The Applicability of the IHR; With the signing of the revised International Health Regulations (IHR) in 2005, the international community agreed to improve the detection and reporting of potential public health emergencies worldwide. IHR (2005) better addresses today’s global health security concerns and are a critical part of protecting global health. The regulations require that all countries have the ability to detect, assess, report and respond to public health events. In response to the exponential increase in international travel and trade, and emergence and reemergence of international disease threats and other health risks, 196 countries across the globe agreed to implement the International Health Regulations (2005) (IHR). This binding instrument of international law entered into force on 15 June 2007. The stated purpose and scope of the IHR are; "to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade." Because the IHR are not limited to specific diseases, but are applicable to health risks, irrespective of their origin or source, they will follow the evolution of diseases and the factors affecting their emergence and transmission. The IHR also require States to strengthen core surveillance and response capacities at the primary, intermediate and national level, as well as at designated international ports, airports and ground crossings. The International Health Regulations (IHR), a legally binding agreement between 196 States Parties, whose aim is to prevent, protect against, control, and provide a public health response to the international spread of disease, deserve critical examination with regard to their applicability. The emergence and spread of the new mysterious hemorrhagic fever may constitute a public health emergency of international concern (PHEIC) and is therefore notifiable to the World Health Organization under the IHR notification requirement. IHR (2005) is coordinated by the World Health Organization (WHO) and aims to keep the world informed about public health risks and events. As an international treaty, the IHR (2005) is legally binding; all countries must report events of international public health importance. Countries reference IHR (2005) to determine how to prevent and control global health threats while keeping international travel and trade as open as possible. IHR (2005) requires that all countries have the ability to do the following: · Detect: Make sure surveillance systems and laboratories can detect potential threats · Assess: Work together with other countries to make decisions in public health emergencies · Report: Report specific diseases, plus any potential international public health emergencies, through participation in a network of National Focal Points · Respond: Respond to public healt.

1. The Applicability of the IHR;
With the signing of the revised International Health Regulations
(IHR) in 2005, the international community agreed to improve
the detection and reporting of potential public health
emergencies worldwide. IHR (2005) better addresses today’s
global health security concerns and are a critical part of

2. protecting global health. The regulations require that all
countries have the ability to detect, assess, report and respond
to public health events.
In response to the exponential increase in international travel
and trade, and emergence and reemergence of international
disease threats and other health risks, 196 countries across the
globe agreed to implement the International Health Regulations
(2005) (IHR). This binding instrument of international law
entered into force on 15 June 2007.
The stated purpose and scope of the IHR are; "to prevent,
protect against, control and provide a public health response to
the international spread of disease in ways that are
commensurate with and restricted to public health risks, and
which avoid unnecessary interference with international traffic
and trade." Because the IHR are not limited to specific diseases,
but are applicable to health risks, irrespective of their origin or
source, they will follow the evolution of diseases and the
factors affecting their emergence and transmission. The IHR
also require States to strengthen core surveillance and response
capacities at the primary, intermediate and national level, as
well as at designated international ports, airports and ground
crossings.
The International Health Regulations (IHR), a legally binding
agreement between 196 States Parties, whose aim is to prevent,
protect against, control, and provide a public health response to
the international spread of disease, deserve critical examination
with regard to their applicability. The emergence and spread of
the new mysterious hemorrhagic fever may constitute a public
health emergency of international concern (PHEIC) and is
therefore notifiable to the World Health Organization under the
IHR notification requirement.
IHR (2005) is coordinated by the World Health Organization
(WHO) and aims to keep the world informed about public health
risks and events. As an international treaty, the IHR (2005) is
legally binding; all countries must report events of international
public health importance. Countries reference IHR (2005) to

3. determine how to prevent and control global health threats
while keeping international travel and trade as open as possible.
IHR (2005) requires that all countries have the ability to do the
following:
· Detect: Make sure surveillance systems and laboratories can
detect potential threats
· Assess: Work together with other countries to make decisions
in public health emergencies
· Report: Report specific diseases, plus any potential
international public health emergencies, through participation in
a network of National Focal Points
· Respond: Respond to public health events
IHR (2005) also includes specific measures countries can take
at ports, airports and ground crossings to limit the spread of
health risks to neighboring countries, and to prevent
unwarranted travel and trade restrictions.
One of the most important aspects of IHR (2005) is the
requirement that countries detect and report events that may
constitute a potential public health emergency of international
concern (PHEIC) for this matter we are referring to the
hemorrhagic fever.
Under IHR (2005), a PHEIC is declared by the World Health
Organization if the situation meets 2 of 4 criteria:
· Is the public health impact of the event serious?
· Is the event unusual or unexpected?
· Is there a significant risk of international spread?
· Is there a significant risk of international travel or trade
restrictions?
So as soon as the fever was identified in the tropical resorts as
an event of concern, there must be an assessment of the public
health risks of the event within 48 hours. If the event is
determined to be notifiable under the IHR, this must be reported
to WHO within 24 hours.
The example case of the mysterious hemorrhagic fever is highly
applicable to be a notifiable disease under IHR. The mentioned
case appears to hit the tropical resort which is mostly visited by

