In my last post, I introduced the topic of the strengths and weaknesses of the International Health Regulations (2005) as they have been exposed by the world’s response to the Ebola outbreak generally and by the World Health Organization’s response specifically. In this post I’ll address both a strength and a weakness: Annex 2 to the IHR which provides a classification scheme and algorithm for notification of events that may constitute a public health emergency of international concern (PHEIC). The strength of the IHR is that the classification scheme developed to handle potential PHEICs worked more-or-less as it should. The weakness is the IHR’s failure to fully contemplate the iterative nature of PHEICs or the latent delays that might be caused by an outbreak not specifically designated for notification under Annex 2.

Annex 2 to the IHR requires notification to WHO of any case of smallpox, poliomyelitis due to wild-type poliovirus, human influenza caused by a new subtype, or SARS as those are “unusual or unexpected and may have serious public health impact”. Ebola falls within a second category of diseases that requires an assessment that “the public health impact of the event [is] serious.” It is the seriousness of the Ebola outbreak that WHO will eventually be blamed for failing to expeditiously assess. Indeed, WHO officials at various levels have already tacitly conceded as much. Yet WHO was relatively quick to declare PHEICs for the international spread of wild poliovirus and H1N1 influenza.

Annex 2, of course, regulates the notification systems within the IHR, not what WHO does with the information once it is received. It is this aspect of WHO’s response that reveals at least one key weakness in the IHR: the lack of a system for internalizing the effect one PHEIC may have on subsequent PHEICs. In the case of Ebola, WHO’s slow response was due in part to the differences in transmission between highly infectious diseases like influenza and polio and diseases like Ebola which are less contagious but with long incubation periods between infection and symptoms. WHO’s Director-General, Margaret Chan, an expert in SARS and avian influenza, was criticized for failing to effectively define or convey the (relatively light) severity of 2009 H1N1. The decision to declare a Phase 6 influenza pandemic in 2009 triggered production and procurement clauses in vaccine manufacturers’ contracts with governments, provoking accusations that conflicts of interests on WHO’s Emergency Committee drove the arguably premature declaration. So both the content, structure, and history of PHEICs played a role in WHO’s slow response to Ebola.

There are, of course, other reasons, many of which have nothing to do with the IHR specifically. WHO is governed by nation-states who have decreased WHO’s budget and oriented it toward different health priorities than the IHR contemplate. WHO’s Africa office initially rebuffed overtures by the U.S. Centers for Disease Control and Prevention to take a leading role. The dismal state of health infrastructure in Guinea, Liberia and Sierra Leone as well as cultural practices surrounding death increased the chances for dramatic spread of the disease.

But to be sure, the IHR themselves establish an implicit hierarchy and embed, mostly unintentionally, a scheme for resource redistribution that may be inconsistent with the public health emergencies that facilitated their adoption. Fortunately, the IHR contain provisions that allow Member States to address those gaps, if there is political will to do so.