This article has been written by Sneha Jaiswal, pursuing BA LLB (Hons.) from CHRIST (Deemed to be University), Delhi NCR. This article helps to understand the international law, infectious disease strategies, the governance framework, the principles to control the spread of infectious disease, and the consequences of it in case of failure. It also justifies the current pandemic and international health regulations.
The outbreak of a new infectious disease which is Coronavirus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread to many countries and beyond raises many public health and policy questions and challenges for governments, international organizations, and non-governmental organizations. The SARS outbreak also implicates international law and the efforts to combat the spread of the disease.
Communicable diseases have reshaped the boundaries of global health administration through legally restrictive and delicate legal systems established and embraced within the framework of multilateral institutions such as the World Health Organization, the Food and Agriculture Organization, the World Trade Organization, etc. The globalization of public health has utilized international law as a fundamental apparatus in global health governance pointed at diminishing human vulnerability to the mortality and morbidity burdens of communicable diseases.
International law, infectious disease strategies, and the governance frameworks – an overview
Globalization creates difficulties for infectious disease policy nationally as well as internationally. These difficulties are numerous and different, however theoretically, they can be classified as horizontal and vertical health challenges. Horizontal challenges constitute the public health problems that emerge from increased cross-border microbial traffic, brought about by the speed and volume of worldwide exchange and travel. The worldwide movement of populations and products forces countries to confront increased dangers from the cross-line transmission of pathogenic microbes. The horizontal challenges are, hence, strategy challenges among numerous states. Expanded cross-border microbial traffic through globalization unveils shortcomings in domestic public health systems, such as insufficient surveillance capacities. The vertical challenges address the issues that nations face inside their domains, from the national to the regional level. Vertical challenges responses aim to reform public health practices and strategies inside a state but not between states.
The effect of globalization on infectious disease shows that states can’t deal with the two strategies namely horizontal or vertical strategies sufficiently without cooperation. Against cross-border pathogen traffic, unilateral state efforts can have only a limited effect when the source of the issue is beyond the jurisdiction and sovereignty of the affected state. Likewise, many countries, particularly developing countries, want help from other countries or states and international organizations to improve domestic public health. Methods to facilitate international cooperation, like international law, are significant to public wellbeing responses to globalization’s effects on infectious disease prevention and control.
International law establishes the body of binding rules that oversee the relations between sovereign states. The body of international human rights law demonstrates that international law rule applies to non-state actors as well which include organizations or individuals that are not directed by, affiliated with, or funded through the government. But the bulk of contemporary international law still manages the intercourse between sovereign states. International law shows different capacities to function within the contexts of both vertical as well as horizontal public health strategies on infectious diseases and the three-governance structure.
Vertical and horizontal strategies for infectious disease control
Strategies to control infectious diseases are classified into two different categories: horizontal strategy and vertical strategy. The general approaches to prevent the spread of healthcare-associated prevention have taken two conceptually different approaches:
The general ways to deal with contamination of infectious disease control have taken two theoretical different paths. In the first place, the vertical strategy aims to decrease infection, colonization, and transmission of explicit pathogens, to a great extent use of active surveillance testing (AST) to distinguish carriers, followed by execution of measures aimed at preventing transmission from carriers to other patients. And, secondly, the horizontal approach aims to decrease the risk of infections because of a wide cluster of pathogens through the execution of standardized practices that don’t rely upon patient-specific conditions.
Horizontal strategies are applied universally, the population-based approach targets all pathogens that are transmitted via the same mechanism. A horizontal strategy aims at the prevention of infection and control measures refers to a broad-based approach that attempts to reduce all infections due to all pathogens. The horizontal approach aims to get rid of all infections and is population-based. When it comes to application, the horizontal approach is generally universal. In terms of resource utilization, the horizontal approach is usually less efficient, and more utilitarian. This approach allows healthcare facilities to focus on approaches that target all rather than selected organisms in the absence of an organism-specific epidemic. Horizontal strategies include hand hygiene, selective digestive tract decolonization, antimicrobial stewardship, universal decolonization, and environmental cleaning.
