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A comparison of the institutional management of the H1N1 influenza pandemic and the Ebola virus disease epidemic in West AfricaWhy we have not learned the lesson when preparing and responding to Public Health Emergency of International Concern?

Octavio González Segovia and Axelle Ébodé

Résumés

Cet article est une contribution au débat sur la réponse des Etats et des Organisations Intergouvernementales aux Urgences de Santé Publique de Portée Internationale et aux pandémies ; aussi explore-t-il la manière dont le design institutionnel des organisations de santé publique influence l’opérabilité de leurs actions et ainsi leurs résultats.

Cet article soutient l’idée selon laquelle la qualité de la préparation et de la réponse aux Urgences de Santé Publique de Portée Internationale est liée au design institutionnel des organisations qui en ont le mandat. Nous postulons que l’architecture mondiale de la santé n’a pas été réformée de manière adéquate pour faire face aux menaces de santé publique de grande ampleur et aux pandémies. Par conséquent, nous affirmons que l’échec et le succès de la gestion des grandes épidémies et des pandémies est principalement lié à la conception et à l’agencement institutionnels des organisations internationales qui en ont la charge. Sinon comment expliquer qu’après tant d’ateliers de leçons apprises et d’échecs organisationnels la leçon de la préparation et de la réponse aux urgences de santé publique de portée internationale n’ait toujours pas été apprise ? En d'autres termes, s’il est fréquent de conférer un rôle explicatif à l'apprentissage, cette tendance se limite au choix d'une certaine conception institutionnelle. Dans quelles circonstances un certain arrangement institutionnel est-il plus susceptible de se produire et de résoudre un problème particulier ? Nous partons de l'hypothèse selon laquelle les États choisissent délibérément entre différents arrangements institutionnels. Ils considèrent que l'un ou l'autre est plus pratique pour faire face à de nouvelles conditions ou à de nouveaux problèmes. Dans le cas du domaine de la biosécurité, nous soutenons que le choix se limite à deux arrangements institutionnels : les réseaux transgouvernementaux (RTD) ou les traités multilatéraux liés aux organisations intergouvernementales. Nous soutenons également que dans certaines conditions, les acteurs optent délibérément pour les TGN car ils les considèrent comme des dispositifs plus efficaces comme en témoigne la pandémie de grippe A (H1N1) de 2009.

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Introduction

  • 1 John Hopkins University & Medicine, Coronavirus Resource Center. Covid-19 Map. (2020, April 8). Ret (...)
  • 2 The New York Times (2020, April 9). Retrieved from:https://www.nytimes.com/2020/04/09/us/coronaviru (...)
  • 3 OECD, (2020, March 2). OECD Interim Economic Assessment. Coronavirus: the World economy at risk. Re (...)

1As of April 9 2020, SARS-CoV-2, the causal agent of Covid-19 has infected 1, 536, 979 people in 185 countries/territories. Of these, 93, 425 died and 346, 376 recovered1. Only in the United States, more than 16 million people have lost their jobs in a period of three weeks2. Assuming the epidemic peaks in China in April, and outbreaks in other countries prove mild and are kept under control, global growth in 2020 could decrease by .5 percent (i.e. from an estimate of 2.9 to 2.4)3. Among other lessons that may arise at a later stage, the recent Covid-19 pandemic has demonstrated us the need for revising and updating the global health security architecture. Thereon, we claim that both failure and success in the handling of major epidemics have to do predominantly with the institutional design of international organizations operating in the biosecurity field (i.e. transgovernmental networks and intergovernmental organizations), and thus, with the global health security architecture. As already evidenced during the A (H1N1) Influenza pandemic, we need to strengthen international and inter-institutional collaboration for dealing with scientific uncertainty, sharing knowledge and effectively responding to Public Health Emergencies of International Concern (PHEIC). One of the main lessons that we learned during the Ebola Virus Disease (EVD) epidemic in West Africa was that counting with robust health systems for effectively applying the International Health Regulations (2005) was imperative. Nonetheless, the ongoing Covid-19 pandemic demonstrates that even the most robust and efficient health systems can collapse in the absence of adequate preparedness and collaboration. In that respect, the political determinants of health are fundamental because they determine priorities, strategies, budgets, organizations, structures and reforms.

Background

  • 4 WHO, “Report of the Review Committee on the Functioning of the International Health Regulations (20 (...)

2In May 1995, the World Health Assembly requested the Director General (DG) of the WHO to start a major review of the 1969 IHR. Negotiations lasted ten years, and worldwide entry into force was finally reached in June 15th 2007, two years after the adoption of the revised IHR referred to as IHR (2005). The IHR (2005) have two main functions. The first one is “to establish a regime for routine public-health protection and provide for the ongoing management of disease threats both within countries and at their borders”. The second one aims “to provide a framework for coordinated and proportionate responses to significant and urgent disease threats, ranging from national public-health events to events of regional or global public-health significance”4

  • 5 Karen Grépin, (2015) “International Donations to the Ebola Virus Outbreak: Too Little, Too Late?,”; (...)
  • 6 WHO, “Report of the Review Committee…", 6.
  • 7 WHO, “Report of the Ebola Interim Assessment Panel”, May 2015, WHO reference number: A68/25

3However, the 2009 influenza pandemic and the Ebola epidemic in West Africa revealed several institutional shortcomings and challenges5. Concerning the former, the Review Committee on the functioning of the IHR (2005) in relation to pandemic A (H1N1) (2009), identified the IHR (2005) as insufficient, citing: “ vulnerabilities in global, national and local public-health capacities, limitations of scientific knowledge, difficulties in decision-making under conditions of uncertainty, complexities in international cooperation and challenges in communication among experts, policy-makers and the public”6. As for the Ebola epidemic, the independent panel of experts convened by the WHO and whose assessment was conceived as a learning exercise concluded that the Ebola crisis exposed not only organizational failings in the functioning of the WHO, but also demonstrated shortcomings in the application of the IHR (2005). The panel even noted that “independent and courageous decision making by the Director General Margaret Chan and the WHO Secretariat was absent in the early months of the Ebola crises”. What is more, the panel went beyond and asserted that the “Ebola outbreak might have looked very different had the 2011 recommendations of the Review Committee on the functioning of the IHR (2005) in relation to the pandemic been fully implemented7.

  • 8 Barbara Koremenos, Charles Lipson, and Duncan Snidal, “The Rational Design of International Institu (...)
  • 9 Elke Krahmann, “Security Governance and Networks: New Theoretical Perspectives in Transatlantic Sec (...)

4Then, why is it that after so many lessons-learned workshops and organizational failures we still have not learned the lesson when preparing and responding to PHEIC such as the EVD epidemic or the Covid-19 pandemic? There are three reasons why this research question is relevant: first, while there seem to be enough studies that underline a multifactorial explanation of failure and success in the handling of biosecurity threats, there is an overemphasis in the issue of lessons-learned as if the variable learning were the most important explicative factor. Second, neither scholars nor state leaders know which institutional design will solve a particular problem8. Third, we do not know the conditions under which Transgovernmental networks (TGNs) are most likely to arise and be effective, being that particularly the case of the TGNs operating in the biosecurity field9. Consequently, by simply repeating lessons-learned without reflecting on the institutional design of organizations dealing with PHEIC we may be prescribing the “wrong medicine” for the “wrong patient”.

5Therefore, the research question helps us to compare and better understand two different kinds of international organizations dealing with PHEIC, i.e. TGN´s such as the Global Health Security Initiative (GHSI) or the BRICS Health Network and intergovernmental organizations (IGO´s) such as the WHO or the West African Health Organization. Understanding these organizations is important because their actions can shape global health governance. Moreover, it is important to reflect on the institutional design of these organizations because PHEIC can have significant impacts on political, social and economic life, as demonstrated by the 2009 A (H1N1) influenza pandemic, the 2014 EVD epidemic in West Africa, the 2016 Zika virus outbreak in the Americas or more recently and even more acute by the Covid-19 pandemic.

Case selection.

  • 10 Vetter, P., Dayer, J., Schibler, M. et al. (2016). “The 2014–2015 Ebola outbreak in West Africa: Ha (...)
  • 11 MacNeil, A., & Rollin, P. E. (2012). Ebola and Marburg hemorrhagic fevers: neglected tropical disea (...)

