Beyond borderspotential gaps in the international system of

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					Beyond borders: potential gaps
in the international system of
public health surveillance

Martin McKee
London School of Hygiene and
Tropical Medicine
Gastein, 2006
       Micro-organisms do not
       respect national frontiers
!   Some of the earliest
    international treaties
    dealt with the threat of
    communicable disease
!   The first embassies
    were established in
    medieval Italy as a
    means of providing city
    states with information
    of outbreaks occurring
    in their neighbours
         The revised International
         Health Regulations
!   The new regulations
    place obligations on
    national authorities to
    reduce the threat of
    infections emanating
    from their territory
!   What happens when
    these obligations
    cannot be fulfilled?
Some problems have no
easy solutions
!   Ongoing conflict removes swathes of territory from
    effective control of central government
     " Afghanistan
     " Cote d’Ivoire
     " Sudan
!   Fragile states do not have institutional resources to
    control their territory
     " Democratic Republic of Congo
!   Areas under military occupation
     " British Sovereign Base Areas in Cyprus
     " Guantanamo Bay, Cuba
     " Bagram Air Base, Afghanistan
     " Diego Garcia
     " ? Secret bases for “extraordinary rendition” elsewhere
… but some should be more easily

!   Typically entities that are not independent
    states but have many of the functions of
!   In some cases, this status has been a
    temporary stage on road to independence
    "   East Timor
    "   Eritrea
!   In others, the situation can persist for
    "   Taiwan
         Republic of North Cyprus (I)

!   Independence only
    recognized by Turkey
!   Movement of Turkish
    and Greek Communities
    between northern and
    southern parts of
    Cyprus permitted since
        Republic of North Cyprus (II)
!   Exchange of health related
    information across border is
!   Northern Cyprus does notify
    outbreaks to WHO but
    surveillance capacity weak
!   Agreement between
    authorities both parts of
    island to coordinate
    influenza preparedness
         Transdneistria (I)
!   Predominantly ethnic
    Russian enclave within the
    territory of the Republic of
!   Proclaimed independence
    in 1990, with tacit support
    from Russia but
    independence never
!   Extremely poor and a
    major centre for smuggling
    and organised crime.
          Transdneistria (II)
!   Communication with Moldovan
    authorities is tenuous, often involving
    mediators such as the Organisation
    for Security and Cooperation in
!   Ministry of Health and Social Security
    in Moldova maintains some limited
    epidemiological oversight through
    contacts in Transdneistria
!   Weaknesses in the public health
    monitoring system in Moldova mean
    that the effectiveness of this
    oversight is questionable.
              Nagorno Karabakh
!   Territory entirely within the borders
    of Azerbaijan, but populated
    entirely by Armenians.
!   virtually no movement between
    Nagorno Karabakh and Azerbaijan
!   Armenian citizens can enter
    Nagorno Karabakh freely but all
    others require a visa
!   access via a short stretch of road
    that crosses Azeri territory.
!   Some limited information about the
    health situation obtained by
    Ministry of Health in Armenia but
    situation far from adequate.
           South Ossetia
!   Semi-autonomous enclaves
    within territory of Georgia,
    enjoying some support from
!   Reasonable cooperation
    between public health
    authorities in the enclaves and
    those in Georgia
!   Often via mediators, in
    particular UNICEF and some
    non-governmental organisations
!   In practical terms, few
    difficulties in exchanging
!   Province of Serbia under
!   Relatively robust
    surveillance system in
    place, run by United
    Nations peacekeeping
!   Kosovo administration
    reports directly WHO
        Palestinian Authority (I)

