Dictionary / Encyclopedia Article
Reference
Health and International Cooperation
MBENGUE, Makane Moïse
MBENGUE, Makane Moïse. Health and International Cooperation. In: Wolfrum, R. The Max Planck Encyclopedia of Public International Law (Online Edition) . Oxford : Oxford University Press, 2011.
Available at:
http://archive-ouverte.unige.ch/unige:56191
Disclaimer: layout of this document may differ from the published version.
Content type:
Encyclopedia Entries Article last updated:
August 2010
Product: Max Planck Encyclopedia of Public International Law [MPEPIL]
Public Health, International Cooperation
Makane Moïse Mbengue
Subject(s):
Development — World Health Organization (WHO)
Published under the auspices of the Max Planck Foundation for International Peace and the Rule of Law under the direction of Rüdiger Wolfrum.
A. Evolution of International Co-operation in Public Health from the 19th Century to 1945
1. From National Quarantine Measures to International Sanitary Conferences: The First Era of International Co-operation in Health
1 For many centuries, States were mainly concerned with protecting their territory against pestilence brought to their shores. It was only under the urge of the cholera outbreak in Europe between 1848 and 1850 that the first efforts were achieved to foster international co-operation in maritime quarantine. In this context, 1851 is a cornerstone year for public health (see also Health, Right to, International Protection). For the first time, infectious diseases control became a matter of inter-State concern. At that time, willing to deal with the legal vacuum created by fragmented and unco-ordinated regulations governing maritime quarantine, France convened the first International Sanitary Conference in Paris. The purpose of that Conference was to discuss the adoption of a uniform code applicable to quarantine measures. Albeit limited in its scope—only three infectious diseases were discussed, ie cholera, plague, and yellow fever—the regime set forth in 1851 laid down the foundations for international co-operation in public health. Prior to that critical date, prevention of the spread of infectious diseases was an issue of the domaine réservé of States.
National measures to quarantine ships and travellers were the traditional response to the threat of imported diseases. The adoption of a quarantine code in Venice in 1348 following the spread of plague from Crimea to Genoa is a perfect illustration of that well-established State practice (Stock 309). The first international sanitary conference reflected the conviction of several European States that prevention of diseases spreading across borders could only be efficiently managed through international co-operation. However, States were not guided primarily by health
considerations per se. As pointed out by Fidler, the origins of international co-operation in public health lie in non-State and State interests in minimizing interference to international trade through a fragmented patchwork of national quarantine regulations (Fidler [2005] 329).
2 Following the failure of the 1851 Conference due to diverging political objectives and scientific views of the participants, a series of international sanitary conferences took place. In 1859 France called another conference in Paris which adopted the Projet de Convention ([signed 30 August 1859, never entered into force] in Ministère des Affaires étrangères Protocoles de la Conférence sanitaire internationale: ouverte à Paris le 9 avril 1859 [Imprimerie Impériale Paris 1859] 234).
Unfortunately, political events in Europe prevented the entry into force of said instrument. In 1866, France again convened a conference in Constantinople with a particular attention being paid to cholera owing to the fear of its spread by the Mecca pilgrims. Eight years later, in 1874, Austria convoked a conference in Vienna which adopted principles of quarantine and suggested the establishment of a permanent international sanitary commission. In 1881, the United States of America (‘US’) organized a conference in Washington. During that conference, attention focused for the first time on the issue of the international notification of infectious diseases. Because of the need to control the introduction of cholera from the East into the Mediterranean basin, other conferences took place at Rome (1885) and at Venice (1892), where the very first International Sanitary Convention was concluded in 1892. It concerned measures for quarantine and hygiene practices for cholera. This was not, nevertheless, the first international convention dealing with health issues. The 1878 Convention Respecting the Measures to be Taken against Phylloxera Vastatrix can be considered as the first multilateral instrument pertaining to public health in general and to plant diseases in particular. A new International Sanitary Convention was adopted by a conference in 1893 at Dresden, while in 1894 another international conference in Paris adopted the International Sanitary Convention for the Protection of the Pilgrimage to Mecca from Disease, and for Establishing Sanitary Inspection in the Persian Gulf. The revival of plague in Bombay in 1896 and its exponential spread to various parts of the world led to a conference in Venice in 1897 and a further conference in Paris in 1903. The latter conference sowed the seeds for a new era of international co-operation to fight infectious diseases.
