Lessons from SARS: why the WHO must provide greater economic incentives for countries to comply with international health regulations.(severe acute respiratory syndrome)

TABLE OF CONTENTS

  I. INTRODUCTION
 II. BACKGROUND: THE SCOPE OF THE THREAT FROM INFECTIOUS
     DISEASE, SARS, AND THE WHO
     A. The Scope of the International Threat from Infectious
        Disease
     B. SARS: An International Wakeup Call
        1. Characteristics of SARS
        2. The Chinese Government Did Not Have
           Sufficient Incentives to Disclose the Disease
     C. The WHO's International Law-Making Powers
III. THE WHO'S ANSWER TO THE THREAT: REVISING THE
     INTERNATIONAL HEALTH REGULATIONS
     A. The Previous Regulations and the Legal Obligations of
        Member States
     B. Problems with the Previous IHR
     C. The WHO's Limited Answer: Revise the IHR
        1. Reporting of Public Health Emergencies
        2. Reports from Non-State Actors
 IV. INEFFICIENCES IN INTERNATIONAL DISEASE CONTROL: THE WHO
     Is INHERENTLY DISADVANTAGED
  V. How MEDICAL ECONOMICS RELATES TO THE FIGHT AGAINST
     DISEASE
     A. Public Health as a Public Good
     B. All Nations Have an Interest in Joining the Fight Against
        Infectious Disease
 VI. SUGGESTIONS FOR IMPROVEMENT
     A. The WHO Must Attract Funding through Efficiency of
        Operation
        1. The WHO Must Give Wealthy Nations and
           Organizations a Reason to Provide Funding
        2. The WHO Needs to Spend Money in a More
           Cost-Efficient Manner
        3. The WHO Should Avoid Politicization by Sticking
           to its Technical Mandate
     B. The WHO Must Provide Further Incentives for States to
        Comply with the Regulations
     C. International Health Should Not Be Bound by International
        Politics
VII. CONCLUSION

I. INTRODUCTION

In 1969 the United States Surgeon General announced that humans had effectively won the battle against infectious diseases. (1) As a result, health care professionals around the globe turned their focus from infectious diseases to chronic illnesses. (2) This "premature triumphalism" (3) caused government and public health officials to become complacent concerning infectious diseases, increasing the morbidity and mortality caused by infectious diseases internationally. (4) Since that time a record number of new diseases have emerged throughout the world, including HIV/AIDS, Lyme disease, Hepatitis C, Ebola, Dengue hemorrhagic fever, and SARS. (5) Billions of dollars have been spent and millions of lives lost as a result of these and other diseases. In fact, in 1996, infectious diseases claimed 17,312,000 lives, comprising 33% of all deaths worldwide. (6) In the United States alone, even the common flu kills over 36,000 people a year. (7) Put simply, the spread of infectious disease is one of the most important global problems facing international leaders today.

Currently the World Health Organization (WHO or Organization) is the only multilateral organization charged with combating infectious diseases internationally. For decades the WHO has worked--with varying degrees of success--to fulfill this role. Currently, the WHO believes that the best way to help nations combat the international spread of infectious disease is to strengthen the International Health Regulations (IHR or Regulations). The IHR are the only existing international laws dealing with infectious diseases. They describe the surveillance and reporting requirements of member states concerning infectious outbreaks. Unfortunately, the IHR have proven largely unsuccessful, and member states treat them more like recommendations than international law. In the hope that strengthening the IHR would improve compliance with the Regulations, the WHO spent the past decade working to modify the IHR. This work culminated a few months ago when WHO member states voted to accept a new version of the Regulations.

Changing the IHR is a welcome development that is long overdue. After all, even with the advent of HIV/AIDS, the previous Regulations were not changed for twenty-three years. But it is a mistake to believe that simply changing the IHR will be sufficient for the WHO to face the current threat from infectious diseases. As regulations of the WHO, the IHR are subject to the weaknesses inherent in the WHO itself. Therefore, changing the Regulations without also addressing the WHO's inefficiencies will have only a limited impact on the global spread of disease.

This Note argues that the WHO must initiate further changes if it is going to effectively lead the fight against the international spread of disease. Most important, the WHO must help provide member states with greater economic incentives to improve their disease surveillance systems and to report outbreaks immediately after they occur. This Note will provide examples from the most recent international epidemic--the SARS virus--to show that simply changing the IHR will not suffice.