4. tourists thus making the disease a public health concern. The
tourists might easily spread the disease all over the globe. This
needs to be reported and ensure that all necessary measures to
detect it early, manage and contain it within the area of disease
eruption.
As noted, the number of tourists has decreased and
economically this has an impact to the affected country. This in
some cases might pose hesitation to report among the affected
state fearing that it might scare the tourists and hence impact
the member state economically. However, the risk of spread
outweighs the economic risks. If the disease is not reported,
other member states might fail to support. As it is mentioned as
the scope of IHR "to prevent, protect against, control and
provide a public health response to the international spread of
disease in ways that are commensurate with and restricted to
public health risks, and which avoid unnecessary interference
with international traffic and trade."
Some diseases always require reporting under the IHR, no
matter when or where they occur, while others become
notifiable when they represent an unusual risk or situation.
The world threat posed by the spread of hemorrhagic fever
cannot be addressed by individual countries alone, but requires
a coordinated international response. Recognizing the
applicability of the IHR to this outbreak will serve as a “wake-
up call” and strengthen global surveillance and response, which
could in turn contribute to containing the spread of the fever.
Notifications of events should serve as alerts and can be an
important instrument in the chain of “the global early warning
function, the purpose of which is to provide international
support to affected countries and information to other countries
if needed”. The immediate consequence of notification is to
initiate an “exclusive dialogue between the notifying State Party
and WHO concerning the event at issue” and to make a joint
risk assessment. The dissemination of information through the
WHO Event Information System (EIS) could expediently
increase awareness in multiple countries, allow early

5. implementation of screening measures for persons at risk (e.g.,
international hospital transfers), and prevent the establishment
of new strains in unaffected countries. IHR can also facilitate
the international dissemination of appropriate measures to
counter the spread of hemorrhagic fever.
Importantly, the IHR focuses on a societal investment in core
surveillance and response capacities at different levels by
setting minimum standards. WHO pledges to collaborate with
the States Parties concerned “by providing technical guidance
and assistance and by assessing the effectiveness of the control
measure in place, including the mobilization of international
teams of experts for on-site assistance when necessary”.
Applying the outbreak of hemorrhagic fever to IHR may face
obstacles as well, for instance: Even if WHO and a majority of
States Parties consider that the fever should be addressed under
the IHR, technical, financial, and political obstacles might
interfere. Notification of an event to WHO depends on it being
detected (requiring a functioning health system and adequate
laboratory capacities), and reported to the National IHR Focal
Point. There is a concern that many States Parties are far from
being compliant with the IHR's minimum core capacity
requirements for surveillance and response. Even if relevant
information filters through to the national level, notification
decisions may be under political control which in many cases
cannot be interfered with.
The IHR framework provides a global surveillance
infrastructure and orchestrates an appropriate public health
response. The IHR are ultimately “owned” by the States Parties,
some of whom increasingly understand the extent and urgency
of the threats posed by emerging disease outbreaks. However, it
is up to WHO to provide leadership on the role of the IHR.
The role of national sovereignty in mounting a global response.
National sovereignty is the beginning of global governance,
particularly in the arena of global infectious disease control,
encompasses range of integrated policy, information

6. management, command and control mechanisms for facilitating
collective action to achieve the objectives of prevention,
detection, and response (Global Health Risk Framework, 2016).
The structural elements of public health protection and
healthcare delivery are controlled by either national
governments. The states still remain the most important actor in
determining whether health is assigned a high priority, or is
ignored. The states remain the principal gatekeepers between
global health governance in theory, as well as practice
(Stevenson & Cooper, 2009).
The concept of state sovereignty is largely been associated with
and understood in association with Westphalian principle.
Westphalian principle forbids armed interference by one state in
the internal affairs of another. A crucial aspect of world order
(agreed upon by most countries), is respect for international
borders. There is an unspoken respect for international borders.
Millions will die to protect their state’s sovereignty; this
reflects the intense depth of commitment to the precept of state
sovereignty. Strong loyalty to the sovereignty paradigm endures
as states fiercely guard and protect their state’s sovereignty,
even if it is meant to bring aid and assistance. Francis Deng,
South Sudan’s Roving Ambassador, observes and aptly puts into
perspective that “whether international involvement in a
domestic problem is strategically motivated or driven by
humanitarian concerns, it nearly evokes a reaction that is both
appreciative of the assistance and hostile to foreign
intervention”. Furthermore, there is the notion that “when the
state fails to honor the responsibilities of national sovereignty,
the people will retain their consciousness of pride, honor and
independence, despite their need for external help” (Etzioni,
2016).
In the emerging post-Westphalian model sees states as just one
set, most important, of a complex of multiple actors. These
actors have some degree of legitimacy in both inter and intra-
state governance. In context of health governance these include
health organizations such as WHO, non-governmental

7. organizations (Doctors without Borders), private philanthropic
foundations (e.g., Bill and Melinda Gates Foundation), and
public-private partnerships (e.g. Global Fund), where business
actors partner with public actors in the provision of health
related commodities. The post-Westphalian model is linked with
both governance (justification for existence) and with global
governance (recognition of multiple authorities). There are two
well established normatives in global health governance that
instruct responsibilities of states within the domain of
healthcare delivery and public health protection. The two
normatives are: 1) health is a human right which must be
safeguarded by states and 2) safeguarding public health is an
essential element of preserving collective security in today’s
globalized community. Given these normatives, states are
responsible and expected to constantly protect population health
within their respective territorial jurisdictions; especially those
vulnerable to poor health and disease. Simultaneously, these
same states are expected to uphold internationally agreed-upon
regulations and standards of public health, like those outlined in
the International Health Regulations. Adherence to these
international regulations (IHR) requires that states acknowledge
and recognize the legitimacy of the external authority when
developing domestic policy; generally, in this process, some
elements of state sovereignty are inevitably are relinquished.
State sovereignty in this case, is extremely difficult to
capitulate and public health crises and outbreaks are not an
exception (Stevenson & Cooper, 2009).
Ultimately, the sovereign state is responsible and accountable to
both internal, as well as external constituencies, as we are all
interconnected living in a global community, where one thing
indubitably affects everything else. In the 2004 UN Secretary-
General’s High-level Panel on Threats, Challenges and Change
in their report entitled “A More Secure World – Our Shared
Responsibility”, “today, the notion of State sovereignty carries
with it the obligation, of a State to protect the welfare of its
own peoples and meet its obligations to the wider international

