DTIC ADA559194: PANDEMICS: Recommendations for International Preparedness, Response and Coordination

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by  Defense Technical Information Center

PANDEMICS: Recommendations for
International Preparedness,
Response and Coordination
MATT BREW AND HAL SCHMIDT
The influenza pandemic of 1918 in terms of the toll in lives, but also the concerning pandemic preparedness,
was one of the worst global health havoc pandemics and epidemics can response, and cooperation through the
crises in recorded history. The wreak on weak governments. Age-old World Health Organization (WHO).
influenza pandemic of 1918-1919, diseases such as cholera, tuberculosis, This paper provides an overview of
known as the “Spanish Flu”, killed more and malaria, coupled with emerging the current structure of international
people than World War I--estimates diseases like HIV/AIDS, SARS, H5N1 organizations and policies related to
range somewhere between 20 and (Avian Flu), and H1N1 (Swine Flu) disease prevention and control, presents
40 million.1 In the two years that this demonstrate that the international com- a summary of pandemics that currently
scourge ravaged the earth, a fifth of munity cannot continue to isolate the threaten the global community, exam-
the world’s population was infected, disease challenges of one nation from ines several case studies reflecting the
and more people died of influenza in other nations, conceptually or practi- deficiencies in the current pandemic
a single year than in four-years of the cally.7 Increased trade and commerce preparedness and response policies on
Black Death Bubonic Plague from 1347 and the ability of international travelers an international level, and presents rec-
ommendations for improving the readi-
The 1918 influenza pandemic represents the threat that ness of the international community for
preventing and dealing with pandemics.
pandemics pose to the international community, not only
in terms of the toll in lives, but also the havoc pandemics
World Health Organization
and epidemics can wreak on weak governments.
First an understanding of the
function and structure of the WHO is
to 1351.2 It is estimated that 28% of all to go from New York to Beijing in less necessary. According to the WHO Con-
Americans were infected.3 The influenza than a day evidence the ever-increasing stitution, “The objective of the World
virus had an intense virulence, with a urgency and inter-dependence of global Health Organization…shall be the
mortality rate of 2.5% compared to the health conditions,8 especially the threat attainment by all peoples of the highest
previous influenza epidemics, which of pandemic disease spread. Given the possible level of health.”10 The Interna-
were less than 0.1%.4 Furthermore, current estimate global population of tional Health Conference adopted the
the death rate for 15 to 34-year-olds of 6.9 billion9, if a pandemic of the same WHO Constitution in New York from
influenza and pneumonia were 20 times virulence as the 1918 influenza were to 19 June to 22 July 1946, which repre-
higher in 1918 than in previous years, spread across the globe today, 2.3 billion sentatives of 61 States then signed on 22
which was extremely unusual since would be infected and 76 million would July 1946, clearing the way for the con-
influenza typically targets the elderly be killed. The global community cannot
and young children.5 Its effect contin- afford such a healthcare crisis, as even
Cadet Matt Brew is an Astronautical
ues to be felt, as the United States bases the most basic healthcare services are
Engineering major in the Class
its assumptions for severe pandemic insufficient in many states today.
of 2011. Cadet Hal Schimdt is
response on the 1918 influenza.6 This article asserts that the United
an Electrical Engineering major/
The 1918 influenza pandemic repre- States must take an active role in mobi-
Spanish minor and “Top Grad” in
sents the threat that pandemics pose to lizing support for the establishment
the Class of 2011.
the international community, not only of a direct international convention
14 Airman Scholar • Fall 2011
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1. REPORT DATE 3. DATES COVERED
2011 2. REPORT TYPE 00-00-2011 to 00-00-2011
4. TITLE AND SUBTITLE 5a. CONTRACT NUMBER
PANDEMICS: Recommendations for International Preparedness,
5b. GRANT NUMBER
Response and Coordination
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6. AUTHOR(S) 5d. PROJECT NUMBER
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14. ABSTRACT

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Standard Form 298 (Rev. 8-98)
Prescribed by ANSI Std Z39-18
stitution to enter into force on 7 April considered desirable.16 Additionally, the paredness, the Director-General (or his
1948.11 Eighty two articles comprise WHA oversees the financial policies of representative) may establish procedures
the WHO Constitution, outlining the the organization, reviews and approves by agreement of the member states that
functions, membership, organs, budget, the budget, instructs the Board and the permit him direct access to their various
voting, legal capacity, and interpretation Director-General to inform the member health administrations and national
of the WHO.12 states and international organizations, health organizations, governmental or
Of particular importance to pre- governmental or non-governmental, non-governmental.23 It is important to
paredness and response to pandemics, about any matter regarding health which note that this access may only occur
the constitution outlines the following the WHA considers appropriate.”17 with express permission of the member
WHO functions: “to establish and main-
tain such administrative and technical
75 percent of epidemics during the last three decades
services as may be required, including
epidemiological and statistical services; have occurred in countries where war, conflict, and
to stimulate and advance work to eradi- prolonged political violence have crippled their capacity to
cate epidemic, endemic and other dis-
respond.
