Science, Medicine, and Anthropology
The Zika virus was recently declared a Public Health Emergency of International Concern (PHEIC), which puts the World Health Organization (WHO) at the centre of the global response to the virus. Given the recent controversies around the management of infectious disease outbreaks – where the WHO has been variously accused of underreacting or overreacting to threats – the unfolding of Zika is likely to play an important part of continuing discussions about the function and role of the organisation within global public health.
In assessing these criticisms, it is important to look into the act of PHEIC declaration, and the role of the WHO. From the WHO’s perspective, by calling a PHEIC, they’re putting into action a certain set of relationships between nation-states and the WHO around surveillance, detection, monitoring and the dissemination of information. Additionally, the WHO provides input into coordinating research and providing advice to health authorities and around clinical care. But this has to be contrasted with the symbolic meaning derived from a declaration of a public health emergency. The PHEIC declaration has been taken up by others actors, such as the media, as a representation of a very high-risk, and globally-risky, event.
Zika presents a unique challenge for the WHO. One of the reasons is because of the extent of uncertainty that surrounds the disease and how it might manifest. This means that policy options become quite tenuous, since no one can really predict how the event is going to unfold.
For example: if a woman has been infected by Zika, what is the likelihood that she will actually have a microcephalic baby? We’ve seen, just recently, the possibility that the virus could be sexually transmitted or transmitted through saliva, which would speak to another set of management issues, in addition to the problem of vector control. On top of this is the uncertainty around the ethical and social implications of various public health actions targeting (potentially) pregnant women. This sense of uncertainty makes it quite problematic for the WHO either to act or not act, because the evidence – at this point – is scarce. All of these issues make it difficult to define risk, which also makes it quite challenging to specify effective policy options.
This problem of uncertainty also highlights the inherent tensions within the International Health Regulations and declarations of PHEIC. The WHO has declared PHEICs around four different infectious diseases so far, which are Zika, H1N1, Ebola, and the spread of polio. From this list you can see that these are really diverse events. They are diverse diseases in terms of severity, risk, geographical spread and in terms of the population groups that are vulnerable.
This diversity points to the fact that the PHEICs may not necessarily be a very well specified policy instrument. One of the reasons why the WHO was criticised around H1N1 was because the public experience of that disease was one of very low severity, even though H1N1 was widely spread, geographically-speaking. On the other hand, the WHO was criticised for under-reacting to Ebola, and clearly severe disease with a devastating impact. However, for Ebola there wasn’t this strong sense of geographical spread, one of the underlying principles in triggering a PHEIC.
The WHO is in a position where there’s no ‘correct’ option because they must to be seen to act, in the absence of sufficient information to make a strong policy decision. Nonetheless, as the event progresses, it is likely that the WHO’s actions will be evaluated with the benefit of hindsight, after the present uncertainties have been resolved.
For academic discussion on the WHO and IHRs, see:
Abeysinghe, S. (2015). Pandemics, Science and Policy: H1N1 and the World Health Organization. London: Palgrave Macmillan
Gostin, L. O., DeBartolo, M. C., & Friedman, E. A. (2015). The International Health Regulations 10 years on: the governing framework for global health security. Lancet 386(10009), 2222-2226.
Kamradt-Scott, A. (2015). WHO’s to blame? The World Health Organization and the 2014 Ebola outbreak in West Africa. Third World Quarterly,1-18.
Sudeepa Abeysinghe is a sociologist and expert in infectious disease control, particularly on issues around the WHO, declarations of emergency, regulation, and the sociology of organisations.
2 replies on “Zika, Uncertainty and Global Health Policy”
Dr. Abeysinghe,
This is a nice piece on the policy implications of the WHO’s declarations, and how uncertainty is circulated and communicated across a variety of levels.
It would be important to clarify that the Zika virus itself was not declared a PHEIC. Per the WHO briefing you provide, the advisory was that “the recent cluster of microcephaly cases and other neurological disorders reported in Brazil, following a similar cluster in French Polynesia in 2014, constitutes a Public Health Emergency of International Concern (PHEIC)”. This has been an important, but often overlooked distinction both in the media and in global health discussions more broadly.
That said, the WHO and others are acting as if the spread and consequences of Zika itself ought to be addressed and tackled as an emergency event (so perhaps it’s just semantics). The differences in risk communication between Ebola and Zika are worth noting, with some lauding the clarity and consistency– and the unusual amount of transparency– regarding the uncertainties surrounding the outbreaks. See, e.g., Peter Sandman’s recent piece (http://www.psandman.com/articles/zika-1.htm).
What remains to be seen is how the ongoing restructuring at the WHO for its Emergency and Outbreaks Platform is impacting how the PHEIC plays out. As you put it, the WHO is in a tough spot (as usual), but it seems that many are approving of its approach thus far.
Thanks again for your timely and informative article.
[…] at the WHO are united by such frustrations as well, as Sudeepa Abeysinghe has recently illustrated in an examination of the WHO’s decision to declare Zika a Public Health Emergency of […]