The Short- and Long-Term Shortcomings of the International Health Regulations (IHR) Exposed by COVID-19

Abstract:

Numerous studies have been conducted regarding the outcomes of COVID-19 on the world healthcare system, the global economy, and on mental health, as well as what epidemiological factors contributed to the spread of the virus. However, little research has been completed to analyze other factors that helped the disease thrive, beyond the characteristics of the virus itself, and where society stands today as it prepares for a possible future epidemic.  

The objective of this paper is to critically analyze the primary body that was tasked with controlling a pandemic – the World Health Organization (WHO) – and the measures they put in place – The International Health Regulations (IHR) – to manage the risk of an event like COVID-19. More specifically, through case studies and examples drawn from the pandemic response efforts, along with directional input from a former staff member of the WHO, the research will dig into what non-biological aspects contributed to the spread of the virus, what steps have been taken by the WHO since, and what potential gaps still exist today.

By advocating for improved international public health collaboration and concerted efforts to enhance pandemic preparedness, this research contributes to the intellectual discourse on mechanisms to help ensure a more-resilient response to future global health threats in an increasingly interconnected world.

Keywords: COVID-19, WHO, IHR, IHR 2005, PHEIC

I. Introduction

Founded in 1948, the World Health Organization (WHO) is a United Nations agency of 194 member states that is tasked with promoting health on a global scale. Because a key element of its charter is to help prevent the spread of serious public health threats beyond a country’s borders, the WHO later established the International Health Regulations (IHR) to more effectively control specific highly contagious diseases. These regulations have been updated multiple times since their adoption in 1969, including important changes contained in a revision called IHR 2005, to deliver even better protection worldwide.

Despite the WHO’s efforts to put a foundation in place for effectively addressing a pandemic (with the IHR and its amendments), COVID-19 exposed serious gaps in global preparedness. A lack of transparency and sharing of information across countries underscored the need for quicker identification and collaboration worldwide. Clear differences in how member states reacted once a pandemic was declared highlighted the need for more consistent reporting and response. And considerable differences in the containment strategies used by these countries to slow the spread of the disease, both inside and outside their borders, shined a light on the inadequacies of the existing regulations.

In the years following the deadly outbreak, countries have banded together to revise and update the IHR even more. In June 2024, additional amendments were announced, which included a clearer definition of a pandemic emergency and a more-effective way to declare one. Member states also made a recommitment to solidarity and equity, and they agreed to better share resources in the future to prevent (and collectively respond to) similar outbreaks.

This paper aims to better understand the shortfalls of IHR 2005 – the version of the regulations in place at the time of the COVID-19 outbreak – that led to less-than-ideal responses. It will also evaluate the potential effectiveness of the most recent 2024 amendments and identify possible roadblocks to success in addressing a future public health threat of a similar magnitude, as well as offer suggestions for better future pandemic management.

II. Overview of COVID-19 and the Role of IHR

A. Background on COVID-19

COVID-19, was caused by the SARS-CoV-2 virus, a novel coronavirus that is part of a family of viruses that includes those responsible for the common cold, as well as more severe illnesses like SARS (Severe Acute Respiratory Syndrome) and MERS (Middle East Respiratory Syndrome). Coronaviruses are characterized by crown-like spikes on their surface, which helps them attach to host cells. Genomic sequencing of SARS-CoV-2 revealed it to be closely related to coronaviruses found in bats. It also shares similarities with the virus responsible for SARS, suggesting (although disputed) that it may have originated in bats and then jumped to humans, possibly through an intermediary host, which is a phenomenon known as zoonotic spillover. (Lora, 2021). 

COVID-19 reportedly first emerged in December 2019 in Wuhan, Hubei Province, China. The initial cases were linked to a seafood market in Wuhan, which also sold live wild animals. By January 2020, COVID-19 cases were spreading rapidly in Wuhan, leading to the imposition of localized lockdowns and travel restrictions. (History, 2023). Due to its many transmission methods the disease was already in a position to spread across borders as worldwide travel generally continued. 

