Is telemedicine the de-evolution of medicine?
New global structure needed for infectious disease control
World leaders are now advancing the idea of a treaty to better prepare for the next pandemic. However, a treaty between states would not cure the myriad inefficiencies revealed by the response to COVID-19. The structural change needed requires a "whole of society" approach on a global scale, i.e. the integration of nonstate actors, such as NGOs and civil society as well as a funding shift that includes not only states but the private sector as well. The World Health Organization (WHO), the mandate of which extends well beyond infectious diseases, should be enhanced by a governance regime solely focused on the issue of infectious diseases - one that can force relevant entities to act in the best interests of the international community and to fully realize the concept of health as a basic human right.
Proponents of the treaty proposition claim that by leveraging the WHO constitution, a renewed collective commitment for international cooperation and solidarity will emerge. Unfortunately, the WHO constitution, which mainly focuses on the policies and procedures of the World Health Assembly, only reinforces the limited structure of a state-centric model. There is no magical text within the document that will foment a shift towards altruistic and responsible behavior during the next pandemic. Also, the WHO constitution relies on the International Court of Justice (ICJ) as the arbiter of disputes. This is problematic in that its "compulsory jurisdiction" is consent-based and replete with reservations, which allows for states to elude its reach.
Moreover, even if states consent to ICJ jurisdiction and a case escalates to the United Nations Security Council (UNSC) for enforcement, this highly politicized and gridlocked body - itself arguably comprised of global health infractors - cannot be relied upon as a trusted final authority. As the WHO's principal legal officer, Steven Solomon, stated in a revealing assessment about the prospective treaty: "Specifics about enforcement will be up to member states to decide on."
Notably, China, Russia, and the U.S. are not signatories to the treaty proposal statement, a sign that even in a hyper-globalized world in the wake of an infectious disease catastrophe, a modicum of state sovereignty will not be ceded voluntarily by some of the world's most influential countries. In short, a treaty founded upon existing principles within the status-quo system is not the answer - notwithstanding the laudable declarations of its advocates.
The WHO suffers from its own internal issues as well: for instance, turf wars between regional offices and headquarters, an entrenched bureaucracy, and budget troubles due to its over-reliance on voluntary contributions and donations that are earmarked for specific projects. A larger issue is that because its funding is not from dues but rather from voluntary state contributions, the WHO is beholden to its benefactors who can cut off funding streams. Thus, some states are more equal than others.
An infectious disease-centric global governance model must be both inclusive and collaborative. It requires a deliberative voting body and an adjudicative forum, both comprised of states parties and all relevant stakeholders whose infrastructure, expertise, and access to capital markets, can be leveraged to maximize our collective ability to detect, report, respond to, and ultimately, prevent infectious disease outbreaks. This architecture would serve to distribute power among the multitude of actors with a stake in this space and refocus funding strategies away from donations toward public-private partnerships.
WHO Director-General Tedros Adhanom Ghebreyesus argues that a treaty would help to strengthen implementation of the WHO's International Health Regulations (IHRs). But without a judicial body with enforcement powers to compel states to act in the best interests of the global common good, we will likely see the same self-interested behavior that created a moral hazard for the global community during the COVID-19 crisis. Nations will continue to falsify infectious disease data for economic or political reasons, impose travel and trade restrictions that can negatively affect broader response efforts, and disregard the IHR requirements because the system is simply ill-equipped to stop them. A judicial forum would establish a transparent and fair process of adjudication that would hold state and nonstate parties accountable for derogation of their duties as prescribed within the governance structure.
The currently inefficient international regime for infectious disease control requires a new overarching structure that will harmonize, integrate and coordinate the existing relevant legal structures that deal with infectious disease issues - including the WHO, the Biological and Toxin Weapons Convention, the WTO, G7/G20, the IMF, the World Bank, and others. By incorporating existing networks, the governance structure would synergize noble and constructive efforts that are already underway. Until a central authority is empowered to truly govern global infectious disease control, we will continue to see fractured and inconsistent responses to outbreaks like COVID-19.
Harvey Rubin, MD, PhD, is an Infectious Diseases specialist and a professor of Medicine at the Perelman School of Medicine at the University of Pennsylvania. Nicholas Saidel is the associate director of the Institute for Strategic Threat and Analysis and Response (ISTAR). The opinions expressed in this article do not represent those of the University of Pennsylvania Health System or the Perelman School of Medicine.