The International Health Regulations (IHR) is the quintessential binding international public health framework. The IHR emphasizes surveillance, notification, and response systems, establishing clear obligations for countries and the World Health Organization (WHO) during public health emergencies. In a perfect world, the IHR, established in 2005, would have ushered in an age of global health cooperation. Yet, this is not the case. Five years removed from the 2020 shutdown, COVID-19 has highlighted the sheer failure that the global medical industry faced as a result of lackluster international policy and diplomacy efforts. While the IHR seeks to establish a clear baseline, it falls victim to delayed and inconsistent reporting, weak intrastate capacity for surveillance and response, and finally, significant political pressure and the weakness of the WHO’s authority. 

The case of COVID-19 seems like a distant past, but nearly half a decade later we are still reeling in its effects. Most notable is the lack of transparency states have regarding their reports. Take, for example, China’s delay in reporting initial cases to the WHO. China was criticized for delaying the disclosure of crucial information about human-to-human transmission, violating the IHR’s requirement to notify the WHO within 24 hours of identifying a potential threat. However, China faced little-to-no backlash from the WHO due to both the status the world superpower holds along with the IHR framework lacking an enforcement mechanism. Without enforcement, reporting is based on speculation and individual states’ willingness to come forward. Such expectation fails on the world stage, where states are heavily incentivized to protect their domestic information and assets. However, it is not just superpowers that have not been forthright in relaying information to the WHO, as during the 2014 Ebola crisis. Guinea, Liberia, and Sierra Leone failed to report early signs of the outbreak, contributing to its rapid spread. The IHR’s fundamental goals of surveillance and notification fail at all levels, as states have no real reprimand.

The 2014 Ebola crisis displays a rarely discussed aspect of how meaningless the IHR’s requirements are, as it concerns states that have significant intrastate difficulties. Many low-and middle-income countries (LMICs) lack the resources to meet the IHR’s core capacity requirements (the ability to detect, assess, notify and report events). This is for a multitude of reasons, from the neo-colonialist policies of states, such as China with its Belt and Road initiative, the U.S.’ strong military presence, or even just the after-effects of centuries of colonial rule. However, these effects culminate in the significant underfunding of critical national healthcare infrastructure, which was highlighted by West Africa’s Ebola outbreak. Yet, the IHR has limited resources to address this issue. The WHO itself provides no financial aid, let alone structure, for these states to begin creating robust healthcare infrastructure, choosing only to temporarily patch the leaks through initiatives such as COVAX and the African Vaccine Acquisition Trust (AVAT). COVAX failed to have an impact due to richer states hoarding vaccines in the interest of domestic national security, further exacerbating the global pandemic. Fundamentally, LMICs prioritize domestic stability, causing international cooperation and information sharing to become low priorities. 

Nothing highlights the weakness of the IHR and the WHO as a whole as the disregard states have for its authority. With the U.S. exit from the WHO earlier this year, despite being a founding member, the purpose of the WHO has been called into question. When the WHO attempted to declare a Public Health Emergency of International Concern (PHEIC) for COVID-19, there was significant political pressure from China for it to not be released. There is no real punishment for states failing to abide by the core tenets of the IHR, leading to gross negligence on the part of states. No “stick” to compel states to act means that states will simply act in their best interest, avoiding disclosing any data they deem detrimental to their image abroad or at home. On top of this, when the WHO released a PHEIC for the H1N1 pandemic (2009), it faced significant backlash from the international community for supposedly “over-exaggerating the significance of the outbreak,” which killed over half a million people globally. Even when the WHO does its job properly, states will continue to complain, leading to de-prioritization. This can have dire consequences in a context where 4.5 billion people worldwide lack access to basic health services and two billion people face financial hardship due to health costs.The best way to address the failing WHO is to take conditional aid and trade measures (soft penalties), emergency intervention protocols, and strengthen partnerships with regional bodies. Similar to the World Bank, IMF, or WTO, tying the requirements of the IHR to economic measures would ensure that states prioritize their domestic reporting infrastructure and decrease the likelihood of states failing to report to the WHO when concerns do come up. In extreme cases where a country conceals or suppresses critical public health information, the WHO could invoke emergency powers to deploy rapid response teams and work directly with states to be able to mobilize neighboring countries or regional coalitions to address the outbreak.

This framework has largely been ignored by states due to their national security concerns, but at the end of the day, human security is what should matter. Allowing for the IHR and the WHO to have a realistic, non-military enforcement mechanism is the best possible solution to its current failings. Finally, working with regional bodies such as the Africa CDC, European Centre for Disease Prevention and Control (ECDC), or ASEAN BioDiaspora Initiative would allow for a more global approach as well as a general increase in the legitimacy of the WHO’s mission and existence. On top of this, regional bodies often have better diplomatic leverage and cultural understanding. Partnering and working with them would decrease issues related to sovereignty, as well as expedite information communication between individual states and the WHO. The best way forward is to create a path in which the WHO can truly operate on the world stage. Without these changes, we risk the collapse of the only significant international framework that seeks to benefit the health of people worldwide.