8. community.” In order to be a legitimate sovereignty, the state
must show responsibility with at a minimum of providing the
basic needs of its people (Etzioni, 2016). Ultimately,
community engagement is decisive tool/strategy in commanding
and controlling outbreaks, people understand, and own a
problem, they carve out their own socially and culturally
accepted solutions.
Lack of political will and lack of capacity are two major aspects
of national sovereignty. Will political leaders place collective
action as top priority item on their agenda and will they provide
ample funding to build IHR core capacities? The IHR 2005
framed the impact of security upon the global health agenda.
States could understand the security rationality behind the
implementation of IHR. International anxieties and concerns
about health security threats were influential in breaking the
sovereign deadlock. According to Davies et al., in the book, In
Disease Diplomacy, it was the “the crucial zeitgeist of the
securitization of infectious disease” and mobilization of a
security conversation that helped to persuade states that it was
in their best interest to take a cooperative posture. Also, it was
in the states’ best interest to institute mechanisms that would
foster both more transparency in disease reporting and a more
impactful and commensurate international response (Nunes,
2017).
The way society responds to health conditions (e.g., diseases
and risk factors) is based on the framework on national level, as
well as on the global level. Faced with set of health
situations/conditions, a nation/country articulates a response
through its national health system. The more robust, the system,
the more efficient and effective a health response is detected
and mounted. Ultimately and ideally, national governments
should be equipped to be responsible for larger-scale responses
sustainably on the foundation of existing community structures.
Due to globalization, cross-border health threats, leading to a
situation of health interdependence (notion that no nation,
entity or organization can singularly handle the potential health

9. threats, rather they must instead lean on others to some extent
to mount an effective response. This is the current and most
likely, the future reality. The organized social response to
health conditions at the global level is referred to as the global
health system (Frenk and Moon, 2013). At the national level,
there are traditional instruments in place for mobilizing action,
such as taxation, routine law enforcement, and democratic
decision-making and policy making procedures. The core of the
global health system is the national governments with their
national ministries, departments and agencies. National
governments coordinate their responses to common health
challenges through a multiple of mechanisms. Nations must
swiftly and effectively harness management of externalities to
prevent or mitigate negative health effects or decisions
originating in one country may affect another. Responses
involve the deployment of such instruments as surveillance
systems, coordination mechanisms, information-sharing
channels. These instruments are critical for controlling the
international transfer of risks and ensuring timely response to
threats which can spread across borders (e.g., pandemics,
environmental pollutants, drug resistance, etc.). The
management of externalities rests on the caliber of national
sovereignty and its accountability to respond to global health
crises, as well as other situations that would affect the global
community (Frenk and Moon, 2013).
The principle of state sovereignty is that it is the state
singularly decides on which actions and measures take place
within their respective territory. At times, there are areas of
conflict between national sovereignty and global health
security. For instance, according to the IHR (2005), a WHO
member state maintains clear points of contact and thus, they
must establish a “National IHR Focal Point”. These focal points
are responsible for reporting possible public health threat
directly to the WHO, as well as to their respective governments.
Once WHO receives this information from the National IHR
Focal Point about such a potential threat, WHO has discretion to

10. make such information public via a WHO-issued
recommendation. In essence, this action could impede the
state’s role of informing its citizens of any domestic health
issues. Member states may want to preserve national security, as
it may not be in the state’s best interest to have information
about a potential public health threat immediately being shared
to the public. Member states may need more time (than 24 hours
as mandated by IHR 2005) to muster and mobilize exigent
resources to prevent a possible escalation of a domestic health
threat (Mack, 2006). In addition, IHR 2005 requires each WHO
member state to have core capacities to “detect, assess, notify
and report events”. However, some member states do not have
the resources or capacity to implement such, sometimes drastic,
public health programs. It will be demanding task in terms of
financial and personnel resources. The implementation of such
programs requires certain domestic infrastructure to be in
existence along with necessary technological knowledge to
execute and maintain such a system. “Some nations are poor and
cannot afford sophisticated public health systems, whereas
others are failed states in the midst of civil strife, war, or
natural disaster” (Mack, 2006). In such developing regions, they
face a “double burden” as they are dealing with indigenous
diseases and illness originating from their struggles to emerge
from poverty. Such nations, certainly do not have the capacity
to increase their national capacity for monitoring and
surveillance of new, emerging health threats, which are required
by IHR 2005. This creates a “triple burden” for the less
developed member states. Some critics would argue that such a
surveillance requirement (IHR 2005) seems to intrude on a
state’s right to address and make decisions on the best ways to
monitor initial domestic threats. Another area of national
sovereignty which may be compromised by IHR 2005 is the
notification of outbreaks of infectious diseases to WHO. Often
health authorities are not able to completely understand the
scope and impact of newly emerging diseases, information
regarding potential public health threats will often more times

11. than not, be unpredictable. This unpredictability factor affects
the ability of domestic health authorities to appropriately
evaluate all the risks involved in the public health threat. Once
WHO public releases information regarding the occurrence of
the defined syndromes, those affected member states may run
the risk of serious economic and social harm even before any
actual disease has been definitely identified. WHO member
states can opt not to comply with regulations adopted by the
World Health Assembly, but typically do not due to negative
backlash. With the continuance of such compliance, as long as
it remains beneficial to the member state. The underlying factor
influencing any program’s success continues to be the
immediate economic benefits stemming from the state
compliance. (Mack, 2006). Noncompliance is an option that the
affected member state may select, however, it is not often times,
the most realistic option. In the case that the affected member
state declines collaboration with the international community,
the WHO may, “when justified by the magnitude of the public
health risk” communicate information regarding the public
health risk with other member states. No enforcement
mechanisms are outlined in the IHR (2005) provisions for
noncompliant state members. However, there are potential
ramifications of noncompliance, manifested in economic terms,
and serve as a compliance tool (Mack, 2006).
Although health continues to be primarily a national
responsibility, the intensified transfer of health risks across
boundaries signifies that the determinants of health and the
means and subsequently the means to fulfill those
responsibilities are typically beyond the control of any
individual state or nation, for that matter. As Genest observes
that “in a global epidemiological world, there is no place to
hide”. We live “in a unified microbial world in which there is
no place that can be out of reach of infections and pathologies”.
In a global and fluid world, global surveillance and intelligence
is viewed as the most effective means to control disease spread.
As we have moved beyond the national level for reliance on