eases; to develop, establish and promote
international standards with respect to
food, biological, pharmaceutical and The second body of the WHO is states. Moreover, he may establish direct
similar products…”13 Additionally, the Executive Board, which acts as the relations with international organiza-
Article 20 provides that each member executive organ of the WHO and meets tions whose activities and efforts come
state undertakes that it will take action at least twice a year.18 Its functions within the areas of responsibility of the
to comply with any convention or include advising the WHA on questions WHO.”24
agreement adopted by the WHA within referred to it by the WHA and on issues According to Professor Allyn Taylor
eighteen months after the WHA agrees assigned to the WHO by conventions, of the Georgetown University Law
to adopt said convention or agree- agreements and regulations, submit- Center, “The foundation of the WHO’s
ment. Following any action taken, each ting to the WHA for consideration unique responsibility to implement the
member state will notify the Director- and approval a general program of right to health is the organization’s affili-
General of the action taken, and if the work covering a specific period, and ation with the United Nations system
member state is unable to the conven- taking emergency measures within the as a specialized agency.”25 The United
tion or agreement within the time limit, functions and financial resources of Nations charter provides the basis for
it will provide a statement explaining the WHO to address events requiring the relationship between the UN and
the the reasons for non-acceptance. In immediate action.19 Specifically, “it may WHO—specifically those sections that
case of acceptance, each member will authorize the Director-General to take establish UN as the “directing and co-
make an annual report to the Director- the necessary steps to combat epidem- ordinateing authority on international
General of its status in implementing the ics, to participate in the organization of health work.”26 The WHO assumes the
convention or agreement.”14 health relief to victims of a calamity and chief responsibility to execute the aims
The WHO constitution establishes to undertake studies and research the of the UN Charter with respect to health
three bodies that carry out the functions urgency of which has been drawn to the and disease mitigation.27 With specific
of the WHO: the World Health Assem- attention of the Board by any Member focus on the preventing and limiting the
bly (WHA), the Executive Board, and or by the Director-General.”20 spread of diseases, the WHO promul-
the Secretariat. The WHA is composed The third body of the WHO is the gated the International Health Regula-
of delegates representing the member Secretariat, which is composed of the tions (IHR).
states, and it meets annually.15 It is Director-General and any administra-
tasked with determining the policies of tive and technical staff deemed neces- International Health
the organization, appointing the Direc- sary to the WHO’s operation.21 The Regulation
tor-General, reviewing and approving Director-General is responsible for According to the WHO, the “Inter-
reports and activities of the Board and of managing and reporting to the Execu- national Health Regulations (IHR) are
the Director-General and instructing the tive Board on the budget and expenses an international legal instrument that
Board about matters upon which action, of the WHO.22 Additionally, and of is binding on 194 countries across the
study, investigation or report may be interest in relation to pandemic pre- globe, including all the Member States of
Pandemic Interagency Response 15
WHO. Their aim is to help the interna- instrument provides state parties with malaria, and tuberculosis, the ongoing
tional community prevent and respond the parameters used to decide whether HIV/AIDS pandemics39, and the more
to acute public health risks that have the or not a specific event needs to be noti- recent outbreaks of SARS, H5N1, and
potential to cross borders and threaten fied to WHO under the 2005 update to H1N1.
