Managing Public Health Threats That Traverse Geopolitical Borders: A Look at the Impact of SARS
Monica E. Nussbaum
Updated 19 December 2003
paper introduces readers to societal issues that must be studied from a
geopolitical perspective and incorporated into state-level policy-making
discussions for the establishment of effective domestic public health policy
and legislation. With the increasing ease of individual travel
for business and pleasure, and the transporting of goods across geopolitical
borders, public health threats can rapidly traverse the globe and cause
detrimental outcomes in multiple locations within human populations, animal populations,
and the environment. This paper briefly
discusses the history of the formation of international discourse on public
health threats, the development of
States must develop domestic public health policy by utilizing an international perspective as guidance for potential threats to human, animal, and environmental health. The interplay between human, animal, and environmental health signifies the importance of ensuring that public health policies and laws are sufficiently broad to provide for health protection and promotion, including but not limited to human health.
Geopolitical borders – demarcated lines that separate states – constitute the principal boundaries of international politics and law. Boundaries remain highly significant for jurisdictional purposes; however, boundaries are decreasing in importance regarding trade, economics, development, and global health. With increasing globalization, increasing interdependencies between states, and increasing travel, existing geopolitical borders, without additional preventive measures, no longer afford sufficient protection for the public health of a state’s population – “[g]lobalization of trade and travel has increased the chances for the spread of infections.”
Communicable diseases easily cross state lines and will continue to do so with ever increasing prevalence, which is why proactive measures must be taken to reduce the spread of public health threats and to counter and control known and future unknown threats. Consequently, domestic and international barriers impeding public health, such as the General Agreement on Tariffs and Trade (“GATT”) ruling that prohibits the use of trade restrictions for enforcement of public health laws, and those barriers, which also impede the implementation of effective health policy, must be reduced significantly if not eliminated. The GATT ruling should be revised to allow restrictions to be imposed that are most likely to effectively contain a public health threat until that threat is dissipated. The impact of SARS during 2003 signifies how “globalization has continued to erode the geopolitical boundaries of nation states, facilitating their permeation by infectious agents from distant places.”
State governments use health policies as a means of regulating and promoting the social utility of its available medical knowledge and capital. However, to establish effective public health policy, a state must look beyond strict economics and incorporate human values and ethics. Human values are the mechanisms by which objectives, priorities, and channels are chosen to establish policy. Human values can be viewed on an individual level, i.e., how an individual would act; or on a societal/communal level, i.e., the best interests of the community. Medical care largely focuses on the individual without requiring analysis of the impact on a community. Public health, by its very definition, must focus on the community and what is in the best interest of the community as opposed to the individual; therefore, in the development of public health policy and legislation, human values must be determined from the societal level. Ethics bridge health policy and values by examining the moral turpitude of required decisions and seeking to resolve conflicts among values. States must balance their focus when establishing public health priorities for several reasons. First, public health laws can significantly impair individual freedoms. Second, finite resources limit the ability of a state to guard against all threats; consequently, threats must be analyzed according to potential outcomes and characterized by the feasibility of preventing negative outcomes. For example, a state could vaccinate the entire population against a specific disease; however, that action would expend valuable resources which would then no longer be readily available, and that vaccination might have significant adverse reactions along the human scale, excluding financial cost, such as death or deformities. In the context of communicable diseases, diseases that do not present short-term death cannot preside in priority status over diseases the cause immediate death. However, states must create flexible public health policies so that programs and resources can be readily adapted with little notice to reduce the impact that a burgeoning disease may have.
