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International public health emergencies

  • Page updated onMarch 16, 2025
International public health emergencies
Photo: Bruno Abarca

In 2009, an outbreak of influenza A (H1N1) put the entire planet on alert. There had been other pandemics before, of course. However, this was the first since the new International Health Regulations were agreed in 2007. This set of legal responsibilities and duties in the face of international public health emergencies was now being put to the test. Moreover, the declaration of this outbreak as a Public Health Emergency of International Concern would not be the last. Following the influenza A (H1N1) pandemic there have been seven other declarations for polio, ebola, Zika virus, COVID-19 and monkey pox (mpox).

Some of these international public health emergencies have had major consequences in populations affected by humanitarian crises. In these contexts there are weak health systems and specific difficulties in responding to epidemics. This, added to the resurgence of these types of infections and the slow progress and evolution of global commitments to public health, invites reflection. What will be the next big epidemic? How will it affect the most vulnerable populations? Will we be prepared?

The International Health Regulations 2005

There is a legal duty to respond to international public health emergencies

The current International Health Regulations (IHR) were adopted in 2005. It was largely motivated by the outbreak of severe acute respiratory syndrome that in 2002-04 affected more than 8,000 people in 29 countries. Since then, it has been the main global instrument for preventing and responding to the international spread of diseases and public health emergencies. Its measures also seek to respect the dignity, freedom and rights of people, without unnecessary interference with international transport and trade.

The Regulation is a binding legal framework for all member states of the World Health Organization. It has antecedents in international agreements of the 19th and 20th centuries for the control of some infectious diseases. After coming into force in 2007, it was updated in 2014 and again in 2022. The latest amendments came into force in May 2024.

The regulation provides a framework for the public health functions of the states

On the one hand, the International Health Regulations provide a framework for the routine public health functions of a state. Moreover, it mandates that all countries assess, strengthen and maintain their capacity for epidemiological surveillance, risk assessment, reporting and response. This, however, may require for many countries large investments and international technical support. For this reason, several years were given for all countries to make it operational.

This framework also obliges states to establish a national center or public health department. It must be responsible for verifying the events detected through epidemiological surveillance. Likewise, it is in charge of notifying the World Health Organization of the most important ones. These are the ones that may constitute a Public Health Emergency of International Concern (PHEIC). These emergencies are defined as extraordinary events that constitute a risk to the public health of other States through the international spread of disease. As such, they may require a coordinated international response.

The IHR also provides a framework for international coordination in public health

On the other hand, the International Health Regulations also provide a framework for the coordination of actors in the international response to the most urgent threats. These can affect multiple countries and even the entire planet. According to this framework, only the Directorate General of the World Health Organization can declare a Public Health Emergency of International Concern. To do so, it must consult with an Emergency Committee.

Despite the IHR, the overall preparedness and response capacity can be greatly improved

Having a binding legal framework is no guarantee of success. Successive international public health emergencies have demonstrated this. With each major pandemic and epidemic, weaknesses and problems in global preparedness and response capabilities have been revealed. As Harvey V. Fineberg, chairman of the committee to review the operation of the International Health Regulations in the influenza A (H1N1) pandemic: "Pandemics are fearsome masters".

Influenza A (H1N1) 2009-2010 and public communication issues

The influenza A (H1N1) pandemic of 2009-2010 was the first public health emergency of international concern, d according to the International Health Regulations. The response to this pandemic was marked by an emphasis on prevention. There was also great fear of the unpredictable nature of influenza, with variants that were either highly contagious, highly lethal, or both. In this case, it was a highly contagious but not very lethal variant.

The pandemic exposed important limitations in public health capabilities at all levels. Some were related to the available scientific knowledge and to making difficult decisions under great uncertainty. It also revealed weaknesses in global health cooperation and the problems of the lack of sanctions for countries that did not adopt the recommendations.

In addition, there were great problems with communication between authorities, specialists and the general public. In many places the population was exposed to headlines and public statements with confusing and alarming terminology. Even uncommon terms such as "pandemic" anticipated a much more severe influenza A (H1N1) epidemic than it finally turned out to be. After all, the evidence initially available showed an alarming lethality, up to five times greater than what was experienced in the following months. This generated distrust toward global health and public health authorities in many countries. In fact, in many cases they were accused of being influenced by the commercial interests of companies manufacturing vaccines and antiviral treatments. However, no conclusive evidence of large-scale corruption was found. In any case, it raised a great deal of debate about the enormous influence of the pharmaceutical industry on public health decisions.

The West African Ebola epidemic of 2013-16

The 2013-16 West African Ebola epidemic in 2013-16 threatened countries with very few resources

Many of the weaknesses in the response to the influenza A (H1N1) pandemic manifested themselves again as of December 2013. It was at that time that the largest Ebola epidemic on record to date began. The outbreak hit the population of three countries in West Africa: Guinea, Liberia and Sierra Leone very hard. None of them had experience with this disease. It also affected other countries, with imported or linked cases, but with little local spread. It caused a total of 11,000 deaths and a huge level of panic globally.