people worldwide,”28 while limiting the IHR. When a state party identifies
interference with global travel and a notifiable event, it must report it to SARS
global commerce. The WHA adopted WHO within 24 hours of assessing the China’s failure to disclose infor-
the original IHR in 1969, having been public health information related to mation concerning the Severe Acute
preceded by the International Sanitary the event.35 Notification must “include Respiratory Syndrome (SARS) epidemic
Regulations of 1951, which Fourth details of any health measure employed in early 2003 prompted World Health
World Health Assembly adopted.29 The in response to the event as well as Assembly resolutions to update Interna-
1969 Regulations, which initially cov- accurate and sufficiently detailed public tional Health Regulations which would
ered six “quarantinable diseases” were health information available, including in turn broad outbreak control measures
amended in 1973 and 1981, primarily to case definitions, laboratory results and and expand information-sharing.40 Due
reduce the number of covered diseases number of cases and deaths.”36 to surveillance and investigation limita-
from six to three (yellow fever, plague As mentioned above, the 2005 tions of the previous regulations within
and cholera) and to mark the global IHR establishes a decision instrument sovereign nations, the viral respiratory
eradication of smallpox.”30 The 2005 for states to use in assessing whether illness spread from Guangdong, China
revisions to the IHR, which entered into or not public health events qualify as to over 40 countries around the world
within weeks, resulting in 8,098 infec-
tions and 774 deaths before the outbreak
Their aim is to help the international community prevent was finally contained.41 While press
reports claim that new WHA resolutions
and respond to acute public health risks that have the
give WHO greater “power” and “author-
potential to cross borders and threaten people worldwide
ity” to combat international threats
posed by infectious diseases, this case
study will determine if the revisions will
force on 15 June 2007, “require countries “notifiable”. According the IHR, the four
indeed do more to mitigate and prevent
to report certain disease outbreaks and decision criteria are: “(1) the serious-
modern-day diseases in the intercon-
public health events to WHO.”31 The ness of the event’s public health impact;
nected world.42
impetus to update them in 2005 was (2) the unusual or unexpected nature
Severe Acute Respiratory Syndrome
the 2003 SARS epidemic that began in of the event; (3) the risk of interna-
is a respiratory illness caused by the
China. As the WHO Director-General tional disease spread; and (4) or the risk
SARS-associated coronavirus (SARS-
at the time stated, “SARS has shown us that travel or trade restrictions will be
CoV). It typically begins with a fever of
the size of the challenges we face. These imposed by other countries.”37 Events
104.1° F or more and may include other
new measures will help us respond even that meet one or more of the criteria
symptoms such as headache, discom-
more effectively to the next public health must be assessed by the state party,
fort, and body aches. Some people have
threat.”32 and those that meet two or more of the
mild respiratory symptoms at the start
The updated IHR have in theory criteria must be notified to the WHO.38
and after 2-7 days may develop a dry
significantly improved the international The IHR is a key factor in current
cough that leads to pneumonia. Severe
community’s abilities and resources to international policy on preventing and
diarrhea occurs when SARS attacks the
respond to the spread of disease. In responding to pandemic diseases, as
digestive system in about 10-20% of
particular, the IHR 2005 created deci- well as on cooperation to mitigate their
patients. The infection spreads primarily
sion instrument criteria that facilitate effects.
through close person-to-person contact;
more rapid assessment and notifica-
the virus that causes SARS, in particu-
tion of health/disease events.33 Under New Threats
lar, is transmitted most readily through
the IHR, state parties are required to The primary factors making pan-
indirect contact by infected droplets
assess at the national level all reports demic preparedness a crucial issue for
that are inhaled or land on a surface or
of urgent events inside their territories international security are the resur-
object when a person coughs or sneezes.
within 48 hours by applying the decision gence of the some of the human race’s
When another person touches the
instrument specified by the IHR.34 This oldest nemeses in the forms of cholera,
16 Airman Scholar • Fall 2011
contaminated surface and then touches after being exposed to it. The sever- housing estate where 213 people had
their mouth, nose, or eyes, the virus is ity of the SARS symptoms and rapid already been admitted to the hospital
passed on. Those at risk of becoming infection of health care workers wor- for SARS to prevent spread beyond the
infected with SARS include people age ried international health authorities of 15,000 residents of the estate. In April,
40 or older, especially those over 65, and a new pneumonia epidemic. Thus, in China began quarantining citizens with
people with other medical conditions March 2003, the WHO issued its first SARS to camps and resorts to further
or returning illnesses that weaken the global alert about SARS. When a doctor isolate the infection. Also in April,
immune system. Health care workers treating the first affected people in Hong criticism in China and abroad emerged
and family members of someone who Kong stayed at a hotel in the Kowloon concerning the undercounting of SARS
is infected with SARS are also cases in hospitals. When cases would
at risk. As one might expect, be identified as “probable” in Taiwan,
health care workers were cases in Shanghai would be identi-
most affected from the SARS fied as “suspected” and death cases
epidemic in 2003.43 due to SARS were reported as being
The first case of SARS due to other complications.44 Finally,
was reported in the south- under mounting pressure, Chi-
ern province of Guangdong, nese officials allowed international
China in November 2002. officials to investigate the situation.