6Several arguments justify the choice of these two health crises i.e. 2009 Influenza A(H1N1) pandemic and 2014-2015 EVD epidemic in West Africa. First, both outbreaks were declared PHEIC and hence represented a litmus test for the revised IHR (2005) since its entry into force on June 15th 2007, and called into question the spirit and the letter of that regulation. Second, whereas the 2009 Influenza A(H1N1) outbreak elicited a fast response from the international community and was soon declared a PHEIC, response to the EVD outbreak was too slow and the declaration of a PHEIC was delayed10. Third, both EVD and A(H1N1) are RNA viruses, which mean they must continually replicate or die. Fourth, both pathologies are infectious diseases but display different statutes: On the one hand, influenza is an over monitored disease, while Ebola is on various accounts –at least until 2014-, a neglected disease11. In this respect, whereas Influenza benefits of a globalized research activity, research on EVD is circumscribed to a few labs and institutes mostly localized in western countries (a notable exception being the INRB in the DRC or the Wuhan National Biosafety Laboratory opened in 2015). Furthermore, whereas the Decision instrument for Assessment and Notification of IHR (2005) grouped EVD together with other neglected diseases such as Dengue (see Annex 2) or diseases affecting mostly developing countries (e.g. Lassa fever, Yellow fever, Cholera, etc.), human influenza is grouped together with SARS or Smallpox meaning that it is more straightforward to declare the event to the WHO. Finally, the diversity of the contexts (socio-cultural, political, and economical) and places (countries, regions, continents) where those two outbreaks first appeared enable us to observe the possible differences in the application of the IHR (2005), but also to assess whether the international community is attending structural causes or is just politically reacting. Thus, these two situations of biomedical enquiry, which stand at the antipodes, give us the opportunity to describe and analyze processes of learning, institutional design and effectiveness when it comes to global health governance.

  • 12 David Fidler and Lawrence Gostin, Biosecurity in the Global Age: Biological Weapons, Public Health, (...)

7The purpose of the paper is to twofold. First, with the help of rational choice and network theories we suggest some conditions for modifying international organizations dealing with PHEIC and determining when a TGN can have advantages over an IGO. This may prove to be helpful for both scholars and government officials seeking to design more effective institutional arrangements in a rapidly changing and poorly understood domain12. Second, based on these insights, we compare the handling of two recent PHEIC i.e. the Influenza A(H1N1) pandemic and the EVD epidemic. The aim of comparing these two case studies is to detect not only what went wrong and what should be considered elsewhere, but also to highlight the conditions under which it is more likely to witness the formation of TGN´s in the biosecurity field.

8The paper is structured in the following way. First, we explore the relationship between learning, success and failure in the handling of PHEIC, and call into question the legitimacy and effectiveness of the actors and structures intervening in the management of PHEIC. Second, we review the literature related to global health governance and offer some alternatives to reconfigure the global health architecture. Third, drawing on rational design and network theories, we formulate five hypotheses (conditions) under which we should expect governments to choose TGNs when dealing with PHEIC. Fourth, we compare and discuss through timelines the handling of these two PHEIC. Finally, we draw the conclusion and suggest avenues for future research.

Learning, success and failure in the handling of PHEIC.

  • 13 Amy K. Donahue, Robert V. Tuohy, “Lessons We Don't Learn: A Study of the Lessons of Disasters, Why (...)

9Scholars have identified various mechanisms for sharing experience. These mechanisms are generally called “lessons-learned” processes, and comprise tools like in-progress reviews, after-action reviewing and reporting, and various kinds of debriefings. While these processes vary, they have the common objective of sharing performance information in order to prevent the recurrence of adverse events and actions and to better contend with situations and problems that are likely to arise again. In this respect, the majority of processes involve some version of three core components: 1. evaluating an incident through systematic analysis of what happened and why; 2. identifying lessons, which imply detecting strengths to be sustained and weaknesses to be corrected; and finally, learning i.e. specifying and inculcating behavioral changes consistent with the lessons (Donahue & Tuohy 2006)13.

  • 14 Aliye Bastug, Hürrem Bodur, “Ebola viral disease: What should be done to combat the epidemic in 201 (...)

10We ascribe our failures to our inability to learn a specific lesson, but when it comes to Health and PHEIC there are always a great deal of lessons-learned case studies, workshops and official reports (Ravi et. al. 2019; Hoffman & Silverberg 2018; Youde 2018; Bastug & Bodur 2015; Gostin 2015; Oleribe et al. 2015; Fineberg 2014; Heymann et al. 2015; Agyepong 2014, Kalra, et al. 2014, GHSI 2014, Hagar 2009; Report of the Ebola Interim Assessment Panel 2015; Report of the Review Committee on the Functioning of the IHR 2005 in relation to the Pandemic (H1N1) 2009)14. For instance, the health system failing situation in some countries like Liberia, or Sierra Leone due to long civil war and structural adjustments was long identified by the HIV-AIDS actors in their lessons-learned workshops and recommendations. Thus, it seems that what lies behind failure might be something else. The WHO mea culpa regarding its late and inadequate response to the Ebola virus disease (EVD) epidemic on the one hand, and the political and specialists´ criticisms of the WHO (in)action on the other, look very much like those of 2009-2010 concerning the response to the A(H1N1) influenza pandemic.

  • 15 Ravi, S. J., Snyder, M. R., & Rivers, C. (2019). Review of international efforts to strengthen the (...)
  • 16 Hoffman, S. J., & Silverberg, S. L. (2018). Delays in global disease outbreak responses: lessons fr (...)
  • 17 Tess van der Rijt, Tikki Pang, “Resuscitating a comatose WHO: Can WHO reclaim its role in a crowded (...)

11To this effect, the belated response by the international community to the EVD epidemic makes us realize that we certainly have not learned the lesson, or ironically, that we did not learn the right lessons15. We acknowledge that at the outset of the outbreak the international community struggled to identify the threat and confused it with Cholera16. Nonetheless, to a greater or lesser extent, with the notable exception of Médecins Sans Frontières, it seems clear by now that all competent actors failed, from international organizations such as the WHO or the World Bank (WB) to national and local governments such as Sierra Leone, Liberia, Guinea, Spain or New York city. How can we explain it? Is it really a matter of learning or is it something else? Are the international organizations operating in the biosecurity field, the public health specialists of the developed world17and the G7 setting the global health policy objectives according to their interests, priorities and perceptions?

  • 18 MacNeil, A., & Rollin, P. E. (2012). Ebola and Marburg hemorrhagic fevers: neglected tropical disea (...)

12Is that for example the reason why, as some claim, we have neglected diseases such as Ebola, Cholera or Dengue?18 While there are important similarities in the handling of the A(H1N1) influenza pandemic and the EVD epidemic, there are also important differences that call into question the priorities and legitimacy of some global health actors (e.g. the G7), not to mention the effectiveness of their actions . Does it have to do with the institutional design of international health-related organizations or even with the phrasing and categorization of their proceedings (e.g. the decision mechanism, also known as algorithm, of the IHR 2005 to help states in determining what constitutes a PHEIC)? If so, to what extent? As with human beings, organizations can learn, hence it does not seem plausible to explain failure by solely ascribing guilt to the learning process.

13Table 1 below summarizes the main recommendations of the Fineberg’s report that should have been implemented for providing an effective response to the EVD epidemic in West Africa. Due to the shortcomings in the application of the IHR (2005) during the AH1N1 influenza epidemic - the first under this new set of rule - ,WHO Director-General Margaret Chan decided to set up a review committee in accordance with Article 50 of the IHR (2005). The aim of it was to assess the functioning of the IHR (2005) in relation to the pandemic and propose recommendations for its improvement. However, the majority of them were not followed due to a number of factors: For instance, the cumbersome and bureaucratic procedures, or the fact that WHO does not have its own resources; it is dependent on contributions from States and partners to set up an emergency fund. Ultimately, the delay in implementing these recommendations can be interpreted as a lack of learning, since urgency was not perceived as the lesson to be learned concerning uncertainty. The ongoing COVID-19 pandemic also shows the difficulty policy makers face when managing scientific uncertainty and urgency.

14We may also wonder whether the decision mechanism of the IHR (2005) to help states in determining what constitutes a PHEIC is not by itself an institutional shortcoming or even a hindrance to the rapid detection and attention of viral hemorrhagic fevers such as EVD, Marburg or Lassa. At the very least, it looks suspicious that the steps needed to notify the WHO of an event that may constitute a PHEIC are more in the case of viral hemorrhagic fevers than in the case of respiratory diseases such as SARS and Influenza which affect both developed and developing countries (see figure 1). The same applies to Dengue and Cholera, which are neglected diseases affecting developing countries with weak or collapsed health systems and/or poor sanitary conditions provoked by war (e.g. DRC, Iraq, Syria, etc.), natural disasters (e.g. Haiti), poverty (e.g. Haiti & Tanzania) or a combination of some of these factors (e.g. Sudan, South Sudan, Yemen, Venezuela)19. Of course, some may contend that due to their transmission mechanisms, SARS and Influenza can spread more rapidly and easily than viral hemorrhagic fevers, and consequently the diagram was designed in that way. Nonetheless, it should also make us reflect on the need to readjust it and adequate it to the reality of different health systems and capacities as exemplified by the delayed institutional response in West Africa.

  • 20 WHA, 2005 International Health Regulations, 9, pa.6,
  • 21 Fidler and Gostin define biosecurity as a society’s collective responsibility to safeguard the popu (...)
  • 22 WHA, 2005 International Health Regulations, 43.