Today’s Zika outbreak is not the first time mosquitos have caused an international panic. In 1841, the British ship HMS Eclair docked in Sierra Leone to replenish their dwindling supplies. After filling their holds, they began steaming back toward England, but unknowingly were leaving with far more than hard tack and whale oil. While on a one-day shore leave, the ship’s sailors had come under onslaught by one of man’s deadliest assailants – the mosquito.

After losing two-thirds of its crew, the HMS Eclair sought refuge on Portugal’s Cape Verde. Within a week, yellow fever had jumped the confines of the wooden ship and spread throughout the island, ultimately killing one-third of its residents. By the time the Eclair finally reached its English homeland, global political leaders were in an uproar. In a never-ending cycle of blame, Portugal faulted Great Britain for negligence, Great Britain charged Sierra Leone with failing to protect docked ships from pestilence, while Sierra Leone pointed the finger at other African nations for originating yellow fever.

The political furor continued on for a decade. In the name of disease containment, seclusion became an underhanded tactic as governments imposed quarantines on foreign vessels. Many Mediterranean ports completely barred British ships. Politicians attested that it was only done in the name of preventing yellow fever’s spread and impeding the trade of rival countries was merely a side benefit. Colonial commerce was waylaid by the politics of plagues, rather than guided by medical science.

Over 150 years later, epidemics remain fertile breeding grounds for political fodder. Two years ago, the world was once again held captive by a looming public health crisis – the threat of Ebola. The largest outbreak of its kind in history, the epidemic was responsible for over 11,000 deaths, mostly in three African nations – Liberia, Sierra Leone, and Guinea. Although the risk to Americans was miniscule, far less than the danger of being crushed by an elevator, fear took hold. After the first U.S. patient was diagnosed in Dallas, political leaders stepped forward with the solution to keep Americans safe – a travel ban.

Republican senators Ted Cruz (TX) and Thom Tillis (NC) led the charge, demanding that the White House immediately ban all direct travel from these three countries in order to stem the spread of Ebola. Current presidential candidate Donald Trump added that if the flights were not stopped, the plague would start and spread inside our borders.

The question of travel bans morphed into a pre-election litmus test for candidates. Democrat Senator Jeanne Shaheen (NH), facing steep criticism from her Republican challenger, acknowledged that she didn’t think a travel ban made sense, but would support travel bans if they made Americans feel safer. Democrat Andrew Cuomo (NY), engaged in a not-even-close gubernatorial race, embraced a travel ban after his Republican opponent chided him for a lack of leadership in the fight for public health.

There was just one problem with the proposed travel ban: there were no direct flights to the U.S. from these African nations. In fact, Thomas Duncan, the Dallas patient, had arrived in the U.S. via a flight from Belgium. In addition, Ebola cannot be transmitted until the patient shows symptoms and nears death, rendering travel bans nearly useless. It is highly doubtful that a passenger in the final stages of Ebola, bleeding from every orifice of his body, would be allowed onto a plane. A travel ban, while providing a feel-good measure to American citizens, was essentially a toothless political solution to a scientific problem. As Susan Grant, chief nurse executive for Emory Healthcare, noted: “We can either let our actions be guided by misunderstandings, fear and self-interest, or we can lead by knowledge, science and compassion.”

Now another potential plague – the Zika virus –  has crossed our southern border. First discovered nearly 70 years ago in Uganda, Zika is spreading across Latin America at an ever-increasing rate, leaving behind a trail of birth defects.  In Brazil alone, there were 4,000 babies born with Zika-caused microcephaly in the last three months of 2015. Compare that to the 150 confirmed cases from the entire year before.

According to the CDC, there are now nearly 600 pregnant women in the continental U.S. testing positive for Zika. A mere two months ago, there were just four confirmed cases. In Puerto Rico, that number of cases among pregnant women is now 1,000. Most of these cases were likely caused by local mosquitos.

In February 2016, President Obama requested $1.9 billion to fight Zika. Three months later, $1.1 billion in funding, a bipartisan compromise, was approved by the Senate. However, the House added provisions weakening Environmental Protection Agency water regulations and defunding Planned Parenthood and other women’s health clinics. These poison pills sent a political message: Zika solutions would be held hostage until the ransom for their causes had been paid.

Many in Congress feared the funds ear-marked for Zika research would finance abortions for infected women. “This push for more abortion access is heartbreaking,” lamented Representative Jeff Duncan (SC), failing to see that the real push was to ensure the delivery of healthy babies. Despite assurances by Paul Ryan, Speaker of the House, that no Zika funds would be spent on abortions, the bill failed to pass. The next day, Congress left for a seven-week vacation. In the words of CDC Director Tom Frieden,  “This is no way to fight epidemics.”  Congress, returning to work on September 6, will find an unprecedented CDC travel advisory for visitors to Miami, Zika mosquitos continuing their northward push, and testing positive for Zika every single day.

Zika will certainly not be the last health care crisis faced by the United States. A 2016 International Rescue Committee (IRC) report noted that previous reports on Ebola shared one weakness – neglecting to recognize the role of politics. While the public’s fears, both real and perceived, can have a political impact and should be addressed, scientific facts must not be ignored. By taking stock of past global health scares such as yellow fever and Ebola, political leaders can better handle the response needed today to combat Zika while also laying down the defenses for the health crises yet to come.