Posted in Issue 109 - March 2008 Editorial
In many countries, response to outbreaks of communicable diseases, particularly when there is concern among the public and on the part of authorities, is undertaken to a large extent with the excellent collaboration of disaster preparedness and response programs in the ministries of health. While epidemiologists and communicable disease experts assume leadership in the scientific and technical aspects of outbreak response, the complementary operational and management skills of disaster experts in areas such as logistical support, intersectoral coordination, and mobilization of resources is invaluable.
Until recently, obligations for countries governed by the WHO International Health Regulations (IHR) were limited to monitoring, reporting on, and controlling a limited number of diseases. In 1969, when the Regulations were adopted, six communicable diseases were included: cholera, plague, yellow fever, smallpox, relapsing fever, and typhus. By 1981, only cholera, plague, and yellow fever remained on the list. In the past, reporting was often made at the discretion of the affected countries. Cholera, for instance, was underreported or, when politically convenient, re-labeled as “acute watery diarrhea.”
In the last few years, however, international concern over issues such as the spread of severe acute respiratory syndrome (SARS) in industrialized countries, with its consequent global economic impact, the impending threat of an influenza pandemic, or the worst-case scenario of a deliberate release of hazardous agents, has prompted a fundamental revision of the International Health Regulations. Following extensive deliberations, the World Health Assembly adopted the revised Regulations on 23 May 2005.
Important Changes for Disaster Management
- The scope of the revised IHR 2005 has been expanded to include any disease (defined as an illness or medical condition, irrespective of origin or source) that presents or could present significant harm to humans. In practical terms, any release of a hazardous substance, no matter its nature or cause, is now covered by the IHR. Emergencies caused by climate change are not specifically addressed in the IHR, which gives institutions that manage disasters and other ministry of health programs a certain latitude to apply regulations.
- The IHR 2005 introduces the concept of a “public health emergency of international concern” (PHEIC). Any event that affects the public health of more than one WHO Member State may qualify as a PHEIC. This would include a chemical discharge in a river, the atmospheric release of a hazardous agent, the contamination of food crossing borders, an El Niño event, or even a hurricane in the Caribbean.In terms of declaring a PHEIC, WHO may take into account reports from sources other than governments. “Other” sources may include NGOs or the mass media. WHO can disseminate information about an event if it has already been made public (for instance, in the international press or on the Internet).
- PAHO/WHO Member States should designate focal points in their countries to be available to make reports, to manage information, and to maintain ongoing contact with PAHO/WHO-IHR authorities.
Implications for National Disaster Programs in the Health Sector
From the standpoint of disaster management coordinators in the ministries of health, the revisions to the IHR are positive. The designation of an office specialized in epidemiological surveillance, preparation of reports, and notification of events that pose potential hazards for local, national, or international public health has been anticipated for a long time in Latin America and the Caribbean. Expanding the role of epidemiologists to deal not only with traditional communicable diseases but also with a broader range of contaminants (water-borne, air-borne, or transported through commerce) can only contribute to greater preparedness. In fact, this “disaster epidemiology” approach has long been promoted by PAHO/WHO.
The recognition that globalization brings with it new challenges and opportunities for preventing the international spread of disease was the starting point for the revision of the International Health Regulations (1969). The assignment of an IHR focal point is an opportunity to strengthen cooperation and complement the skill sets of disaster managers and epidemiologists. Disaster coordinators should carefully read the guide for national IHR focal points prepared by WHO. The emphasis is clearly on information management (from surveillance to regulations), an area that needs to be intensified in all countries. The IHR guide does not provide guidance on mechanisms for operational intra- or intersectoral coordination, logistic support, or response management, areas in which the health disaster programs are particularly strong and can support the IHR.
The International Health Regulations are designed to protect all countries from potential public health risks originating in any one country. In addition to traditional infectious agents, the emphasis is also on natural events and the accidental or deliberate release of chemical or radionuclear material, as expressed in the letter of “Reservation and Understanding” from the U.S. Government to WHO, written in 2006. This change in emphasis will require IHR focal points to have the support of disaster coordinators to ensure that ministries of health and other entities provide precise information and respond to events according to the type of hazard involved.
Public health emergencies resulting from climate change are harder to define. Is a particularly severe hurricane the result of a change in climatic patterns or a random occurrence? What is the role, if any, of IHR focal points in monitoring the health consequences of hydrometeorological disasters? Will WHO declare the next El Niño a PHEIC? What will the value of the IHR be when it comes to information management or the coordination of disaster response when hurricanes threaten several countries, as they always do in the Caribbean? Managing the IHR and monitoring the health impact of climate change are very distinct responsibilities and issues. It is the responsibility of Member States or international agencies to decide how best to assign these functions in their own organizations.
One of the main challenges during disaster response is to control the spread of rumors. Having different sources and types of information circulating in the same institution or government can have catastrophic results, especially when there are suspicions that it is being done deliberately. When defining operational responsibilities, health authorities should be guided by a single objective: to apply a multi-hazard approach while using a single, coordinated response system. The countries of Latin America and the Caribbean will not benefit from the creation of a parallel mechanism for preparedness and response to different types of disasters. Multi-sectoral implications and coordination issues are identical. When the international community becomes involved, whether for reasons of solidarity, political convenience, or fear of the health consequences, a single, strong coordination mechanism is required.
In summary, the revision and implementation of the IHR provide an opportunity to strengthen ministries of health and national capacity by building a more effective reporting and monitoring system. It is now up to disaster programs in the ministries of health to use this opportunity to provide better information, an essential element in gaining trust and credibility for coordinating response efforts. These disaster programs also have the chance to broaden their scope and put an end to vertical and isolated organization. They can become truly supportive and cooperative mechanisms for response, utilizing the specialized knowledge and expertise of other technical departments in the ministries of health.
Disaster programs can support IHR focal points by compiling and producing quality information. With better information produced by ministries of health, there will be greater interest internationally, and better chances for appropriate responses both from the national and international humanitarian systems.
For more information on the IHR, consult http://www.who.int/csr/ihr/en/index.html.