TRANSPARENCY POLICIES

17. Disclosing International Infectious Disease
Outbreaks to Protect Public Health

From the mid-nineteenth century on, nations sought to create international practices to control the spread of infectious disease. International surveillance—the rapid reporting of disease outbreaks—was early recognized as a key to preventing deaths and illnesses. After several devastating cholera epidemics in the early 1800s, many nations negotiated international sanitary conventions that sought to harmonize variable national surveillance and quarantine laws.

Since 1951, the International Health Regulations of the World Health Organization (WHO) have governed international surveillance of infectious diseases among member countries. An arm of the United Nations, the WHO is governed by a World Health Assembly composed of representatives of the WHO member governments. International Health Regulations require member governments to inform the WHO about cases of specified infectious diseases within set time periods. Traditionally, national governments have controlled the flow of information on which disease surveillance is based. Regulations also specify public health activities at ports and airports and set procedures for trade and travel restrictions, including limits on those restrictions. Their stated purpose is to minimize the international spread of disease with minimal interference with trade and travel.230

By the 1970s, however, the WHO surveillance system was moribund. Only plague, cholera, and yellow fever were subject to international reporting rules and member states routinely violated even those reporting obligations. In practice, member governments’ incentives to protect national reputation and economic stability often outweighed incentives to join in international efforts to report disease outbreaks. At the same time, vaccines and antibiotics minimized some common infectious diseases in the United States and Europe, easing political pressure for effective surveillance.231 But in the 1980s, the AIDS epidemic as well as the spread of other infectious diseases highlighted the failure of existing international regulations and reawakened international interest in more effective surveillance. In the United States, the national Institute ofMedicine identified fifty-four infectious diseases that were on the rise owing to a combination of increased travel and trade, germs’ adaptability, and a lack of public health measures.232

In 1995, the World Health Assembly directed the World Health Organization to revise the failed government-centered surveillance rules. But reaching agreement on new surveillance rules proved to be a slow process. New International Health Regulations were not adopted until 2005.233 Meanwhile, the WHO cooperated with private groups to create informal networks to share information. The Global Outbreak Alert and Response Network was designed to pool public and private information for response to international outbreaks. In 2001, the four-year-old network was officially endorsed by the World Health Assembly.234

However, it was the rapid spread of SARS (Severe Acute Respiratory Syndrome) in 2002 and 2003 that sparked the revival of the international system of infectious disease reporting. The disease first appeared in China’sGuangdong Province inNovember 2002, spread to thirty countries in six months, and killed more than seven hundred people. Public fears fed by a paucity of reliable information contributed to large economic costs—estimated at $40 billion.235

Significantly, initial information about the SARS outbreak did not come from government reports. It came from millions of cell phone and Internet messages in Guangdong Province and elsewhere in early 2003, as well as from information provided by private reporting systems such as ProMED-mail. It was these on-the-ground reports from ordinary citizens and local health workers that spurred the WHO to make inquiries of the Chinese government, which, in turn, led the Chinese government to acknowledge the outbreak and led the WHO to issue a global alert on March 12 and a travel advisory on March 15.236

The new capabilities of information technology not only marshaled far-flung resources to identify the source and character of the disease but also helped to combine the scientific expertise of many nations to bring the epidemic under control. Public health authorities in many countries cobbled together informal networks to respond with unprecedented speed. The WHO coordinated sixty teams of medical personnel to help control the disease in affected areas and a network of eleven infectious disease laboratories in nine countries, linked through a secure Web site and daily conference calls, to work on the disease’s causes and diagnosis. These networks made new scientific information available to researchers around the world and hastened collaborative progress on diagnosis and treatment. Researchers were able to identify the cause of SARS within a month. By July 2003, the five-month epidemic had ended.237

In retrospect, it was clear that the SARS epidemic coupled with advances in communication technology signaled the end of government control of the flow of information about disease outbreaks. Even in the absence of an international legal obligation, China was pressured into reporting the spread of SARS by masses of local data provided by villagers and aggregated by private electronic surveillance systems. In May 2003 the World Health Assembly acknowledged the legitimacy of the crisis-driven de facto changes in the international reporting system. In an important change, the assembly asked the WHO to continue using nongovernmental sources of information for surveillance. The WHO concluded that the SARS crisis demonstrated that government attempts to hide information carried a very high price—“loss of credibility in the eyes of the international community, escalating negative domestic economic impact, damage to health and economics of neighboring countries, and a very real risk that outbreaks within the country’s own territory can spiral out of control”238

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FOOTNOTES
230. Constitution of the World Health Organization, July 22, 1946, 61 Stat. 2349, 14 U.N.T.S. 185 (also available at http://w3.whosea.org/aboutsearo/pdf/const.pdf and http://www.yale.edu/lawweb/avalon/decade/decad051.htm#1). See also Revision to the International Health Regulations 2005, A58/4, art. 2, May 16, 2005, http://www2a.cdc.gov/phlp/docs/58assembly.pdf (sites accessedMay 23, 2006).
231. Fidler, 2004, p. 35.
232. Institute of Medicine, 1992.
233. World Health Assembly, Revision to the International Health Regulations 2005, WHA 58 3, May 23, 2005, http://www.who.int/csr/ihr/WHA58 3-en.pdf (site accessed May 23, 2006).
234. World Health Organization, 54th World Health Assembly, Global Health Security – Epidemic Alert and Response, A54/9, April 2, 2001.
235. Institute of Medicine, 2003, p. 16.
236. Institute of Medicine, 2003, p. 8; Fidler, 2004, pp. 74–80.
237. Fidler, 2004, p. 14 (noting that by June 2003, SARS had been “[s]topped dead in its tracks”).
238. Institute of Medicine, 2003, p. 8.
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