The SARS outbreak is ideal for this analysis for two reasons. First, it was the only major outbreak of a newly emerging disease since the WHO began the process of changing the IHR in 1995. Second, most readers are familiar with the spread of SARS because the outbreak was given significant attention by the international media. SARS touched nearly every corner of society and scared millions worldwide. At one point, even though there was never a major outbreak in the United States, 43% of Americans were worried about SARS. (8) By analyzing what happened internationally during the SARS outbreak, this Note will demonstrate that changing the IHR is an insufficient answer by the WHO to one of the world's most challenging problems. Nations also need further economic incentives to ensure compliance with WHO regulations.

This Note begins in Part II by providing three essential pieces of background information. This section first illustrates the scope of the threat from infectious disease and the factors that have increased that threat internationally. Even though modern technology has improved medical conditions in many areas, this section will show that technological advances have also made nations more susceptible to epidemic outbreaks. The section continues by illustrating the basic characteristics of the SARS epidemic. The events surrounding the SARS outbreak show the reader the factors that allow diseases to travel so quickly in the world today, and the reasons nations are unwilling to report disease outbreaks when they occur. The section ends with a brief discussion about the WHO and its international legal powers. Because the WHO has largely neglected its legal powers in the past, the Organization is often ignored by member states when outbreaks occur.

In order to compel nations to improve their disease surveillance mechanisms and report outbreaks when they occur, the WHO labored to convince states to accept changes to the IHR. Part III describes what the previous IHR required member states to do and discusses the criticisms that were often raised against the Regulations. The section continues by outlining the major changes made to the Regulations. Though some of the changes could help the WHO better fight the spread of disease, there are still significant problems with the recently adopted IHR.

Accordingly, changing the IHR will only have a limited effect on the fight against infectious disease. This is because the WHO itself is inherently disadvantaged and inefficient, limiting the effectiveness of any regulations stemming from the Organization. Part IV summarizes some of the WHO's flaws and reveals that no matter what the Organization mandates, it will always be limited by the sovereignty of its member states. Thus, regardless of improvement to the IHR, unless the WHO does a better job providing member states with incentives to voluntarily comply, member states will still be reluctant to adhere to the Regulations, and the WHO will be powerless to enforce compliance.

Economics are behind nearly every national decision concerning public health. Therefore, before it is possible to fully discuss possible answers to the WHO's problems, it is first necessary to understand the basic principles of medical economics. Part V introduces the basic theories of medical economics and shows how economic incentives can help compel nations to comply with international regulations. The WHO must better utilize these principles of economics in order to provide nations with incentives to comply with WHO regulations. For example, the WHO needs greater funding from member states. But for that to happen, the WHO needs to give nations greater economic incentives to donate funds. Thus, the WHO must be more cost efficient in spending and focus on programs that benefit all nations. In Part VI, this and other suggestions are discussed at length in an attempt to help the WHO find a more prominent role in the future. Finally, the Note ends in Part VII with some concluding remarks.

II. BACKGROUND: THE SCOPE OF THE THREAT FROM INFECTIOUS DISEASE, SARS, AND THE WHO

In order to understand why the WHO needs to provide nations with greater economic incentives to fight infectious disease, one must first have a basic understanding of three things: the scope of the threat from infectious disease, the influence SARS had on global health governance, and the extent of the WHO's lawmaking powers.

A. The Scope of the International Threat from Infectious Disease

Infectious diseases have always threatened humankind. For example, the plague killed 14 to 15 million Europeans in the fourteenth century. (9) More recently, the 1918 flu killed between 20 and 40 million people worldwide (10) and is considered the worst human epidemic on record. (11) But it is important to realize that such devastating epidemics remain possible today, despite the many advancements in medical technology that have taken place. SARS and other illnesses have conclusively shown that diseases travel more quickly today than ever before. Historically, deadly influenza strains surface about once every forty years. (12) If SARS had been one of these more deadly strains, it would have destroyed the lives of millions around the globe rather than just thousands.