The epidemic revealed the weakness and limited public health capacity of countries with fewer resources and affected by complex humanitarian crises. It also revealed the enormous importance of strengthening their health systems, for the sake of their populations and international health security. In this epidemic, the International Health Regulations were not being applied and were of no use.

It took several months from the beginning of the outbreak before the first cases were confirmed and reported. As a result, the response to the outbreak started too late. In addition, the population lacked information and a total lack of trust in the local and national authorities. As a result, many of their attempts to control the epidemic caused violence, stigma and fear towards the disease, health personnel and the government.

The Ebola epidemic also revealed to the world the slowness and tardiness of the international response

The crisis highlighted the lack of global leadership in public health. It also exposed the fragile vision of a global health system that was far from equitable and completely neglected the most vulnerable populations. In fact, the slow international response was not fully activated until the danger increased for countries such as Spain and, mainly, the United States.

Cases began in Guinea in December 2013 and reached other neighboring countries in March 2014. In June, moreover, MSF began warning of the need for a massive international deployment for the response to a completely out-of-control outbreak. However, the World Health Organization did not declare the epidemic a Public Health Emergency of International Concern until August 2014. It was this declaration that multiplied international humanitarian aid efforts, months after the outbreak began.

Humanitarian action contributed to the availability of health services with adequate infection control practices. However, the turning point in transmission only occurred when communities mobilized to adopt public health measures. Among these, one of the most important was the modification of traditional funeral practices. This greatly reduced transmission of the virus. However, by the time this occurred, the numbers of Ebola infections and deaths were already enormous. The epidemic also disintegrated many essential maternal and child health services and decimated the fragile economies of the affected countries.

Ebola put the WHO under scrutiny, unable to fulfill its responsibilities under the International Health Regulations. The organization was funded mostly by voluntary contributions from member countries and donors. Recently, in 2011, it had suffered major cutbacks. This clearly damaged its technical, operational, normative and global health leadership capacity.

From 2014 to 2018: Polio, Zika and Ebola (in DRC)

A polio emergency was declared in 2014 and is still ongoing

In May 2014, the Director-General of the World Health Organization declared a new public health emergency of international concern. It was polio due to its recent spread to three new countries: Afghanistan, Iraq and Equatorial Guinea. This was only two years after the international spread had, in theory, been halted.

The Emergency Committee of the International Health Regulations has decided to continue to renew this declaration in 2024. This comes at a time when efforts to achieve eradication of wild poliovirus type 1 by 2026 are emphasized. Current global targets also include elimination of circulating vaccine-derived poliovirus type 2 by 2028.

In 2016, an emergency was declared due to an outbreak of the Zika virus in several American countries

The new emergency was declared in February 2016 despite the apparent mildness of the disease. In fact, Zika, a virus transmitted by the bite of the Aedes mosquito, usually causes infections that are generally asymptomatic. Only in 20% of cases does it cause mild symptoms. However, there was great concern about the apparent link between infection in pregnant women and effects in newborns. Zika could cause neurodevelopmental defects in newborns, and an epidemic of microcephaly. There was also concern about possible sexual transmission of the infection.

In the absence of vaccine and despite efforts to control the vector, the incidence of Zika reached very high values. This contributed to generate herd immunity, slowing down transmission. As a consequence, in November of the same year, the WHO declared the end of the emergency.

Ebola shook the world again in 2018, this time from the Democratic Republic of the Congo

In this new public health emergency of international importance, the response overcame many of the weaknesses of the 2013-16 outbreak. This time, detection by national authorities, aware of the virus, and the international response were swift, despite the complicated context. In addition, for the first time, a new, highly effective vaccine against Ebola was available. It had been researched and tested in the last months of the previous outbreak.

However, the response was severely affected by insecurity and violence linked to the ongoing conflict. In areas where the conflict had a higher intensity, peaks of violence coincided with those of higher disease incidence. Several analyses show that, in the absence of ongoing conflict, vaccination would have had a much stronger effect. This epidemic ended up being the largest Ebola outbreak in the history of the African country.

From 2020: COVID-19 and monkeypox

From 2020 to 2023, the COVID-19 pandemic again highlighted global inequity

The new COVID-19 emergency caused more than 700 million cases and 7 million deaths in more than 200 countries. This pandemic caused a global economic crisis and reduced the availability of and access to health services worldwide. It also greatly influenced the resurgence of many infections. The pandemic again showed the poor compliance with the International Health Regulations. It also highlighted the need for WHO to be able to investigate public health threats quickly. In addition, the pandemic showed the inequity in access to vaccines, diagnostic tests, protective equipment and oxygen.