15As set forth in the IHR (2005), the WHO has the mandate to coordinate its activities with other international organizations/bodies to ensure application of adequate measures for the protection of public health and to strengthen the global public health response to the international spread of disease20. This includes the diseases previously mentioned, but also events of unknown causes or sources such as biological terrorist attacks (see box two of figure one). The IHR (2005) define these sorts of dangers in a broad and ambiguous way, however the scope of regulation is fundamentally the same as in the definition of biosecurity provided by Fidler21. As explained in the IHR (2005), a “PHEIC refers to an extraordinary event, including those of unknown causes or sources, which constitutes a public health risk to other states through the international spread of disease, and which requires a coordinated international response22. Accordingly, we equate the PHEIC with the threats posed by pathogenic microbes regardless of their source.

Global health governance architecture and transgovernmental networks

What needs to be done? Who should coordinate the response?

  • 23 Ravi, S. J., Snyder, M. R., & Rivers, C. (2019). Review of international efforts to strengthen the (...)
  • 24 Ravi, S. J., Snyder, M. R., & Rivers, C. (2019). Review of international efforts to strengthen the (...)

16After every major outbreak, experts voice their concerns and suggest a series of changes to correct what went wrong. However, disagreement persist among scholars whose positions influence governments on how to reform the global health governance architecture and who should coordinate global response. For instance, Ravi, Snyder & Rivers (2019) assessed the programs, initiatives and institutions established in the aftermath of the 2014-16 EVD epidemic and concluded that despite advances in public health preparedness and response, there are still critical gaps in global detection capabilities, programmatic financing and lack of transparency23. They also detected that high-income and Western countries financed the majority of the initiatives they identified in their review with the exception of Africa CDC, WHO Global Emergency Workforce and the WHO R&D Blueprint. Furthermore, they found that although many lessons-learned reports and papers indicated a need, actors working on GHG launched few new programs. That is particularly the case of the programs focused on the detection phase, the main exception being the REDISSE initiative launched by the WB. This is not a minor issue taking into account the difficulty for detecting and diagnosing the EVD in the initial months of the outbreak24.

17A parallel finding of their research is the multiplicity of actors founding the new initiatives and hence contributing to GHG. Actors include national governments (e.g. Germany, Australia, etc.) and IGOs (e.g. the WHO, the WB, UNICEF, etc.), but also supranational organizations (e.g. the African Union or the European Union), NGOs (e.g. Gates Foundation) and research centres (e.g. Harvard, Institute Pasteur, etc.). This shows that the GHG landscape looks increasingly complex, which raises questions concerning how to modify institutions and who should coordinate global response in the face of a PHEIC.

  • 25 John J. Kirton and Jenevieve Mannell, “The G8 and Global Health Governance,” in Governing Global He (...)
  • 26 Fidler, “From International Sanitary Conventions to Global Health Security", 342.
  • 27 Andrew F. Cooper, John J. Kirton, and Ted Schrecker, eds., Governing Global Health : Challenge, Res (...)

18Kirton and Mannell, claim that “the old WHO has proven inadequate in addressing the major health challenges and crises of a rapidly globalizing world”. Evidence of its failure lies in the rapid spread of HIV/AIDS, the re-emergence of old diseases (e.g. measles), the eruption of bioterrorism, the assault from SARS and the threat of an avian influenza pandemic25. These factors, amplified by accelerating processes of globalization, prompted the revision of the IHR in 1995. It became evident that new international policy and legal frameworks were required to provide more robust and sustained public health responses from the local to the global level26. Of this, various scholars argue that the G7/G8 has thus far addressed some of those issues, and by doing so, is either contributing to global health governance (GHG) or emerging as the potential “global health governor”27.

  • 28 Kickbusch, Hein, and Silberschmidt, “Addressing Global Health Governance…", 12.
  • 29 Hoffman, “The Evolution, Etiology and Eventualities of the Global Health Security Regime,” Health P (...)

19Conversely, Kickbusch et al. e.g. argue that the global health network requires a “superstructural node” which could coordinate all the representatives of the different health-related organizations. They regard the WHO as the only actor who could legitimately occupy that position and propose accordingly strengthening the WHA by creating a “C Committee”. Despite recognizing the importance of “club models” such as the G8, they disqualify them as legitimate alternatives for governing global health28. In contrast, scholars such as Hoffman, Fidler & Gostin posit that “the WHO lacks the authority and resources commensurate with its vast responsibilities” and that “it is unable to coordinate all global communicable disease control activities”. Additionally, they describe it as a “bureaucratic”, “complex” and “outdated”29.

  • 30 Hoffman, “The Evolution…", p. 514; Nuzzo and Gronvall, “Global Health Security”, 4.
  • 31 Gostin, L. O. (2015). The future of the World Health Organization: lessons learned from Ebola. The (...)

20Although some scholars acknowledge certain improvements brought by the IHR (2005), such as an expansion of its scope, they identify as shortcomings the lack of enforcement and verification mechanisms, the weak implementation measures, and the failure to specify how members are in fact supposed to coordinate their strategies30. According to Gostin, the Ebola epidemic revealed “deep flaws in IHR compliance and effectiveness”. As a means for remedying these failures, he suggests three reforms. First, IHR should insist that states invest in capacity building and require WHO to rigorously assess their performance. Second, to avoid political pressures such as the ones the WHO D-G experienced before declaring a PHEIC, Gostin considers the response should be incremental as an outbreak becomes more serious. In parallel, IHR committee deliberations should be transparent and accompanied by an independent committee with the function of advising the D-G. Third, incentives and compliance mechanisms should be set up to highlight countries, which do not follow the D-G recommendations (e.g. bans on travels, trade and the enforcement of quarantines)31.

  • 32 Idem
  • 33 Cooper, Kirton, and Schrecker, Governing Global Health; Fidler and Gostin, Biosecurity in the Globa (...)
  • 34 Hoffman, “The Evolution…", 518.

21Due to WHO errors and omissions, Hoffman argues “the existing global health security architecture is in transition and that the elements may be in place for a new global health security power to emerge”32. In this respect, Cooper and others claim that a group of powerful actors such as the Global Health Security Initiative (GHSI) or the G20 could provide new solutions for governing global health security33, and may have the capacity to assume leadership in this area through ‘networked governance’. Hoffman argues along the same lines and adds that a “concert of powers” could be more effective than the WHO in making the necessarily difficult decisions and coercing others into following them34.

22This raises the question whether states need to opt for a certain institutional arrangement, or they need to better coordinate the workings of existing TGNs and IGOs. Thus, if as stated the WHO is responsible for achieving GHG, and if the IHR (2005) are already addressing the same threats as a TGN such as the GHSI, why did the G7 members decide to preserve a TGN whose objectives are the same? Is it because they regard the network-form as a more effective institutional arrangement to deal with biosecurity threats?

  • 35 Medecins sans Frontieres, “Pushed to the limits and beyond. A year into the largest ever Ebola outb (...)
  • 36 Fidler and Gostin, Biosecurity in the Global Age, 3.
  • 37 Ibid., 252.
  • 38 Avery, “The North American Plan…", 17.

23Fidler and Gostin argue that “security and public health can no longer view the world through the state-centric lenses of national governments and intergovernmental coordination”. Therefore, governance mechanisms need to reflect the different roles non-state actors such as Médecins Sans Frontières play in the handling of epidemics, as witnessed during the EVD epidemic in West Africa35. Otherwise, it will not be possible to achieve and maintain biosecurity in a sustainable way36. Consequently, Fidler and Gostin advocate the creation of a global biosecurity concert (GBC) as a mechanism to improve biosecurity and strengthening global governance in the areas of biological weapons and public health. Despite recognizing the limitations of the GHSI both in terms of its membership and in terms of activities, they regard it as an important element of a GBC that could be replicated and instrumented in other regions of the world37. Likewise, Avery suggests that a TGN such as the North American Plan for Animal and Pandemic Influenza (NAPAPI) could serve as a successful model for other regions and for strengthening the global strategy of the WHO38.

Theoretical framework: Rational Design Theory and network theories.

  • 39 Koremenos, et al, “The Rational Design…", 781–2.
  • 40 Fidler and Gostin, Biosecurity in the Global Age, 231.

24We depart from four broad rational choice assumptions that underlie four of the five hypotheses framing this paper. First, states act self-interestedly and thus deliberately choose and design international institutions to further their own goals. Second, the value of expected gains from cooperation is strong enough to support an institutional arrangement. Third, establishing and participating in international organizations is costly; and fourth, states are risk-averse when creating or modifying international institutions39. As for the fifth hypothesis, we derived it from some insights within the biosecurity domain40.

  • 41 Ibid., 762.

25We broadly define international institutions as explicit arrangements, negotiated among international actors, which prescribe, proscribe, and/or authorize behaviour41. We argue that when confronting biosecurity threats, states can choose between a TGN such as the GHSI or the BRICS Health Network and an IGO such as The East, Central and Southern African Health Community (ECSA-HC), the Pan American Health Organization (PAHO) or the Amazon Cooperation Treaty Organization (OTCA). Other examples of TGNs operating in the biosecurity field include The Foreign Policy and Global Health Initiative (FPGHI) and the APEC Health Working Group (see Network 1).

