New International Health Regulations and the Federalism Dilemma, The

According to the article, as a result of the lessons learned from the outbreaks of severe acute respiratory syndrome (SARS) and in anticipation of possible outbreaks of avian influenza (also known as avian flu or bird flu), the international health community has recognised that pandemic planning and response needs to be multi-governmental. The ability of pathogens to cross borders and rapidly spread around the globe requires highly co-ordinated public health responses that involve the co-operation of local, regional, national, and supranational governments. The understanding of this reality has informed the current International Health Regulations (IHR) revision process.

Approved in May 2005, the revised IHR have increased the disease surveillance requirements of states in an effort to better inform the pandemic response process and to protect the health of the global community. The revisions have also outlined recommendations that the World Health Organization (WHO) could issue if an outbreak originating in one country is perceived to be a threat to other countries. According to the authors, the practical implementation of these proposals may encounter obstacles, particularly for WHO member nations that have federal systems of government.

One of the limitations of federations is that the division of powers can create obstacles to the development of centralised approaches to national challenges. Such scenarios can arise when the country's constitution distributes the key powers in question to the regions. When international treaties are signed by a federal government, the cooperation of regional governments (states, provinces, etc.) is necessary for compliance with the treaty. The article provides examples from the SARS experience. Reviews of the Canadian response to SARS showed that the transfer of data from the Ontario provincial government to the federal government was a key obstacle to the management of the crisis and, in particular, limited the federal government's ability to effectively communicate the status of the outbreak to the WHO. The United States encountered similar jurisdictional problems when developing strategies to address the threat of bio-terrorism following the 2001 anthrax attacks, because public health is primarily within the jurisdiction of the states.

The multi-dimensional nature of disease outbreaks also contributes to the challenge, as the response to an infectious outbreak could involve issues of national security, emergency response, environmental protection, and food and water safety, all with potentially different areas of responsbility within governments. Such a scenario could produce conflict or confusion when attempting to determine which order of government has the ultimate authority over the management of the outbreak. A further complication is the extended scope of the role and functions of the WHO, which largely depends on data being quickly gathered and disseminated in collaboration with governments.

According to the article, it is apparent that the challenges posed by federalism will need to be addressed, both by member nations and by the WHO, if the revised IHR are to be implemented successfully. Potential measure to address this would include using what constitutional means may be available to centralise necessary public health powers concerning surveillance and outbreak response, making efforts to establish effective collaborative inter-governmental arrangements, and developing appropriate public health capacity at the local level. The authors propose that the WHO must also make efforts to assist federations in this regard. These efforts could include the provision of guidelines on strategies federal governments can use to address some of the challenges. To facilitate collaboration, federal governments could enter into agreements with regional governments to ensure co-operation on matters such as the timely and adequate transfer of data. The likelihood of adherence to such agreements would be greatly enhanced if conditional funding were provided by the federal government to assist in developing the necessary surveillance and response infrastructure at the local level.

The article concludes that "given the importance of the IHR revision process, every effort should be made to ensure that member nations can comply with the new requirements. The size and power of several federations in the World Health Organization require that the particular nuances of their governance structure be acknowledged and respected. Failure to do so could threaten the long-term support of the IHR by key federations, such as the United States, India, and Russia, which would undermine their fundamental objective of protecting the global community. Ultimately, however, it is the responsibility of federations to make the appropriate adjustments in their approach to public health governance so that they can effectively identify, respond to, and communicate information on disease outbreaks."