On March 11, 2020, the WHO declared COVID-19 a global pandemic. The decision was based on its rapid and widespread transmission, the likes of which the world had not seen for more than a century with the Spanish Flu in 1918. The virus soon spread to other countries, primarily through international travel, and it reached 200 countries in just months – quickly reaching Europe, North America, and around the globe. This outbreak led to widespread health crises, economic disruptions, and societal changes. (WHO, 2024). 

B. Background on the WHO and its Relationship with IHR

Headquartered in Geneva, Switzerland, the WHO is a specialized agency of the United Nations, which was established on April 7, 1948. This date, now celebrated annually as World Health Day, marks the beginning of a global effort to improve health standards and manage health crises on an international scale. (WHO, 2021). WHO’s core mission is to promote health, keep the world safe, and serve the vulnerable, encompassing a broad array of activities aimed at enhancing global health standards and coordinating international health efforts. (WHO, 2024).

The WHO operates through a structured governance system. The World Health Assembly (WHA), its decision-making body, comprises representatives from all member states and convenes annually to set policies, approve budgets, and make critical decisions on health issues. (WHO, 2021). The Executive Board, composed of 34 members elected for two-year terms, implements WHA decisions and provides guidance on health policies and programs. The WHO Secretariat, led by the Director-General, manages the organization’s daily operations.

Among its many functions, the WHO is known for developing international health standards, providing technical assistance to countries, and monitoring global health trends. It also plays a crucial role in disease prevention, strengthening health systems, and helping coordinate emergency response. Notable achievements include the eradication of smallpox and ongoing efforts to control polio, which underscore the WHO’s significant impact on global health. (WHO, 2021).

The IHR is an international legal agreement first adopted in 1969 by all 194 WHO member states with the goal of managing specific diseases such as cholera, plague, yellow fever, smallpox, relapsing fever, and typhus. (WHO, 2021). However, as global health threats evolved, so too did the IHR with several changes adopted over the next 35 years. 

In the early 2000s, the IHR was revised once more to address an even broader spectrum of public health emergencies, reflecting the changing nature of worldwide health risks and the impact of globalization. This latest set of amendments, called IHR 2005, were introduced to prevent, protect against, control, and provide a public health response to the international spread of diseases while minimizing unnecessary interference with international travel and trade. It was the version of the IHR in place when COVID-19 first emerged. 

In more recent years, the IHR was updated once again, covering all public health emergencies – not just those related to specific diseases – and emphasizes a comprehensive approach to health security. This includes requirements for countries to develop and maintain core capacities to detect, assess, notify, and respond to public health threats. (Taylor, 2020).

III. Shortcomings of IHR 2005 Exposed by COVID-19:

Even though the WHO worked hard to prepare for a pandemic, including the approval of IHR 2005, it was not fully prepared for a disease that spread with the speed and ease of COVID-19. In retrospect, there were critical gaps in its regulations – and in how each member state interpreted and executed them – that led to delayed and inconsistent compliance. Ultimately, these problems had national and global repercussions, including the death of millions of people, the investment of trillions of dollars in relief, and a significant impact on people’s mobility, work, and even mental health. These are some of the key shortcomings that were exposed:

A. Slowness of Declaration of a PHEIC

One clear gap in IHR 2005 was how and when a Public Health Emergency of International Concern, or PHEIC, is declared. A PHEIC is defined by the IHR as “an extraordinary event which is determined to constitute a public health risk to other states through the international spread of disease and to potentially require a coordinated international response.” The purpose of declaring a PHEIC is to prompt global cooperation and mobilize resources for a coordinated response to manage and contain health emergencies. (Stuckleberger, 2020). This designation facilitates the implementation of measures and strategies to prevent the spread of the disease and reduce its impact on global health.

Despite early indications of a novel respiratory illness in China in late 2019, a PHEIC was not declared until January 30, 2020. (History, 2020). This delay was in part caused by China placing considerable effort into suppressing information and attempting to prevent critical test results from leaving China’s borders, but it was also caused by an apparent lack of clarity on the wording of what constitutes an extraordinary event. 

The results of a delayed PHEIC were significant on a global scale, with clear implications to global response timing, coordination, and resource allocation. For instance, WHO noted that a late start dampened efforts to mobilize resources, coordinate surveillance, and deploy critical medical supplies and personnel to affected regions. (WHO, 2024). In order to prevent similar results in the future, new language and alignment on the definition of a PHEIC would be needed, and the WHO would need to provide greater assurances to individual countries that sensitive information would be protected in order to encourage them to willingly share information. 

