Several epidemiological metrics exist to inform determinations of whether an epidemic or pandemic has ended, e.g., when a disease has become relatively stable, predictable, and manageable, and when disease rates have been reduced to an 'acceptable' level. However, decisions about whether and when a pandemic has 'begun' or 'ended' inherently have social, cultural, political, economic, and, ethical dimensions and implications. Important questions arise about who should be involved in decision-making about matters such as what constitutes an 'acceptable' level of disease, and the considerations that should inform such determinations. This seminar, the network's 40th, examined the ethical dimensions of determinations of when epidemics and pandemics begin and end.
Patricia Kingori, Professor of Global Health Ethics, Ethox Centre, University of Oxford, Oxford, UK
Suerie Moon, Co-Director, Global Health Centre, Professor of Practice, Interdisciplinary Programmes and International Relations/Political Science, The Graduate Institute Geneva, Switzerland
Ruipeng Lei, Professor of Bioethics Executive Director, Center for Bioethics, Vice Dean, School of the Humanities, Huazhong University of Science and Technology, China
Calvin Ho, Associate Professor, Department of Law and Centre for Medical Ethics and Law, The University of Hong Kong, Hong Kong SAR, China
Professor Calvin Ho began the seminar, arguing the current primary motivation for declaring a pandemic, involves the scientific evaluation of public health risk; particularly in relation to emerging infectious diseases. This is followed by a motivation to secure and strengthen national healthcare systems, and to protect vulnerable populations as well. Declaring the start of a pandemic has several effects, including the scaling up of public health surveillance and the introduction of public health countermeasures which can include border controls and changes to resource allocation. The basis of any declaration sits within the International Health Regulations, 2005 (IHR, 2005), which states a ‘Public Health Emergency of International Concern (PHEIC) is ‘an extraordinary event which […] constitute[s] a public health risk to other States through the international spread of disease.’ However, the current model can be considered flawed. Despite adopting a broad ‘all-hazards’ approach, the IHR PHEIC is primarily an alerts-based system which remains entrenched in scientific and technical evaluations of threats to public health, while discounting various economic, social and cultural impacts. Consequently, it also detaches states from legal and ethical obligations which arise in the context of a pandemic, and the agencies which could attend to those aspects as well. As a result, Dr Ho argued states need to think more broadly about the ethical dimensions of any declaration, including the concept of global justice and the just distribution of benefits and burdens across the world. Secondly, the moral principle that an action should be no more severe than what is required. Thirdly, respect for solidarity, common interest and mutual support. The Westphalian model currently focuses on state sovereignty, which has several detrimental impacts, including the naming or shaming of states which are not compliant, or not sharing information. This is politically destabilising and undermines trust, communication and collaboration. Notwithstanding these considerations, Dr Ho suggests the World Health Organization should continue to have the role of declaring whether a pandemic has begun or ended, but the focus should shift away from purely technical evaluation, toward a more collaborative approach. A pandemic is a shared concern and therefore must have a shared response.
Professor Ruipeng Lei began her presentation by arguing that the ‘ending’ of an epidemic doesn’t necessarily imply its eradication, but rather its endemicity. This is particularly likely in the case of COVID-19. Ethical considerations are important, because they look beyond the biology of public health events, toward political, economic, cultural and societal impacts, all of which will play a key role in determining an endpoint. Determining whether an epidemic or pandemic has ended should be based on the result of a comparative assessment of the ratio of risks and benefits of either lifting or retaining strict public health countermeasures. An argument can be made that ending should be declared only when lifting restrictions will bring about fewer risks than keeping them. If restrictions are lifted, then society must be willing to tolerate a certain level of risk, including higher transmission and mortality. Professor Lei also noted the importance of people’s attitudes and beliefs. For example, if citizens grow tired of restrictions they may consider an epidemic to be over, even if the virus continues to circulate. As for ‘who’ determines when an epidemic ends, decisions should be based on discussions that include experts beyond the field of medicine, such as ethicists, philosophers, sociologists, political scientists, anthropologists, historians and economists. If all necessary precautionary measures are in place, then a determination can be made that a pandemic has ended, and a declaration can also be made that it has returned if conditions worsen. Ultimately, the end of the epidemic depends on how a society responds to a pathogen that keeps circulating, which involves a complex, and at times opaque, process of negotiation.
Professor Suerie Moon highlighted the complex consequences of an international declaration when applied to regional, national and local populations. Drawing on her work on the WHO’s ‘Pandemic Treaty’, she noted that a declaration can be mapped across the different levels at which it may apply. Global governance is a thin layer of governance sitting on more robust layers of national and local governance; therefore, just because WHO makes a strong declaration one way or the other, states must consider to what extent this should apply nationally, regionally or locally. For example, while we may have a perceived end to a pandemic internationally, there may still be a public health emergency at regional, national and local levels. Turning to the decision-making process, Professor Moon argued that decisions must be based on data; and made transparently. Decision-makers, should strive to be inclusive, and welcome the views of diverse stakeholders; particularly those who may be positively and negatively affected by any declaration. Finally, although decision-makers should be accountable, this is not always easy at a global or even a national level. However, if accountability is reframed as answerability it can help provide more practical answers. A decision-maker should be answerable to critiques, and welcome debate and disagreement. Any decision should also be reversible. Professor Moon concluded by noting that any official declaration triggers a whole series of consequences and sends a political message. However, measures need not be linked to a declaration. For example, we know the mental health consequences of COVID-19 will be substantial, as are the impacts on education, and measures to respond to these impacts should be put in place, regardless of any declaration. This is about being creative and proactive in the face of uncertainty.
What is the value of declaring a pandemic over? Is it actually helpful or not?
The panel noted that one important outcome of any declaration is that it can facilitate data-collection practices which in turn can inform future public health strategy. Decision-makers need to consider how communities and governments are going to react; for example in the case of COVID-19, in many cases led to state arguably over-reacted to the declaration of a public health emergency of international concern. It’s also important to note that there is a distinction between what is in the IHR and what happened during COVID-19. From January 2020, Dr Tedros exhorted countries to take action. At multiple points he was pressured by commentators to call COVID-19 a pandemic, however, he didn’t do so until it had met the threshold in the middle of March 2020, at which point the declaration made every newspaper headline. There is no legal definition of a pandemic, but by using this word it did seem to elicit a much more forthright response among states. Consequently, we might argue that compelling people to act is essential, and yet there is still a lot of work needed to ensure leaders take those decisions in a way which holds them to account.In relation to the ‘ending’ of a pandemic; the cultural-historical narratives of any particular country must be taken into account. Technical evaluation conducted at an international level is limited because it is the country’s population which determines whether a pandemic is perceived to be over or not. A key challenge of the COVID-19 pandemic is that policymakers have not listened enough to local communities, and also not communicated well enough. Ethical community engagement in the context of a public health emergency is always difficult, and so in some cases, a conservative approach has been applied. However, if strict public health measures are implemented, it’s also important to consider when restrictions will be scaled back. At the point of vaccines? At the point of immunity? If we don’t have either, how should we make such decisions and communicate about them? Arguably the current global health governance system doesn’t equip national governments with the tools needed to address these issues, let alone equipping NGOs, individuals or communities. It might be useful to distinguish between emergencies and pandemics. HIV is a pandemic which continues to cause death and disability, and yet the arrangements at international and national levels mean it is no longer considered a global emergency.