2. From Surveillance to Institutionalization: The Second Era of International Co-operation in Health
3 The main goal of the international sanitary conferences and conventions of the first era was to harmonize quarantine measures. With the beginning of the 20th century, a new paradigm in
international co-operation arose. It is referred to as the ‘shift from quarantine to surveillance’ (Fidler [1999] 116). In light of the growth of scientific evidence concerning some infectious diseases, epidemiologists started to advocate surveillance instead of quarantine as an international public health strategy. Surveillance is not as trade-restrictive as quarantine. Focus was to be put on travellers and no longer on merchandise and cargo. The International Sanitary Conference of 1903 led to the conclusion of the International Sanitary Convention of 1903 which was of great
importance as it adopted the surveillance approach. According to Art. 11 Sanitary Convention of 1903 no merchandise is capable by itself of transmitting plague or cholera. It only becomes dangerous when contaminated by plague or cholera products. The Sanitary Convention of 1903 was also the first successful attempt to regulate infectious diseases in a holistic rather than a fragmented manner. It dealt both with cholera and plague, as the part played by rats in the spread of the latter disease had been scientifically documented. Thus, the first trace of a global public health perspective in international co-operation could be identified. The Sanitary Convention of 1903 was amended by the International Sanitary Conventions of 1912 and 1926 in order to incorporate such a perspective. In particular, the International Sanitary Convention of 1926 required the immediate notification by every State to other States and to the Office International d’Hygiène Publique (‘OIHP’) of cases of plague, cholera, yellow fever, epidemic typhus, and smallpox. When the 1926 International Sanitary Conference took place, delegates still had in mind the influenza pandemic of 1918 and the need to develop a more progressive framework for international co-operation. The International Sanitary Convention of 1926 was modified in 1938.
Meanwhile, regional efforts by American States were being made with the adoption of the Sanitary Convention ([signed 14 October 1905, entered into force 30 April 1906] 199 CTS 230) as well as the Pan-American Sanitary Code ([signed 14 November 1924, entered into force 26 June 1925] 86 LNTS 43). The rapid development of international air traffic prompted the conclusion of the
International Sanitary Convention for Aerial Navigation in 1933. It was modified in 1944, as was also the International Sanitary Convention of 1938. During the same time frame, progress was made on the co-operation in animal diseases with the adoption in 1935 of multilateral treaties for the control of animal and food-borne diseases. The most important treaty was the International Convention for the Campaign against Contagious Diseases of Animals.
4 The first steps of international co-operation in public health were mostly of a normative nature.
Co-operation did not rest upon any international institutional framework. Ad hoc conferences served mostly as institutional bases for international co-operation in health. The sole exceptions were the Constantinople Superior Board of Health which was established in 1838 and the
Quarantine Board of Egypt which was created in 1831. The first body was abolished by the Treaty of Peace with Turkey, with related Documents ([signed 24 July 1923, entered into force 6 August 1924] 28 LNTS 11; Lausanne Peace Treaty [1923]). The Quarantine Board of Egypt, which in a large measure was regulated by successive international sanitary conventions, had its
headquarters in Alexandria. It was created for the purpose of preventing the spread of cholera and other diseases by and among pilgrims on the way to and from Mecca. Analysing the status of that body under international law, the International Court of Justice (ICJ) in its Interpretation of the Agreement of 25 March 1951 between the WHO and Egypt (Advisory Opinion), said of the Quarantine Board of Egypt that it had:
subsequently acquired a certain international character as a result of the association with its quarantine work of seven representatives of States having rights in Egypt under the capitulations régime; and in 1892 its character as an international health agency became more pronounced as a result of changes in the structure of its council effected by the International Sanitary Convention of Venice of that year. (At para. 13)
5 In the second era, international co-operation benefited from the creation of international health organizations. Those organizations—without being international organizations in the normal sense
—were mainly set up at the regional level. At the European level, the International Sanitary
Conference of 1903 adopted the proposals, first made at Vienna (1874), to create an international health office, and in 1907 the OIHP was established with permanent headquarters in Paris by the Agreement for the Creation of an International Office of Public Health. Under the agreement, the OIHP was in principle open to universal membership. Indeed, several non-European States like the US were members of the OIHP. However, de facto the OIHP functioned more as a regional
organization. Its mandate was to maintain and report epidemiological data as well as to co-ordinate quarantine measures. The OIHP was dissolved in 1946 and its epidemiological service was
transferred to the Interim Commission of the World Health Organization (WHO) in January 1947. The OIHP was not the first international institution dealing with public health. At the American level, the Pan American Sanitary Bureau (‘PASB’), with headquarters in Washington, had already been founded by the Resolution of the Second Pan-American Conference Relative to Sanitary Police in 1902 and was the first international health organization. The PASB was an institutional response to a yellow fever outbreak that had spread from Latin America to the USA. In 1947, the PASB was renamed the Pan American Sanitary Organization. In 1949, it was integrated into the WHO as a regional office while at the same time keeping its status as an autonomous international organization in accordance with Art. 54 Constitution of the World Health Organization (‘WHO Constitution’). The organization’s name was changed again in 1958 to Pan American Health Organization. Another international institution, the International Institute of Agriculture, has also been created before the OIHP. Under the Convention for the Creation of an International Agricultural Institute ([signed 7 June 1905, entered into force 19 July 1906] 198 CTS 355), one of the functions of the said organization was to ‘[m]ake known the new diseases of vegetables which may appear in any part of the world’ (at Art. 9 (d)).