Two types of infectious disease are of importance. Emerging infectious diseases are new diseases that have not previously threatened humans. (13) Reemerging infectious diseases are pathogens that were no longer considered a danger to health but then reappeared to threaten humans. (14) Over the past two decades the world has had to fight an increasing number of infectious diseases. (15) This increase is a result of a number of factors. For example, international complacency by government and public health officials caused infectious diseases to be pushed into the background. (16) Also, advancements in technology have allowed both humans and diseases to travel more rapidly than ever before. (17) Moreover, areas of the world that were once considered remote are now easily accessible to large numbers of travelers. (18) As a result, diseases can be transferred from remote corners of the globe within a day.

Similarly, the expanding world population forces humans into previously uninhabited areas and increases the prevalence of overcrowded cities, both of which facilitate the spread of disease. (19) This expansion has led to environmental changes and degradation, causing sanitation problems which aggravate the occurrence of infectious diseases. (20) Finally, there has been an increase in antimicrobial resistance, making diseases more difficult to treat. (21) Because of these factors, controlling emerging and reemerging infectious disease is the WHO's "paramount challenge for the beginning of the twenty-first century." (22)

The origin of the SARS virus is the perfect example of all of these factors at work. Southern China has been called "the world's most efficient virus factory and ground zero for most of the globe's influenza epidemics." (23) Southern China was not only the geographic origin of SARS; it is also believed that the major flu outbreaks of 1919, 1958, and 1969 all originated from there. (24) Moreover, China is believed to be the source of Avian Flu outbreaks in both 1997 (25) and 2004.

The reason China is such a "notorious crucible for disease" (26) is because it combines most, if not all, of the factors listed above. "The warm, humid climate of southern China, with millions of people living in close proximity to pigs, chickens, and goats, makes it the world's leading incubator for new viruses." (27) Many of the diseases that originated in southern China were formed by genetic mutation, crossing the species barrier from animals to the human population. (28) For example, the 1997 avian flu jumped species, showing that a single change in the genetic code can mean the difference between dead birds and dead humans. (29)

Moreover, China's massive population has made it difficult to identify and track diseases when they occur. China has densely populated cities and 100 million migrant workers. (30) Many of these workers do not have access to health care, are less aware of the news, and can carry diseases throughout the nation undetected. (31) In fact, the first SARS cases in Beijing originated from a migrant who worked in the Guangdong Province. (32) Finally, technology has increased the mobility of the Chinese people, helping SARS to move freely throughout China, and then the rest of the world.

Thus, SARS shows how new diseases are able to emerge and spread more quickly than ever before. Because of these factors, infectious diseases have negative effects both vertically within nation states and horizontally between nations. For example, illnesses aggravate already existing tensions in international relations, particularly the inequality between rich and poor countries. (33) Infectious diseases like HIV/AIDS can also slow foreign trade, threaten national resources, and disrupt investment in developing countries. (34)

In fact, the increasing economic instability resulting from infectious disease has undermined the military capabilities in some parts of the developing world, and some argue that this could undermine regional balances of power. (35) For instance, countries in Africa, Asia, and Latin America could have their military capabilities destabilized as a result of AIDS as both their manpower and military preparedness are being degraded by the disease. (36) Up to one-third of the prospective soldiers in Russia are unfit for service because of chronic hepatitis or HIV infection. (37) If HIV/AIDS continues to undermine the economies and military capabilities in certain nations, the U.S. State Department argues that "it may be a potential 'war-starter' or 'war-outcome-determinant.'" (38)

Infectious diseases, therefore, are contributing not only individual suffering, but also to "social disintegration that triggers civil and perhaps even interstate war." (39) This thought is even more chilling when one considers the threat from bioterrorism that exists in the world today.

B. SARS: An International Wakeup Call

In November 2002, somewhere in southern China, a new coronavirus bridged the species gap, transferring from an animal host to a human host. With that simple beginning, Severe Acute Respiratory Syndrome (SARS) was born. From November 2002 to July 2003, over 8,000 people worldwide contracted the SARS virus; of those unlucky people, 774 died. (40) This previously unknown disease had an uncanny power: it seemed to force nations into a global trance as daily news reports tracked its progress from country to country and scientists on nearly every continent frantically searched for a cure.

SARS was "the first severe infectious disease to emerge in the twenty-first century, pos [ing] a serious threat to global health security, the livelihood of populations, the functioning of health systems, and the stability and growth of economies." (41) The SARS virus is particularly important for two reasons. First, SAILS showed "the global havoc that can be wreaked by a newly emerging infectious disease." (42) It spread quickly and overwhelmed many nations economically, socially, and politically. Second, the way in which China handled the SARS situation clearly demonstrated that nations need better disease surveillance systems and greater economic incentives to disclose outbreaks.