B. Delayed Reporting and Fragmented Response Mechanisms

Effective pandemic response hinges on the prompt and transparent reporting of outbreaks by member states. As mentioned, the initial reaction to COVID-19 was compromised by local Chinese authorities hiding information and downplaying the severity of the situation. However, other countries around the world also established barriers in reporting cases and sharing crucial information about the virus. This inability, or unwillingness, to comply with reporting obligations specifically called out by IHR 2005 led to critical global delays in assessing the gravity of the problem and the timing of a coordinated counterattack.

A second component of response that broke down during the pandemic was the consistency in which corrective efforts – called the “response mechanism” – were carried out worldwide. Many countries, particularly low and middle-income nations, struggled to allocate adequate funds for surveillance, laboratory capacity, and public health infrastructure. (Jones, 2021). They simply had too many domestic needs competing for limited resources, and thus reacted with varying degrees of effectiveness. Compounding the problem, the WHO’s ability to support these countries of lower socioeconomic status with technical assistance and financial support was hindered by funding shortages and competing global health priorities. This divide highlighted the urgent need for sustainable financing alternatives to bolster global health security and enhance pandemic preparedness, as well as more-effective prioritization amongst states themselves, to deliver a more-complete response mechanism worldwide.

The combination of delayed reporting and a fragmented response mechanism delivered a perfect environment for a pandemic to thrive. Inconsistencies in how countries communicated about the health risk highlighted vulnerabilities in the enforcement of the IHR 2005. (Stuckleberg, 2020). Added to this, a significant variance in the protections put in place by individual member states to control the spread of the disease resulted in cracks that led to a faster spread. Together, these challenges put the WHO in a position where it was not able to effectively execute on its mission. 

C. Inconsistent Compliance with WHO Recommendations on Travel Restrictions and Quarantines Across Member States

A third and critical deficiency of IHR 2005 was also uncovered by the pandemic: containment. The IHR recommends travel restrictions and quarantine to curb the spread of disease, while minimizing disruptions to international travel and trade. These guidelines are based on scientific evidence and aim to protect global health by advising member states on proportionate measures. (UN, 2020). 

 At the onset of the pandemic, countries implemented travel restrictions at different times based on their assessment of the threat and local public health capabilities. Some nations, such as New Zealand and Australia, quickly imposed strict travel bans and border controls. In contrast, other countries were slower to act, or they implemented partial measures at first – allowing the virus to spread more widely before restrictions were enforced. (Illmer, 2021). 

Quarantines were also not consistent in terms of scope. For instance, some states imposed comprehensive bans on non-citizens and non-residents, while others were less stringent, particularly within their region. Some countries also enforced strict protocols for travelers arriving from high-risk areas, including mandatory health screening and isolation in designated facilities for multiple days. Other countries allowed self-isolation at home or imposed less-rigorous monitoring and enforcement, leading to varying levels of effectiveness in preventing virus transmission. (Illmer, 2021). 

Finally, the extent and frequency of testing for travelers varied widely from one member state to another. Some required multiple tests and proof of negative results, which might have included a mix of tests taken before departure, upon arrival, during a stay, and before return. Other countries required less-frequent testing – sometimes just at arrival or departure, if at all. (Illmer, 2021). 

These differences in approach prevented authorities from detecting and isolating cases quickly. Importantly, the inability to contain the virus also led to more, and faster, mutations – making it even more difficult to diagnose and treat the symptoms, as well as to build an effective vaccine for prevention and elimination. To limit the scale of future pandemics and drive more consistency in the implementation of containment techniques, the WHO would need to better manage numerous factors, including clearer rules, consistent health infrastructure, social factors, and even communication barriers. 

IV. Recent Responses to Address Shortcomings: Amendments to IHR 

While IHR 2005 represented a considerable step forward from its predecessors in terms of preparing the world for a global pandemic, COVID-19 exposed a number of inadequacies in it as well – particularly in the areas of declaration, response, and containment. One of the best ways to address these deficiencies on a global scale was to adjust the IHR even further, which was completed by the WHO in 2024 with a new set of amendments. Below are some of the most important changes that were included.