12. health response and surveillance to that of a global health
surveillance, where there is an associative relationship between
health and security/risk issues. States sometimes have displayed
a strong incentive to hide epidemiological information and data
from the rest of the global community for “fear of the blame
and shame boomerang effect”. The development of
technologies with potential to be global in scope, the ongoing
mechanism of health surveillance evolved to a global
perspective via managerial practices, risk analysis, and security
preferences. A new mode of surveillance, systemic pre-
detection, rests on the collection, interpretation, dissemination
and acting on health information. This represents a fundamental
shift from traditional sovereign actors and actions (border
closure, national emergency plans, internal drug policy, etc.) to
a form of communicative and information-based power, no
longer the sole capability of the state or nation (Genest, 2015).
States are inclined to “stretch” their sovereignty with respect to
global health security and surveillance, so that they can have
access to information and resources. The cost of sovereignty
losses appears to be a tradeoff for better information into, and
about the global apparatus of information where they can tap
into the global space of diseases. Given the contemporary fluid
global community, “health systems must address the wide-
ranging effects of poverty, civil upheaval, cultural beliefs, and
other factors that undermine. Namely, the rights of sovereign
states and the need for global security, each country must be
able to detect potential outbreaks. Through appropriate and
judicious leveraging of the IHR, WHO is obliged to help
countries establish core capacities for early disease detection,
timely and transparent notification. A delicate balance exists
between preservation of national sovereignty and establishing
global security in a borderless world.
Whether priority should be given to prevention or treatment.
Numerous challenges face clinical trials taking place in
outbreak situations. In this scenario, decision on whether
priority should be given to prevention or treatment is crucial. In

13. developing the guidelines for WHO coordinated response, it is
recommended that priority be given to treatment for various
reasons.
First, since the discovery is new, there may be a number of
unknowns regarding vaccination. For example, the durability
and rapidity of immune responses is unknown. Rapidity of an
immune response is important because it determines the relative
effectiveness of the vaccine in the context of ring vaccination.
Ring vaccination strategy has been shown to be effective in
preventing new cases and limiting the spread of infectious
diseases. Therefore before prioritizing TropicX as vaccine,
more research is needed in the area of efficacy and
immunogenicity.
Another unknown regarding TropicX as a vaccine relates to
adverse events. Although few serious vaccine-related adverse
events have been observed, additional large-scale trials need to
determine the overall safety of new vaccines (Levy et al, 2018).
For example, one of the Ebola vaccine (rVSV-ZEBOV) has been
shown to be a risk factor in the development of arthritis to
females who have a medical history of arthritis (Levy et al,
2018).
As such, there may also be challenges in administering the
vaccine. In an outbreak context, it may be easily interpreted the
vulnerable group, children and pregnant women, receive every
possible protection from the disease. But since these two groups
are seen as particularly vulnerable, they should not be placed on
the “front line” of interventions that have yet to be fully tested.
Therefore excluding them from the vaccines may raise ethical
concerns.
The final unknown relates to community engagement and
ongoing trust-building throughout the vaccine process which are
crucial. Distrust towards vaccines might exist in the population
and negatively affect cooperation with the vaccine
administration or even lead to suspension, as occurred in Ghana,
where two Ebola vaccine trials were suspended because of
negative rumours ( Kummervold et al, 2017).

14. In addition, the affected population may also not accept the
vaccines particularly when the research is led by foreign
institutions or personnels. For example, the current outbreak of
Ebola in DRC, ring vaccination of those who fall ill and their
contacts has not succeeded in limiting the spread of the virus
because there is mistrust of the vaccine (www.theguardian.com,
2019). Some people falsely believe that Ebola vaccine is what is
making people sick (www.theguardian.com, 2019). Hence there
maybe confusion and mistrust since the vaccine is new.
Finally, since the supply of TropicX is limited, managing the
demand for vaccine intervention will be challenging. Limited
supply of the vaccine means denying somebody the right to an
intervention which might be effective. This may raise questions
especially in this situation where the case fatality rate from the
disease is high.
Thus, priority should be given to treatment because it provides
the greatest possible benefit for participants under imminent
threat of the disease. Treatment also provides optimal care to
patients already suffering the disease. To wrap it up, in absence
of approved vaccines, control of the epidemic should rely on
treatment or on nonpharmaceutical interventions such as quick
identification and isolation of cases.
How to address misconceptions and opposition
We saw in the H1N1 pandemic review how the WHO was
exposed as underperforming in their leadership role.
Thus far, 40% of persons affected by the new hemorrhagic fever
at tropical resorts have died. This suggests we are very
possibly entering another disastrous season of disappointing
unpreparedness.
Clearly, world opinion concurred earlier, and as we are now
seeing: WHO desperately needs reconfiguration. It needs to fine
tune practices leading to global health safety, security, and
sustained ethical global health equity
The WHO thought processes--‘one size fits all’ is an illusion.
The complexities of regional differences and the unique needs
of populations are real considerations. Insufficient standardized