6 International co-operation in public health continued to be increasingly institutionalized after World War I and went beyond infectious diseases control. A quest for more universalism was pursued in the design of international health institutions. In 1922, and in accordance with Art. 23 Covenant of the League of Nations dealing, inter alia, with the prevention and control of diseases, the League of Nations Health Committee and Health Section (together referred to as the Health Organization of the League of Nations; ‘HOLN’) were established. Through the activity of the HOLN, several vaccines (eg, for diphtheria, tetanus, and tuberculosis) were standardized world-wide. For these reasons, the HOLN is considered one of the most successful auxiliary agencies of the League of Nations. The founders of the HOLN were convinced that all the existing international health institutions had to be placed under the direction of the League of Nations. The fusion never took place in practice because of the US’s refusal. The quest for universalism was thus obstructed but not definitely cast aside. In January 1924, the need to fight animal diseases at the international level led to the creation of a still barely known health organization based on universal membership, the Office International des Epizooties. In May 2003, the Office International des Epizooties became the World Organization for Animal Health (‘OIE’).
7 Institutionalization of international co-operation related to public health was maintained during World War II and acquired a new face. In 1943, the representatives of the 44 United and
Associated Nations signed in Washington the Agreement for United Nations Relief and Rehabilitation Administration ([signed and entered into force 9 November 1943] 145 BFSP 159; United Nations Relief and Rehabilitation Administration [UNRRA]). One of the aims and activities of UNRRA concerned the giving of aid in order to prevent the spread of pestilence. A health committee was set up to advise the administration of UNRRA. The health committee was at the origin of the elaboration and adoption of the 1944 International Sanitary Convention. UNRRA was dissolved in July 1946.
8 These developments highlight that public health has benefited from international co-operation both at the normative and institutional levels. Nevertheless, in spite of the major progress made in
international co-operation during the 19th century and the first half of the 20th century, only few States were formally bound by the international sanitary conventions or were members of the health organizations. A study from 1949 showed, for instance, that, of about 70 sovereign States in the world as far as maritime navigation was concerned, 16 countries were not bound by any international sanitary convention whatsoever (‘International Sanitary Conventions’ [1949] 1 British Medical Journal 22 ). So far as aerial navigation was concerned, 36 States were not bound by any international agreement. More universality was then needed in the fight against international public health risks. The post-1945 international system of co-operation enshrined such a need for
universalism, notably with the creation of the WHO.
B. Features of International Co-operation in Public Health since 1945
1. The Challenge of Universalization: The World Health Organization as the Pillar of International Co-operation in Public Health Issues
9 During the United Nations Conference on International Organization held in San Francisco in 1945 and following the strong activism from the Brazilian and Chinese delegations, a declaration was adopted recognizing health as a field which the United Nations must deal with (Summary Report of Thirteenth Meeting of Committee II/3, 120). In February 1946, the United Nations, Economic and Social Council (‘ECOSOC’) convened the International Health Conference. The mandate of the international conference was to consider
the scope of, and the appropriate machinery for, international action in the field of public health and proposals for the establishment of a single international health organization of the United Nations. (Final Act of the International Health Conference [done 22 July 1946] 9 UNTS 4 para. 1)
10 The WHO Constitution was adopted and opened for signature on 22 July 1946. Like many constituent instruments of international organizations, the WHO Constitution is a treaty of a particular type owing to its ‘character which is conventional and at the same time institutional’
(Legality of the Use by a State of Nuclear Weapons in Armed Conflict [Advisory Opinion] [1996] ICJ Rep 66 para. 19; Nuclear Weapons Advisory Opinions). Following the entry into force of its
Constitution, the WHO was effectively established on 7 April 1948 as the UN specialized agency for health within the terms of Art. 57 Charter of the United Nations (United Nations, Specialized
Agencies).
