Emerging norms for the control of emerging epidemics.

doi:10.2471/BLT.08.051771 (Submitted: 31 January 2008 – Revised version received: 23 April 2008 – Accepted: 27 May 2008 ) Introduction Recent WHO initiatives, including the revised International Health Regulations (IHR),1 the final report on Ethical considerations in developing a public health response to pandemic influenza 2 and the interim protocol on Rapid operations to contain the init ial emergence of pandemic influenza,3,4 are representative of a new strategy for multilateral cooperation on emerging and epidemic-prone infectious disease (EID). These initiatives together define emerging legal, ethical and operational norms for the global prevention and management of outbreaks and other public health emergencies. Each one also reflects a revolutionary willingness of the international community to accept new forms of supranational authority and to abide by the principle that national sovereignty can in some circumstances be subordinate to public health protection.5 As such, they are integral parts of the evolution of international health governance towards a global public health security regime.6 A significant but underexamined normative shift lays behind this dramatic change in strategy. Following the 2002–2003 severe acute respiratory syndrome (SARS) epidemic, before the approval of the revised IHR, we explored the concordance between the values and norms that guided global health authorities during the former and those subsequently elaborated as the core principles of the latter (Table 1). We identified four substantive themes that characterize the normative shift: (i) the effectiveness of global solidarity in providing the public good of EID surveillance and response; (ii) the responsibility of WHO to act as a supranational public health authority; (iii) the justifiability of necessary and proportionate coercive global public health measures to control outbreaks; and (iv) the imperative to reduce inequalities in capacities and access to resources across countries in the service of security, equity and reciprocity. We discuss these observations and their implications for future development of efforts to establish global public health security.