The primary determinants of health are significant when studying international, regional, and local patterns of disease. The primary constructs of health include: human biology, environment, lifestyle, and medical care. Of these, only one construct presents significant difficulty for management – human biology, i.e., genetics. State policy makers have varying measures of power to impact the environment, individual lifestyles, and access to and quality of medical care. By controlling these factors and thus reducing the risks posed to the public health of a population, states are able to formulate effective public health policy. However, states must incorporate global awareness into domestic health policy as “[c]ommunicable diseases present enormous transnational (and often global) challenges that are beyond the governance capabilities of individual nation states and require multilateral/global approaches.” Communicable diseases know no borders, travel extensively and rapidly, and are relatively indiscriminate in choosing victims. The following table lists many health issues that should be studied and addressed in the formulation of domestic public health policy.
Public Health Issues that Can Cause Disparate Impacts Across Geopolitical Borders
Drug Trafficking and Use
Individuals Seeking Political Asylum
Medical Care: Access, Quality, and Treatment
Ports of Entry
Poverty (Individual and State)
Travel (Public and Private)
§ Cruise Ships
§ Taxi cabs
Weapons of Mass Destruction
“Because communicable diseases do not respect the geopolitical boundaries of nation states, and state sovereignty is an alien concept in the microbial world, all of humanity is now vulnerable to the emerging and re-emerging threats of communicable diseases.”
‘transnationalization’ of infectious diseases across geopolitical boundaries
during the European cholera epidemics of 1830 and 1847 catalysed the evolution
of the earliest multilateral governance of communicable diseases.” In 1851,
states restrict tourists and immigrants infected with specific diseases from
entering their territory. Some states
test all arriving foreign residents for specific diseases while others test
specified groups. For example, the
is one of the primary public health agencies in the
Executive Order 13295, dated April 4, 2003, grants the CDC authority to apprehend or detain individuals to prevent the introduction, transmission, or spread of the following specified communicable diseases: “Cholera; Diphtheria; infectious Tuberculosis; Plague; Smallpox; Yellow Fever; and Viral Hemorrhagic Fevers (Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet isolated or named.” In addition, the Executive Order added the newly discovered disease SARS to the list of quarantinable diseases.
Title 42 section 71 of the United States Code regulates foreign quarantine by specifically regulating those diseases that are quarantinable, reporting measures for various methods of travel, sanitary inspection requirements upon arrival at US ports, and how to handle imported goods. Title 42 of the United States Code (42 U.S.C. §§264-272) specifies the regulations controlling communicable diseases, the regulations for quarantine, and the applicable penalties for violations. Section A provides for promulgation and enforcement by the Surgeon General. Section B provides for the apprehension, detention, or conditional release of individuals. Section D provides for the apprehension and examination of persons reasonably believed to be infected with a communicable disease in a communicable stage.
265 regulates “the suspension of entries and imports from designated places to
prevent spread of communicable diseases.” The CDC operates eight fully staffed
quarantine stations in the
In 1951, the World Health Organization created and adopted the International Sanitary Regulations, which was subsequently modified and renamed as the International Health Regulations (IHR). The IHR, a legally binding set of regulations, constitutes “one of the earliest multilateral regulatory mechanisms strictly focusing on global surveillance for communicable diseases.” The fundamental principle of the IHR is to keep interference with world traffic at a minimum while ensuring maximum security against the spread of diseases. The WHO requires member states to report outbreaks of specified communicable diseases. In addition, during outbreaks of specific diseases, the IHR requires travelers from infected areas to present health and vaccination certificates.
Compliance with the WHO IHR appears to be lax as member states are fearful about consequences, such as trade restrictions, if outbreaks are reported. Consequently, the WHO, through revision, has focused on “five key areas: global health security (epidemic alert and response), public health emergencies of international concern, routine preventive measures, national IHR focal points, and the need for synergy between the IHR and other related international regimes.” Additionally, international organizations, not formally associated with healthcare and public health, are beginning to understand the impact of public health threats across a broad spectrum of arenas. For example, the World Trade Organization (WTO), an international organization outside of the health sciences field, adopted the Doha Declaration, in recognition of “the gravity of the public health problems afflicting many developing countries, especially HIV/AIDS, tuberculosis, malaria, and other epidemics.” Additionally, the Declaration on the TRIPS Agreement and Public Health, adopted on November 14, 2001, outlined seven issues related to the promotion of public health by the World Trade Organization, including intellectual property rights for pharmaceuticals and allowing members to take necessary steps to protect public health.