11 The objective of the WHO is defined in Art. 1 WHO Constitution as being ‘the attainment by all peoples of the highest possible level of health’. From the mid-19th century to 1945, international co- operation in public health meant in specie co-operation to control the spread of infectious diseases.
The establishment of the WHO is synonymous with the epistemological evolution of international co- operation in health. It sets the stage for a redefinition of the meaning of health. Health is no longer defined exclusively by reference to diseases. Under the preamble of the WHO Constitution, health is defined and conceptualized as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. Therefore, international co-operation in health is willing to embrace a wide range of factors that promote conditions in which people can live a healthy life, as well as extending to the underlying determinants of health, such as food and
nutrition, housing, access to safe and potable water, adequate sanitation, safe and healthy working conditions, and a healthy environment. This conceptual evolution is perceived through the
constitution of certain international standardization institutions. It is the case of the Codex Alimentarius Commission (CAC) which was jointly set up in 1963 by the WHO and the Food and Agriculture Organization of the United Nations (FAO) to develop food standards with a view to protecting the health of the consumers and to ensuring fair trade practices in the food trade. The
conceptual evolution is also noticeable in some of the mechanisms created for inter-organizational co-operation in health such as the joint partnership between the WHO and the United Nations Environment Programme (UNEP) named the Health and Environment Linkages Initiative, or the Inter- Organization Programme for the Sound Management of Chemicals (‘IOMC’). The IOMC was
established in 1995 to strengthen co-operation and increase co-ordination in the field of chemical safety. The seven participating organizations of the IOMC are the FAO, the International Labour Organization (ILO), the UNEP, the United Nations Industrial Development Organization (UNIDO), the United Nations Institute for Training and Research (UNITAR), the WHO, and the Organization for Economic Co-operation and Development (OECD).
12 Besides the redefinition of health, new guiding principles for international co-operation in the field of public health are embodied in the WHO Constitution. Its preamble, more especially, sets out the ‘enjoyment of the highest attainable standard of health’ as ‘one of the fundamental rights of every human being’. The status of health as a human right was subsequently recognized in a large spectrum of international and regional human rights instruments, and recently by international organs such as the Committee on Economic, Social and Cultural Rights (CESCR). In its General Comment No 14: The Right to the Highest Attainable Standard of Health (Art. 12 of the Covenant), the CESCR states that
health is a fundamental human right indispensable for the exercise of other human rights.
Every human being is entitled to the enjoyment of the highest attainable standard of health conducive to living a life in dignity. (at para. 1)
Especially noteworthy is the reference made by the CESCR to the pivotal role of the WHO in international co-operation:
The realization of the right to health may be pursued through numerous, complementary approaches, such as the formulation of health policies, or the implementation of health programmes developed by the World Health Organization. (at para. 1)
13 Furthermore, with the establishment of the WHO, various avenues for international co-operation in public health are opened, and unpredictable linkages are made between health and other subject matters. For instance, health is recognized in the preamble of the WHO Constitution as fundamental for other areas of international co-operation such as the maintenance of international peace and security. This rather pioneering vision is a new milestone for public health. In 2000, the UN Security Council adopted its first health only resolution (UNSC Res 1308 [2000] [17 July 2000]
SCOR 55th Year 159) on the responsibility of the UN Security Council in the maintenance of
international peace and security, stressing that ‘the HIV/AIDS pandemic, if unchecked, may pose a risk to stability and security’ (at Preamble). The very same resolution presses for international co- operation given the importance of a ‘coordinated international response’ (at Preamble) to the HIV/AIDS pandemic.