Network 1: Biosecurity TGNs.

26Network 1 shows some of the most visible TGNs operating in the biosecurity field. Likewise, it displays the links between some of the more influential TGN members (i.e. more connected) as well as the links among different networks. For instance, the United States, Canada and Mexico belong to the GHSI, the NACOBPI and the APEC Health Working Group, whereas China and Russia are members of the BRICS Health Network and the APEC Health Working Group. Both Brazil and South Africa belong to the BRICS Health Network and the Foreign Policy and Global Health Initiative (each country is represented by a node whose colors are similar to their national ones). Of all networks, the GHSI and the NACOBPI are perhaps the most integrated and the ones that collaborate the most, as exemplified during the A(H1N1) Influenza pandemic.

  • 42 Eilstrup-Sangiovanni, “Networked Politics,”198-201.

27Lastly, it is important to clarify that the linkages between the various TGNs represent not necessarily a tie but the multiple memberships certain states have (e.g., France, represented by a dark blue rhombus bordered in red is linked to the GHSI and the FPGHI). The GHSI serves as a typical case of a TGN since it exemplifies a representative set of values of this kind of organizations. To be specific, it meets all relevant criteria (see Table 2)42. With regard to the membership, the actors representing the state are neither head of states nor ministers of foreign affairs but high- and mid-level officials from the ministry of Health. Regarding the structure of the GHSI, it has lateral ties, a decentralized decision-making and lacks a legitimate organizational authority to settle disputes among its members. In terms of the degree of legalization, cooperation within the GHSI tends to be informal and non-binding. In other words, there is no treaty or ratified charter behind this TGN, and is characterized by its low visibility. Hence, the GHSI would be contingent on the willingness, reciprocal trust and capacities of its members.

  • 43 Robert Keohane, After Hegemony: Cooperation and Discord in the World Political Economy (Princeton U (...)
  • 44 Koremenos, et al. “The Rational Design…", 761–99.
  • 45 Anne-Marie Slaughter, “The Real New World Order,” Foreign Affairs. 76, 5 (1997): 183; Anne-Marie Sl (...)
  • 46 Lipson, “Why Are Some International Agreements Informal?”; Kenneth Abbott and Duncan Snidal, “Hard (...)
  • 47 Koremenos, et al. “The Rational Design…", 767.

28To know how biosecurity TGNs operate, when they form, and why they include some states and not others, we drew on the insights of functional regime theory43, rational design theory44, as well as on the literature on networks45 and legalization46.Koremenos argues that many institutional arrangements are best understood through “rational design” among multiple participants. States for instance use diplomacy and conferences to select institutional features to further their individual and collective goals. They do so by creating new institutions and modifying existing ones. The difficulty of creating or modifying institutions is evidence that institutional design is deliberate. Most institutions evolve as members learn, new difficulties arise and international structures change. However, even institutional evolution involves deliberate choices made in response to changing circumstances47.

  • 48 Ibid.
  • 49 Raustiala, “The Architecture of International Cooperation”, 6.
  • 50 Abbott and Snidal, “Hard and Soft Law in International Governance”, 423; Eilstrup-Sangiovanni, “Net (...)

29Prior outcomes and evolutionary forces provide the conditions for institutional development. As institutions evolve, rational design choices can arise in two ways. First, members may adjust institutions gradually, by making purposeful decisions contingent on the new circumstances, by adopting features from other institutions that work well, or by designing explicit institutions to strengthen informal cooperation. Second, institutional arrangements may change as States and other actors chose among them over time. Finally, States favor certain institutions because they regard them as more convenient for dealing with new conditions or new problems and downplay or withdraw from those that are not48. Contrary to the view held by scholars such as Raustiala49, who claim that TGNs are “supplementary” to international treaties, we adhere to the position that under certain conditions international actors purposely choose TGNs because they regard them as more effective than IGOs, which are backed up by an international treaty50.

Factors affecting international cooperation.

  • 51 Fritz Wilhelm Scharpf, Games Real Actors Play: Actor-Centered Institutionalism in Policy Research, (...)
  • 52 Scharpf, Games Real Actors Play, 1997:138.
  • 53 Anne-Marie Slaughter, A New World Order (Princeton: Princeton University Press, 2004), 192; Raustia (...)
  • 54 Abbott and Snidal, “Hard and Soft Law in International Governance,” 430–434.

30The factors affecting cooperation (or independent variables) can be categorized into various kinds of problems (distributional or enforcement-related), uncertainty (about behaviour, the state of the world and others’ preferences), and others, such as the number of actors and the asymmetries among them. However, we do not expect to observe enforcement problems in TGNs, because of the “generalized trust” that exists among their members51. As pointed by Scharpf, “membership in a network allows access to a larger number of potential partners of trustworthy interactions and thus increases the value of social capital”52. Network specialists contend that regulatory agreements between states are “pledges of good faith” that are self-enforcing because each state will be better able to enforce its national law by implementing the agreement provided that the other members of the network do likewise53. Whenever there are incentives for non-compliance with international commitments, states will opt instead for hard legalization in the form of institutions, procedures as well as normative and reputational arguments to materially reduce the costs of enforcement54. Therefore, if states have incentives to defect, we would expect them to select an IGO rather than a TGN.

  • 55 Koremenos, et al. “The Rational Design…", 773–9.

31Uncertainty in a broad sense refers to the extent to which actors lack complete information about the state of the world or about others’ behaviour or others’ preferences. However, we do not expect to see the two last kinds of uncertainty in TGNs. Since TGNs are based in trust and frequent contacts, and because its members have relatively homogeneous values and interest, we assume that information would not be a problem. Finally, the factor “number” designates the relevant actors who are potentially admissible to join the organization, either because their actions affect others or vice versa. “Number” also includes asymmetrical distribution of actors’ capabilities55.

Institutional form resulting from the combination of factors affecting cooperation.

  • 56 Koremenos, et al. “The Rational Design…"; Abbott and Snidal, “Hard and Soft Law in International Go (...)
  • 57 Abbott et al., “The Concept of Legalization,” 763.

32The institutional variation we expect or dependent variable (DV) is represented by a TGN or an IGO. Our choice of DV is largely informed by the rational design project56and by the institutional characteristics selected by Eilstrup-Sangiovanni in her study of TGNs and multilateral treaties. To conceptualize the DV, we combined the institutional dimensions emphasized by Koremenos in rational design theory and by Abbot in his concept of legalization. According to Koremenos, institutions may vary in five dimensions : membership rules, scope of issues covered, centralization of tasks, rules for controlling the institution, and flexibility of arrangements. Some of the advantages of using these dimensions are their significance, i.e., the fact that they are the focus of both negotiators and academics; their measurability, as they enable us to compare different institutions; and finally, their applicability to all kinds of institutional arrangements57.

  • 58 Podolny, “Network Forms of Organization,” 59; Miles Kahler, “Networked Politics. Agency, Power, and (...)
  • 59 Abbott et al., “The Concept of Legalization,” 406–7.
  • 60 Eilstrup-Sangiovanni, “Networked Politics,” 198.

33Drawing on these institutional dimensions, as well as on the literature on networks58, and legalization59, we conceptualize TGNs as highly flexible institutional arrangements of consciously coordinated action whose main objective is to change international outcomes and national policies. Other features that define TGNs are a limited scope, a restricted membership of at least two members, a consensus-based mode and a low degree of centralization, obligation, precision and delegation60. Hence, we would expect governments to select between these kind of institutional arrangements and IGOs, which in varying degrees represent the opposite features (see Table 2).

Table 2. Main features of TGNs and IGOs.

Source: Own elaboration based on Eilstrup-Sangiovanni 2009, 201.

34Since we seek to determine the conditions under which it is more effective to choose a TGN for dealing with a PHEIC, it is not our purpose to test any of the following conditions, but rather to use them as departing point to inform the comparison of the handling of PHEIC. Thus, we may hypothesize that TGNs are the best option to deal with biosecurity threats:

35C1: Among strongly committed and capable states.

36C2: Between states which have similar interests and values, and when the group is small.

37C3: When speed is a priority.

38C4: When states are uncertain regarding the “state of the world”.

39C5: When states aim to reconceptualise their responsibilities and interests with respect to biosecurity threats.

40C1: Committed and capable states

  • 61 Ibid., 209.
  • 62 Raustiala, “The Architecture of International Cooperation,” 7.
  • 63 Kahler, Networked Politics, 2009, 15.

41Contrary to IGOs, which often strive for universality, TGNs enable a few states to initiate an agreement without consulting the others61. Hence, we argue that by setting the rules for membership, members can for example prevent the admission of spoilers. By limiting an initiative to a small group of highly influential states, “insiders” can set standards that “outsiders” are later compelled to accept62. This is particularly the case when the initial group includes a majority of powerful states in an issue-area. Furthermore, the lack of membership rules of TGNs confer them advantages in comparison to IGOs. For instance, TGNs can easily incorporate new members and issues at a relatively low cost without altering the basic form of the organization and second, they can exclude “troublesome prospective members who might force their way into an IGO”63.