The patient was a farmer who, It revealed an old healthcare system
despite being attended to at a with bureaucracy and a lack of com-
local hospital, died soon after munication in an attempt to con-
without a known cause of vince its citizens and the world that
death. Suddenly, five people everything had been going smoothly.
were reported dead in an China finally decided to cooperate
outbreak of a flu type virus. with the WHO and updated their
While the Chinese govern- total cases to 1190 with 46 deaths. On
ment took initial action to June 26, 2003, the WHO stated that
prevent the spread of the “the global public health emergency
infection, it did not notify caused by the sudden appearance and
the WHO of the “Atypical rapid spread of SARS is coming to an
Pneumonia” outbreak until end.”45 Regrettably, the end came with
February 2003 when it a total of 774 deaths.
became clear that it could In order to prevent sovereign
US AIRMAN PROVIDING VACCINE TO
not contain the epidemic. nations from similarly hiding or
COLOMBIAN WOMAN AND CHILD
Even then, the information masking the effects of an epi-
was vague. This unwilling- demic, the WHA adopted two
Peninsula, he infected 16 of the hotel
ness to cooperate with the international resolutions on SARS and international
visitors. The WHO later issued its first
community ultimately meant delays in law on infectious disease control at
SARS-related travel advisory when cases
efforts to control the worldwide out- its 56th Annual Meeting.46 The SARS
were reported in Singapore, Canada,
break. resolution advises WHO member
Hong Kong, and the United States as
In February, cases began appear- states to take eleven courses of action
a result of those visitors traveling. The
ing in Vietnam when an American to “enhance, support, and strengthen
WHO coordinated international effort
businessman traveling from China was national, regional, and international
to identify and treat SARS. Experts from
treated for pneumonia type symptoms efforts to address the SARS outbreak.”47
the Organization were even provided to
in Hanoi and the medical staff assist- The resolution does not create new
assist the Chinese Ministry of Health in
ing him developed the disease. Doctor obligations, but simply recommends
epidemiological and laboratory support
Carlo Urbani at the hospital identified that WHO member states report SARS
upon request.
the unusual outbreak and informed the cases quickly and transparently. The
At the end of March, the Hong
WHO and Vietnamese government. resolution also requests the WHO
Kong Department of Health issued
He too would later die from the disease Director-General take eleven steps to
isolation orders for the Amoy Garden
Pandemic Interagency Response 17
respond to SARS. Each request, like the While WHO issued SARS related alerts infectious disease can weaken and desta-
request to “strengthen the functions throughout the outbreak, its authority to bilize state governments.53 According to
of WHO’s Global Outbreak Alert and do so is not specifically stated in previ- UNAIDS, there are 33.3 million people
Response Network,” falls into existing ous IHR or in the WHO Constitution. globally living with HIV, the AIDS
areas of WHO policy for disease control, This does not seem to result, however, causing virus, of whom 22.5 million are
meaning WHO powers have not really in drastic change of international law. living in sub-Saharan Africa.54 As Dr.
increased. 48 The global alerts issued during the Peter Piot, former UNAIDS Executive
According to David Fidler, the IHR epidemic were met, so acceptance of this Director, warns, “How can govern-
resolution also does not change existing WHO capability was present before the ments function, public services operate,
international law by giving WHO more resolution. Furthermore, WHO places agriculture and industry thrive, and law
power and authority. The WHO Con- the decision of how it will use its ability enforcement and militaries maintain
stitution states that WHA resolutions to issue alerts in the hands of WHO security, when they are being stripped
are not legally binding. For instance, member states. According to the WHO of able-bodied and skilled women and
the WHA can adopt treaties or IHR, but Constitution, alerts may be issued “on men.”55 Exacerbating the issue is that
they only become binding international the basis of criteria and procedures countries with poor governance tend to
law when a WHO member state has jointly developed with Member States.”51 resist IHR with the intention to protect
agreed to be bound. The provision of Although the resolutions do not state and global populations because
the resolution to consider information create international law that binds its they appear to threaten their national
attained from non-governmental sources member states, they do serve as exam- sovereignty.56 AIDS, like the SARS and
and to check it using disease study prin- ples of “soft law,” or non-binding norms, H5N1 viruses, emphasizes the impor-
ciples had already been approved by the principles, and practices that influ- tance of rising above the concept of
WHA.49 The WHO’s Global Outbreak ence state behavior.52 They encourage sovereignty if global pandemics are to be
Alert and Response Network had been member states to cooperate with other effectively prevented or contained.