the WHO established a partnership to combat river blindness in
The Importance of Public Health Protective, Preventive, and Containment Measures during the SARS Outbreak of 2002 and 2003
Recently, individuals located not only in one geographic
region but also around the world have contracted the relatively new and unknown
disease known as Severe Acute Respiratory Syndrome (SARS). The rapid spread of this highly contagious
disease greatly taxed the public health systems of numerous states. “As bacteria and viruses become resistant to
anti-microbials and new emerging infections appear, it can be expected that
personal restrictions and isolation will again be a core strategy in public
health.” The outcomes of outbreak, which initiated in
Provided information about SARS to air travelers
and to persons traveling via cargo and cruise ships who were arriving, directly
or indirectly, from
§ Distributed over 20,000 health notices advising travelers that they might have been exposed to SARS and how to monitor their health,
§ Assessed symptoms of individuals on airplanes to ensure they do not have SARS, and
§ Updated government agencies, and state and local health departments.
health is no longer the prerogative of physicians and epidemiologists. International health law, which encompasses
human rights, food safety, international trade law, environmental law, war and
weapons, human reproduction, organ transplantation, as well as a wide range of
biological, economic, and sociocultural determinants of health, now constitutes
a core component of global communicable disease architecture.” Specific behaviors and related diseases
disproportionately affect developing countries, which already have fragile
health and social infrastructures. For
example, the increase of injecting drug users in developing countries presents
threats of outbreaks of HIV and hepatitis C. To effectuate scientific solutions for global
health threats, the international community must make a coordinated global
response. Dr. John Evans, Chairman of
the Commission on Health Research for Development, aptly remarks in testimony
before the United States House Appropriations Committee, “that with increased
awareness of global interdependence in health, self-interest should reinforce
humanitarian concerns’ in our efforts to improve global health.” One mechanism by which to achieve improved
global health is to shift public health education from focusing primarily on
research to preparing and enabling providers to implement appropriate public
health practices. However, to effectively combat the spread of
highly communicable diseases, especially those diseases which are new and the
pathology of which is not yet understood or known, it is imperative for states
to inform the international community of local public health problems. The spread of SARS might have remained much
more localized if
 Schambra, Dr. Philip E. “Testimony on the
 Many of the issues discussed are to some extent reflected upon by international health organizations for the formulation of international governmental and organizational policies; however, this paper serves to illustrate the importance of incorporating these issues into the formulation of domestic public health policy to safeguard against threats and to ensure a healthy public.
 See Gina Kolata, Flu: The Story of the
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 Basic Facts About the United Nations.
 GATT’s restriction has one exception: trade
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harm democracy, ecology, & the
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 Infectious diseases largely do not discriminate between persons; however, individual risk factors, including age, general health status, and co-infections, do impact both the likelihood that an individual will acquire a specific disease and the impact of that disease on the individual. Although the average of persons with SARS was in the range of thirty to forty years of age, young children and olders persons, and persons with other health problems were much more likely to have significantly worse outcomes, including death, brought on by the SARS virus.
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 “AIDS Pandemic: Global
 Schambra, Dr. Philip E. Supra note 1.
 Exec. Order No. 13,295: Revised List of Quarantinable Communicable Diseases, revoking Exec. Order No. 12,452 of December 22, 1983.
 42 U.S.C. § 264(a).
 42 U.S.C. § 264(b).
 42 U.S.C. § 264(d).
 42 U.S.C. § 265.
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 Id at 948.
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 “Declaration on the Trips Agreement and Public Health.” Adopted November 14, 2001. Available at: http://www.wto.org/english/thewto_e/minist_e/min01_e/mindec1_trips_e.htm. Accessed on: December 16, 2003.
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