The Fuss Over Who Should Declare Public Health Emergencies in Africa
africa cdc
Ahmed Ogwell Ouma, Africa CDC’s Acting Director (right) with WHO Director General Tedros Adhanom Ghebreyesus (left)

Africa CDC wants to be able to declare public health emergencies of continental security but the WHO warns this could be a risky move that could isolate African countries and create confusion regarding response.

The World Health Organization’s African Regional Office (WHO AFRO) has found itself explaining its disapproval of the Africa CDC’s quest for a mandate allowing it to be able to declare a “Public Health Emergency of Continental Security.”.

Last week, news broke that the WHO was mounting a drive to curtail Africa CDC’s ambitions to expand its powers – and particularly its request to African Union ministers of health to be empowered to declare a “Public Health Emergency of Continental Security”. 

The issue emerged as about 40 African Union health ministers convened in a meeting last week to discuss revisions to the statutes under which Africa CDC operates, which could give it more authority, including the power to declare regional or continent-wide health emergencies. 

At the meeting, 12 ministers reportedly supported WHO’s call to limit Africa CDC’s powers to declare such emergencies – which sources say  was a result of WHO’s lobbying of member states. The health ministers are due to reconvene again Tuesday to make a final recommendation on the amendments – which would eventually be placed before the AU Executive Council for a decision. 

In a statement, WHO’s African Region (AFRO) called for the assessment of the proposed policy’s benefits and risks to member states. It noted that while the policy change could reduce Africa’s dependence on others, it could also trigger more travel and trade restrictions and isolate the continent as occurred with the travel bans imposed by many countries in southern Africa after scientists there identified the emergence of the Omicron variant of the SARS CoV2 virus.

Arrivals to border control at London’s Heathrow Airport – quarantine rules were based on where they were vaccinated – and not the vaccine received.

“WHO believes a careful reflection on the interfacing between the declaration of a public health emergency of continental security and the global process would be of benefit,” WHO stated.

Speaking with Health Policy Watch Dr Abdou Salam Gueye, WHO AFRO’s Regional Emergency Director, added that creating a new type of emergency declaration at continental level, under the administration of Africa CDC rather than WHO, also could lead to confusion. And this he said could delay, rather than speeding up, countermeasures. 

At the same time he added, ““I believe that WHO is very open to discuss and see the best way to settle this issue.” 

Africa CDC’s acting director says more authority is justified 

Explaining why Africa CDC needs the mandate, Ahmed Ogwell Ouma, Africa CDC’s Acting Director, noted that African Union emergency response procedures – from recruiting response teams to medicines and vaccines procurement – cannot be activated without some kind of formal declaration of a public health emergency. 

“At the moment, that declaration of emergency is usually at two levels. First is at the national level. Governments are able to make that declaration that there is a public health emergency within their own borders. And beyond the borders, the WHO usually does that at the Geneva level,” Ouma said, speaking at an Africa CDC briefing last Thursday.

That, he noted, is the reason that AU policy organs are considering mandating Africa CDC to be able to declare regional public health emergencies within Africa, in order to ensure improved  continental health  security. 

Regional alert system doesn’t really exist

WHA President Dr Hiroki Nakatani of Japan applauds the decision of the 75th WHA to update the International Health Regulations.

Currently, WHO is only empowered under its International Health Regulations to declare public health emergencies at the global level and not at regional level.  

While there has been much criticism of this “binary” approach to the rules, it will take several more years to make amendments to the existing IHR, under a process that was just approved at last month’s 75th  World Health Assembly

And if there was to be a change in the existing yes-or-no alert system, the solution that has been most discussed is the addition of a global “yellow light” warning, rather than regional signals.  

Past history, however, has shown that it took considerable time for regional outbreaks in Africa to rank as sufficiently severe to warrant a global health alert. In the 2014-2016 Ebola outbreak in West Africa, a WHO public health emergency of international concern (PHEIC), was only declared in August 2018 – more than eight months after the first Ebola virus cases were reported in Guinea – and 6-8 months after the virus had already spread well into Liberia and Sierra Leone

In the case of the 2018 Ebola outbreak in the Democratic Republic of Congo,  there were 3 meetings of WHO’s Emergency Committee after the outbreak first began in May before a fourth meeting activated the PHEIC alarm in August 2018. Although considered a rapid response, in comparison to 2014, by that time the virus had already spread to Uganda, was threatening the borders of some 7 other states, and 1,700 people had already died.

Potential spillover of Ebola virus during the 2018-2020 outbreak to nine countries sharing borders with the Democratic Republic of Congo (Wadoum et al, 2021)

The experience underlines the importance of greater inter-African planning and cooperation on outbreak response, coordinated by Africa CDC, in the words of one retrospective study by a group of African and European researchers. 