14 A rather fragmented approach to international co-operation prevailed during the 19th century and the first half of the 20th century due to the proliferation of international instruments on
infectious diseases and the regionalization of health institutions. Through the creation of the WHO, international co-operation in public health was to be governed by a new rationale, ie universalism in the normative and institutional management of public health issues. As stated in the preamble of the WHO Constitution, the WHO is established ‘for the purpose of co-operation’ among the
Contracting Parties ‘and with others to promote and protect the health of all peoples’. Henceforth, the international normative-making power in health-related issues is largely vested in the WHO, and health co-operation rests primarily upon the WHO as ‘the’ competent universal organization. The first World Health Assembly—the policy-making organ of the WHO—adopted the World Health Organization Regulations No 1 regarding Nomenclature (including the Compilation and Publication of Statistics) with Respect to Diseases and Causes of Death ([done 24 July 1948, entered into force 1 January 1950] 66 UNTS 25) regarding the unification of the statistical classification of morbidity
and mortality for purposes of comparability. Three years later, in 1951, international co-operation in health faced an unprecedented challenge with the adoption of the International Sanitary
Regulations—World Health Organization Regulations No 2 (‘ISR’) by the fourth World Health Assembly: the challenge of coherence. For half a century, a number of sanitary conventions were simultaneously in force. None of them replaced its predecessors since different States were parties to different conventions or group of conventions. Moreover, some of their provisions were obsolete, not based on current scientific knowledge, and caused serious disturbance to traffic and trade. The ISR revised the existing international sanitary conventions and replaced them with a single code based on modern epidemiological principles (Art. 105 ISR). The ISR dealt with six of the most serious communicable diseases: plague, cholera, yellow fever, smallpox, louse-borne typhus, and relapsing fever. The adoption of the ISR is a typical illustration of the universal character of the WHO decision-making power. Such a power is rooted in the WHO Constitution and a large array of instruments can be designed by the WHO in order to foster international co-operation in public health.
15 Those instruments can be binding or non-binding. Non-binding instruments in the form of recommendations and guidelines play an important role in the system of international co-operation put in place by Art. 23 WHO Constitution (see also Soft Law). The WHO has issued non-binding guidelines in various fields such as the guidelines regarding the World Health Organization Certification Scheme on the Quality of Pharmaceutical Products Moving in International Commerce ([29 May 1975] Official Records of the World Health Organization No 226, 94). The most famous recommendation to date is the International Code of Marketing of Breast-Milk Substitutes. Binding instruments include conventions or agreements adopted under Art. 19 WHO Constitution. That provision was used for the first time in 2003 with the adoption of the WHO Framework Convention on Tobacco Control ([adopted 21 May 2003, entered into force 27 February 2005] 2302 UNTS 166).
Other instances of binding instruments are the regulations adopted under Art. 21 WHO Constitution.
16 The adoption of regulations is a major part of the WHO’s normative activity and has been until now a landmark for international co-operation in public health. The movement from International
‘Sanitary’ Regulations to International ‘Health’ Regulations depicts the paradigmatic shift in international co-operation in health. ‘Sanitary’ regulations were governed by the old vision of co- operation, aimed at ensuring mainly the ‘“defence of Europe” against exotic pestilences’
(Beigbeder 73). ‘Health’ regulations are grounded on the very idea of co-operating to protect the international community against diseases of international importance. The 1969 International Health Regulations (‘1969 IHR’) replaced the ISR in order to put in place a new legal framework for
international co-operation in infectious diseases control and to strengthen the obligation of States to notify cases of diseases occurring in their territories. The purpose of the 1969 IHR, which were amended in 1973 and 1981, was to ensure the maximum security against the international spread of diseases with a minimum interference with world traffic. Recourse to regulations sought to facilitate international co-operation in health. This is due in particular to the flexibility inherent in the
‘opting out’ technique (see also Tacit Consent/Opting Out Procedure). Once the World Health Assembly has adopted a regulation and once this regulation has been duly notified, the regulation enters into force for all WHO Member States, except for those which have rejected or made reservations to the regulation (see also Treaties, Multilateral, Reservations to). This practice differs from the classical practice of ‘opting in’, according to which a State is only bound by an
international instrument if it so signifies by a positive act. The opting out technique enhances the universalism of co-operation in health.