42C2: Likeminded states & small group

  • 64 Eilstrup-Sangiovanni describes ‘homogeneous groups’ as those who have ‘harmonious preferences’ in t (...)
  • 65 Eilstrup-Sangiovanni, “Networked Politics,” 205.

43We should expect governments to favour TGNs for two reasons. First, small groups are more likely to benefit from the speed and flexibility associated with network cooperation. Second, networks are more likely among small homogeneous groups64 due to credibility issues, since cheating among such groups is less likely and because effective peer-to-peer monitoring is easier to achieve among small numbers65.

44C3: Speed is a priority

  • 66 Raustiala, “The Architecture of International Cooperation,” 24.
  • 67 Eilstrup-Sangiovanni, “Networked Politics,” 206–7.
  • 68 Anne-Marie Slaughter, “The Real New World Order,” Foreign Affairs. 76, no. 5 (1997): 193; Anne-Mari (...)
  • 69 Lipson, “Why Are Some International Agreements Informal?” 500–1.

45TGNs are generally faster to set up than IGOs66.Consequently, “reliance on TGNs should shorten the time between when a problem is identified and some form of collective action can be taken”67. Slaughter contends that the network form of TGNs is ideal for providing the speed and flexibility required for functioning effectively in the information age68. Similarly, Lipson argues that “less formal” instruments will be chosen when security issues must be resolved quickly or quietly to avoid serious conflict. Since these kinds of instruments do not require elaborate ratification, it is faster to conclude them and enforce them. This is particularly so in complex, rapidly changing circumstances such as the ones prevailing in the biosecurity domain where speed is clearly an advantage69.

46C4: Uncertainty concerning the “state of the world”

  • 70 Eilstrup-Sangiovanni, “Networked Politics,” 207–8.

47Governments are more likely to opt for a TGN when they are uncertain regarding the “state of the world” as they would then hesitate about the longer-term implications of agreements. Eilstrup-Sangiovanni argues that “there may be situations in which states´ interests are uncertain due either to inadequate information about the situation at hand or doubt about the likely outcomes of different courses of action”. Uncertainty about the “state of the world” refers specifically to states’ lack of knowledge about the consequences of their own actions or those of other States. This kind of uncertainty favours arrangements that are more flexible. Under uncertainty, actors will pursue institutional flexibility as a way of protecting themselves against unanticipated costs or adverse distributional consequences70.

48C5: Reconceptualization of responsibilities and interests with respect to biosecurity threats.

  • 71 Fidler and Gostin, Biosecurity in the Global Age, 231.

49Governnments are more likely to select a TGN to better reconceptualise their responsibilities and interests with respect to biosecurity threats. Fidler & Gostin argue that the reconceptualization of state responsibilities and interests in biosecurity make states hesitant to accept binding schemes of international governance as envisioned by the Biological Weapons Convention protocol or various proposals for new treaties. They claim that “partnering arrangements” enable states to engage in cooperation without contracting the high transaction costs of negotiating and implementing formally binding rules. Due to the prevailing disagreement about which biosecurity policies are more appropriate, “flexible, cooperative relationships have advantages in allowing states to navigate uncertainties present in the new worlds of biological weapons and public health governance”71.

Methods

50We employed a combination of qualitative methods. Among them we undertook a content analysis of documents (e.g. WHO reports), scientific journals, specialized databases such as the UPMC center for health security, NGO reports (e.g. Médecins Sans Frontières), and conducted face-to-face, telephone and skype semi-structured interviews with health senior civil servants in Brazil, Cameroun, Canada, Chile, Italy, Kenya, Mexico and the United States of America.

Comparison of the handling of the EVD epidemic in West Africa and the AH1N1 Influenza pandemic originated in North America.

51The EVD epidemic was not only a public health issue, it also constituted a political, social, administrative, and an economic crisis at different scales that illustrate the issue of neglected diseases. To highlight the differences and similarities in the detection and handling of PHEIC, we drew two timelines: the first one is related to Influenza A(H1N1), and the second to EVD. In the two of them, we point out to the following four aspects: steps given to determine a PHEIC, assessment of the situation, responses linked to actor´ capabilities (e.g. financial and human resources), and finally, the importance of the place where the outbreak occurred. When applicable, we also combined these four aspects with the presence/absence of the five conditions suggested in the theoretical framework. In this way, we aim to highlight the conditions that favour the use of TGNs to confront PHEIC.

The decision-making process: Time needed to declare a PHEIC, and situation assessment.

  • 72 Fidler, “From International Sanitary Conventions to Global Health Security,” 340.
  • 73 Skype interview with a former health senior official who participated in several meetings of the GH (...)

52Fidler, points out that the inapplicability of the old IHR to address most emerging and re-emerging infectious diseases indicated that the techniques incorporated into the WHO constitution aiming to revise and update the IHR rapidly proved to be more innovative on paper than in practice. For example, the WHO legal Counsel expressed the view that “using binding regulations to combat disease threats was unrealistic because such regulations cannot be adopted quickly enough to meet the health requirements of the moment”72. Evidence provided by former senior officials would support this view. One of them for instance declared that one reason to select a network-form of cooperation pertained to the necessity of having “a more rapid answer to effectively deal with the changing circumstances”73. This raises the question: Had West Africa counted with a TGN at the outset of the EVD outbreak, have we had a different result.

  • 74 “WHO | Statement on the 1st Meeting of the IHR Emergency Committee on the 2014 Ebola Outbreak in We (...)
  • 75 “WHO | Ebola Virus Disease in Guinea – Update,”.

53The decision making process to characterize a health outbreak as a PHEIC is based on article twelve and on the Annex 2 of the IHR (2005), i.e. the Decision instrument (also called the algorithm) for the assessment and notification of events that may constitute a PHEIC (see Figure 1). In the case of the EVD, the decision to characterize it as a PHEIC was made in august 8th 2014 by the DG of WHO Margaret Chan under the recommendation of the Emergency Committee74. That is almost five months after the first positive case was confirmed in the laboratory and notified on March 23th 2014 by Guinea75 (see Timeline 2b). At least this raises two questions: First, if speed was a priority (Condition 3), why did it take so long? Second, once the problem was identified (i.e. once experts realized it was not Cholera, but EVD), why not setting a regional TGN for reacting rapidly? Alternatively, if we need to react promptly –as is always the case when dealing with PHEIC- why not modifying current health-related IGOs in order to make them more flexible?

  • 76 Podolny, “Network Forms of Organization,” 65–6.

54One of the benefits of networks is its adaptability to unanticipated environmental changes. By encouraging greater communication than the one provided by the market, networks contribute to enhancing coordination when changes cannot be fully comprehended or conveyed through price signals. Since the boundaries of the networks are in general easier to modify than the ones of hierarchies (e.g. IGOs), it is also easier to alter the composition of the network to respond to those changes76.

  • 77 WHO, “Report of the Review Committee…” 72.
  • 78 Avery, “The North American Plan…", 13–6.
  • 79 Ibid., 17.

55As stated, the 2009 influenza pandemic exposed some limitations of the IHR (2005), and consequently of the WHO for making decisions under conditions of uncertainty. Nonetheless, it seems that the combined work of different institutional arrangements including TGNs (e.g. the GHSI & the NAPAPI) and IGOs (e.g. PAHO & the WHO) contributed to more effective detection and assessment of the risks posed by the new virus77. Available evidence suggests for instance that the NAPAPI was reasonably effective during the pandemic78. Moreover, the NAPAPI profited from existing health security programs, especially from the GHSI while strengthening the global strategy of the WHO79.

  • 80 WHO, “Report of the Review Committee…”.

56Comparing the duration needed to make a decision concerning the A(H1N1) influenza’s emergency, it clearly appears that Ebola is a neglected disease (see Timeline 1 and Report of the Ebola Interim Assessment Panel). On April 14th, the first cases were detected in a Californian laboratory; on April 25th, Mexico confirmed its first cases, whereas on the same day Canada detected ILI syndrome in Canadians citizens coming back from Mexico. Simultaneously, the emergency committee held its first meeting, stating that a PHEIC was ongoing, consequently that day the DG of WHO Margaret Chan declared a PHEIC80. Conversely, it took much longer (circa five months and half) and needed much more deaths (729) before an emergency committee met up concerning EVD’s epidemics in West Africa. As illustrated in Timeline 2a, the first confirmed case in a laboratory was notified on March 26th 2014. In both epidemics, the Global Outbreak Alert and Response Network (GOARN) was rapidly deployed; however, the situation assessment and the allowance of resources in the case of the EVD epidemic were wrong and insufficient (see Report of the Ebola Interim Assessment Panel).

Actors´ capabilities and response actions.