15. surveillances and responsive follow through, along with dwarf
financial allocations, all contribute to negatively impacting
sought after total health care. Mismanagement of investor
funding coupled with indifference towards poverty driven
states, do little to distribute needed health relief. Well-intended
investor funding does not reach deeply into the abyss of
impoverished people.
But perhaps equally if not, more damaging is the failure of
WHO to attend to and build upon establishing confidences
among all stakeholders regardless of the country’s economic
status. The intrinsic deep care for the poorest and most
vulnerable impoverished nation communities is often
marginalized. Apparently, WHO’s preoccupation with catering
to the pharmaceutical industry can prove more lucrative an
attraction and desired goal than prerequisite universal ethical
standards on global equity matters—despite initial goodwill
intentions under IHR (2005)
We can intensify discussions on systemized surveillance
protocols, reporting and assessment enhancements, and enforced
restrictions on trade/travel in order to curb transmissions. We
can apply excuse for insufficient availability of TropicX. But
how do we deal with social media distortions and the
transformation of wealthier nations getting on board with
committing financially—to embrace the fullness of ethical,
global health equity? How do we address misconceptions and
opposition reported and the recurring responses bombarding
social media which highlight WHO’s oversight and failures, and
the distrust of a growing majority—particularly among
impoverished nations—when distortions erupt and the status
quo is boldly challenged?
Once again, the WHO is caught off guard as with the H1N1
pandemic. Disclosures revealed the failure of Big Pharma
Industries (BPI) to manufacture sufficient quantities of TropicX
medication; 40% of persons affected with the hemorrhagic fever
attack have died. Given the rapid advancement of this eruption,
studied preparedness protocol responses and hoped-for positive

16. outcomes are not forthcoming. And the outcomes have not gone
unnoticed.
Full transparency and honesty, as well as utilization of
accessible communication tools are core expectations
worldwide, if global cooperation is truly the end goal. The
impact of social media cannot be trivialized. It is the one place
where given access, all voices can be heard, privately assessed,
then rapidly thrown into center ring across the entire world—in
opposition, compliance, and everything in between.
Though the ‘voice’ of social media can be a dominant
influencer, national law and the nation’s constitutional
constructs on information flow and governing processes is the
rule of law. If censorship is the central agenda legislatively, and
in the absence of the people’s trust in home government and
donor-driven priorities, unbridled suspicions easily gain
opportunity.
To move into the zone of increased trust, the WHO will need to
engage the people at the planning and development table as
primary stakeholders, and include deliberate representation of
low to middle income nations. Collectively, populations must
see defined, measurable increases in the following areas:
· Early warning and consistent broad-base access to quality
medical treatment and health care practices.
· Regarding the ‘human research enterprise’: Clarification on
informed consent when channeled into a research study;
uncovering its true purpose, along with a guarantee of full
continuing post study support for all participants.
· Guarantee of benefitting from successful research study
outcomes for participants and their home community--foremost
· Provision of sufficient quantity of dedicated, trained
healthcare workers and physicians to care for affected persons,
their families and communities, proportionately
· Expanded quantity of access to laboratories and dependable
commitment to relay lab outcomes rapidly and in full
description of findings, cautions, etc.
· Planned support to protect the health and well-being of field

17. health providers; elimination of syphoning their country’s
health care workers off to wealthier nations via incentives and
facilitated emigrant privileges
· A visible and consistent presence of compassionate
government locals working cooperatively with village leaders,
educating, and maintaining respect for religious and social
lifeways—values and traditions
· Providing clear evidence and full explanation of the country’s
envisioned universal health plan; validating the role each person
has in moving it towards success; getting the message out
consistently via widely broadcasts frequently, across all
available channels of communication
· Removing threats of paternalism or suggesting a hidden
agenda that would subjugate or water down the rights of persons
to coexist healthily and function productively in their own
homeland
· Deriving at ethical decisions systematically: (e.g. provision
of priority access to antiretroviral drugs; attentiveness to
acknowledging the need/practice of applying different
frameworks—despite the surface appearance of similarities—so
that specific cultural/regional needs can be met in a timely
fashion)
· Gender equity practices: i.e. delivery of needed, quality
services and treatments to women and children in order to
sustain continuance and safekeeping of the culture and
community
· Commitment to schedule stakeholder committees to frequently
reconvene, review, make corrections, share relevant new
information, any concerns, conflicts and/or solutions
· Institute a media blitz or social media platform that gets to the
heart of rapidly correcting misconceptions in an effort to offset
opposition and open conflict
· Assistance with strengthening borders surveillances; more
efficiency among donor providers and smooth coordination of
mutual donor-driven priorities
· Securing pledges from wealthier nations to forge ahead with

18. the political will and accompanying resources they are willing
to set in place to ‘help level the playing field’
· Work synergistically to greatly reduce the drain low resource
nations experience when trying to take on complex demands of
diverse international partners, causing fragmented assistance, in
the long run
Guaranteed adherence to pre-agreed criteria and execution of all
things promised.
References
https://journals.plos.org/plosmedicine/article?id=10.1371/journa
l.pmed.1001022
https://www.cdc.gov/globalhealth/healthprotection/ghs/ihr/index
.html
https://www.who.int/ihr/about/10things/en/
Etzion, Amitai (2016 Spring). Defining Down Sovereignty: The
Rights and Responsibilities of Nations. Ethics and International
Affairs, 30(1), 5-20.
DOI: https://doi.org/10.1017/S0892679415000544
Forum on Microbial Threats; Board on Global Health; Institute
of Medicine; National Academies of Sciences, Engineering, and
Medicine. Global Health Risk Framework: Governance for
Global Health: Workshop Summary. Washington (DC): National
Academies Press (US); 2016 May 11. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK349074/ doi:
10.17226/21854.
Frenk, Julio and Moon, Suerie (2013). Governance Challenges
in Global Health. New England Journal of Medicine. 368, 936-