2. The Challenge of Globalization: International Co-operation and Global Public Health Risks
17 Through its normative activity and its institutional capacity (193 Member States), the WHO has met the challenge of universalizing co-operation in public health. Today, international co-operation
in public health is facing a new challenge: the challenge of global public health risks. New
diseases, the resurgence of diseases once thought to be eradicated or contained, and the threat of deliberately spread infectious diseases are a major problem world-wide. Globalization creates an unprecedented opportunity for the spread of diseases. For instance, a new avian influenza subtype (H5N1) emerged in Hong Kong in 1997 and since then Azerbaijan, Cambodia, China, Djibouti, Egypt, Indonesia, Iraq, Lao People’s Democratic Republic, Myanmar, Nigeria, Pakistan, Thailand, Turkey, and Vietnam have also reported human cases of H5N1 infection. The outbreak of Severe Acute Respiratory Syndrome (‘SARS’) in 2003 in China and other countries is another example of the globalization of public health risks and the corresponding need to develop a new framework for the prevention of such risks. Henceforth, international co-operation in health is labelled as co-operation in ‘global public health security’.
18 Normative and institutional strategies of a different nature are drawn to meet the challenges of global public health security. One of them has consisted of the adoption of the International Health Regulations (2005) (‘IHR 2005’) as the axis of co-operation on global public health. They entered into force on 15 June 2007. The purpose and scope of the IHR 2005 are
to prevent, protect against, control and provide a public health response to the
international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.
(Art. 2 IHR 2005)
19 The perception of global public health is embodied in the IHR 2005 through the ‘public health emergency of international concern’ which means
an extraordinary event which is determined … (i) to constitute a public health risk to other states through the international spread of disease and (ii) to potentially require a
coordinated international response. (Art. 1 (1) IHR 2005)
The need for international co-operation is thus at the core of the concept of ‘public health emergency of international concern’. The IHR 2005 set forth a new institutional mechanism purporting to effectively manage public health emergencies of international concern: the IHR Emergency Committee. The efficiency of such a mechanism has been put to the test in 2009 with the management of the swine flu pandemic also known as the pandemic influenza H1N1. The Emergency Committee has regularly given advice on the basis of which the WHO Director-General has issued temporary recommendations to States with respect to the pandemic influenza H1N1.
Those recommendations flesh out the rather proactive and interventionist character of the action of the WHO triggered by the IHR 2005. For instance, following the third meeting of the IHR Emergency Committee in June 2009, the WHO Director-General issued recommendations requesting all States to intensify surveillance for unusual outbreaks of influenza, to continue the production of seasonal influenza vaccine, and not to close borders or to restrict international trade. This latter aspect has given rise to unprecedented co-operation between the WHO and the World Trade Organization (WTO). Indeed, in May 2009 a Joint FAO/WHO/OIE/WTO Statement on Influenza A(H1N1) and the safety of pork was made pinpointing that
in light of the spread of influenza A(H1N1), and the rising concerns about the possibility of this virus being found in pigs and the safety of pork and pork products, we stress that pork and pork products, handled in accordance with good hygienic practices recommended by the WHO, FAO, Codex Alimentarius Commission and the OIE, will not be a source of
infection. To date there is no evidence that the virus is transmitted by food. There is currently therefore no justification in the OIE Terrestrial Animal Health Standards Code for the imposition of trade measures on the importation of pigs or their products.
20 To sum up, through the IHR 2005, the scheme for international co-operation has been drastically reformed. First, co-operation in health through international regulations is no longer
limited to a list of specific infectious diseases, as had been the case for more than a century, but rather covers any ‘illness or medical condition, irrespective of origin or source, that presents or could present significant harm to humans’ (Art. 1 (1) IHR 2005). Secondly, international co-
operation is also no longer exclusively a matter of inter-State concern. Governance of global public health issues involves a network of State and non-State actors. Thirdly, co-operation in health expands beyond the traditional area of prevention of infectious diseases and incorporates a range of new issues related to economics, trade, human rights, environmental protection, and security.
21 These features have resulted in the development of new patterns of co-operation in the field of global public health. The most prominent example––albeit established before the adoption of the IHR 2005––is the Global Outbreak Alert and Response Network (‘GOARN’) which was set up in 2000.