using that technique since it was created countries and with WHO in disease AIDS is the potentially life-threat-
in 1998. Unfortunately it seemed unac- surveillance and outbreak response. The ening final stage of the human immu-
knowledged during its existence that WHO cannot enforce this duty but it is nodeficiency virus (HIV) infection. The
while the network provided opportuni- still politically powerful. One reason is virus weakens the immune system by
ties for greater surveillance, it also posed because the SARS outbreak has proven attacking helper T cells, which serve
challenges to make sure government that international cooperation is in a as the “main switch” for the immune
responses to outbreaks were appropri- country’s self-interest. China suffered in response. By the time an HIV patient is
ate. Likewise, the provision that recom- public health as well as politically and diagnosed with AIDS, which can take 10
mends the Director-General collaborate economically because of its initial deci- or more years from the time of the HIV
with national authorities in evaluating sion to not cooperate, and now serves infection, the body has fought hard to
a disease threat and amount of control as an example of what happens when defeat the virus, but is beginning to lose
measures as well as performing on- a nation attempts to hide an outbreak the battle. The immune system is crip-
the-spot studies is approved by WHO or does not accept assistance. Another pled, giving disease-causing organisms
policies. The resolution does not give the reason is that the WHO gained credibil- that are common in the environment the
WHO power to send personnel into a ity in its response to the SARS outbreak opportunity to cause infection. When
country to investigate an outbreak with- among its member states. Coupled the helper T cells should be activated
out that country’s permission. As one with new resolutions, the organization to fight the invader, the cell is activated
WHO spokesman said, “any country has is leveraging its position to strengthen instead by the viral RNA to become a
an ultimate veto over allowing a visitor international infectious disease control. virus factory for itself. The major modes
entry; there’s no way around that.”50 The of HIV transmission include unpro-
right to sovereignty, then, still poses a HIV/AIDS tected sexual activity, intravenous drug
significant challenge to effective mitiga- Acquired Immune Deficiency use, and infected mother to the child
tion of disease spread. Syndrome (AIDS), a pandemic whose before or during birth through the pla-
The request that the Director-Gen- spread and adverse effects (often sick- centa.57 Given these modes of transmis-
eral alert the international community ness and death) occur prevalently in, sion, it does not come as a surprise as to
of a serious public health threat arguably but are not limited to, fragile states and why fragile and ungoverned states are
grants the WHO new political power. ungoverned spaces, has revealed how most affected by HIV and AIDS. These
18 Airman Scholar • Fall 2011
REGIONAL HIV AND AIDS STATISTICS - 2009
Adults & Children Adults & Children Prevalance among Adult & child
living with HIV newly infected adult population Deaths due to
with HIV Aids
Sub- Saharan Africa
22.5 million 1.8 Million 5.0% 1.3 Million
Middle East and North Africa 460,000 75,000 .02% 24,000
South and South-East Asia 4.1 Million 270,000 .03% 260,000
East Asia 770,000 82,000 0.1% 36,000
Central and South America 1.4 Million 92,000 0.5% 58,000
Caribbean
240,000 17,000 1.0% 12,000
Eastern Europe and Central Asia 1.4 Million 130,000 .08% 76,000
Western and Central Europe 820,000 31,000 .02% 8500
North America 1.5 Million 70,000 .05% 26,000
Oceania 57,000 4500 .03% 1400
Total
33.3 Million 2.6 Million .08% 1.8 Million
states often lack the health education, in the fight against AIDS. The efforts of nation against vulnerable populations
training, and infrastructure needed for these organizations seem to be produc- are among the factors that continue
HIV and AID prevention and treat- ing positive outcomes. From 2001 to to impede access to HIV prevention,
ments. 2009, the rate of new HIV infections treatment, care and support services.”62
The table above shows the regional in 33 countries (22 of which were from Yet another issue is government
HIV and AIDS statistics. While clearly a sub-Saharan Africa) decreased by at ambivalence toward agencies providing
global issue, concern is easily diverted to least 25%. In 2009, services to prevent assistance with HIV/AIDS programs
underdeveloped and developing parts of mother-to-child transmission of HIV and their own National AIDS Control
the world. exceeded 50% worldwide. Before the Program.63 Sovereign nations need to
One of the leading organizations end of 2010, greater than 6 million embrace the epidemic as a real problem
in combating HIV/AIDS is UNAIDS, people were placed on antiretroviral that deserves their attention and, in
a joint United Nations program that treatment, or drugs that slow the replica- many cases, external help.
