The Good, Bad, Ugly, and Lame of the New International Health Regulations

The latest news on the failed—or stalled—or soon to be completed—pandemic accord negotiations reveal the human frailties of international cooperation. With the messages swinging from despair (the negotiations failed!) to optimism (there will be agreement, come what may!), what might seem like bipolar messaging is perhaps not wise for global health.

But at a time when hostage deals on one- or two-state solutions for pick-your-favorite-geopolitical-flashpoint is modus operandi in an era of extreme polarization and volatility, the global health community might be excused for its bipolarism. As the world swings from one emotion to the next, we might find this optimism—this human tendency to search for at least silver linings or any speck of hope or goodwill—even adorable. Hence, the latest messaging on the pandemic accord and the newly approved International Health Regulations (IHR), however cast with rose-tinted glasses: “Success! Now we can go on summer vacation!”

Indeed, the global health community needs any success it can find and promote. The pandemic, to put it mildly, was not exactly peak performance of international cooperation on health, with all the failures, flaws, and whoops of international cooperation. While human tendency is to place blame on some specific cause (Disinformation! Bad leaders!), it is impossible to have an excessive amount of humility. In this spirit of improvement and self-reflection, here’s my take on the good, the bad, and the ugly on the new IHR.

The Good: a new label

First, the formal definition of a “pandemic emergency” creates a tier above the “public health emergency of international concern” (PHEIC). The PHEIC, however poorly pronounced in English as “fake", is given a lower status compared to a “pandemic emergency.” This sleight of hand may seem minor, but in my view, it represents a step in the right direction towards better labels and better communication through a tiered system. It’s still not ideal, but with my rose-tinted glasses, I think it’s an improvement

Another good item is that the IHR now requires states to maintain or increase domestic funding for supporting implementation of IHR (article 44). With domestic health funding basically flat in the golden era of global health, this emphasis is welcome and much needed.

Hooray!

The Bad: lack of transparency

One of the repeated flashpoints of the COVID-19 pandemic was the lack of transparency and the delay in an originating state party reporting to WHO (with a subsidiary non-member state sending a query to WHO instead). As written, the IHR keeps the status quo on public reporting which is highly dependent on states reporting to WHO and in turn WHO reporting to other states.

The most efficient means of communicating with the world in an era of strident transparency is through transparent and public reporting, not through a third party such as WHO that holds the information in confidence or at its discretion. Indeed, it states: WHO “shall not make this information generally available to other States Parties” (article 11). A similar lack of transparency is also observed in the reporting of the review committee which is shared only with the director-general (article 52).

But what evidence do we have that less transparency will save more lives? This clause is counterproductive and unwise not only to countries who need timely information, but also puts a straitjacket on WHO. By this clause, WHO loses power and credibility by being a confidential information holder of state party reports on the IHR.

How does this loss of power work? Countries acting in national interest will recognize that this lack of transparency in reporting on pathogens can be extremely costly. And in response, such countries, if they are strategic and if they have the resources and means, would invest in their own international surveillance networks rather than rely on WHO to share information with all parties in a timely manner. Thus, the clause in the IHR will result in countries going out on their own and relying even less than they already do on WHO for such information.

The Ugly: vaccine inequity

One of the ugliest flashpoints during the COVID-19 pandemic was the lagged and unequal distribution of vaccines. There were many examples of hypocrisy, but the crux starts with rich countries demanding other countries report valuable information on COVID and other pathogens of pandemic potential in the name of global cooperation, unity, and solidarity.

But in the next breath, those same rich countries nonchalantly punish countries by:

1. Imposing travel bans on those countries which reported in good faith (e.g. the case of the Omicron reported from South Africa)
2. Effectively failing to share vaccines in a timely manner, vaccines which have been based on such information reported, through various tactics such as:
   1. Calling for countries to get vaccines if they can pay for them or stand in line to purchase them on a first-come first-served basis based on ability to pay, in part due to an attachment to the notion of “leaving vaccine distribution to the market,”
   2. “Donating” vaccines near-expiry, which is effectively exporting trash, or
   3. Blaming countries for ineffective vaccine distribution due to corruption, lack of infrastructure, and ability to implement.

This hypocrisy is a bit like a potluck gone awry: imagine all the world’s nations have a potluck, where we each bring something to the party. At this potluck, countries with more should bring more. Countries of more modest means bring information and sharing of data. But then, the richest country who plans to bring the main course—the vaccines—decides that he’s first. Only after he’s had a third filling of his plate will he even bother to consider to let other countries stand in line for their first filling.

While zealous optimism gives warm and fuzzy feelings about faster-than-ever vaccine innovation, in the end such efficiency does not trump equity. It should be embarrassing. These hypocritical actions are nothing new and reminiscent of colonization, which works like this: powerful rich nations take the assets of others, then arrogantly do what’s in their best interest first while putting others down. “Do as we say, not as we do” is the refrain.

But for global partnership and cooperation to work, there cannot be only taking; there must also be giving. Whatever is given should not make the receiver feel like the giver has acted with profound generosity. Such sharing is just a mere act of reciprocity of mutual benefit. Perhaps the most ironic aspect is, while hypocrisy seems to do little to motivate rich countries to share vaccines faster in the next pandemic, the most important reason for why rich countries should share is that they only risk harming themselves more, as a pandemic will be extended longer with more variants as it circulates.

Anyway, getting back to the latest text of the IHR, we can read between the lines that the major emphasis on “equitable access to relevant health products” is not just a nice-to-have, but it is in direct response to the hypocrisy of the pandemic. There should be emotional weight and a sense of indignity that is carried with this phrase.

The Lame: facilitation is like kumbaya

Despite the laudable aspiration of moving towards equitable access, the truth as we all know is that WHO lacks the power or resources to finance and ensure such equitable access. Even the mandate in text is quite weak: “WHO shall facilitate… timely and equitable access.” Facilitation is not a contentious function that we were not sure whether WHO should or should not do. Facilitation is a kind of kumbaya word; you can’t disagree with it. Of course, WHO should do facilitation!

Sometimes, political documents become a buffet of terms of reference. But in fact there is nothing stopping WHO from facilitating timely and equitable access today as we speak. And there was nothing holding WHO back from doing such facilitation even before this reviewed IHR. WHO’s ability to facilitate was not the bottleneck for failure to achieve timely equitable access.

The problem is not a lack of mandate for facilitation, but rather that the mandate for enforcement is too weak. In other words, if certain states or countries fail to ensure equitable access or if countries fail to share information in a timely manner, what recourse does the WHO or other states have?

Assuming no new resources or ability to finance, then enabling WHO to have the teeth and accountability, including for naming and shaming states which fail to meet a standard of sharing, or conversely lauding cooperative states—being a good guest to the potluck—is the only thing that’s left. What else is a so-called “norm-setting institution” supposed to do?

In reality, the member state structure and political economy of WHO makes naming and shaming nearly impossible—or so goes the repeated excuse for “why it’s impossible.” But this bureaucratic excuse, posing as mere logic, needs further probing—and not to mention creativity and an extra dose of optimism.

With thanks to Brian Webster for helpful research assistance.