Vertical strategies focus on individual pathogens that are considered to be significant and include high resource usage and expenses. A vertical approach refers to a narrow-based program targeting a single pathogen. Generally, the goal of a vertical strategy is to decrease infection or colonization due to specific pathogens. This approach is universal and selective. In terms of resource utilization, the vertical approach is commonly high in addition, a vertical program advances exceptionalism.
Governance responses to the challenges of globalization
The difficulties globalization presents for infectious disease policy demand governance responses. For the horizontal challenges given by cross-line microbial traffic, the governance response focuses on building interstate cooperation to limit infection exportation and importation. The vertical challenges of insufficient public health systems inside states require strategies that look to diminish the infectious disease prevalence within states through the improvement of domestic public health performance. The development of vertical and horizontal strategies on infectious diseases constitutes the fundamental objective of public health governance in the time of globalization, governance responses to globalization challenges come in three essential forms that are interdependent.
The three frameworks of governance
The state and its administration establish the key actor in public health governance for infectious diseases. Public health is a “public good,” the production of which falls to the public sector because private actors lack sufficient incentives or resources to do what is necessary to protect population health. When globalization forces a state, its governance response can happen within three distinctive governance classifications: national, international, and global.
National governance addresses the endeavour a state takes within its own domain and under its own laws to react to globalization-related concerns. International governance implies that states which are engaged in worldwide collaboration among themselves face globalization challenges. International governance often includes the making of norms, rules, and institutions to facilitate interstate participation. Global governance includes not only states and international institutions but also non-state actors which include organizations or individuals that are not directed by, affiliated with, or funded through the government, such as multinational corporations (MNCs), international non-governmental organizations (NGOs). NGOs and MNCs administer governance roles in light of the fact that their cooperation and information become necessary to the success of the overall undertaking. Global governance efforts influence the mechanism of both national and international governance.
Impact of horizontal versus vertical safety programs in infection control
A vertical strategy favours the hospital whereas the horizontal strategy favours the patient, and both strategies differ in terms of time expected to get results. A vertical strategy is a short-term approach whereas a horizontal strategy is designed both for the present and for the long-term. Finally, the strategies diverge in terms of interventions; vertical strategy encompasses active surveillance and vaccination of healthcare workers, whereas horizontal strategy embraces hand hygiene, care bundles, and exercises that reduce presenteeism among healthcare workers. Vertical strategies are expensive and their effect is short-lived. Horizontal strategies are cost-effective and utilitarian.
The horizontal challenges are, subsequently, challenges among various states. Increased cross-border microbial traffic through globalization reflects shortcomings in domestic public health systems, like inadequate surveillance capabilities. The vertical challenges address the issues that nations face inside their domain, from the national level to the local level. Responses to vertical challenges aim, therefore, to change public health practices and approaches within a state, however not between states. A key concern with the arrangement of active detection strategies is the resource costs related to these programs; money and time dedicated to these programs come at a cost to other infection control initiatives that frequently show a noteworthy effect.
Principles need to adhere for effective infection control
Standard precautions are a set of infection control practices that are used to prevent the transmission of diseases that can be caused by contact with blood, non-intact skin, body fluids, and mucous membranes. Standard precautions are the basic infection prevention practices that apply to all patients, regardless of whether they are suspected or proven of having an infection, in any setting where medical services are conveyed. These practices are intended to safeguard the spread of infections among patients. Standard precautions include:
- hand hygiene,
- use of personal protective equipment like gloves, masks, eyewear, etc,
- respiratory hygiene/cough etiquette,
- safe handling of needles and other sharps devices, safe injection practices,
- sterilization of instruments and devices,
- clean and disinfected environmental surfaces, and
- proper waste disposal.
Consequences of ignoring the principles of safety programs in infection control
Failure to apply infection control measures favours the spread of pathogens. Healthcare settings can act as amplifiers of disease during outbreaks, with an impact on ‘both’, hospital and community wellbeing. Infection control fundamentals deal with the expenses of care, keeps away from the insight that a product or device is a substitute for the infection control fundamentals (e.g., hand hygiene, housekeeping, device maintenance), and helps to maintain or improve patient safety.