“leads and inspires the world in achiev- tion of HIV, in low and middle income
ing universal access to HIV prevention, countries.60 H5N1
treatment, care and support.”58 As a Despite these achievements, there Another recent example of the
UNAIDS Cosponsor, WHO is respon- are still many areas in which to improve. challenges to current pandemic response
sible for leading the response to HIV/ For every person who starts antiret- policies was Indonesia’s refusal to
AIDS. WHO supports the development roviral treatment, two people become share H5N1 (Avian Flu) samples with
of national HIV/AIDS treatment and newly infected with HIV. Furthermore, WHO in late 2006. Indonesia chose
care programs while increasing HIV 7,000 people a day become newly not to share influenza H5N1 samples
prevention and strengthening health infected with HIV.61 According to with WHO for “risk assessment (e.g.,
systems.59 Many other organizations UNAIDS, “weak national infrastruc- surveillance) or risk management (e.g.,
such as the NGO World Vision also aid tures, financing shortfalls and discrimi- vaccine development) purposes.”64
Pandemic Interagency Response 19
Indonesia’s decision was primarily con- law under the Convention on Biological has identified a variety of innovative
cerned with the iniquities in the global Diversity (CBD), which was developed mechanisms for securing international
vaccine system: developing countries to address biological diversity.70 The agreement on environmental matters.
cannot afford vaccines developed from CBD recognizes that countries have By structuring its conventions with
samples that pharmaceutical companies sovereign control of biological resources broadly framed international agree-
freely obtain from the WHO-operated found within their territories.71 It is ments combined with requirements for
Global Influenza Surveillance Network unlikely that Indonesia would have been implementation through domestically
(GISN).65 Indonesia’s concerns were able to successfully withhold samples based legislation, the organization has
reinforced by WHO’s acknowledgment once the revised IHR took effect in May attracted the widest possible consensus.76
that patents had been sought on modi- 2007. However, a continued weakness of The Montreal Protocol on Sub-
fied versions of H5N1 samples shared the IHR (and the current international stances That Deplete the Ozone Layer to
through the GISN without the con- approach to pandemic preparedness) the Vienna Convention for the Protec-
sent of the countries that supplied the is that is does not mandate that coun- tion of the Ozone Layer provides a
samples. H5N1’s spread and the threat tries share infectious disease samples, prime example.77 To slow the depletion
of pandemic influenza heightened this only that states alert the WHO if public of the ozone layer, UENP cultivated
perceived inequality, as experts posited health incidents meet the decision broad consensus among nations.78
that developing countries would have criteria.72 Under the Montreal protocol, ratifying
minimal access to vaccine for pandemic nations are required to gradually reduce
influenza without substantial changes in RECOMMENDATIONS their consumption and production of
global vaccine production and supply.66 Based on the significant threats the particular ozone-depleting chemicals. It
The standoff showcases the difficul- international community faces from also states that member nations should
ties posed by the current non-binding diseases old and new, action must be establish domestic legislation and poli-
soft law policies related to cooperation taken to better secure the global com- cies that conform to the convention.79
on disease spread and fundamental munity from the possible catastrophe Many governments established national
problems extant in the global vac- of a world-wide pandemic. Two areas legislation in conformity with the treaty,
cine system. Essentially, Indonesia of focus are prominent: prevention including the United States, Mexico, and
claimed that the samples are its sov- and response. Before examining the twelve European nations.”80
ereign property and do not constitute areas from improvement, it is useful to The International Maritime Organi-
resources that other countries or the investigate whether or not international zation (“IMO”) has also employed agree-
international organizations can access organizations have been successful in ments that appeal to a broad base of
and use without Indonesia’s consent.67 the past in attempting to convince states nations, coupled with nationally crafted
This claim directly contradicted the to adopt international law to address implementation measures, to secure
ethos and practice of sample sharing multi-laterally threats to international adoption of international agreement on
under which GISN had operated, which security. marine environmental matters.81 As a
are based on accessing and analyz- Precedent for the creation of inter- consequence of the 1989 Exxon Valdez
ing influenza virus samples to inform national laws by international orga- oil spill, IMO convinced nations to take
development of interventions.68 Legally, nizations that motivate governments action on the grave threat posed by oil
Indonesia’s arguments were plausible, to adopt appropriate legal standards pollution, and encouraged adoption of
as WHO did not organize GISN under to address international issues can be the International Convention on Oil
treaty law, so no states had treaty obliga- found in the experiences of the United Pollution Preparedness, Response and
tions to share samples. In addition, Nations Environment Programme Cooperation (OPRC).82 According to
international law on infectious diseases (UNEP) and the International Mari- the convention, “Parties to the OPRC
applicable to Indonesia when this con- time Organization (IMO).73 In some convention are required to establish
troversy began contained no obligations cases, UNEP has served as an effective measures for dealing with pollution inci-
to share samples with WHO, as the 2005 lawmaking platform for nations in areas dents, either nationally or in co-opera-
revision to the IHR had not yet taken related to the human and environmen- tion with other countries.”83 In addition
effect.69 tal health.74 By doing so, UNEP has to wide-ranging measures for emergency
In addition to exploiting basic significantly advanced the development international response, the treaty man-
sovereignty principles of international of international law that is focused on dates that each nation institute its own
law, Indonesia exploited international local conditions and concerns.75 UNEP national system for preparedness and
20 Airman Scholar • Fall 2011
response, including a national contin- tional pandemic emergency fund for language establishes measures for pun-
gency plan.84 As of March 2011, 105 use in case of a pandemic outbreak in ishing ratifying states that do not comply
states, including the United States, have a country that ratifies the convention. with the convention. These measures
signed the OPRC.85 This fund would be used to provide might include denying states access to
The success of UNEP and IMO vaccine research and production for the the international pandemic emergency
illustrate that international organizations disease in question and medical care for fund, as well as denying access to scien-
can have significant influence on devel- infected persons. Release authority for tific data related to pandemic prevention
oping international hard law. The OPRC funds would fall to GOARN, perhaps produced by WHO and GOARN.