  • 81 “WHO | Ebola Virus Disease in Guinea – Update.”
  • 82 Interviews with Dr. Alpuche Arranda and Mexican Health Vice minister Dr. Hugo Lopez-Gatell Ramirez, (...)
  • 83 “WHO | Ebola Virus Disease, West Africa – Update,”.

57On April 24th 2009, the GOARN was rapidly and adequately deployed in Mexico to respond to A(H1N1). Five years later, on March 26th, it was similarly deployed to respond to EVD epidemic in Guinea81. However, as the A(H1N1) epidemic was spreading in space and its duration advancing in time, Mexican officials soon learned that the WHO recommendations’ did not correspond anymore to the local situation82; Therefore, Mexican officials decided to follow their own way. This seems to be similar to what has occurred in the EVD epidemic, i.e. although there were good early response actions, there was a misassessment following those first actions, which in combination with financial, human resources and infrastructure shortage lead to the catastrophic situation of August 2014. The response action lead by WHO in West Africa included logistic leadership, facilitator process, review support, and the establishment of an AFRO mission which provided support to Guinea on reviewing the outbreak response operations83.

  • 84 Ibid.
  • 85 Ibid.

58In Sierra Leone, one of the WHO response actions consisted in supporting the country in developing proposals to be submitted to CERF, OCHA Emergency Fund and UK Department for International Development84. No doubt, one of the major problems confronted by Liberia, Sierra Leone and Guinea during the EVD epidemic had to do with the lack of resources (infrastructures, human and financial). The first two are linked to the postwar national contexts and to the structural adjustments, whereas the last one is still important to face the epidemic. Consequently, it is on July 24th 2014, that the DG of WHO started discussing with funders and development actors to find ways for improving performance85.

  • 86 Face-to-face interview with a lab Mexican official, June 2014.
  • 87 Skype interview with former Mexican minister of Health, Dr. Julio Frenk, April 2012; skype intervie (...)

59The mismanagement problem in relation to the EVD epidemic appears at all scales of WHO structure. For example, whereas the GOARN team adjusted pretty well to the Mexican local reality during A(H1N1) pandemic, response actions in West Africa were at first inadequate to the local reality (e.g. recommendations concerning burial practices)86. The place where the outbreak or the PHEIC is occurring can also determine the response type and the speed to react. That was the case, we argue, with the influenza A (H1N1) epidemic that took place in North America. Indeed, the response and its coordination there were so articulated due to the common membership of the North American partners to various transgovernmental networks (e.g. NACOBPI, GHSI, APEC Health working group) as evidenced by both scholars and policy makers87. This brings support to Condition 2 related to small group and homogeneous interests and values (i.e. like-mindedness)

  • 88 Van der Rijt and Pang, “How ‘Global’ Is ‘Global Health’?.”

60Second, due to the USA’s leading role in the production of theoretical knowledge and practical knowhow in global health biosecurity and public health88, the most powerful and capable of the NACOBPI partners (Condition 1) was able to promptly share knowledge and infrastructure with their needed neighbors, particularly with Mexico. Thus, it is interesting to notice the rapid and coordinated response to a new virus causing air born disease in 2009, and the slow and discoordinated response to an old known virus causing a higher lethal rate in West Africa. Consequently, would not make sense to set regional TGNs in Africa with at least a capable state for pooling efforts and resources?

The importance of the place where the outbreak is occurring

  • 89 WHO, “Report of the Review Committee…", 58.

61At the political and symbolic level, it is important to mention the early visit of WHO DG Margaret Chan to the PAHO/WHO office on April 24th. By now we know that she was informed about the A(H1N1) outbreak’s in North America while she was on her way to New York, and then decided to change her route to join other health officers at the headquarters of PAHO in Washington89. Of course, this could be related to her personal background because she was responsible for Health in Hong Kong during the SARS outbreak in 2003, but we cannot deny the influence of the USA.

  • 90 Hoffman, S. J., & Silverberg, S. L. (2018). Delays in global disease outbreak responses: lessons fr (...)
  • 91 “WHO | Ebola Virus Disease, West Africa – Update.”.

62In that respect, Hoffman convincingly argues that one of the reasons why the WHO reacted faster to the A(H1N1) influenza outbreak in North America than to the EVD outbreak in West Africa, and thus declared sooner the PHEIC in the former case, related to the fact that the A(H1N1) influenza outbreak affected US citizens from the outset90. In contrast to the outbreak originated in North America, the first WHO high staff member to travel to two of the three most affected countries where EVD epidemic started, occurred almost four months after the beginning of the epidemic. Indeed, Dr. Fukuda visited Sierra Leone from July 7th to July 10th, whereas DG Chan visited Guinea from July 31st to august 1st 91.

63Consequently, we can clearly observe that the place where the epidemic is occurring makes a difference. Indeed, depending on the neighbors, their capabilities, and the regional agreements in place (i.e. whether a TGN exists or not), the international response and the available resources will not be the same. That is undeniably one of the lessons the handling of the EVD and the A(H1N1) is teaching us.

Conclusion

64Within the biosecurity field, we still lack convincing answers of why states sometimes select IGOs as opposed to TGNs for their international agreements. Nonetheless, preliminary evidence suggests that when confronted with a PHEIC capable states may prefer to opt for more flexible and informal arrangements (i.e. TGNs) as a means for coping with uncertainty and making faster decisions. We observed this pattern in North America where, as suggested by our five conditions, the three like-minded and strongly committed North American countries were able to set a small network to reconceptualise their responsibilities and interests with respect to some biosecurity threats.

65Furthermore, the 2009 influenza pandemic revealed not only some of the institutional limitations of the WHO but also some strong points of transgovernmental networks and interinstitutional cooperation. As stated, it seems that the combined work of different institutional arrangements including TGNs (the NACOBPI and the GHSI) and IGOs (the PAHO and the WHO) contributed to detect and assess more effectively the risk posed by the new influenza virus. In contrast, the EVD epidemic in West Africa revealed a lack of coordination among the different national and international organizations and confirmed the ineffectiveness of the WHO as a global coordinator in charge of providing adequate measures for the protection of public health and for strengthening the global public health response to the international spread of disease. Moreover, when compared to the EVD epidemic, it seems clear that the North American TGNs played a fundamental role in information and capacity sharing, surveillance, and early identification of the virus. Hence, we should wonder whether it was enough to establish centres for Disease Control and Prevention in Africa but not regional TGNs integrated by like-minded and at least one capable country.

66What are the lessons we can draw from these experiences? Echoing the work of Fidler and Gostin, should we design a “global biosecurity concert” based on regional TGNs as a mechanism to improve biosecurity? Or should we simply replicate the NAPAPI (the plan behind NACOBPI) as Avery suggests? In this respect, can a regional TGN among many African, Asian or South American countries with different values, capabilities and interests be as effective as one in North America? What would be the most effective institutional design to accommodate heterogeneous countries? Finally, will the WHO be able to coordinate all regional TGNs and function as a super structural node as suggested by some scholars?

Figure 1. IHR (2005) decision instrument for the assessment and notification of events that may constitute a Public Health Emergency of International Concern.

Source: Own elaboration based on the WHO, International Health Regulations (2005), Annex 2, 43.

Timeline 1: Decisions by WHO regarding the 2009 A (H1N1) Influenza pandemic.

Source: Own elaboration

Timeline 2a: Decisions by WHO regarding EVD epidemic in West Africa.

Source: Own elaboration

Timeline 2b: Decisions by WHO regarding EVD epidemic in West Africa (continued).

Source: Own elaboration.

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Notes

1 John Hopkins University & Medicine, Coronavirus Resource Center. Covid-19 Map. (2020, April 8). Retrieved from: https://coronavirus.jhu.edu/

2 The New York Times (2020, April 9). Retrieved from:https://www.nytimes.com/2020/04/09/us/coronavirus-live-updates.html?action=click&module=Spotlight&pgtype=Homepage

3 OECD, (2020, March 2). OECD Interim Economic Assessment. Coronavirus: the World economy at risk. Retrieved from: https://www.oecd.org/berlin/publikationen/Interim-Economic-Assessment-2-March-2020.pdf

4 WHO, “Report of the Review Committee on the Functioning of the International Health Regulations (2005) in Relation to Pandemic (H1N1) 2009,” Geneva: WHO, 2011.

5 Karen Grépin, (2015) “International Donations to the Ebola Virus Outbreak: Too Little, Too Late?,”; Martin Enserink and Jon Cohen, (2009) “The Novel H1N1 Influenza,” Science 326, 5960 (2009): 1607–1607; Gostin, L. O. (2015). The future of the World Health Organization: lessons learned from Ebola. The Milbank Quarterly93(3), 475; Aliye Bastug, Hürrem Bodur, “Ebola viral disease: What should be done to combat the epidemic in 2014?”, Turkish Journal of Medical Sciences, vol. 45, (2015); Obinna O Oleribe et al. “Ebola virus disease epidemic in West Africa: lessons learned and issues arising from West African countries“, Clinical Medicine, Vol. 15 (2015) 1: 1-4; Harvey V. Fineberg, “Pandemic Preparedness and Response — Lessons from the H1N1 Influenza of 2009”, The new england journal of medicine, 2014;370:1335-42; DL Heymann et al., “Global health security: the wider lessons from the west African Ebola virus disease epidemic.”, Lancet. 2015 May 9;385(9980):1884-901; GHSI, Ministerial Statements Tokyo, Japan, 11 December, 2014, Fifteenth ministerial meeting of the Global Health Security Initiative (GHSI); WHO, Report of the Ebola Interim Assessment Panel, Geneva, 2015.