Focusing time and resources on ineffective or marginally effective vertical programs may restrict the overall effect of a hospital’s horizontal strategy. The costs for vertical strategy appear to be substantial with their effect contrasted with horizontal strategy. Thus, resources expended on them have to be based on excellent data showing great value for the additional intervention. In particular, failure to institute a horizontal strategy will significantly adverse results on the total infection rates.
The current pandemic and International Health Regulations (IHR)
The link between handwashing and the spread of disease was established many centuries ago and until relatively, infection control was managed through the administration of antibiotics and the endeavours of infection control nurses who generally consider infection as an unavoidable issue related to an older and sicker populace.
On December 31, 2019, the coronavirus outbreak came to light when the People’s Republic of China informed the World Health Organisation regarding a group of cases of pneumonia with an obscure reason in the city of Wuhan in Hubei Province. Hence, the disease spread to more Provinces in China, and to the rest of the world. The WHO has now announced it as a pandemic. The virus has been named SARS-CoV-2 and the disease is now referred to as COVID-19. The COVID-19 pandemic has prompted a dramatic loss of human life worldwide and presents an unprecedented challenge to general wellbeing, food frameworks, and the workplace. The monetary and social disruption caused by the pandemic is highly destructive.
The emergence of life-threatening infections such as severe acute respiratory syndrome (SARS) and viral hemorrhagic fevers highlight the urgent need for efficient infection control practices in health care. If outbreaks hit health care settings without a culture of safe practices, the risk of disruption to the health care system can be high. The implementation of the International Health Regulations (2005) is essential for protection against the international spread of disease. Fast response to infectious threats of public health concern requires early caution. Health-care settings are in the front-line of containment and response strategies, and the hospital-based and public health surveillance systems must be formally and efficiently linked to assure such early notification.
International Health Regulations – protecting everyday life
In 1951, the World Health Organization adopted the International Sanitary Regulations, the outcome of the nineteenth-century international sanitary conferences, which were renamed the International Health Regulations (IHR) in 1969, and further modified in 1973 and 1981. The International Health Regulation is a legitimately restricting arrangement of guidelines embraced under the support of WHO as a worldwide organization, and one of the earliest multilateral administrative systems stringently focusing on worldwide surveillance for communicable diseases.
The IHR is a tool of international law that is legitimately binding on 196 nations, including the 194 WHO member states. The IHR outgrew the reaction to deadly epidemics. They set rights and obligations for nations regarding the necessity to notify public health issues. The regulation also focuses on the criteria to decide if a specific occasion comprises a “public health emergency of international concern”. After that, WHO communicates the data to all the other member states as part of its order on control and reaction to the worldwide outbreaks and spread of infectious diseases.
Simultaneously, the IHR requires nations to assign a National IHR Focal Point for interchanges with WHO, to establish and maintain core capacities with regards to observation and reaction, including assigned points of entry. Extra arrangements address the spaces of international travel and transport, for instance, the well-being documents needed for worldwide traffic. And, the IHR acquaints significant shields to secure the privileges of travellers and other people according to the treatment of individual information, informed assent, and non-discrimination in the utilization of wellbeing measures under the Regulations.
One of the reasons referred for the ineffectiveness of the IHR includes WHO’s relative inexperience in making and implementing the lawful system. The IHR’s inability to adjust to changing circumstances in a global rush, exchange, and general wellbeing; their coverage of only three diseases; and the lack of core surveillance capacity in the many WHO Member States. As a result, in 1995 the World Health Assembly embraced the resolution of worldwide health security: economic alert and reaction which requested that the IHR be reviewed to take more effective account of the threat posed by the international spread of new and re-emerging infections.
The globalization of general wellbeing makes irresistible sickness challenges that power states to take part in the worldwide cooperation. International law has been a significant instrument for working with international public health cooperation. Utilization of international law in international infectious disease control interfaces with the governance challenges globalization presents in the general wellbeing context. A gigantic gap still exists between the information accumulated over the past many years and the implementation of infection control practices. This gap is significantly more profound in a poor-asset context with devastating consequences. Breaches in infection control measures subvert each advance and interest in health care.
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