Finally, the World Health Organization has declared the world’s latest Ebola outbreak a global health emergency. But what, exactly, does that mean?
The decision this week by the WHO’s director-general, Tedros Adhanom Ghebreyesus, to designate the long-running Ebola outbreak in the Democratic Republic of the Congo a public health emergency of international concern generated a flood of news coverage.
Some global health experts have been vociferously insisting for months now that a PHEIC (pronounced FAKE or PHEEK) needed to be declared. They say it could improve the outbreak response and speed an end to the crisis.
But how might it do that? Read on.
What is a PHEIC?
Sometimes it’s easiest to define something by talking about what it’s not. That’s definitely the case when trying to describe a PHEIC.
Despite the fact the name combines “emergency” and “international,” a PHEIC isn’t necessarily a true global emergency. It can be — say, if a new disease began to spread globally or another flu pandemic started.
But in the case of the latest Ebola outbreak, the reality is people in Indianapolis and Istanbul, Shanghai and Sydney are at no greater risk today than they were before the PHEIC was declared. The declaration is not the WHO’s way of sending up a flare to warn that Ebola will be spreading around the globe from northeastern DRC.
This event is a crisis in the affected region of DRC and a real risk to neighboring countries. Governments around the world need to be paying more attention to it, but the risk of global spread is low
So that’s what it isn’t. But what is it?
A PHEIC is defined as “an extraordinary event that poses a public health risk to other countries through international spread and that potentially requires a coordinated international response.” In short, it’s a tool the WHO’s member states have given the global health agency to help it deal with difficult transmissible disease situations.
It was created when the International Health Regulations — a treaty designed to prevent and control the international spread of disease — were updated after the 2003 SARS outbreak.
(If you don’t remember SARS, it was a disease that spread rapidly from China to other parts of Southeast Asia and also to Canada, sickening more than 8,000 people and killing about 800. It was completely unknown and alarming. But scientists and public health authorities figured out quite quickly how to control SARS and, except for a few cases the following year, it hasn’t been seen since.)
The goal of the IHR is to keep the world safe from transmissible diseases like this by requiring countries to report dangerous outbreaks so their neighbors can be on the lookout for cases and prepare to respond if needed.
A PHEIC gives the WHO some temporary powers it can wield in a crisis. For instance, it can share information about what’s happening with other countries, even without the consent of the affected nation.
WHO’s director-general can also issue what are known as temporary recommendations; those typically take the form of instructions to other countries (and indirectly, companies) not to penalize the affected nation by closing borders, restricting airline flights, blocking importation of goods or suspending visas issued to people from the affected countries.
Wouldn’t you want to stop travel and commerce from a disease-affected country to prevent spread?
Here’s the thing: Countries that know they’re going to take a financial hit or be ostracized internationally are less likely to fess up when they’re dealing with a dangerous disease.
You don’t want to penalize a country that’s been forthcoming. But you also don’t want to make it harder to move people and goods into or out of the affected area. The WHO needs to send in teams of experts, of health workers who can assist in an outbreak response. Doctors Without Borders and the other NGOs working on a response need to be able to ship in equipment. If air travel is cut off or reduced during a health emergency, it impedes the world’s ability to control the disease.
Are there any downsides to declaring a PHEIC?
It was designed to help but experience has shown a PHEIC can be a double-edge sword. There have been real concerns that declaring a PHEIC in this case could hurt the economy of the region, which could further inflame the tensions between people in the affected region and the people trying to extinguish this outbreak.
What about those temporary recommendations? Don’t countries have to follow the instructions of the WHO director-general?
In a word: No. The WHO is not the world’s health police. The director-general can advise, urge, exhort, or even condemn countries. But at the end of the day, countries are sovereign and will do what they think is best for their citizens.
During the massive Ebola outbreak in West Africa in 2014-2016, many countries stopped issuing visas to citizens of the affected countries. The WHO publicly challenged a few to explain their actions. In at least one case, that led to an angry call to the director-general at the time, Margaret Chan. The country that made that angry call, Canada, did not change its visa policy.
And most airlines stopped flying to Guinea, Liberia, and Sierra Leone, the countries at the heart of that outbreak. To this day there’s a deep well of gratitude in the global health community for Brussels Airlines and Royal Air Maroc, which heroically maintained flights into the region.
How often have PHEICs been declared?
Far less often than you’d think. For instance, an emergency committee of experts set up to assess the threat posed by Middle East Respiratory Syndrome met 10 times and decided at each meeting that MERS did not warrant declaring a public health emergency of international concern.
Is the disease a threat to some people in a few Arabian Peninsula countries? Yes. More than that? Not so far. The committee held firm even when a South Korean businessman who got sick in the Middle East went home and ignited a major outbreak — nearly 200 cases — in Seoul.
Likewise a large and dangerous yellow fever outbreak in Angola that moved into DRC’s capital, Kinshasa, in 2016 — an outbreak that nearly tapped out the global supply of yellow fever vaccine — was not declared a PHEIC.
There had been four PHEICs declared prior to this week’s addition of the DRC Ebola outbreak. The first time the tool was used was during the 2009 H1N1 flu pandemic, the first flu pandemic in 41 years. The West African Ebola outbreak of 2014-2016 was a PHEIC, as was the 2017 Zika virus outbreak in Latin America.
The other PHEIC was different from all the rest. It wasn’t a response to the emergence of a new disease, or one like Ebola that breaks out of nature occasionally to infect people. In 2014 the polio eradication campaign was floundering, and a decision was made to declare wild polio transmission a public health emergency of international concern. (That PHEIC remains in place five years later.)
The idea was to raise awareness of the issue at higher levels within governments around the world; that is what PHEICs are intended to do.
That, it’s hoped, is what will result from declaring the North Kivu-Ituri Ebola outbreak a PHEIC — that governments around the world, with their purses and emergency response expertise, will start paying more attention to this long-running crisis.