19. 942. DOI: 10.1056/NEJMra1109339.
Genest, Gabriel Blouin (2015). The Politics of Global Health
Security: Problemetizing a Social Evidence. GLOCALISM:
JOURNAL OF CULTURE, POLITICS AND INNOVATION, 3.
DOI: 10.12893/gjcpi.2015.3.3
Nunes, Joao (2017 September). Disease Diplomacy:
International Norms and Global Health Security by Sara E.
Davies, Adam Kamradt-Scott, and Simon Rushton. he Rights
and Responsibilities of Nations. Ethics and International
Affairs. Retrieved from
https://www.ethicsandinternationalaffairs.org/2017/disease-
diplomacy-international-norms/
Mack, Eric (2006). The World Health Organization's New
International Health Regulations: Incursion on State
Sovereignty and Ill-Fated Response to Global Health Issue.
Chicago Journal of International Law, 7(1), 365-377.
Stevenson, Michael A. and Cooper, Andrew F (2009).
Overcoming Constraints of State Sovereignty: global health
governance in Asia. Third World Quarterly, 30(7), 1379-1394.
https://doi.org/10.1080/01436590903152686
The guardian, 2019. DRC Ebola epidemic is international
emergency, says WHO
https://www.theguardian.com/world/2019/jul/17/drc-ebola-
epidemic-is-international-emergency-says-who
Kummervold PE Schulz WS Smout E Fernandez-Luque L
Larson HJ Controversial Ebola vaccine trials in Ghana: a
thematic analysis of critiques and rebuttals in digital news.
BMC Public Health. 2017; 17: 642
Lévy Y, Lane C, Piot P, Beavogui AH, Kieh M, Leigh B, et al.
Prevention of Ebola virus disease through vaccination: where
we are in 2018. Lancet (London, England). Elsevier; 2018;392:
787–790. pmid:30104048
Guide to infection control in the healthcare setting – Hospital
acquired infections. Retrieved from isid.org/guide/hospital/.
n.d.

20. Global Health Surveillance - Supplements July 27, 2012 /
61(03);15-19
St. Louis, Michael –Center for Global Health, CDC
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https://www.cdc.gov/mmwr/preview/mmwrhtml/su6103a4.htm
(April 2014) WHO guidelines - Infection prevention and control
of epidemic and pandemic prone acute respiratory infection in
health care
Retrieved from:
https://www.who.int/csr/bioriskreduction/infection_control/publ
ication/en/
Simulation in STATA
Starting with a blank STATA session, you can set the number of
observations and declare the file to be a time series as follows.
If you want to create a file with 100 observations, use the
commands:
.set obs 100
.gen t=_n
.tsset t
Before generating random numbers you can set the “seed” for
the random number generator. The command takes the form
.set seed 149834500
where in this example the “seed” is the number . If you don’t
specify a seed the default is 123456789 when Stata is started
up.
To simulate a Gaussian white noise process use the command
.gen e=rnormal()
This generates a variable “e” filled with random normal N(0,1)
shocks.
To create a moving average process �' = �' + 0.3�'45, use the
command
.gen y=e+0.3*L.e

21. This takes the variable “e” previously defined, creates the
lagged value and creates a moving average process with
coefficient 0.3.
To create the autoregressive process �' = 0.5�'45 + �' with y1
= 0, use the following two- command sequence:
.gen y=0
.replace y=0.5*L.y+e if t>1
where “e” and “t” are as previously defined.
Simulation in STATA
Starting with a blank STATA session, you can set the number of
observations and declare the file to be a time series as follows.
If you want to create a file with 100 observations, use the
commands:
.set obs 100
.gen t=_n
.tsset t
Before generating random numbers you can set the “seed” for
the random number generator. The command takes the form
.set seed 149834500
where in this example the “seed” is the number . If you don’t
specify a seed the default is 123456789 when Stata is started
up.
To simulate a Gaussian white noise process use the command
.gen e=rnormal()
This generates a variable “e” filled with random normal N(0,1)
shocks.
To create a moving average process �' = �' + 0.3�'45, use the
command
.gen y=e+0.3*L.e
This takes the variable “e” previously defined, creates the
lagged value and creates a moving average process with
coefficient 0.3.
To create the autoregressive process �' = 0.5�'45 + �' with y1
= 0, use the following two- command sequence:

22. .gen y=0
.replace y=0.5*L.y+e if t>1
where “e” and “t” are as previously defined.
Economics 202
Homework #2
Due: October 7, 2019
1. Find the September 2019 “Employment Situation”
released by the Bureau of Labor
Statistics on October 3. What are the seasonally
adjusted numbers of unemployed
for August and September 2019? What are
the seasonally unadjusted numbers of
unemployed for the same months? Briefly discuss
the magnitude of the seasonal
adjustment.
2. Consider the model
�" = �% + �'����" + ,�.�." + �"
0
.1'
With estimates
�2% =0.2

23. �2'=0.01
�3'=0.5
�34 =0.8
�30 =0.2
The time index at the end of the sample is
Timen = n = 200, and the final observation
is the
second quarter of 2019. What are your point
forecasts for the third and fourth quarters of
2019?
3. The following FRED codes are for monthly
US unemployment rates, 1948m1
through 2019m8, not seasonally adjusted, for people
aged 20 and over.Men:
LNU04000025 Women: LNU04000026. Fit simple
seasonal dummy models for
the two series. Plot fitted values for one year.
These fitted values are estimated
seasonal patterns. Is the seasonality the same for
men and women, or different?
What is different?
4. Rewrite the following expressions without using
the lag operator.
a. (1 − ��)�" = �"

24. b. (1 + 0.2� − 0.8�4)�" = �"
c. �" = (1 − ��)�"
d. �" = (1 − 0.3� + 0.5�4)�"
5. Rewrite the following expressions in lag
operator form.
a. �" = 0.8�"B' + �"
b. �" = 0.2�"B' + 0.3�"B4 − 0.7�"BD + �"
6. Consider the MA(1) process �" = 2.3 − 0.95�"B' +
�"
a. What is the optimal forecast for time periods
T+1, T+2, and T+3. Write
your answer as a function of �',�4,�0,…�H
IJK
LM
�',�4,…�H
b. Now suppose that eT = 0.4 and eT-1 = -1.2.
Re-answer part (a).
7. The FRED codes for housing starts in
the Midwest are HOUSTMW and
HOUSTMWNSA (seasonally adjusted and not
seasonally adjusted, respectively).
For the South they are HOUSTS and HOUSTSNSA.
Graph the autocorrelation
functions for thesefour series. Comment and discuss.
8. Use the real GDP growth data from FRED code
A191RL1Q225SBEA. Run an
AR(1) regressionon thesedata (with constant).
Save the residuals from that
regression(predict e, residuals). Graph the