The mandate of the GOARN is mainly to improve the co-ordination of international disease
outbreaks responses and to ensure prompt technical support to affected populations. The GOARN has formulated standards of international epidemic response through the adoption of Guiding Principles for International Outbreak Alert and Response as well as operational protocols to
standardize epidemiological, laboratory, clinical management, research, communications, logistics support, security, evacuation, and communications systems. The GOARN is a partnership between the WHO, national scientific institutions, medical and surveillance initiatives, regional technical networks, networks of laboratories, UN organizations (eg, the United Nations Children’s Fund [UNICEF]; UN High Commissioner for Refugees; Refugees, United Nations High Commissioner for [UNHCR]; International Committee of the Red Cross [ICRC]), and international humanitarian non- governmental organizations such as Médecins Sans Frontières, the International Rescue Committee, and Merlin). International co-operation in global public health benefits from the multiplication of such public informal mechanisms or partnerships composed of national
administrations, international organizations, and non-governmental organizations. States are also keen to establish more informal partnerships at the inter-State level to strengthen co-operation on global public health issues. It is the case of the Global Health Security Initiative, a partnership among like-minded countries designed to strengthen health preparedness and global responses to threats of biological, chemical, radio-nuclear terrorism, and pandemic influenza. This initiative was launched in 2001 by Canada, the European Union, France, Germany, Italy, Japan, Mexico, the United Kingdom, and the US. In addition to these informal partnerships, informal health agreements or instruments are being elaborated by States to deal with global public health issues. One
particular example is the 2008 Guidelines to Further the Practical Implementation of Article 6 of the Agreement on the Application of Sanitary and Phytosanitary Measures adopted by the Committee on Sanitary and Phytosanitary Measures of the WTO (Sanitary and Phytosanitary Standards). Those guidelines appertain to the process of recognition by States of pest- or disease-free areas.
22 Besides the development of public informal partnerships, international co-operation is strongly benefiting from global public private partnership[s] (‘PPPs’) like the Global Alliance for Vaccines and Immunization (‘GAVI’), the Global Fund to Fight AIDS, Tuberculosis and Malaria, UNITAID, the Clinton HIV/AIDS Initiative, the Stop TB Partnership, the Roll Back Malaria Partnership, etc. These PPPs highlight the emergence of a new form of co-operation in health. During the 19th century, co- operation in health was mostly swayed by national concerns. The 20th century witnessed the development of co-operation in health as a matter of real inter-State concern, ie as a concern for the international community erga omnes. The new millennium calls for a different blueprint of co- operation in public health. That blueprint reveals that what may be called ‘global co-operation in health’ plays a more important role than purely classic paradigm of international co-operation. PPPs are illustrative of such a trend. They further a nexus of relations between multilateral organizations, governments, civil society, affected communities, and, more interestingly, the private sector. For instance, the GAVI partnership encompasses developing country governments (Developing Countries), industrialized country governments, industrialized country vaccine industry (eg, Novartis Vaccines, GlaxoSmithKline), developing country vaccine industry (eg, Bio Farm, Institut Pasteur Dakar, Serum Institute of India Ltd), civil society organizations, the Bill & Melinda Gates
Foundation, the WHO, the UNICEF, and the World Bank Group. PPPs represent also a new approach to international health financing. Indeed, innovative funding mechanisms that draw mostly on private sector thinking are being set up at the international level. It is the case of the International Finance Facility for Immunization and the Advance Market Commitment put in place by the GAVI as well as of the ‘Debt2Health’ Agreements concluded among some countries and the Global Fund to fight AIDS, tuberculosis, and malaria.
23 Despite the major achievements, global co-operation in health is confronted with numerous other challenges. One of them relates to the international community’s ability to recognize the status of ‘health entity’ of territories such as Taiwan. The latter has ‘customs entity’ status at the WTO. In 2006, the European Parliament Resolution on Taiwan ([18 May 2006] OJ C297E/387) was adopted, in which it was noted that ‘Taiwan would be excluded from UN protection if an epidemic were to break out on the island, which means that there would be no coordinated co-operation with Taiwan’ (at para. G).
24 Global co-operation in health requires that entities of this sort be included as participants in the WHO GOARN or/and other global partnerships to ensure rapid exchange of information on the spread of infectious diseases like SARS at the regional and global levels.
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Documentation Française/Bruylant Paris/Brussels 2009) 111–38.
Select Documents
Additional Regulations Amending the International Health Regulations of 1969, as Amended by the Additional Regulations of 23 May 1973 (adopted 20 May 1981, entered into force 1 January 1982) 1286 UNTS 390.
Additional Regulations Amending the International Health Regulations of 1969, in Particular with respect to Articles 1, 21, 63–71 and 92 (adopted 23 May 1973, entered into force 1 January 1974) 943 UNTS 428.
