemic through a President's Emergency Plan for AIDS Relief. (20) UNAIDS, the joint UN program on HIV/AIDS, also advocates for a global response. (21) Similarly and more broadly, in the 2005 UN World Summit Outcome Document, States recognized that "HIV/AIDS, malaria, tuberculosis and other infectious diseases pose severe risks for the entire world and serious challenges to the achievement of development goals." (22)

    These legal, security, and policy developments have made it clear that public health has become a matter of international concern, one that often cannot be addressed exclusively by one State, but that requires action by the international community as a whole. Undoubtedly, there is currently a certain degree of collaboration among States on some public health matters. Several multilateral organizations exist at the regional level and collaborate on health issues. (23)

    Various international organizations, including WHO and UNICEF, (24) have also assumed coordination and facilitation roles in international public health matters. For example, epidemiologists from around the world meet periodically at the WHO Headquarters in Geneva to identify and recommend the most effective vaccine for the upcoming influenza season. (25) In addition, several international, national, and non-governmental organizations (NGOs) intervene in support of national health sectors during humanitarian crises--which often occur in situations of conflict and State failure--and provide basic health care. (26)

    However, there are currently no binding general agreements that address the problem of global health emergencies, and no agreements on comprehensive plans or specific actions in situations of transboundary health emergencies. (27) Members of the international community realized that this lacuna was potentially deeply problematic during the game-changing 2002 SARS virus epidemic in China.

    SARS, a serious form of highly contagious viral pneumonia, was first diagnosed in Southern China in 2003 and eventually spread to twenty-seven countries--including Hong Kong, Canada, the Philippines, Russia, and Spain--allegedly causing 774 deaths. (28) The Chinese authorities initially failed to report the new disease to WHO and, in fact, tried to conceal its existence. (29) The Chinese government revealed the extent of the epidemic only in March 2003, after mounting media and political pressure, and after the disease was diagnosed in other countries. (30) At that time, it allowed a WHO team to enter its territory and assess the situation for the first time. (31) By that point, the alarm caused by a new, unknown disease had already spread worldwide, and WHO had issued a global alert for the disease. (32) WHO was also able to release daily updates describing the progress of the epidemic and controlling efforts with the support of reports from national health monitor systems and several governments. (33) WHO issued a travel alert discouraging travel to several countries in Asia and to Canada, where the virus had already been diagnosed and resulted in casualties. WHO's vigorous and coordinated response bore fruit, and by the beginning of July, the epidemic had been stopped. (34)

    The reactions to the SAILS epidemic are instructive for several reasons. On the one hand, the initial mishandling of the epidemic by the Chinese authorities demonstrated the need for coordinated intervention by international actors in situations of global health emergencies. China's response revealed the limitations of the existing emergency control system. In fact, had China declared the emergency sooner, the result of the epidemic would have been far less serious, and effective control measures could have been implemented much earlier. Instead, China designated any news relating to the epidemic as State secrets and denied access to outside actors, including WHO and the media, for several crucial...

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