25. time series of the residuals. Graph
the autocorrelation function of the residuals.
Comment and discuss.
9. Using the simulation instructions at the end of
the homework, simulate T=100
observations from each of the four models below.
For each series, graph the
autocorrelation function, and estimate an MA(2) model.
Comment and discuss.
For estimation, use the command (where y is
the name of the variable that you
created): arima y arima(0,0,2)
a. yt = et (white noise)
b. yt = et + 0.8et-1
c. yt = et – 0.6et-1 + 0.4et-2
d. yt = 0.5yt-1 - et
The Applicability of the IHR;
With the signing of the revised International Health Regulations
(IHR) in 2005, the international community agreed to improve
the detection and reporting of potential public health
emergencies worldwide. IHR (2005) better addresses today’s
global health security concerns and are a critical part of
protecting global health. The regulations require that all
countries have the ability to detect, assess, report and respond
to public health events.
In response to the exponential increase in international travel
and trade, and emergence and reemergence of international
disease threats and other health risks, 196 countries across the
globe agreed to implement the International Health Regulations

26. (2005) (IHR). This binding instrument of international law
entered into force on 15 June 2007.
The stated purpose and scope of the IHR are; "to prevent,
protect against, control and provide a public health response to
the international spread of disease in ways that are
commensurate with and restricted to public health risks, and
which avoid unnecessary interference with international traffic
and trade." Because the IHR are not limited to specific diseases,
but are applicable to health risks, irrespective of their origin or
source, they will follow the evolution of diseases and the
factors affecting their emergence and transmission. The IHR
also require States to strengthen core surveillance and response
capacities at the primary, intermediate and national level, as
well as at designated international ports, airports and ground
crossings.
The International Health Regulations (IHR), a legally binding
agreement between 196 States Parties, whose aim is to prevent,
protect against, control, and provide a public health response to
the international spread of disease, deserve critical examination
with regard to their applicability. The emergence and spread of
the new mysterious hemorrhagic fever may constitute a public
health emergency of international concern (PHEIC) and is
therefore notifiable to the World Health Organization under the
IHR notification requirement.
IHR (2005) is coordinated by the World Health Organization
(WHO) and aims to keep the world informed about public health
risks and events. As an international treaty, the IHR (2005) is
legally binding; all countries must report events of international
public health importance. Countries reference IHR (2005) to
determine how to prevent and control global health threats
while keeping international travel and trade as open as possible.
IHR (2005) requires that all countries have the ability to do the
following:
· Detect: Make sure surveillance systems and laboratories can
detect potential threats
· Assess: Work together with other countries to make decisions

27. in public health emergencies
· Report: Report specific diseases, plus any potential
international public health emergencies, through participation in
a network of National Focal Points
· Respond: Respond to public health events
IHR (2005) also includes specific measures countries can take
at ports, airports and ground crossings to limit the spread of
health risks to neighboring countries, and to prevent
unwarranted travel and trade restrictions.
One of the most important aspects of IHR (2005) is the
requirement that countries detect and report events that may
constitute a potential public health emergency of international
concern (PHEIC) for this matter we are referring to the
hemorrhagic fever.
Under IHR (2005), a PHEIC is declared by the World Health
Organization if the situation meets 2 of 4 criteria:
· Is the public health impact of the event serious?
· Is the event unusual or unexpected?
· Is there a significant risk of international spread?
· Is there a significant risk of international travel or trade
restrictions?
So as soon as the fever was identified in the tropical resorts as
an event of concern, there must be an assessment of the public
health risks of the event within 48 hours. If the event is
determined to be notifiable under the IHR, this must be reported
to WHO within 24 hours.
The example case of the mysterious hemorrhagic fever is highly
applicaple to be a notifiable disease under IHR. The mentioned
case appears to hit the tropical resort which is mostly visited by
tourists thus making the disease a public health concern. The
tourists might easily spread the disease all over the globe. This
needs to be reported and ensure that all necessary measures to
detect it early, manage and contain it within the area of disease
eruption.
As noted, the number of tourists has decreased and
economically this has an impact to the affected country. This in

28. some cases might pose hesitation to report among the affected
state fearing that it might scare the tourists and hence impact
the member state economically. However, the risk of spread
outweighs the economic risks. If the disease is not reported,
other member states might fail to support. As it is mentioned as
the scope of IHR "to prevent, protect against, control and
provide a public health response to the international spread of
disease in ways that are commensurate with and restricted to
public health risks, and which avoid unnecessary interference
with international traffic and trade."
Some diseases always require reporting under the IHR, no
matter when or where they occur, while others become
notifiable when they represent an unusual risk or situation.
The world threat posed by the spread of hemorrhagic fever
cannot be addressed by individual countries alone, but requires
a coordinated international response. Recognizing the
applicability of the IHR to this outbreak will serve as a “wake-
up call” and strengthen global surveillance and response, which
could in turn contribute to containing the spread of the fever.
Notifications of events should serve as alerts and can be an
important instrument in the chain of “the global early warning
function, the purpose of which is to provide international
support to affected countries and information to other countries
if needed”. The immediate consequence of notification is to
initiate an “exclusive dialogue between the notifying State Party
and WHO concerning the event at issue” and to make a joint
risk assessment. The dissemination of information through the
WHO Event Information System (EIS) could expediently
increase awareness in multiple countries, allow early
implementation of screening measures for persons at risk (e.g.,
international hospital transfers), and prevent the establishment
of new strains in unaffected countries. IHR can also facilitate
the international dissemination of appropriate measures to
counter the spread of hemorrhagic fever.
Importantly, the IHR focuses on a societal investment in core
surveillance and response capacities at different levels by