!   Occupied by Israel
    in 1967 Israeli
    military authorities
    withdrew from Gaza
    Strip in 2005, but
    West Bank
    territories remain
    under Israeli military
          Palestinian Authority (II)
!   Israel member of WHO’s European Region while Palestinian
    Authority not a member of WHO but treated as one by Eastern
    Mediterranean Regional Office of WHO, to which it reports
    outbreaks and vital statistics
!   Unified surveillance
    system established in
    1997, combining the three
    earlier systems, operated
    in West Bank, Gaza Strip,
    and by the United Nations
    Relief and Works Agency
!   Processes well defined but
    considerable under-
!   Microbiological support provided by the Beit-Dagan laboratory
    and the central virological laboratory of the Public Health
    Services, both in Israel
           Western Sahara (I)
!   Spanish colony until mid 1970s
    now claimed by Morocco and
!   International Court of Justice
    rejected territorial claims and
    recognised right Saharawis to self-
    determination but planned
    referendum has never taken place
!   Much of country occupied by
    Morocco, which has built walls to
    demarcate the territory it holds from
    that held by the Saharan Arab
    Democratic Republic
           Western Sahara (II)
!   Surveillance system in
    Moroccan part of Western
    Sahara fully integrated with
    that in Morocco
!   Epidemiological facility in
    Laayoune, former capital of
    the Spanish colony
!   Although Moroccan
    occupation not recognised by
    international community,
    Western Sahara effectively
    treated as part of Morocco by
!   Recognized as
    government of China,
    with seat on United
    Nations Security
    Council, until 1972,
    when it was replaced
    by government of the
    People’s Republic of
       Taiwan and the WHO (I)
!   2005 Memorandum of Understanding between the
    WHO and the People’s Republic of China allows
    only very limited official communication between the
    WHO and the Taiwanese authorities
!   Beijing authorities insist on highly bureaucratic
    procedures and avoidance of anything that in any
    way implies an independent status for Taiwan
!   All possible contacts need to be cleared, via a WHO
    contact point, with the Chinese delegation in
    Geneva no less than five weeks before they take
!   Chinese authorities will decide which Taiwanese
    individuals will be contacted
      Taiwan and the WHO (I)
!   Communications should not identify Taiwan but just the
    city from which the expert comes from
!   Taiwanese citizens not to be invited to join expert
    advisory panels
!   As far as possible, the WHO will invite experts from the
    People’s Republic of China to any meetings attended
    by Taiwanese officials
!   WHO is required to take care that Taiwanese citizens
    are not inadvertently included within delegations of
    non-governmental organizations attending its meetings
!   Direct contact possible in an emergency, designated
    as such by the WHO’s Director General, although
    again subject to agreement with the Chinese
    Some practical difficulties…
“As to the geographic expression to be included in the
mailing address for any correspondence with invited
Taiwanese experts, the use of "Republic of China" or
"Taiwan" is not acceptable. At the same time, the use
of the expression "Taiwan, China" could possibly
discourage the participation of the invited experts.
Consequently, technical units should only indicate the
name of the city of the addressee, without indicating a
"country" of destination, and invitations should as
much as possible be sent by telefax to avoid problems
with the regular mail. Any deviation from this practice
should be cleared with the Focal Point”
   A free and open discussion?

“The Secretariat shall request the experts in question
not to engage in political activities during their
participation. If they do not comply with this
requirement, the Secretariat should request them to
stop any activity of a political nature and, if necessary,
shall terminate their participation in the technical
“The technical unit concerned should make efforts to
also invite medical and public health experts from
mainland China when inviting Taiwanese experts.”
       Some observations

!   A remarkably high proportion of “non-state”
    entities lie on the migratory paths of birds
Influenza and bird migration
       Some observations

!   A remarkably high proportion of “non-state”
    entities lie on the migratory paths of birds
!   With a few exceptions (such as Taiwan and
    Kosovo) territorial surveillance systems are weak
    but their exclusion from the international system
    makes it difficult to provide international support
    to strengthen them
       Some observations
!   A remarkably high proportion of “non-state”
    entities lie on the migratory paths of birds
!   With a few exceptions (such as Taiwan and
    Kosovo) territorial surveillance systems are weak
    but their exclusion from the international system
    makes it difficult to provide international support
    to strengthen them
!   More optimistically, in some cases the threat of
    infectious disease has broken down political
       Signs of progress?
!   United Nations/ United Nations Development
    Programme office in Cyprus has facilitated the
    sampling of birds from the buffer zone between the
    two parts of the island
!   In December, 2005, a potential regional cooperation
    framework to prepare for an avian flu pandemic was
    discussed by Israeli, Jordanian and Palestinian health
    and veterinary officials meeting in Istanbul
!   This was the first meeting in which experts from all
    three nations participated
!   Recommendations were made relating to cooperation
    in disease surveillance, risk communication,
    immunization, research and restrictions on movement
    of people and goods before and during any outbreak
… but not everywhere

!   Taiwan is the one example of a “non-state”
    where the problems could be tackled at the
    stroke of a pen
!   After all, it has been possible in other fields
    "   Fisheries
    "   World Trade
    "   Nuclear proliferation
!   Why not health?

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