Covid and mpox are here to stay, but the WHO’s emergencies may be nearing an end

Over the next week or so, the World Health Organization may declare a formal end to two long-running global health emergencies, Covid-19 and the mpox outbreak, after independent expert panels meet to assess whether these health events still merit being called Public Health Emergencies of International Concern.

What the panels will recommend, and what WHO Director-General Tedros Adhanom Ghebreyesus will ultimately decide, remains to be seen.

But a number of global health experts told STAT on Wednesday that they believe the time has come to wind down these two PHEICs, as they are known. A few went so far as to say a third — the longest running PHEIC on record, for polio — should also be ended.

Lawrence Gostin, an international law professor at Georgetown University, said he expects both the Covid and the mpox expert panels will recommend that the PHEIC for the disease they have been monitoring should be declared over, and that the WHO director general will accept that advice. (Tedros does not have to. He has the power to overrule an emergency committee’s recommendation, and he has used it.)

“I think that’s the right thing to do and the wise course of action. All emergencies have to come to an end,” said Gostin, who is also director of the WHO Collaborating Center on National and Global Health Law.

Gostin and others pointed out that governments around the world have resumed normal operations. Many have ended or will soon end their own Covid emergencies; the U.S. government’s public health emergency ends May 11. There’s widespread Covid fatigue and substantial political backlash against containment efforts, Gostin said. “I think it dilutes the value and importance of a global health emergency — or any public health emergency — if it drags on too long.”

The Covid-19 PHEIC has been in effect since Jan. 30, 2020. When the Covid emergency committee convenes on Thursday, it will be the 15th time it has done so. The mpox PHEIC was declared more recently — on July 23, 2022. At that time, the number of countries detecting cases of mpox — a cousin of the eradicated killer smallpox — was growing rapidly. But there has been a sharp drop in detected infections globally since last autumn. The mpox emergency committee will meet next Wednesday.

“My best guess is that [the mpox PHEIC] will be ended due to being in the tail end of reported cases for this global outbreak,” said Louise Ivers, director of the Harvard Global Health Institute.

Tom Bollyky, director of the global health program at the Council on Foreign Relations, agreed.

“It doesn’t mean it’s not important to do something about that disease. But it doesn’t meet the requirements of a public health emergency of international concern anymore,” he said.

Bollyky also believes that the Covid PHEIC should be ended. “It is fair to say that we still have many people getting sick, many people dying of this virus internationally, but that’s true for many health conditions and we don’t declare them a public health emergency,” he said. “The moment for this one is now ending.”

A PHEIC is a tool created within the International Health Regulations to help the WHO respond to disease events with the potential for global spread. When a PHEIC is in place, the WHO director-general can make special recommendations, mainly aimed at discouraging countries from closing borders or restricting trade — actions that could deter countries from alerting the WHO if they are dealing with dangerous disease outbreaks.

The IHR is a legally binding agreement, but one that has no teeth. As was seen in the early stages of the Covid pandemic, a number of countries ignored the WHO’s calls not to close their borders.

The criteria for declaring a PHEIC make up a short and rather vague list. A PHEIC may be called in response to a serious, sudden, unusual, or unexpected disease event that poses a risk of international spread and may require coordinated international action.

Victoria Fan, a senior fellow at the Washington, D.C.-based Center for Global Development, is not a fan of PHEICs in general. The binary nature of this tool — an emergency switch that can only be off or on — is of limited value, she argued. (Tedros may agree. He has spoken publicly about this limitation of PHEICs.)

A more nuanced tool would be more useful, said Fan, who suggested that on the question of the current Covid PHEIC, “the relevance is not apparent.”

“The longer it goes on, the less relevance it has,” she said.

David Heymann, a professor of infectious diseases epidemiology at the London School of Hygiene and Tropical Medicine, worries that prolonged PHEICs diminish the value of this provision of the IHR.

Heymann, a former WHO assistant director-general, chaired the emergency committee struck by former Director-General Margaret Chan during the Zika outbreak of 2015-2016. (The disease, spread by infected mosquitoes, was discovered to trigger profound developmental damage in some babies that were infected in utero.) He said that once the Zika emergency committee was assured that WHO had set up an expert committee to advise it on who to handle the outbreak on an ongoing basis, the committee recommended ending the PHEIC.

Preben Aavitsland, state epidemiologist at the Norwegian Institute of Public Health, thought the Covid-19 PHEIC should have been declared over in January, when the emergency committee last met. The explosive surge of cases in China at the time — the country had dropped its zero Covid policy in late 2022 — may have played a role in the committee’s decision not to urge ending the PHEIC at that point.

In an email, Aavitsland said it is clear Covid no longer meets the criteria for a PHEIC.

“The virus has been around the globe for almost three and a half years now. We cannot claim that the virus now ‘constitutes a risk to other states through the international spread of disease,’” he said. “It’s already everywhere. The need for a coordinated international response is no longer there.”

“If the WHO insists on keeping the PHEIC for another three months, I am afraid it may hurt the confidence in the organization. Some people will start looking for hidden motives behind the reluctance,” said Aavitsland, who served as acting chair of a previous emergency committee on the long-running Ebola outbreak in the northeastern part of the Democratic Republic of the Congo.

Aavitsland also noted that when the WHO announces the termination of the Covid PHEIC, the world will perceive it as a declaration of the end of the pandemic.

In reality, even though it appeared that Tedros declared the start of the pandemic on March 11, 2020 — STAT, among others, reported it as such — the WHO does not have the authority to declare a start to a pandemic and it cannot declare an end to one.

But there was a clue Wednesday that the Geneva-based global health agency is preparing for a time after the Covid PHEIC. It issued an updated Covid management plan, “a guide for countries on how to manage Covid-19 over the next two years in the transition from an emergency phase to a longer-term, sustained response.”

Among the experts STAT spoke to about the Covid and mpox PHEICs, only Ivers argued for maintaining the emergency status of Covid for a while longer.

“I think that the challenge of transitioning from PHEIC to a ‘public health issue that we should all be paying attention to’ is not easy and I have some concerns that stopping the PHEIC would slow down momentum around access to important diagnostics and regulatory environment for vaccine production, etc.,” she wrote in an email.

Two of the experts STAT canvassed on this issue called also for the end of a third PHEIC — the only other one in existence and by far the PHEIC of longest duration. This Friday will be the ninth anniversary of the WHO’s declaration that transmission of wild poliovirus constituted a PHEIC, a move widely seen as a political effort to shore up the then-flagging eradication effort. The polio emergency committee has met a total of 34 times, most recently in February, when it unanimously recommended extending the PHEIC.

Both Gostin and Heymann, who used to oversee WHO’s polio eradication team, question the value of using this tool this way; Gostin said it “borders on the absurd.”

Bollyky, though, disagreed. “Really what they’re trying to do is defend the progress that has been made in eliminating the virus from many countries. And that does require more coordinated action,” he said. “Certainly an argument can be made in the other direction, but I actually think it’s on stronger footing than what we’re seeing now on mpox or Covid, where that level of international coordination frankly isn’t necessary to fundamentally change the direction of those diseases.”

Correction: An earlier version of this article incorrectly stated that a PHEIC was never declared for the North Kivu Ebola outbreak.