29. setting minimum standards. WHO pledges to collaborate with
the States Parties concerned “by providing technical guidance
and assistance and by assessing the effectiveness of the control
measure in place, including the mobilization of international
teams of experts for on-site assistance when necessary”.
Applying the outbreak of hemorrhagic fever to IHR may face
obstacles as well, for instance: Even if WHO and a majority of
States Parties consider that the fever should be addressed under
the IHR, technical, financial, and political obstacles might
interfere. Notification of an event to WHO depends on it being
detected (requiring a functioning health system and adequate
laboratory capacities), and reported to the National IHR Focal
Point. There is a concern that many States Parties are far from
being compliant with the IHR's minimum core capacity
requirements for surveillance and response. Even if relevant
information filters through to the national level, notification
decisions may be under political control which in many cases
cannot be interfered with.
The IHR framework provides a global surveillance
infrastructure and orchestrates an appropriate public health
response. The IHR are ultimately “owned” by the States Parties,
some of whom increasingly understand the extent and urgency
of the threats posed by emerging disease outbreaks. However, it
is up to WHO to provide leadership on the role of the IHR.
References;
https://journals.plos.org/plosmedicine/article?id=10.1371/journa
l.pmed.1001022
https://www.cdc.gov/globalhealth/healthprotection/ghs/ihr/index
.html
https://www.who.int/ihr/about/10things/en/
4. Whether priority should be given to prevention or treatment.

30. Numerous challenges face clinical trials taking place in
outbreak situations. In this scenario, decision on whether
priority should be given to prevention or treatment is crucial. In
developing the guidelines for WHO coordinated response, it is
recommended that priority be given to treatment for various
reasons.
First, since the discovery is new, there may be a number of
unknowns regarding vaccination. For example, the durability
and rapidity of immune responses is unknown. Rapidity of an
immune response is important because it determines the relative
effectiveness of the vaccine in the context of ring vaccination.
Ring vaccination strategy has been shown to be effective in
preventing new cases and limiting the spread of infectious
diseases. Therefore before prioritizing TropicX as vaccine,
more research is needed in the area of efficacy and
immunogenicity.
Another unknown regarding TropicX as a vaccine relates to
adverse events. Although few serious vaccine-related adverse
events have been observed, additional large-scale trials need to
determine the overall safety of new vaccines (Levy et al, 2018).
For example, one of the Ebola vaccine (rVSV-ZEBOV) has been
shown to be a risk factor in the development of arthritis to
females who have a medical history of arthritis (Levy et al,
2018).
As such, there may also be challenges in administering the
vaccine. In an outbreak context, it may be easily interpreted the
vulnerable group, children and pregnant women, receive every
possible protection from the disease. But since these two groups
are seen as particularly vulnerable, they should not be placed on
the “front line” of interventions that have yet to be fully tested.
Therefore excluding them from the vaccines may raise ethical
concerns.
The final unknown relates to community engagement and
ongoing trust-building throughout the vaccine process which are

31. crucial. Distrust towards vaccines might exist in the population
and negatively affect cooperation with the vaccine
administration or even lead to suspension, as occurred in Ghana,
where two Ebola vaccine trials were suspended because of
negative rumours ( Kummervold et al, 2017).
In addition, the affected population may also not accept the
vaccines particularly when the research is led by foreign
institutions or personnels. For example, the current outbreak of
Ebola in DRC, ring vaccination of those who fall ill and their
contacts has not succeeded in limiting the spread of the virus
because there is mistrust of the vaccine (www.theguardian.com,
2019). Some people falsely believe that Ebola vaccine is what is
making people sick (www.theguardian.com, 2019). Hence there
maybe confusion and mistrust since the vaccine is new.
Finally, since the supply of TropicX is limited, managing the
demand for vaccine intervention will be challenging. Limited
supply of the vaccine means denying somebody the right to an
intervention which might be effective. This may raise questions
especially in this situation where the case fatality rate from the
disease is high.
Thus, priority should be given to treatment because it provides
the greatest possible benefit for participants under imminent
threat of the disease. Treatment also provides optimal care to
patients already suffering the disease. To wrap it up, in absence
of approved vaccines, control of the epidemic should rely on
treatment or on nonpharmaceutical interventions such as quick
identification and isolation of cases.
Reference
The guardian, 2019. DRC Ebola epidemic is international
emergency, says WHO
https://www.theguardian.com/world/2019/jul/17/drc-ebola-
epidemic-is-international-emergency-says-who

32. Kummervold PE Schulz WS Smout E Fernandez-Luque L
Larson HJ Controversial Ebola vaccine trials in Ghana: a
thematic analysis of critiques and rebuttals in digital news.
BMC Public Health. 2017; 17: 642
Lévy Y, Lane C, Piot P, Beavogui AH, Kieh M, Leigh B, et al.
Prevention of Ebola virus disease through vaccination: where
we are in 2018. Lancet (London, England). Elsevier; 2018;392:
787–790. pmid:30104048
A mysterious new hemorrhagic fever has begun to appear at
tropical resorts around the world. It is fatal to approximately
40% of those who contract the disease. This has resulted in a
significant decrease in tourist travel and some embargos on
fruits and vegetables.
A pharmaceutical company called BigPharma Industries (BI)
has discovered that one of its orphan drugs, TropicX, is
effective as both a vaccine and as treatment. Unfortunately, BI
can only produce enough TropicX for 20% of the affected
population.
To complicate matters, social media has begun carrying stories
that TropicX is part of a plot to reassert colonialism around the
globe.
You have been invited to join a panel of experts to develop
guidelines for a WHO coordinated response. As a group,
prepare a 10-12 page paper describing:
1. The applicability of the IHR.
2. The role of national sovereignty in mounting a global
response.
3. Whether priority should be given to prevention or treatment.
4. How to address misconceptions and opposition.