6 WHO, “Report of the Review Committee…", 6.

7 WHO, “Report of the Ebola Interim Assessment Panel”, May 2015, WHO reference number: A68/25

8 Barbara Koremenos, Charles Lipson, and Duncan Snidal, “The Rational Design of International Institutions,” International Organization 55, 04 (2001): 761–99.

9 Elke Krahmann, “Security Governance and Networks: New Theoretical Perspectives in Transatlantic Security,” Cambridge Review of International Affairs 18, 1 (2005): 15–30; Mette Eilstrup-Sangiovanni, “Varieties of Cooperation. Government Networks in International Security,” in Networked Politics: Agency, Power, and Governance, ed. Miles Kahler (Ithaca: Cornell University Press, 2009), 194–227; Brian Rathbun, “Before Hegemony: Generalized Trust and the Creation and Design of International Security Organizations,” International Organization 65, 02 (2011): 243–73.

10 Vetter, P., Dayer, J., Schibler, M. et al. (2016). “The 2014–2015 Ebola outbreak in West Africa: Hands On”. Antimicrob Resist Infect Control 5, 17. https://doi.org/10.1186/s13756-016-0112-9; Hoffman, S. J., & Silverberg, S. L. (2018). „Delays in global disease outbreak responses: lessons from H1N1, Ebola, and Zika”. American journal of public health, 108(3), 329-333; Ravi, S. J., Snyder, M. R., & Rivers, C. (2019). Review of international efforts to strengthen the global outbreak response system since the 2014–16 West Africa Ebola Epidemic. Health policy and planning, 34(1), 47-54.

11 MacNeil, A., & Rollin, P. E. (2012). Ebola and Marburg hemorrhagic fevers: neglected tropical diseases?. PLoS neglected tropical diseases, 6(6); Nunes J., Rushton S. & Anderson E. (2015). Ebola: Why wasn´t the world prepared? CSD round table. University of York, Department of Politics. See: https://www.york.ac.uk/politics/research/current-projects/neglected-diseases/?fbclid=IwAR20nxgueTYno4dmj30ILTJc-ujhlmt76DGyU0a_-X9Mwg4iEfQLGPtxPMY; Dallatomasina, S., Crestani, R., Sylvester Squire, J., Declerk, H., Caleo, G. M., Wolz, A., ... & Spreicher, A. (2015). “Ebola outbreak in rural West Africa: epidemiology, clinical features and outcomes”. Tropical Medicine & International Health, 20(4), 448-454.

12 David Fidler and Lawrence Gostin, Biosecurity in the Global Age: Biological Weapons, Public Health, and the Rule of Law (Stanford: Stanford University Press, 2008); Donald Avery, “The North American Plan for Avian and Pandemic Influenza: A Case Study of Regional Health Security in the 21st Century,” Global Health Governance III, 2 (2010); Ilona Kickbusch, Wolfgang Hein, and Gaudenz Silberschmidt, “Addressing Global Health Governance Challenges through a New Mechanism: The Proposal for a Committee C of the World Health Assembly,” Journal of Law, Medicine and Ethics 38, 3 (2010): 550–63; Jennifer Nuzzo and Gigi Gronvall, “Global Health Security: Closing the Gaps in Responding to Infectious Disease Emergencies,” Global Health Governance IV, 2011.

13 Amy K. Donahue, Robert V. Tuohy, “Lessons We Don't Learn: A Study of the Lessons of Disasters, Why We Repeat Them, and How We Can Learn Them” Homeland Security Affairs 2(2) · January 2006.

14 Aliye Bastug, Hürrem Bodur, “Ebola viral disease: What should be done to combat the epidemic in 2014?”, Turkish Journal of Medical Sciences, vol. 45, (2015); Obinna O Oleribe et al. “Ebola virus disease epidemic in West Africa: lessons learned and issues arising from West African countries“, Clinical Medicine, Vol. 15 (2015) 1: 1-4; Harvey V. Fineberg, “Pandemic Preparedness and Response — Lessons from the H1N1 Influenza of 2009”, The new england journal of medicine, 2014;370:1335-42; DL Heymann et al., “Global health security: the wider lessons from the west African Ebola virus disease epidemic.”, Lancet. 2015 May 9;385(9980):1884-901; GHSI, Ministerial Statements Tokyo, Japan, 11 December, 2014, Fifteenth ministerial meeting of the Global Health Security Initiative (GHSI); WHO, Report of the Ebola Interim Assessment Panel, Geneva, 2015.

15 Ravi, S. J., Snyder, M. R., & Rivers, C. (2019). Review of international efforts to strengthen the global outbreak response system since the 2014–16 West Africa Ebola Epidemic. Health policy and planning34(1), 47-54; Vetter, P., Dayer, J. A., Schibler, M., Allegranzi, B., Brown, D., Calmy, A., ... & Iten, A. (2016). “The 2014–2015 Ebola outbreak in West Africa: hands on”. Antimicrob Resist Infect Control 517. https://doi.org/10.1186/s13756-016-0112-9; Hoffman, S. J., & Silverberg, S. L. (2018). Delays in global disease outbreak responses: lessons from H1N1, Ebola, and Zika. American journal of public health108(3), 329-333.

16 Hoffman, S. J., & Silverberg, S. L. (2018). Delays in global disease outbreak responses: lessons from H1N1, Ebola, and Zika. American journal of public health108(3), 329.

17 Tess van der Rijt, Tikki Pang, “Resuscitating a comatose WHO: Can WHO reclaim its role in a crowded global health governance landscape?” Global Health Governance, Vol. vi n°2 (Summer 2013).

18 MacNeil, A., & Rollin, P. E. (2012). Ebola and Marburg hemorrhagic fevers: neglected tropical diseases?. PLoS neglected tropical diseases6(6); Troncoso, A. (2015). “Ebola outbreak in West Africa: a neglected tropical disease”. Asian Pacific Journal of Tropical Biomedicine5(4), 255-259; Hotez, P. J. (2016). “Neglected tropical diseases in the Anthropocene: the cases of Zika, Ebola, and other infections”. PLoS neglected tropical diseases10(4); Dallatomasina, S., Crestani, R., Sylvester Squire, J., Declerk, H., Caleo, G. M., Wolz, A., ... & Spreicher, A. (2015). “Ebola outbreak in rural West Africa: epidemiology, clinical features and outcomes”. Tropical Medicine & International Health20(4), 448-454.

19 WHO, “Dengue and severe dengue”, March 2020, see: https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue; “Cholera crisis, a neglected disease is back in the headlines”, November 2015, see: https://www.npr.org/sections/goatsandsoda/2015/11/06/454691258/cholera-crisis-a-neglected-disease-is-back-in-the-headlines; WHO, “Neglected tropical diseases”, see: https://www.who.int/neglected_diseases/diseases/en/?fbclid=IwAR2UMK_O2HLRifMp6HFq6ileEXMEeBbZckr9hra4CCIXcA5ifJ41ZU17jsg; Hotez, P. J. (2017). “Ten failings in global neglected tropical diseases control”. PLoS neglected tropical diseases11(12).

20 WHA, 2005 International Health Regulations, 9, pa.6,

21 Fidler and Gostin define biosecurity as a society’s collective responsibility to safeguard the population from dangers presented by pathogenic microbes, whether intentionally released as in the case of biological weapons or biological terrorist attacks (e.g. 2001 Anthrax mail attacks) or naturally occurring, as with infectious diseases such as influenza, Ebola or Zika. Cfr. Fidler, David P., and Lawrence Ogalthorpe Gostin (2008) Biosecurity in the global age: biological weapons, public health, and the rule of law. Stanford: Stanford University Press, pp. 4-5; David Fidler, “From International Sanitary Conventions to Global Health Security: The New International Health Regulations,” Chinese Journal of International Law 4, 2 (2005): 365; Nuzzo and Gronvall, “Global Health Security”; WHO, “Report of the Review Committee…", 31.

22 WHA, 2005 International Health Regulations, 43.

23 Ravi, S. J., Snyder, M. R., & Rivers, C. (2019). Review of international efforts to strengthen the global outbreak response system since the 2014–16 West Africa Ebola Epidemic. Health policy and planning34(1), 52-53.

24 Ravi, S. J., Snyder, M. R., & Rivers, C. (2019). Review of international efforts to strengthen the global outbreak response system since the 2014–16 West Africa Ebola Epidemic. Health policy and planning34(1), 52; Hoffman, S. J., & Silverberg, S. L. (2018). Delays in global disease outbreak responses: lessons from H1N1, Ebola, and Zika. American journal of public health108(3), 329.