A. PHEIC and Pandemic Emergency Declaration

Article 54 of the 2024 IHR amendments represents a critical element in the revision process aimed at improving the management and response to PHEIC. This article specifically sets out to address the conditions under which a PHEIC is declared and managed, as well as streamline the PHEIC process, enhance the effectiveness of global responses, and ensure that future emergencies are managed more efficiently. (WHO, 2021).

Specifically, the language now includes better guidance on how to assess the severity of the health threat, its potential for international spread, and the impact on public health systems. (WHO, 2024). It also requires the WHO to assess potential emergencies more promptly, with predefined timelines for decision making and communication. And in addition to addressing past delays in emergency identification, these changes also seek to reduce the risk of premature or inappropriate declarations that may distract important resources during an emergency, by ensuring that only events meeting these stringent criteria are classified as PHEICs.

Once a PHEIC has been named, there is also a need for ongoing assessment of them. Article 54 introduces the concept of mandatory periodic reviews. The WHO Emergency Committee is now tasked with evaluating the status of each in-process PHEIC at regular intervals. (WHO, 2024). These reviews assess whether the conditions warrant the continuation of the PHEIC status, or determine if the status should be downgraded or lifted. This action, which includes evaluating ongoing risks and the effectiveness of response measures, ensures that the PHEIC designation remains relevant and appropriate based on the evolving situation. (Farge, 2023).

B. Reporting and Response in the Context of IHR Amendments

IHR 2005 introduced significant enhancements to promote transparency in information sharing among member states and with the WHO. These amendments were integrated into multiple sections of the IHR, notably Article 10 which focuses on the dissemination of information, and Article 11 which addresses confidentiality and publication of information (Searchinger, 2024).

During the COVID-19 pandemic, the challenges of transparency under the IHR 2005 were highly visible. Timely and complete sharing of information between Chinese health authorities and the WHO would have been essential in understanding the nature and severity of the emerging threat. These initial delays, and inconsistencies in reporting and information sharing, greatly impacted early international awareness and response efforts. (WHO, 2024).

Under the latest 2024 amendments, there is a clear emphasis on comprehensive information exchange during public health emergencies. Member states are now further obligated to share timely and accurate data related to disease outbreaks, public health risks, and planned response measures with the WHO and other relevant stakeholders. (Farge, 2023). This includes epidemiological data, laboratory findings, surveillance reports, and best practices in outbreak response.

The amendments also clarify the confidentiality provisions outlined in Article 11, ensuring that sensitive information is appropriately protected while facilitating the dissemination of critical health information. (IHR, 2024). The combination is intended to promote openness and collaboration among member states, aiming to foster a unified global approach to managing health crises.

C. Coordinating Financial Mechanism

Another key revision now included in the IHR is the Coordinating Financial Mechanism, which aims to break down financial constraints and improve the allocation of resources during health emergencies. The introduction of this mechanism reflects the lessons learned from past crises, including the 2014 Ebola outbreak and the COVID-19 pandemic, which highlighted the need for more-robust financial coordination and support. (WHO, 2021).

The primary goal of the Coordinating Financial Mechanism is to ensure that sufficient funds are available for effective response to public health emergencies. This includes covering the costs associated with emergency interventions, such as medical supplies, vaccines, and treatments. By securing a reliable funding source, it intends to eliminate financial barriers that may hinder timely and effective responses to health crises. (Stucklerberger, 2020).

The newly defined mechanism also seeks to improve coordination among various funding sources, including governments, international organizations, and private sector entities. This involves streamlining financial contributions and ensuring that resources are allocated efficiently and transparently. The enhanced coordination helps avoid duplication of efforts and ensures that financial resources are directed to where they are most needed, thereby improving the overall effectiveness of the response. (Stucklerberger, 2020).

Lastly, in order to create and build capacity, this mechanism focuses on expanding resources, particularly in second and third-world countries. This includes funding to strengthen health infrastructures, improve surveillance systems, and train healthcare workers. By addressing capacity gaps, it aims to improve the preparedness and response capabilities of countries with limited resources, ensuring a more equitable and effective global response. (Miller, 2024).