serves as an excellent model for a global supplemented by a voting process for The ICPPRC would constitute an
convention on pandemics, perhaps even all ratifying nations. This fund would enormous step in improving inter-
titled “The International Convention on ensure GOARN and the WHO have national preparedness and response
Pandemic Preparedness, Response and resources ready to immediately put mea- capability for a pandemic, but the U.S.
Cooperation” (ICPPRC). The conven- sures in place to minimize the effect of a and global community must also address
tion would specify mandate that state pandemic outbreak. the global health system in order to
parties take certain precautions against Next, the convention would specify effectively support the adoption and
pandemic spread, establish manda- that WHO employees and GOARN implementation of the ICPPRC. To
tory reporting procedures, and make it members are allowed access to ratify- begin to address the global health
incumbent upon developed state parties ing states’ populations for research system, the global community—led by
to aid lesser developed parties in dealing and sample collection without needing the U.S.—needs to accomplish two criti-
with pandemic outbreaks. The United permission from the state in question to cal tasks. First, the U.S. must spearhead
States should sponsor and promote the enter the state’s territory. This require- a program to ensure vaccines are more
adoption of such a convention through ment is intended to prevent future accessible to Third World countries and
the mechanisms of the WHO and IHR, incidents similar to Indonesia’s refusal developing countries that are most vul-
while emphasizing the multi-lateral to share H5N1 samples with the WHO nerable to pandemic disease spread and
nature of the convention.
The ICPPRC would reinforce the
With the current budget-cutting atmosphere in
efforts of WHO’s already established
Washington D.C., it will be all too easy for pandemic
Global Outbreak Alert and Response
Network (GOARN). The stated primary preparedness to fall by the wayside.
aims of GOARN are to:
in 2006, which increase the likelihood the ensuing social instability that can
Assist countries with disease control
of pandemic spread and decrease the result from pandemic disease spread.
efforts by ensuring rapid and appro-
international community’s ability to A salient example of the international
priate technical support to affected
provide aid to affected states. (Indo- community’s failure to support devel-
populations, investigate and character-
nesia’s issues with the global vaccine oping countries with affordable and
ize events and assess risks of rapidly
supply system are addressed later in this reliable vaccines is the H5N1 outbreak
emerging epidemic disease threats, and
paper). However, WHO and GOARN mentioned previously. Indonesia’s
support national outbreak preparedness
would only be able to take samples with argued that the WHO’s handling of the
by ensuring that responses contribute
the assistance of domestic health care development of H5N1 vaccines incident
to sustained containment of epidemic
officials, to ensure proper treatment of exposed inequities in the global influ-
threats.86
infected persons and to notify the state enza surveillance system.87 Developing
The ICPPRC would give GOARN
of the occurrence. countries provided information and
more financial and technical resources
Finally, the convention would virus samples to the WHO-operated
to accomplish its objectives of better
strengthen WHO’s enforcement capa- system, pharmaceutical companies in
securing the global community against
bilities if ratifying countries choose not industrialized countries then obtained
the threat of pandemics and mitigating
to comply with the convention. Reliance free access to such samples, exploited
their effects, as well as provide GOARN
on the tradition adherence interna- them, and patented the resulting
with better access to nation’s populations
tional laws like the OPRC and Montreal products, which the developing coun-
for study and research.