25 John J. Kirton and Jenevieve Mannell, “The G8 and Global Health Governance,” in Governing Global Health: Challenge, Response and Innovation, eds. Cooper, Kirton, and Schrecker (Burlington: Ashgate Publishing, 2007), 115–17.

26 Fidler, “From International Sanitary Conventions to Global Health Security", 342.

27 Andrew F. Cooper, John J. Kirton, and Ted Schrecker, eds., Governing Global Health : Challenge, Response, Innovation (Aldershot ;;Burlington VT: Ashgate, 2007); Andrew Price-Smith, The Health of Nations Infectious Disease, Environmental Change, and Their Effects on National Security and Development (Cambridge Mass.: MIT Press, 2002); Nicholas Bayne, Hanging in There : The G7 and G8 Summit in Maturity and Renewal (Brookfield USA: Ashgate, 2000); Peter Hajnal, Civil Society in the Information Age (Aldershot Hampshire Ashgate, 2002).

28 Kickbusch, Hein, and Silberschmidt, “Addressing Global Health Governance…", 12.

29 Hoffman, “The Evolution, Etiology and Eventualities of the Global Health Security Regime,” Health Policy and Planning 25, 6 (2010): 510–22; Fidler and Gostin, Biosecurity in the Global Age.

30 Hoffman, “The Evolution…", p. 514; Nuzzo and Gronvall, “Global Health Security”, 4.

31 Gostin, L. O. (2015). The future of the World Health Organization: lessons learned from Ebola. The Milbank Quarterly, 93(3), 477.

32 Idem

33 Cooper, Kirton, and Schrecker, Governing Global Health; Fidler and Gostin, Biosecurity in the Global Age; Hoffman, “The Evolution…"; Sudeep Chand et al., “From G8 to G20, Is Health next in Line?,” The Lancet, June 23, 2010.

34 Hoffman, “The Evolution…", 518.

35 Medecins sans Frontieres, “Pushed to the limits and beyond. A year into the largest ever Ebola outbreak. (2015).

36 Fidler and Gostin, Biosecurity in the Global Age, 3.

37 Ibid., 252.

38 Avery, “The North American Plan…", 17.

39 Koremenos, et al, “The Rational Design…", 781–2.

40 Fidler and Gostin, Biosecurity in the Global Age, 231.

41 Ibid., 762.

42 Eilstrup-Sangiovanni, “Networked Politics,”198-201.

43 Robert Keohane, After Hegemony: Cooperation and Discord in the World Political Economy (Princeton University Press, 1984); Robert Keohane, “Transgovernmental Relations and International Organizations,” World Politics: A Quarterly Journal of International Relations 27, 1 (1974): 39.

44 Koremenos, et al. “The Rational Design…", 761–99.

45 Anne-Marie Slaughter, “The Real New World Order,” Foreign Affairs. 76, 5 (1997): 183; Anne-Marie Slaughter, “Disaggregated Sovereignty: Towards the Public Accountability of Global Government Networks,” Government and Opposition 39, 2 (April 1, 2004): 159–90; Joel Podolny, “Network Forms of Organization,” Annual Review of Sociology 24 (1998): 57; Kal Raustiala, “The Architecture of International Cooperation: Transgovernmental Networks and the Future of International Law,” Virginia Journal of International Law. 43, 1 (2002): 1; Miles Kahler, ed., Networked Politics : Agency, Power, and Governance (Ithaca: Cornell University Press, 2009); Eilstrup-Sangiovanni, “Networked Politics,” 205–10.

46 Lipson, “Why Are Some International Agreements Informal?”; Kenneth Abbott and Duncan Snidal, “Hard and Soft Law in International Governance,” International Organization 54, 03 (2000): 421–56; Kenneth Abbott et al., “The Concept of Legalization,” International Organization 54, 03 (2000): 401–19.

47 Koremenos, et al. “The Rational Design…", 767.

48 Ibid.

49 Raustiala, “The Architecture of International Cooperation”, 6.

50 Abbott and Snidal, “Hard and Soft Law in International Governance”, 423; Eilstrup-Sangiovanni, “Networked Politics.”

51 Fritz Wilhelm Scharpf, Games Real Actors Play: Actor-Centered Institutionalism in Policy Research, vol. 1997 (Westview Press, Boulder, 1997), 137–138; Podolny, “Network Forms of Organization”, 60–62; Rathbun, “Before Hegemony,”, 247–8.

52 Scharpf, Games Real Actors Play, 1997:138.

53 Anne-Marie Slaughter, A New World Order (Princeton: Princeton University Press, 2004), 192; Raustiala, “The Architecture of International Cooperation,” 24.

54 Abbott and Snidal, “Hard and Soft Law in International Governance,” 430–434.

55 Koremenos, et al. “The Rational Design…", 773–9.

56 Koremenos, et al. “The Rational Design…"; Abbott and Snidal, “Hard and Soft Law in International Governance.”

57 Abbott et al., “The Concept of Legalization,” 763.

58 Podolny, “Network Forms of Organization,” 59; Miles Kahler, “Networked Politics. Agency, Power, and Governance”, (Ithaca: Cornell University Press, 2009), 1–20.

59 Abbott et al., “The Concept of Legalization,” 406–7.

60 Eilstrup-Sangiovanni, “Networked Politics,” 198.

61 Ibid., 209.

62 Raustiala, “The Architecture of International Cooperation,” 7.

63 Kahler, Networked Politics, 2009, 15.

64 Eilstrup-Sangiovanni describes ‘homogeneous groups’ as those who have ‘harmonious preferences’ in terms of interests and values.

65 Eilstrup-Sangiovanni, “Networked Politics,” 205.

66 Raustiala, “The Architecture of International Cooperation,” 24.

67 Eilstrup-Sangiovanni, “Networked Politics,” 206–7.

68 Anne-Marie Slaughter, “The Real New World Order,” Foreign Affairs. 76, no. 5 (1997): 193; Anne-Marie Slaughter, “Disaggregated Sovereignty: Towards the Public Accountability of Global Government Networks,” Government and Opposition 39, 2 (April 1, 2004): 162.

69 Lipson, “Why Are Some International Agreements Informal?” 500–1.

70 Eilstrup-Sangiovanni, “Networked Politics,” 207–8.

71 Fidler and Gostin, Biosecurity in the Global Age, 231.

72 Fidler, “From International Sanitary Conventions to Global Health Security,” 340.

73 Skype interview with a former health senior official who participated in several meetings of the GHSI, the NACOBPI and the APEC Health Group, 06/04/2011.

74 “WHO | Statement on the 1st Meeting of the IHR Emergency Committee on the 2014 Ebola Outbreak in West Africa,” WHO, accessed July 4, 2015.

75 “WHO | Ebola Virus Disease in Guinea – Update,”.

76 Podolny, “Network Forms of Organization,” 65–6.

77 WHO, “Report of the Review Committee…” 72.

78 Avery, “The North American Plan…", 13–6.

79 Ibid., 17.

80 WHO, “Report of the Review Committee…”.

81 “WHO | Ebola Virus Disease in Guinea – Update.”

82 Interviews with Dr. Alpuche Arranda and Mexican Health Vice minister Dr. Hugo Lopez-Gatell Ramirez, June, 2014

83 “WHO | Ebola Virus Disease, West Africa – Update,”.

84 Ibid.

85 Ibid.

86 Face-to-face interview with a lab Mexican official, June 2014.

87 Skype interview with former Mexican minister of Health, Dr. Julio Frenk, April 2012; skype interview with US Secretary of Health and Human services (HHS), Alex Azar II, April 2012; face-to-face interview with Canadian Assistant Deputy Ministers Rainer Engelhardt & Sarah Lawlley, April 2012; skype interview with Pablo Kuri Morales Mexican Under-secretary of Prevention and Health Promotion, May 2012; Telephone interview with Hugo López-Gatell Under-secretary of Prevention and Health Promotion, May 2012; face-to-face anonymous interview with three senior civil servants of the US department of HHS, April 2012.

88 Van der Rijt and Pang, “How ‘Global’ Is ‘Global Health’?.”

89 WHO, “Report of the Review Committee…", 58.

90 Hoffman, S. J., & Silverberg, S. L. (2018). Delays in global disease outbreak responses: lessons from H1N1, Ebola, and Zika. American journal of public health108(3), 329-333.

91 “WHO | Ebola Virus Disease, West Africa – Update.”.

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Octavio González Segovia and Axelle Ébodé, « A comparison of the institutional management of the H1N1 influenza pandemic and the Ebola virus disease epidemic in West AfricaWhy we have not learned the lesson when preparing and responding to Public Health Emergency of International Concern?  »Face à face [En ligne], 16 | 2020, mis en ligne le 27 octobre 2020, consulté le 28 octobre 2020. URL : http://journals.openedition.org/faceaface/1787

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