1. Characteristics of SARS

SARS has many characteristics that combined to make it an international threat. First, SARS has neither a vaccine nor effective treatment. (43) SARS derived from a coronavirus, a family that is well known for frequent mutations. (44) This made it extremely difficult for medical researchers to develop a vaccine for the disease. Additionally, isolation and quarantine are the only available means for public health workers to control the spread of the disease. (45) Such basic measures required health officials to resort to the "earliest days of empirical biology." (46)

Second, the initial symptoms of SARS were "non-specific and common." (47) For example, those who contracted SARS typically had a fever and respiratory symptoms (e.g., cough, shortness of breath, or difficulty breathing). (48) As these are the same symptoms of the common cold or flu, many SARS patients did not know they had the disease until advanced symptoms occurred. In the meantime, they unknowingly spread the disease to others.

Third, the tests available to diagnose SARS in patients are limited, allowing those with the disease to "slip through the safety net of isolation and ... control" and infect others. (49) This is especially true for developing nations that do not have efficient public health mechanisms. Fourth, an alarmingly high percentage of those who contracted SARS were medical personnel. After the initial infection of rural Chinese, SARS quickly became a disease of hospital staff. (50) In the initial SARS hot zones, hospital staff tried to save the lives of their patients and unknowingly infected themselves. (51) When medical personnel are at high risk for contracting an infectious disease, it puts a strain on a nation's entire health care system. (52) The impact from this danger to medical staff is even more apparent when considering the fifth factor: a high proportion of SARS patients require intensive care. (53)

Sixth, SARS has an incubation period of two to ten days. (54) Accordingly, anyone infected with SARS could hop on an airplane and spread the disease throughout the world before the first symptoms even appeared. (55) Finally, the WHO believes that SARS's overall case fatality rate is between 14% and 15%. (56) To put that into perspective, the 1918 flu, which killed between 20 and 40 million people, had a fatality rate between 3% and 5%. (57)

The combination of these factors made SARS a significant threat to international public health. Most diseases have certain characteristics that limit their impact on the international community. (58) For example, transmission of Ebola requires close physical exposure to infected blood and other bodily fluids, and people with Ebola are visibly ill and too sick to travel. (59) Thus, though Ebola has an unusually high fatality rate, (60) it tends to be controllable. The major limitation that SARS had--which probably saved millions of lives worldwide--was that SARS was not as highly contagious as an influenza strain. As a result, international public health governance was given a major test of its effectiveness while not incurring millions of human casualties.

2. The Chinese Government Did Not Have Sufficient Incentives to Disclose the Disease

The previous IHR were ineffective and often provided nations with significant incentives to hide the existence of infectious disease outbreaks within their territory. Once the international community discovered how dangerous SARS was, the nations of the world and the WHO worked very well together to stop the spread of the disease. In fact, even though China took a long time to disclose the outbreak of SARS, once Chinese officials began to openly combat it, they were very effective at controlling the disease. This cooperation revealed that the WHO and its member states are capable of coming together once a crisis is recognized. Thus, the WHO's emphasis should be on the front end of health crises: ensuring that member states have the surveillance capabilities needed to detect disease outbreaks and sufficient incentives to report those outbreaks immediately after they occur.

Unfortunately, because those incentives are not currently in place, many nations have gone to great lengths to hide outbreaks of infectious diseases--even when legally bound to disclose them--in an effort to curb the social, political, and economic effects that infectious diseases invariably bring. Thus, the following discussion is not to criticize China's reaction, but to highlight the problems with the current system, and to demonstrate that many nations would have reacted in the same way.

China's reaction to SARS was similar to reactions of other nations faced with similar outbreaks--it hid the disease. The Chinese government classified SARS as a state secret; local authorities were not allowed to openly discuss the virus unless authorized by the State Council. (61) The Chinese government did not even warn its own doctors about the illness until late January 2003. Moreover, that warning was top secret and was not to be shared with doctors in Hong Kong. (62) More important, Chinese doctors were not allowed to inform WHO officials about SARS.

On the domestic front, Chinese officials were concerned that news of SARS would frighten Chinese citizens and negatively impact local economies. (63) Many have speculated that the government did not …