Agreement for the Creation of an International Office of Public Health (signed 9 December 1907, entered into force 15 November 1908) 206 CTS 31.
Constitution of the World Health Organization (signed 22 July 1946, entered into force 7 April 1948) 14 UNTS 185.
Convention Amending the International Sanitary Convention of June 21st, 1926 (signed 31 October 1938, entered into force 24 July 1939) 198 LNTS 205.
Convention Respecting Measures to be Taken against Phylloxera Vastatrix (done 17 September 1878) 153 CTS 247.
Global Outbreak Alert and Response Network ‘Guiding Principles for International Outbreak Alert and Response’ (adopted April 2000).
International Agreement for the Creation at Paris of an International Office for Dealing with Contagious Diseases of Animals (signed 25 January 1924, entered into force 26 March 1924) 57 LNTS 135.
International Code of Marketing of Breast-Milk Substitutes (adopted 21 May 1981) (1981) 20 ILM 1004.
International Convention concerning the Export and Import of Animal Products (Other than Meat, Meat Preparations, Fresh Animal Products, Milk and Milk Products) (signed 20 February 1935, entered into force 6 December 1938) 193 LNTS 59.
International Convention concerning the Transit of Animals, Meat and Other Products of Animal Origin (signed 20 February 1935, entered into force 6 December 1938) 193 LNTS 37.
International Convention for the Campaign against Contagious Diseases of Animals (signed 20 February 1935, entered into force 23 March 1938) 186 LNTS 173.
International Health Regulations (with Appendices) (adopted 25 July 1969, entered into force 1 January 1971) 764 UNTS 3.
International Health Regulations (2005) (adopted 23 May 2005, entered into force 15 June 2007) in World Health Organization International Health Regulations (2005) (2nd ed WHO Publications Geneva 2008) 6.
International Sanitary Convention (signed 30 January 1892, entered into force 14 February 1893) 176 CTS 395.
International Sanitary Convention (signed 17 January 1912, entered into force 7 October 1920) 4 LNTS 281.
International Sanitary Convention (signed 21 June 1926, entered into force 28 May 1928) 78 LNTS 229.
International Sanitary Convention, 1944, Modifying the International Sanitary Convention of 21 June 1926 (signed 15 December 1944, entered into force 15 January 1945) 17 UNTS 305.
International Sanitary Convention for Aerial Navigation (signed 12 April 1933, entered into force 1 August 1935) 161 LNTS 65.
International Sanitary Convention for Aerial Navigation, 1944 (with Annexes), Modifying the International Sanitary Convention for Aerial Navigation of 12 April 1933 (signed 15 December 1944, entered into force 15 January 1945) 16 UNTS 247.
International Sanitary Convention for the Protection of the Pilgrimage to Mecca from Disease, and for Establishing Sanitary Inspection in the Persian Gulf (signed 3 April 1894, entered into force 20 June 1898) 180 CTS 101.
International Sanitary Regulations—World Health Organization Regulations No 2 (with Appendices and Annexes) (adopted 25 May 1951, entered into force 1 October 1952) 175 UNTS 215.
Interpretation of the Agreement of 25 March 1951 between the WHO and Egypt (Advisory Opinion) [1980] ICJ Rep 73.
Resolution of the Second Pan-American Conference Relative to Sanitary Police (adopted 29 January 1902) 190 CTS 458.
Sanitary Convention (signed 15 April 1893, entered into force 1 February 1894) 178 CTS 369.
Sanitary Convention (signed 3 December 1903, entered into force 6 April 1907) 194 CTS 294.
‘Summary Report of Thirteenth Meeting of Committee II/3’ in United Nations Conference on International Organization Documents of the United Nations Conference on International Organization San Francisco, 1945 vol 10 Commission II, General Assembly (UN Information Organizations New York 1945) 120.
UN Committee on Economic, Social and Cultural Rights ‘General Comment No 14: The Right to the Highest Attainable Standard of Health (Art. 12 of the Covenant)’ (11 May 2000) ESCOR [2001] Supp 2, 128.
WTO Committee on Sanitary and Phytosanitary Measures ‘Guidelines to Further the Practical Implementation of Article 6 of the Agreement on the Application of Sanitary and Phytosanitary Measures’ (16 May 2008) G/SPS/48.
