Exploring the international arena of global public health surveillance
21 Pont Castelain, 6500–Beaumont, Belgium. E-mail: philippe_calain{at}hotmail.com
Threats posed by new, emerging or re-emerging communicable diseases are taking a global dimension, to which the World Health Organization (WHO) Secretariat has been responding with determination since 1995. Key to the global strategy for tackling epidemics across borders is the concept of global public health surveillance, which has been expanded and formalized by WHO and its technical partners through a number of recently developed instruments and initiatives. The adoption by the 58th World Health Assembly of the revised (2005) International Health Regulations provides the legal framework for mandating countries to link and coordinate their action through a universal network of surveillance networks. While novel environmental threats and outbreak-prone diseases have been increasingly identified during the past three decades, new processes of influence have appeared more recently, driven by the real or perceived threats of bio-terrorism and disruption of the global economy. Accordingly, the global surveillance agenda is being endorsed, and to some extent seized upon by new actors representing security and economic interests. This paper explores external factors influencing political commitment to comply with international health regulations and it illustrates adverse effects generated by: perceived threats to sovereignty, blurred international health agendas, lack of internationally recognized codes of conduct for outbreak investigations, and erosion of the impartiality and independence of international agencies. A companion paper (published in this issue) addresses the intrinsic difficulties that health systems of low-income countries are facing when submitted to the ever-increasing pressure to upgrade their public health surveillance capacity.
Key Words: World Health Organization, public health surveillance, bioterrorism, international health regulations, communicable disease control
1 Three key primary sources of information were identified from medical datasets and retrieved systematically: MEDLINE (key word: ‘International health regulations’ and ‘Outbreak surveillance’), the entire collection of the journal ‘Emerging Infectious Diseases’ and all documents published on the EPR (former CSR) website of WHO. Additional references and links quoted in these primary sources were further explored and retrieved as needed. Key public statements identified in this way were submitted to further analysis and selected when they shed light on stakeholders’ intentions.
2 In the 19th Century, William Farr, superintendent of the Statistical Department of the Registrar General's Office in England and Wales, routinely collected mortality data to describe the impact of epidemic influenza in 1847 (Langmuir 1976) and set new public health surveillance standards on the occasion of a cholera epidemic in 1848–49 (Langmuir 1963).
3 For a comprehensive historical and political review of the emergence of this concept, see King (2002).
4 Earlier, essential elements of global public health surveillance (including the role of WHO as a coordinating body) were reviewed at the ‘Technical Discussions’ forum of the 21st World Health Assembly in 1968 (WHO 1968).
5 This outdated meaning of ‘surveillance’ is now officially captured under the definition of ‘public health observation’ (WHO 2005a: Part I, Article 1 Definitions).
6 Thacker broadened the use of public health surveillance beyond the restricted field of communicable diseases, he conceptualized the three classical goals of surveillance data analysis (estimation of morbidity and mortality, detection of epidemics and programme evaluation) (Thacker et al. 1989), and he defined classical indicators used for the evaluation of surveillance systems (Thacker et al. 1988).
7 In the historical context in which the idea of revising the IHR had taken place, their earlier promoters obviously had in mind the control of rapidly evolving emergencies such as outbreaks of haemorrhagic fevers or cholera. But given the broad ‘Purpose and scope’ stated in the IHR(2005) (‘... a public health response to the international spread of diseases’), one wonders how, for instance, the new regulations would have applied in the late 1980s to HIV/AIDS when its spread, albeit slow, became already a matter of urgent international concern.
8 The World Trade Organization (created in 1995) administers 29 multilateral agreements, two of which are particularly relevant to preventing the spread of communicable diseases across borders: the General Agreement on Tariffs and Trade (GATT) and the Agreement on the Application of Sanitary and Phytosanitary Measures (SPS agreement). For an analysis of their mechanisms, see Plotkin and Kimball (1997).
9 For detailed accounts of the initial events of the SARS epidemic in China, see Heymann (2006) and Annex B in Bartlett et al. (2006).
10 What now appears as a cover-up operation by high-level Chinese authorities was quickly revealed publicly by Dr Jiang Yanyong, a prominent military surgeon and party member. Dr Jiang's courageous posture is now acknowledged as an important contribution to halt the spread of SARS (Kahn 2004; Ramon Magsaysay Award Foundation 2004).
11 A typical example has been well documented during the outbreak of Ebola haemorrhagic fever in Kikwit in 1995 (Heymann et al. 1999; Garrett 2001: 77).
12 Article 37 of the Constitution of the World Health Organization, 1946 (WHO 1994).
13 Building around the evolving concept of territoriality, King (2002) has proposed an outstanding historical perspective on global disease information networks.
14 Fidler (2005) also sees this policy shift as pertaining to the particular issue of surveillance: ‘... the United States’ interest in improving global infectious disease surveillance views improved global surveillance as a means to increase national and homeland security against bioterrorism, not as a vehicle for improving global health. Any constructive health consequences for other countries that spill over from improved global surveillance represent a positive externality but are not the primary foreign policy objective.’
Accepted for publication 28 September 2006.
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