Thank you for listening to my presentation. I'm going to make some remarks in particular using my experience as former Legal Counselor of WHO, and as somebody who was very much involved in the revision and some phases of the implementation of the IHR, or the International Health Regulations. As you know, the IHR is an international legal instrument and it's binding, like a treaty on a 196 states, all member states of WHO plus the Holy See and Liechtenstein. So it's a universal instrument. But like a treaty, it raises obligation for its practice. Obligations that impact international, so basically what states should or should not do with each other, but also national, what they should do internally in their own legal system to be compliant with the IHR. As you remember, the IHR has been criticized during the Ebola crisis, during the H1N1 Influenza pandemic for being somehow a weak instrument with low levels of compliance, no sanctions, WHO being too weak in its implementations, and so on. So I'm going to address some of these issues in a few minutes that I have, but I need you to take a step back and look at the context to appreciate the real scope, the real implications for the IHR. In particular the following elements. The first is, everybody focuses on the emergency part of the IHR; the mechanism to declare an emergency, to manage an emergency, and so on. But there is also a routine part of the IHR that tell states what they can and cannot do on a daily basis at the ports, airports, within the health systems, and so on. This part is working pretty well. Nobody talks about it, but it works pretty well. So you need to distinguish the two. The second is that the revision of the IHR was accomplished in a year and a half, very quickly and so under a lot of pressure. So it's not so amazing that mistakes have been made or certain things had been overlooked. It happens in all political decisions and the IHR is no exception. The third is that there are misconceptions on the purpose and the scope of the IHR. You remember during Ebola, people were saying the IHR is a failure because it did not materialize hundreds of millions of dollars, thousands of people, but that's not the purpose of the IHR. The IHR is a coordination system and is a mechanism for international prevention and response. So they are misconceptions and generalization, and what the IHR is about. Finally, as I will say also later in my presentation, there is a crucial issue of resources, financial and political. You can have the best treaty and if it is not well financed, it will remain dead letter. So the financing is not to be blamed on the WHO Secretariat, it's a political decision by WHO member states and other donors. So as you remember after Ebola, there were a lot of reviews on what went wrong on the IHR, on WHO, and beyond. These reviews from different perspective focus on a number of points that I would like very quickly to review today. They have to do with the implementation of the instrument. The first is the so called core capacities. These are Articles 5 and 13 of the IHR. Basically, these are the capacities that national health system have to have to detect, prevent, and control outbreaks of disease. These are big novelty of the IHR. The old IHR was all about, "Let's stop the disease at the border, at the port, or airport." The current IHR are much more intrusive. What they ask is not just a public health tool, it's a legal obligation. This I wonder whether member states have been overambitious, because there has been clear problems even among developed countries to reach the sufficient level of capacity. So that's a very weak point to the IHR, because in a global health security system, we are as secure as the weakest link in the chain. So there is a common interest in helping countries reaching a good level of health capacities. So there are two issues there. The first is that the chronic lack of investment in health systems, in developing and developed countries. Health systems are the bedrock of these core capacities. Also, international development assistance normally does not target routine functions like public health. So there is a disconnect between the need upon a nation health system in developing countries and the available development finance. The second is that the IHR does not have a monitoring and assessment mechanism. There is no collective system to monitor compliance with the core capacities. I think it was an oversight, because many people didn't think it would be so difficult to reach and maintain these core capacities. So this void has been filled after Ebola with a voluntary system, where countries basically offer to undergo this kind of assessment. Interestingly, it has also been addressed outside WHO. You may have heard about the Global Health Security Agenda, GHSA, that was established in 2014. Largely, the initiative of the United States. It is a network that looks at health as very much a security issue and they've been very instrumental in pushing this idea of voluntary assessment. But it's still an open question and I'll mention the legal implication in a moment. The second challenge is the risk management and communication system in the IHR. They revolve around the declaration or what we call a Public Health Emergency of International Concern. But it's too binary and many people have noticed that either there is an emergency or there is basically nothing under the IHR. Reality is very different because you can have health risks that have not escalated to the emergency but are still significant. So there is a challenge on how to incorporate in the mechanism of the IHR a more gradated system of risk communication and risk management. In practice has been done for example, having the so called Emergency Committee of the International Health Regulation giving advice to the Director General even without a public health emergency. The second challenge are what we call Article 43, additional health measures. Article 43 was a very difficult compromise reached at the last day of the negotiation. So it is an ambiguous and messy Article which basically tries to balance the sovereignty of states to take health measures to protect the population and the coordination and discipline that the IHR tries to introduce. You remember, during the Ebola crisis, WHO recommended not to isolate the three countries and many states did exactly the opposite. They suspended visas, they suspended flights, they ended up taking excessive measure that isolated those countries. This can punch a big hole into the fabric of the IHR, and it creates two particular risks. The first risk is that it may act as a deterrent for countries to report outbreaks to WHO, because they are afraid of overreaction by other countries and of being basically penalized and damaged. The second risk is that a lack of deterrence from other countries to adopt these excessive measures because there is no sanction, there is no naming and shaming mechanism. So that's I think one of the biggest implementation questions in the IHR. Finally, there's a lot of discussion about the role of WHO. As a manager of the IHR and beyond, you will remember the criticism: we were too quick with the H1N1 influenza pandemic, we were too slow with the Ebola outbreak. There were perceptions of conflict of interest of being too cozy with the pharmaceutical industry. Again, plagued by a lack of sustainable and predictable financing that slowed down the WHO's response to the Ebola crisis. So there are many aspects, and WHO has taken them seriously. And one of the major reforms has been the establishment of an emergency program that was established in reaction to Ebola. That's a big gamble for WHO, because WHO has never been an operational organization, has never been a fire brigade, but now, it also has to be a fire brigade on top of all its other functions. You will have heard about WHO's intervention in the Yellow Fever outbreak last year in Angola, in Congo, and also its current role in the Ebola outbreak in the Democratic Republic of the Congo. I think the emergency program is working reasonably well, that increasing the credibility of WHO. But again, funding is essential. If WHO continues to be funded largely by voluntary contribution, it's very difficult to have a sustainable emergency system. So these are some of the challenges that IHR and the system of global health security faces. What to do about it? I would like to make two observations, concluding observation. The first is legal. There was a very deliberate political choice not to reopen the IHR, not to amend its text to try to fix some of the problems that are identified. That may have been politically and practically expedient, and certainly the easier way to go to focus on implementing at best what we have. As a lawyer, I always had the reservation, because you risk weakening the integrity of a legal system if crucial functions that have to do with its implementation take place outside the instruments through voluntary system, through GHSA, and so on. You risk weakening in the long-term the IHR. The second is a broader issue and I think it's the one million dollar challenge for the whole world in creating a system of global health securities, basically to take the political decision not just short-term but long-term to invest in global health security. Not just reacting to a crisis and then politicians forget and go home, but to do it systematically. To have discipline, coordination, and organization. There have been good steps, for example, The World Bank has established a pandemic emergency facility that has for example funded the initial response to the current Ebola crisis, and also the UN is stepping up its role. So it's something that goes beyond the IHR and WHO but where the IHR are the legal bedrock of the system of global health security. So things are going in the right direction but there are open questions and many challenges. Thank you very much for your attention.