V. Looking Ahead: Geopolitical Challenges to Global Health Cooperation

The 2024 amendments to IHR 2005 represent meaningful progress in the preparation for the world’s next great pandemic. However, there is still work to be done. Additional obstacles, which previously stood in the way of a unified, global response during COVID-19, will likely remain in place even after the latest changes are implemented. Largely geopolitical in nature and driven by individual countries’ own unique political, economic, and social priorities, these ongoing challenges may require additional clarification, diplomatic efforts, or new amendments to ensure consistent execution against the obligations set out in IHR. 

A. Vaccine Nationalism

Vaccine nationalism emerged prominently during the COVID-19 pandemic, where wealthier nations prioritized securing vaccine doses for their populations through bilateral agreements and domestic production. This approach resulted in disparities in global vaccine distribution, with low-income countries facing delays in accessing vaccines through multilateral initiatives like COVAX (Miller, 2024). 

For instance, countries like the United States and numerous European nations signed early procurement deals with vaccine manufacturers, ensuring rapid vaccination of their populations. In contrast, many third-world countries struggled to secure sufficient vaccine supplies, prolonging the pandemic’s impact on their vulnerable populations. Agreements on vaccine equity and balanced distribution will be necessary to prevent a similar situation in the future. 

B. Political Tensions and Information Sharing

Long-standing tensions among certain member states likely contributed to delays in information sharing and cooperation during the initial stages of COVID-19. China is a known political rival of the United States and other Western countries, which gave them an incentive to withhold critical epidemiological data coming out of Wuhan from the rest of the world in the early days of the pandemic. This, of course, disrupted early global awareness and response efforts, allowing the virus to spread beyond China’s borders before global countermeasures were fully in place. 

China was highly criticized about its lack of information transparency and timely notification to international health authorities. (Miller, 2024). However, past criticism largely from existing rivals may not be enough to change this behavior in the future – particularly when officials may see sharing sensitive information as a sign of geopolitical weakness or as a national security threat. The confidentiality provisions outlined in Article 11 are designed to help prevent these practices, but nationalistic tendencies are more likely to win out during a crisis. Additional international relations efforts by individual states to solidify alignment on global health priorities will be necessary, as will unified global pressure to adhere to the amended principles of IHR.

C. Trade and Export Restrictions

One of the most essential worldwide needs during the pandemic was for healthcare items like respirators, which were critical for some of the hardest-hit COVID patients to breathe. Expecting a high demand domestically for these medical supplies and related personal protective equipment (PPE), numerous countries implemented international trade restrictions and export bans on them. Such protectionist measures disrupted global supply chains and exacerbated shortages of essential medical supplies in regions heavily impacted by COVID-19 (Miller, 2024). 

Similar to what led to vaccine nationalism, country leaders will be tempted in future healthcare crisis situations to protect their citizens first. A commitment to preventing these practices – via additional clarifications to the IHR, or even new amendments – will be needed to avoid putting overseas frontline workers and vulnerable populations at greater risk. Additional diplomatic efforts will also be necessary to ensure open, international cooperation in pandemic response.

VI. Conclusion

COVID-19 highlighted a critical need for transparent communication, enforceable mechanisms, and equitable distribution of resources to ensure effective preparedness and response. IHR 2005 provided a solid starting point to accomplish these core objectives, but a number of deficiencies were exposed during the height of the pandemic that led to unnecessary worldwide disruptions, spending, and suffering. 

The latest round of amendments, which were adopted in June 2024, address some of the most important gaps in IHR 2005 including those related to declaration, response, and containment. They represent the coordinated effort of the WHO and its member states, and they are likely to further enhance global resilience against future health threats and foster international solidarity in health crises. 

However, there are still obstacles to be overcome – most notably geopolitical factors such as vaccine nationalism, political tensions affecting information sharing, and trade barriers – which can lead to disparities in vaccine distribution, delayed international cooperation, and strained global health governance processes. As we reflect on the lessons learned from COVID-19, it becomes evident that investing in global health security frameworks is not only a moral imperative but also a strategic necessity that will require ongoing clarifications, amendments, and diplomatic ingenuity.  

VII. Acknowledgments

The author of this paper would like to acknowledge Dr. Allyn Taylor – for her support throughout the writing process.

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