Georgetown University Law Center Georgetown University Law Center

Scholarship @ GEORGETOWN LAW Scholarship @ GEORGETOWN LAW

2015

3 Critical Challenges for Global Health Security 3 Critical Challenges for Global Health Security

Lawrence O. Gostin Georgetown University Law Center, gostin@law.georgetown.edu

This paper can be downloaded free of charge from:

https://scholarship.law.georgetown.edu/facpub/1615

314 (18) JAMA 1903 (2015)

This open-access article is brought to you by the Georgetown Law Library. Posted with permission of the author. Follow this and additional works at: https://scholarship.law.georgetown.edu/facpub

Part of the Defense and Security Studies Commons, Emergency and Disaster Management Commons, Health Policy Commons, International Public Health Commons, and the International Relations Commons

Copyright 2015 American Medical Association. All rights reserved.

The JAMA Forum

3 Critical Challenges for Global Health SecurityLawrence O. Gostin, JD

International institutions are poised tomake one of the most momentous de-cisions about the future of global health

security since the formation of the WorldHealth Organization (WHO) in 1948.

By the end of this year, 5 global com-missions will have published major cri-tiques of global health preparedness, allspurred by the Ebola epidemic, whichexposed deep flaws in the internationalsystem.

Th e s e c o m m i s s i o n s i n c l u d e t h eWHO’s independent Ebola Interim Assess-ment Panel, which reported in July thatsenior leaders failed to respond effectivelyduring the crisis in West Africa, calling for“significant transformation” of the agency(http://bit.ly/1JS5lQe); the WHO ReviewCommittee on the International HealthRegulations (IHR), which held its firstmeeting in Geneva late August (http://bit.ly/1E5thKN); the Harvard/London Schoolof Hygiene and Tropical Medicine Inde-pendent Panel on Ebola; the Global HealthRisk Framework Commission of theNational Academy of Medicine (formerlythe Institute of Medicine); and the UnitedNations (UN) secretary-general formed aHigh-Level Panel, which includes sittingheads of state to provide political supportfor major reforms of the global health sys-tem (http://bit.ly/1PgRHIk).

All the reports will feed into the Janu-ary meeting of the WHO executive board,with the final decisions taken by the WorldHealth Assembly in May 2016. There are con-cerns that 5 commissions will prove to becostly and duplicative. Moreover, there is noassurance that their recommendations willlead to the meaningful and enduring changesnow so badly needed in the global healthlandscape.

The Sovereignty ChallengeAlthough infectious diseases transcendborders, requiring international coopera-tion and collective action, states assertnational sovereignty as a justification forflaunting international norms (http://bit.ly/1lUq9aZ). The IHR requires states toreport emerging threats and to share

information. Governments, however, havehidden vital information. Saudi Arabia, forexample, hasn’t openly shared informa-tion about Middle East respiratory syn-drome (http://bit.ly/1JfD60q), which, withthe Hajj pilgrimage imminent, is alarming.West African states also did not fullyreport suspected cases of Ebola virus dis-ease until the crisis escalated (http://bit.ly/1PrWhSG).

As required by the IHR, the WHO is-sues temporary recommendations after de-claring a public health emergency of inter-national concern. Yet, state and nationalgovernments flouted WHO recommenda-tions during the influenza A(H1N1) and Ebolaepidemics by restricting travel and trade andinstituting inhumane quarantines. Quaran-tines in New York and New Jersey, for ex-ample, dissuaded health workers from vol-unteering in West Africa because of theprospect of confinement on their returnhome. These actions impeded the interna-tional response, making it harder for healthworkers and essential equipment to move toand from the affected regions.

Most importantly, the IHR requiresstates to develop core health systemcapacities. Yet, less than 35% of countrieshave met core capacities, and 48 countrieshave failed even to report (http://bit.ly/1NA3mms). WHO doesn’t even indepen-dently evaluate how countries perform, re-lying instead on unreliable self-assessments.High-income countries have not devotedsufficient resources to build health systemsin lower-income countries—although the USGlobal Health Security Agenda is now invest-ing in capacity building (http://bit.ly/1KoU33o).

The Challenge of InternationalCooperationClosely related to the sovereignty problemis the challenge of international coopera-tion. The international landscape is diverseand complex, with more than 175 initia-tives, funds, agencies, and donors (http://bit.ly/1KsNeCr). The UN has formed a healthcluster led by the WHO (http://bit.ly/1FkxD1u), with 32 partner institutions (both

inside and outside the UN), national govern-ments, and civil society. Beyond the healthcluster are multiple actors, including public/private partnerships (such as Gavi and theGlobal Fund), private industry, interna-tional charities (such as Médecins SansFrontières) and health ministries, amongmany others. And, of course, public healthgoes well beyond the health sector, span-ning agriculture, migration, trade, climatechange, and much more.

