The Severe Acute Respiratory Syndrome (SARS) outbreak in 2003—the first pandemic of the twenty-first century—infected more than 8,000 people, killed 774 persons, and prompted the World Health Organization (WHO) to adopt in 2005 the most radical international health agreement in history—the International Health Regulations (IHR). Beginning in late 2019, the COVID-19 pandemic infected hundreds of millions, caused more than 7 million deaths, and led IHR state parties to amend the regulations at this year's World Health Assembly meeting.
The amendments have been hailed as a victory for multilateralism and global health. The amendments identified as the most significant, however, do not constitute game-changing reforms, especially concerning low-income countries' demands for equity and financial assistance, on which the negotiations reached, at best, a truce.
Other changes, such as the power to declare a pandemic emergency, do not address problems that COVID-19 exposed or caused, which renders praise for them misplaced. Despite its flawed response to COVID-19, lack of global leadership during the pandemic's first year, and embrace of vaccine nationalism, the United States emerges as a winner in the amendment process.
Changes That Didn't Bark
Arguments that WHO member states should amend the IHR arose before COVID-19, after previous international health emergencies, including the H1N1 influenza pandemic in 2009 and the West African Ebola outbreak in 2014. Those arguments, however, often prompted the fear that amendment negotiations could threaten some of the IHR's most important provisions, such as the WHO's ability to use nongovernmental information about disease events and seek verification from member states about such events based on that information.
In amending the IHR, WHO member states did not gut its sovereignty-biting aspects, even as more governments and politicians froth about infringements on sovereignty. That outcome suggests that COVID-19 did not shake countries' acceptance of core aspects of the IHR, which challenges narratives that the IHR failed during the pandemic. What WHO member states preserved in the IHR deserves as much praise as what they amended.
Changes That Make No Changes
An important revision made to the IHR in 2005 was granting the WHO director-general the authority to declare a public health emergency of international concern (PHEIC), even over the objections of the countries directly affected. The PHEIC declaration power applied to disease events that were, or could become, pandemics, as the PHEIC declarations on H1N1 influenza in 2009 and COVID-19 in 2020 illustrate. The WHO director-general subsequently determined that the H1N1 and COVID-19 emergencies were pandemics.
The IHR amendments formalize that approach by defining a pandemic emergency as a specific kind of PHEIC—and provide that the WHO director-general can declare, when appropriate, a pandemic emergency.
What WHO member states preserved in the IHR deserves as much praise as what they amended
Those new provisions, however, changed nothing about how the IHR functions. As defined, a pandemic emergency is a PHEIC, and no one has questioned that the PHEIC concept encompasses disease events that were, or could become, pandemics or that the WHO director-general could declare a PHEIC concerning such events. WHO member states did not oppose the director-general's past determinations that certain declared PHEICs were pandemics because such determinations did not affect their obligations under the IHR.
Controversies about the IHR's PHEIC provisions often arose from the WHO director-general's reluctance to declare emergencies for some disease events that met the PHEIC definition. That reluctance reflected discontent among WHO officials and global health experts that the IHR's PHEIC declaration provisions forced the WHO director-general to make a binary choice—PHEIC or no PHEIC. The IHR did not allow the director-general to issue different types of warnings about diverse disease events, a concept described as a tiered traffic-light system.
The IHR amendments did not adopt a traffic-light approach but instead clarified what was already clear—that the WHO director-general can declare an emergency concerning a disease event that has or could become a pandemic. As with previous determinations that a declared PHEIC was a pandemic, a pandemic emergency declaration does not alter the IHR's PHEIC provisions and processes, enhance the WHO director-general's authority, or create new pandemic-specific obligations for IHR parties.
Another amendment flagged as significant requires IHR parties to designate, in accordance with national law, a National IHR Authority to coordinate IHR implementation. The IHR already obliged parties to have a National IHR Focal Point responsible for implementation. The perceived need to require designation of an additional authority highlights the gravity of concerns about IHR implementation nearly 20 years after its adoption.
The new implementation mandate, however, is less significant than claimed. The IHR is a treaty, and, under international law, treaty parties are required to implement treaty obligations within their jurisdictions. How parties execute domestic implementation is a matter of national law.
The most serious problems with IHR implementation have not arisen because governments do not know who is responsible for implementing IHR obligations. Poor implementation predominantly occurs because of political decisions and, especially for low-income countries, a lack of resources to implement the IHR effectively.
Not Even Pocket Change
The IHR adopted in 2005 did not require high-income parties to provide financial assistance to help low-income countries meet new IHR obligations on, for example, building and maintaining core public health capacities. As the controversy triggered by Indonesia's withholding of H5N1 influenza samples in 2006 showed, the IHR also have no provisions facilitating timely low-income country access to health products, such as drugs and vaccines, during declared PHEICs. Low-income countries considered the IHR's lack of financial assistance and health-product access provisions inequitable before COVID-19, but collective action on those issues happened outside the IHR, including through the Global Health Security Agenda and the Pandemic Influenza Preparedness Framework.