Africa is split between two WHO regions

Another problem with WHO’s alert system is that within the global health agency,  responsibility for Africa is actually split between two WHO regional bodies – the AFRO region, which coordinates responses in sub-Saharan Africa and the Eastern Mediterranean Regional Office (EMRO). EMRO actually  includes seven African countries – Djibouti, Egypt, Libya, Morocco, Somalia, Sudan, and Tunisia – among its 21 member states and the occupied Palestinian territories, whose territories extend as far east as Afghanistan. 

While the split reflects the traditional cultural and political affiliations of north African with predominantly Muslim states elsewhere in the EMRO region – it also is artificial in terms of the ways in which diseases spread. 

But even if WHO were ever to be empowered to declare regional health emergencies, in the case of Africa,  such a declaration would automatically exclude Africa’s “EMRO” countries which might also be at risk. Or conversely, it would include EMRO countries even though the outbreak may not be relevant to Middle Eastern states  thousands of kilometers away.   

Africa CDC announcement would trigger faster response  

Africa CDC argues that if its request is granted by the AU Executive Council, there would be no change from the standpoint of WHO’s global alert system.  Ouma said emergency procedures would still be activated if WHO makes a pronouncement in Geneva for a public health emergency of international concern. 

But in addition, those procedures could also be triggered if Africa CDC were to make a pronouncement on a public health emergency of continental security – providing a more granular level of alert.

“Emergency set of procedures that will kick in are very similar,” he stressed.

He added that if and when the Africa CDC is eventually granted such authority by the African Union, the center would be able to focus on outbreaks that are largely endemic to Africa. And in that way, response will be faster and containment more effective.  

“We do not have to wait for a long time for a pronouncement to be made. That is our expectation indeed. And that is the expectation with the African Union. That is why this request has been made,” Ouma said.

WHO’s concerns

Preparation and disinfection of a house in Moto, Bikoro,
Equateur Province, after the discovery
of a confirmed Ebola case.

Dr Matshidiso Moeti, WHO AFRO’s Regional Director, told Health Policy Watch that WHO is not lobbying against the move among African ministers of health, who must render a decision. But rather  WHO aims to help them understand the pros and cons of outbreak declarations by different organizations and at different levels.  

“We would recommend that any decision made after this analysis lend itself to a rapid response, mobilization of resources – but also ensure that such declarations don’t then result in the type of isolation that we have seen in the past happen when countries are revealing information about outbreaks,” Moeti said.

Along with travel bans imposed on southern Africa following the identification of the Omicron variant, developed countries have frequently imposed travel advisories in the wake of African  national  outbreak  alerts.  For instance, the United States Centers for Disease Control imposed restrictions on incoming travelers from Guinea and DRC following Ebola outbreaks that involved only a handful of cases in each country.  Moeti expressed WHO’s interest in supporting its Member States and partners to think through such processes.

Aligning and streamlining WHO and Africa CDC efforts

Every year in fact, WHO responds to over 100 public health outbreak events of different sizes and different severity. Outbreaks at national level are declared by national government authorities.  But in the case of Africa or other developing regions, national outbreak announcements are closely coordinated with  WHO and those may also be greatly delayed – as was the case of the Malawi polio outbreak alert last February – which occurred three months after the polio case was first reported.  

Speaking in May at a pre-World Health Assembly briefing  Gueye noted that as with so many other issues in Africa’s health system, there is need for improved coordination between WHO and African members states generally.

Open Briefing to 75th WHA: Left to Right: Priti Patnaik, Agnes Soucat of the French Development Agency and WHO’s Abdou Salam Gueye discuss the global architecture for health emergencies response.

“We need several Africa CDCs in order to tackle those issues,” said Gueye, speaking metaphorically about the need for more resources overall. “What we need is just to have a coordination mechanism where what needs to be done will be clarified, and also people will work together in a complementary manner,” Gueye said. 

Gueye said he had recently visited Addis Ababa, Ethiopia’s capital city, where he discussed with colleagues at the Africa CDC ways to improve collaboration.

“We said what we want to do and they said what they want to do,” he related, suggesting a more formal coordinating mechanism could also be useful. “We could complement each other at any point and there is a place for an additional organization to work together. We need better streamlining in order to know what the other is doing and where we can really put our force together and succeed.”

Elaine Ruth Fletcher contributed to this story.

Image Credits: Ahmed Ogwell/Twitter , @HeathrowAirport/capt_saini, Wadoum et al, 2021, Journal of Risk Management and Healthcare Policy, WHO/Junior D. Kannah, Benoit Varenne , Badur et al (2019).

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