Coordination is vital in health emergen-cies to ensure that all actors understand theirroles and work cooperatively, without du-plicating efforts or erecting bureaucratichurdles. Yet, there has been a patent lack ofharmony in international humanitarian op-erations, ranging from responses to earth-quakes in Haiti and Nepal to the Ebola epi-demic. The failure of effective leadership, forexample, spurred the UN secretary-generalto establish the first emergency health mis-sion, the UN Mission for Ebola EmergencyResponse, to scale up the response on theground and create a unity of purpose (http://bit.ly/15qg8l5). The United States, theUnited Kingdom, and France all sent in mili-tary assets.

The WHO is constitutionally mandatedto “act as the directing and co-ordinating au-thority on international health work” (http://bit.ly/VFrPAj). Yet, it was either unwilling orunable to effectively lead the international

Lawrence O. Gostin, JD

Geor

geto

wn

Uni

vers

ityLa

wCe

nter

News & Analysis

jama.com (Reprinted) JAMA November 10, 2015 Volume 314, Number 18 1903

Copyright 2015 American Medical Association. All rights reserved.

Downloaded From: http://jama.jamanetwork.com/ by a Dahlgren Memorial Library-Georgetown University Medical Center User on 01/27/2016

Copyright 2015 American Medical Association. All rights reserved.

response to Ebola. WHO Director-GeneralMargaret Chan at one point stated thatthe WHO was not an implementing organi-zation, implying that it did not have a cen-tral role in leading activities on the ground.More importantly, WHO country offices re-portedly hindered international effortsto send health workers and medicalsupplies.

There are 2 central questions in any in-ternational emergency response. The first is“Who’s in charge?” The second is “Does aneffective command and control structure ex-ist to deliver all essential functions, includ-ing human resources, training, medical sup-plies, and logistics?” As the Haitian crisisdemonstrated, even a massive scale-up of in-ternational aid cannot work without a co-herent and complementary approach, inwhich actors work collectively to achieve thecommon good.

The “Good Governance” ChallengeGood governance is essential to ensurethat multiple actors operate openly, effec-tively, and with accountability, includinginternational organizations and nationalgovernments. It requires setting targets,creating indicators to measure progress,monitoring and evaluating outcomes,freedom of information and transparency,stewardship and honesty, civil societyengagement, and accountability—criticalfeatures often lacking at the national andinternational levels.

WHO offers a clear illustration of inef-fective governance (http://bit.ly/1I9oY7d),even though it is among the most demo-cratic organizations in the international sys-tem, with virtually all countries repre-sented at the Health Assembly, each with anequally weighted vote. Despite this, a fewpowerful donors, such as the United States,the European Union, and the Gates Founda-tion, heavily influence the organization. Ma-jor donors drive the global health agenda byfunding the agency with earmarked funds,which account for nearly three-quarters ofits overall budget.

In addition the WHO’s policies on openinformation and conflicts of interest arebroadly criticized (http://bit.ly/1KjvtEd). Un-like UNAIDS, the Global Fund, and Gavi, theWHO does not include civil society or othernonstate actors in its governance structures.

Many low- and middle-income statessimilarly exhibit major governance deficits.Often, their decisions are closed to publicscrutiny, they shun or even punish civil so-ciety organizations, and resist accountabil-ity mechanisms. The health sector, more-over, is among the most corrupt of allgovernment sectors (http://bit.ly/1fQ7kX2).Corruption not only siphons critical re-sources intended to improve local and na-tional health, but also undermines social co-hesion and fosters public distrust. Monopolypower, unchecked authority, unaccountabil-ity, and weak enforcement create opportu-nities for corruption.

The Window Is ClosingI’ve had the privilege of being a member of2 Commissions and advising 3 others, and Ihave little doubt that each will expose ma-jor gaps in global health security and offerradical solutions. But the window of politi-cal opportunity following the West AfricanEbola epidemic is rapidly closing, as memo-ries fade and as new daunting threats loom—ranging from ISIS and the refugee crisis inSyria to energy and climate change.

The question remains whether the en-trenched interests of powerful states willblock meaningful reforms. If this historic mo-ment passes with only tepid reforms, weought to hold our political leaders fully ac-countable.

Author Affiliation: University Professor andFaculty Director, O’Neill Institute for National andGlobal Health Law, Georgetown University LawCenter, and Director of the World HealthOrganization Collaborating Center on Public HealthLaw and Human Rights. His most recent book isGlobal Health Law (Harvard University Press).

Corresponding Author: Lawrence O. Gostin, JD(gostin@law.georgetown.edu).

Published online: September 16, 2015, at http//:newsatjama.jama.com/category/the-jama-forum/.

Disclaimer: Each entry in The JAMA Forumexpresses the opinions of the author but does notnecessarily reflect the views or opinions of JAMA,the editorial staff, or the American MedicalAssociation.

Additional Information: Information about TheJAMA Forum is available at http://newsatjama.jama.com/about/. Information about disclosures ofpotential conflicts of interest may be found at http://newsatjama.jama.com/jama-forum-disclosures/.

News & Analysis

1904 JAMA November 10, 2015 Volume 314, Number 18 (Reprinted) jama.com

Copyright 2015 American Medical Association. All rights reserved.

Downloaded From: http://jama.jamanetwork.com/ by a Dahlgren Memorial Library-Georgetown University Medical Center User on 01/27/2016