Protocol would be the primary basis tries could not afford.88 A pandemic of
The first requirement of the conven-
for enforcing the ICPPRC. However, global scale would place unprecedented
tion would be to set aside an interna-
the convention should also include that demands on both international and
Pandemic Interagency Response 21
national health officials and vaccine 2010.95 Economic losses due to Somali The reactionary pattern of interna-
companies.89 “The planning effort will piracy are estimated at between $3 and tional law on infectious diseases can no
be more than a matter for experts in $5 billion since the pirates began their longer be considered adequate among
the fields of influenza virology, surveil- attacks in the mid 2000’s.96 Addition- an international community at risk of
lance, and epidemiology; it must also ally, the failed Somali state stands as a disastrous pandemics from unknown,
involve experts in international politics, fertile training and recruitment area future repositories of virulent diseases.
economics, and law.”90 As recommended for extremist Islamic groups. The U.S. In other words, instead of creating law in
by Dr. David Fedson, a global influenza and the international community must response to an outbreak, states neglect-
vaccine fund “might be needed to facili- ensure that WHO has sufficient funding ing public health and failing to report
tate multinational vaccine purchases to increase basic health care services in disease events to authorities, and then
and distribution, especially for countries developing countries, especially those more guidelines being recommended,
with limited resources.”91 This fund that teeter on the border of becoming states need to work multi-laterally with a
could be implemented as part of the failed states. strong organization defining and enforc-
aforementioned international pandemic ing acceptable behavior. As Taylor notes,
emergency fund, or as a separate fund CONCLUSION “Objective conditions of international
that is constantly in use. The U.S. should International coordination for the life, as reflected by the rapid interna-
take steps to improve the global vac- prevention and response of major infec- tional spread of disease in general, and
cine supply system, making it equitable, tious disease outbreaks is insufficient the HIV/AIDS pandemic in particular,
affordable, and efficient. under current WHO and IHR capacities. evidence the ever-increasing urgency
Second, the U.S. and the interna- In order to address national sovereignty, and inter-dependence of global health
tional community must increase WHO primarily “soft law” IHR, and failed/ conditions.
funding to deal with basic healthcare fragile state challenges to effective Taking steps to improve the interna-
needs and healthcare emergencies international policy, a global convention tional community’s pandemic prepared-
in failed states and developing coun- on pandemics called “The International ness will not be an easy task, especially
tries. A prime example of the results of Convention on Pandemic Prepared- as the world continues to recover from
neglecting this issue is the international ness, Response and Cooperation” should the 2007-2009 global recession. With the
community’s lack of financial support be established. This convention will current budget-cutting atmosphere in
for improving healthcare in Somalia.92 strengthen GOARN in disease surveil- Washington D.C., it will be all too easy
According to WHO spokesperson Paul lance, enforce and strengthen IHR for pandemic preparedness to fall by the
Garwood, “WHO had requested, in among ratifying countries, as well as wayside of national legislation. How-
the 2010 Consolidated Appeals Process ensure the U.S. takes the lead in making ever, the stakes are high—the world can
for Somalia, $46 million, of which only vaccines and funding for basic health- ill afford another global outbreak of dis-
8 per cent have been funded so far.”93 care services and healthcare emergencies ease on the scale of the 1918 influenza
The WHO’s efforts in Somalia have readily available to vulnerable develop- pandemic. The United States must step
resulted in millions of children receiving ing states. Cronin speaks to the impor- into its role as a global leader and meet
vaccinations and hundreds of medi- tance of the latter: the pandemic threat head-on before it
cal staff receiving training in surgery Countries beset by poor gover- strikes while the world is unprepared.
and surveillance of disease outbreaks. nance and low levels of state capacity
However, the WHO is preparing to have failed in today’s world to contain
reduce these activities due to inadequate and manage the spread of a contagion
NOTES
financial support, even as reported and mitigate its economic and politi-
cholera cases continue to rise and the cal toll. The data here are compelling: 1 Molly Billings, “The Influenza Pandemic of
risk of more outbreaks is very high.94 75 percent of epidemics during the last 1918,” Human Virology at Stanford, 1997, <http://
This is exactly the situation the United three decades have occurred in coun- virus.stanford.edu/uda/>.
States and the international community tries where war, conflict, and prolonged
2 Ibid, 2.
cannot allow to occur. In the case of political violence have crippled their
Somalia, the absence of a functioning capacity to respond, leaving their neigh- 3 Jeffery Taubenberger and Ann Reid, “Initial
government has led to piracy that has bors and the world vulnerable. (Cronin Genetic Characterization of the 1918 “Spanish”
adversely affected international ship- 105-106).97 Influenza Virus,” Science, 1997, <http://www.bi.ku.
ping, as 219 attacks on ships occurred in dk/dna/course/papers/L2.taubenberger.pdf>.
22 Airman Scholar • Fall 2011