In less than a year, a vaccine was developed. However, another year after it became available, coverage was highly unequal and reflected profound inequities. The population with a completed initial vaccination schedule was 73% in high-income countries and 6% in low-income countries. Poor people only gained access to the vaccine after the rich. First, the richest countries covered all their needs and hoarded all existing and future production. The WHO Director General, referred to this inequity as [placing the world] "on the brink of catastrophic moral failure". The UN Secretary-General also spoke in terms of a "moral condemnation of the state of the world" and "obscenity".

Initiatives emerged to overcome this inequity. One of them was the Access to COVID-19 Tools Accelerator (ACT-A) and its pillar dedicated to vaccines: COVAX. However, this proposal excluded civil society and poor country governments from its governance and design. These mechanisms proved insufficient. They were subordinated to the political will of donor countries and the voluntary action of the pharmaceutical industry.

Two new emergencies were declared in 2022 and 2024, due to an epidemic of monkeypox

Prior to the end of the COVID-19 emergency, WHO declared a new public health emergency of international concern in 2022. This was an outbreak of monkeypox (monkeypox or mpox) that spread extensively, for the first time, outside Africa.

The WHO declared an emergency again in 2024 for another outbreak of a variant of simian smallpox more lethal than the previous one. This time it was concentrated in the Democratic Republic of Congo, but with several confirmed cases in several neighboring countries and even outside the African continent. Although there is a vaccine available for this disease, once again, inequity in access to the tools to combat epidemics is patent. At the time of notification of the new emergency the vaccine was only available in rich countries. Moreover, pledges of international donations fall short of the needs expressed by the African Centers for Disease Control and Prevention (Africa CDC).

The next pandemic: Will we be prepared?

We do not know when there will be a new pandemic of "disease X", but there will be one

In 2017, following the 2013-2016 Ebola epidemic in West Africa, the CEPI (Coalition for Epidemic Preparedness Innovations) was created. This organization, along with many others and the WHO, have been talking about "Disease X" for years. It is a hypothetical infection, which could be caused in the future by a new or as yet unidentified pathogen. It is believed that it could cause a major epidemic or even pandemic, with global repercussions on the health and economy of the planet. COVID-19 has probably been our first "disease X" since the term was coined. Today, however, we are confident that there will be many other major international public health emergencies.

Against COVID-19, it took the world 326 days to have a vaccine ready. This was a breakthrough unimaginable years ago. However, it is still far from what is considered ideal for addressing the threat of the next major international public health emergencies. The target is set at 100 days, from recognizing the new threat, to developing a safe and effective vaccine ready for licensing and large-scale manufacture.

Progress has been made on a new update of the international health regulations

Prior to the COVID-19 pandemic, we already had an International Health Regulations developed in 2005 and updated several times. This detailed the key actions to be ready to face a major epidemic or pandemic. However, in 2020, this Regulation had still not been well implemented and in many cases was even ignored.

Therefore, after the COVID-19 pandemic, it was decided to update the International Health Regulations (2005). The update to the Regulations was completed in June 2024. New features include, for example, new national authorities in charge of implementing it in their respective country. It has also created a new financial control mechanism for equity in access to medical products.

This update also contemplates a new key term related to international public health emergencies: the "Pandemic Emergency". This term goes beyond the 2005 Public Health Emergency of International Concern. Thus, a pandemic emergency is a communicable disease that has had or may have wide geographic spread in multiple States. It also exceeds or may exceed the capacity of health systems to respond in those States. In addition, it causes or may cause substantial social and/or economic disruption, including disruption of international traffic and trade. It therefore requires rapid, equitable and enhanced international action, with coordinated whole-of-government and whole-of-society approaches.

However, the promise of a Global Pandemic Agreement has not yet been consolidated

After the COVID-19 pandemic, it was also decided to create another instrument: an Agreement on Pandemics. This should ensure international cooperation and global political commitment of the 194 WHO member countries for the response to the next pandemic. This agreement, however, appears to be delayed. The intergovernmental negotiating body created in 2021 has failed to reach an agreement by May 2024. The World Health Assembly has therefore extended its mandate until May 2025. The agreement has been delayed mainly because of discrepancies between the priorities and needs of the 194 countries. It has also been influenced by the loss of political momentum, following the update of the International Health Regulations.

The ambition of the agreement has been lowered as flexibilities have been added to its terms. Thus, the level of obligations regarding global governance has been reduced above the interests and responsibility of each country. It has also lowered the requirement for a fair and equitable distribution of resources. In fact, only 20% of medical products are subject to public health needs and risks. The remaining 80% is left on the market at the disposal of the highest bidder. There is also no clarity on the tools to ensure compliance with the terms of the agreement. It is unknown whether penalties will be included.

Progress is still expected to be made in the negotiations on the most controversial issues. These include equitable access to medical products. Evidently, the aforementioned 20% is not consistent with the number of times the agreement talks about equity. Finally there is also a lack of agreement on obligations to share technology, biological samples and genomic sequencing information on pathogens with pandemic potential. This will be key in responding to international public health emergencies in the future.

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