century to pose a serious threat to ‘global’ health security and to the stability and growth of economies. This was followed later by another novel disease threat, the H1N1 swine flu pandemic emerging from Mexico during the period 2009 and 2010 (Charu et al., 2011). H5N1 highly pathogenic avian influenza (HPAI) also arrived among these novel viruses and continued to spread through ecologic and economic transformations posing a potential threat of mutating to a human-human transmission (Cubley et al., 2008). Ebola and Marburg, referred to initially as the haemorrhagic viruses were more frequently reported from within sub-Saharan Africa (WHO, 2012b). In addition to these ‘new’ viruses, old diseases such as tuberculosis and malaria were also displaying resistance to modern medicine and were added to the list of ‘emerging and re-emerging infectious diseases’ (Farmer, 1999b; Morse, 1996; Leach & Dry, 2010).
Some authors argue that the concept of ‘emerging infectious diseases’ is used as a
justification to shift global health priority towards diseases perceived by wealthier nations as a potential threat to them.
“If certain populations have long been afflicted by these disorders, why are the diseases considered ‘new’ or ‘emerging’? Is it simply because they have come to affect more visible-read, more ‘valuable’-persons? This would seem to be an obvious question from the perspective of the African poor” (Farmer, 1999, p. 39). Despite the global burden of infectious diseases such as malaria, cholera, and typhoid (long entered into the history books of Europe and north America) borne by fragile health
systems in sub-Saharan Africa, priorities in global health have become skewed towards these ‘emerging infectious diseases’. This also became evident by recent policy changes to the International Health Regulations in 2005.
2.6.4 Revision of the International Health Regulations (IHR)
In 2002, the SARS virus spread to 25 countries resulting in over 800 deaths. Economic losses were estimated at between US$30 -50 million (WHO, 2003b). China however was under no legal obligation to report the disease under the IHR regulations at that time and the WHO had no legal authority to demand information. In response to this oversight and with an increased incidence of ‘emerging infectious diseases’ the WHO revisited the IHR. In 2005, the 1969 IHR’s were revised and adopted by the 58th
(WHA) for implementation by June 2007 (WHA, 2013). The revised regulations legally bind all 194-member states to the timely reporting of all incidents that pose a ‘public health emergency of international concern’ (PHEIC) occurring within 24 hours of detection. Declaring an event as a PHEIC is based on three main criteria: an event that has the potential to spread ‘internationally’, an event that is considered ‘unusual or unexpected’, and an event that has ‘significant potential to restrict travel or trade’. EVD among other ‘emerging infectious diseases’ are classified as potential PHEIC’s and have gained
considerable international attention within the realm of global health security and western public consciousness in recent decades.
All member countries are legally obliged to ensure that they strengthen their public health surveillance and response systems as a core priority underlying their public health systems. They are mandated to have adequate capacity for surveillance, reporting, notification, verification, response, and collaboration activities in place. The revised regulations also mandate member countries to develop legal and regulatory mechanisms to ensure that all IHR obligations are met from national to local level (Calain, 2006). The main aim of the revised IHR is based on creating an integrated international surveillance network to contain threats to ‘global’ health security when and where they occur (Calain, 2007a). A five-year deadline from the date of implementation (2007 - 2012) was put in place for all countries to meet IHR compliance.
However, the revised IHR provided no formal source of funding to low or middle-income countries to make the required investments for development (Fischer et al, 2011). Donor countries are encouraged to support health system strengthening in the areas of
surveillance and response capacities in developing countries justified as an investment in their own national interests (Fisher et al, 2011). Partnering it is claimed ensures that if other countries possess the capacity to detect and respond to a public health event before it spills across borders, this would protect their vital interests at home and abroad (Fisher et al, 2011).
In the aftermath of the 2014 - 2016 Ebola epidemic in West Africa, delays in the decision making process to declare it a PHEIC were critiqued (Gostin & Freidman, 2015; Heymann
et al, 2015). WHO declared the epidemic a PHEIC in August 2014, four and a half months after the outbreak had transcended international borders. This puts into question how the institutions governing response to pandemics define ‘international’ in relation to the
was declared a PHEIC it had spread across four West African countries; Guinea, Liberia, Sierra Leone and Nigeria with over 3,000 probable, confirmed and suspect cases and over 1,500 deaths reported among West Africans (WHO, 2014a).
An observation was made that the delayed declaration of a PHEIC in West Africa followed the death of two US citizens (Gostin & Friedman, 2015). In addition, a stark contrast was observed between the delayed interventions to the EVD outbreak in West Africa compared to the subsequent declaration of Zika virus as a PHEIC in 2016. Zika virus is a non-lethal pathogen identified in Uganda in 1947. Human reported cases were confined to equatorial Africa and Asia between 1952 and 2007. Spreading to French Polynesia in 2007 and 2014, it then emerged in a number of countries in South America including Brazil, Columbia, Guatemala, and Mexico in 2015. On February 2nd
two cases were identified in Texas, USA and on the 7th
February 2016 Zika virus was declared a PHEIC (Kindhauser et al., 2016). A bias in priority towards certain infectious diseases threatening the social and economic boundaries of wealthier nations lies in paradox to the ‘disease knows no borders’ rhetoric. The stark inequalities between those who control the global health policy agenda and those who experience the contextual realities on the ground are evident. Why certain diseases are perceived and responded to, as global crises worthy of international intervention while others are not can be considered through the social theories of global altruism and political realism.
2.6.5 Global Altruism
The theoretical assumption of global altruism is based on the understanding that certain diseases including EVD are perceived to be a major threat to human health and security because they transcend international borders beyond their point of emergence. Global altruism posits that a collaborated global surveillance and response network is ‘a global quality’ or a ‘global public good’ (GPG). In other words, there is a justified moral political claim to respond to EVD outbreaks for the global good of all.
As outlined above in section 2.6.2 control of infectious diseases that had the potential to transcend international borders and threaten public health or cause restrictions to
international travel or trade were traditionally under the sole mandate of the WHO. Section 2.6.3 makes reference to the emergence of an array of government and non-government institutions including private sector actors appearing across the global health landscape that