Low-income countries wanted the amendment negotiations to strengthen equity in the IHR. The amendments added the promotion of equity and solidarity as an IHR principle and included new provisions designed to increase equitable access to health products and mobilize financial resources for developing countries.
The new equity provisions create obligations for the WHO concerning issues on which it is already engaged, such as supporting countries seeking to increase the scale and geographic diversity of health-product manufacturing. The amendments subject IHR parties to weak, loophole-laden, and process-oriented duties on health-product access, such as undertaking to collaborate with and assist other parties and support the WHO's activities, "subject to applicable law and available resources."
On financial assistance, the IHR amendments established the Coordinating Financial Mechanism to promote the provision and availability of financing to support IHR implementation, particularly by developing countries. The mechanism's responsibilities include promoting the provision of financing for IHR implementation as well as identifying financing sources and leveraging voluntary contributions for such implementation.
However, like the IHR adopted in 2005, the amendments on equitable access and financial-resource mobilization do not require high-income countries to provide equitable access to health products or financial resources for IHR implementation to low-income countries. That continuity cautions against seeing the equity and financial assistance amendments as groundbreaking. Instead, those amendments reflect lowest common denominator outcomes on issues where the interests of high-income and low-income countries remain in tension.
Change By Committee
Before COVID-19, global health experts analyzed whether periodic reviews of the IHR—through, for example, a conference of the parties—could strengthen implementation of the regulations. The IHR amendments incorporated that idea in establishing the States Parties Committee, which will meet every two years to facilitate implementation. The committee is not a compliance and accountability mechanism. Its mandate is to "be facilitative and consultative in nature only, and function in a non-adversarial, non-punitive, assistive and transparent manner" and to promote and support "learning, exchange of best practices, and cooperation."
The States Parties Committee is not a game-changing development. Before COVID-19, there was no shortage of processes that reviewed the IHR regularly and after major outbreaks. Those processes involved the WHO's IHR Secretariat, Executive Board, World Health Assembly, and review committees that analyzed the IHR following specific disease events. Outside analysis of IHR implementation took place, for example, in the Global Health Security Agenda and in the development of global health security indicators. Those processes operated as facilitative, consultative, non-adversarial, and nonpunitive efforts supportive of cooperation, learning, and the exchange of best practices.
In addition, conference-of-the-parties mechanisms often fail to strengthen treaty implementation on issues important in global health. The UN Framework Convention on Climate Change has held a conference of the parties for 28 years, and the world confronts alarming climate mitigation and adaptation crises. States parties of the Convention on Biological Diversity have met regularly as global biodiversity loss has reached tragic proportions. Many human rights treaties have oversight mechanisms involving states parties and nonstate actors, but activists lament the scale and severity of human rights violations occurring around the world.
The More Things Don't Change
The United States has strongly supported the IHR adopted in 2005. President George W. Bush backed revision of the IHR after SARS. The Barack Obama administration established the Global Health Security Agenda and tasked it with supporting IHR implementation. Amid the COVID-19 pandemic in 2020, President Donald Trump wanted reforms to strengthen the IHR. The Joe Biden administration helped achieve the international consensus behind the IHR amendments.
The outcome of the amendment negotiations represents a win for U.S. global health diplomacy. The amendments preserve aspects of the IHR that the United States values for protecting national and global health security, including the surveillance and information-sharing obligations. The United States agreed to amendments that do not alter how the IHR functions, impose on it substantive equity and financial assistance obligations, or change U.S. implementation of the IHR. The new provisions on equity, financing, and periodic meetings of IHR parties do not ruffle the U.S. global health security strategy.
The outcome of the amendment negotiations represents a win for U.S. global health diplomacy
In addition, the World Health Assembly approved the IHR amendments without negotiations on the Pandemic Agreement reaching consensus. Observers sense that the United States considered the IHR amendments to be more important, whereas low-income countries have prioritized the Pandemic Agreement. The lack of consensus on the Pandemic Agreement highlights that those negotiations are more contentious, particularly on equity and financing.
Going forward, the United States can participate in the extended negotiations on the Pandemic Agreement without worrying that an impasse in those talks will jeopardize the IHR amendments. That delinked context helps the United States because the resumed pandemic agreement negotiations promise hard bargaining on equity, financing, and other issues.
Although a win for the United States, the IHR amendments' domestic political and foreign policy importance should be kept in perspective. U.S. politics remain polarized over COVID-19, with politicians spending more time fighting about the origins of the COVID-19 virus than addressing the domestic public health problems that the pandemic exposed. Domestic political support for U.S. global health engagement depends more on the results of the general election in November than on the IHR amendments.
In foreign policy, the IHR amendments have no significance for American efforts to manage the geopolitical threats that the United States confronts. The amendments were adopted as the United States scrambled to support Ukraine against intensified Russian aggression, respond to Chinese military intimidation of Taiwan and other countries in the Asia-Pacific region, and navigate the worsening fallout from Israel's military campaign in Gaza. In this context, the ongoing global disintegration of multilateralism should temper enthusiasm that adoption of the IHR amendments restores faith in the potential of multilateral action.
