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This report contains discussions of the regulations addressing health emergencies in twenty-five jurisdictions.  The jurisdictional surveys that are included cover countries from six continents and reflect national, regional (European Union, EU), and international (World Health Organization, WHO) approaches to the problem.  The report is supplemented by an annotated bibliography that lists recently published English-language monographs and academic articles on issues related to handling public health crises.  All surveys included in this report review government structures tasked with delivering public health protection, relevant legislative frameworks for addressing health emergencies, and the powers of government institutions in times of health crises and their ability to mitigate the consequences of such crises.  Analyses of the regulation of such issues as disease surveillance and notification systems are also provided.  Individual surveys discuss the role of medical and emergency services personnel in responding to public health challenges, the coordination of government activities aimed at minimizing the spread of epidemics, and the cooperation of national health-care institutions with the WHO in implementing pandemic preparedness measures.  Measures taken by national governments in response to recent outbreaks of infectious diseases, including the Ebola epidemic in western Africa in 2014, are also described. 

I.  Introduction

All the countries surveyed recognize the existence of a threat to public health from a variety of infectious diseases, mass illnesses resulting from technological catastrophes or the malicious distribution of viruses, and the potential use of chemical and biological weapons by terrorists.  All the reviewed jurisdictions appear to be aware of the importance of maintaining national health care infrastructures to combat public health crises and readily available communications systems that inform the public on preparedness plans and serve as clearinghouses for crisis information.

In addition to the national governments, the WHO performs a critical role in confronting health crises.  The WHO coordinates international health work and provides technical and policy assistance to national governments and medical authorities in support of programs to promote health, prevent and control health problems, control or eradicate diseases, and strengthen national health systems.  It also keeps communicable and noncommunicable diseases and other health problems under constant surveillance, sets safety standards, issues regulations that are binding on member states, collects and disseminates health data, and carries out statistical analyses and comparative studies concerning various diseases.

The EU survey reflects measures aimed at improving the coordination of Member States’ actions.  While public health emergencies occurring within the EU fall primarily within the domain of the individual Member States, the legal acts of the EU pertaining to public health complement the national policies of the EU members, coordinate their actions, and facilitate communication and the exchange of information among Member States.  Addressing existing deficiencies in managing health crises, the EU has passed new legislation expanding the list of threats beyond communicable diseases to include biological, chemical, environmental, and other events that may pose a risk.  Three newly established institutions demonstrate the EU’s response to health care challenges that emerged with recent epidemics and terrorist attacks: the European Center for Disease Prevention and Control, modeled after the United States Centers for Disease Control and Prevention; the Early Warning and Response System; and the Health Security Committee, which developed into a full-fledged institution in charge of information exchange and response planning from an informal discussion forum on public threats.

The Nordic states take a regional approach toward tackling health crises through cooperative preparedness efforts.  These countries have mutual obligations to help each other when necessary and may send their patients to other countries for better treatment.  The Baltic states likewise take special actions against contagious diseases jointly.  In another example of the regional approach toward managing health care emergencies, members of the Association of Southeast Asian Nations (ASEAN), together with China and Japan, adopted a joint resolution on standard border controls in 2003 during the SARS (Severe Acute Respiratory Syndrome) epidemic to counter the spread of the disease, and also distributed standardized health declaration cards to all travelers at airports.  In 2009, following the A/H1N1 (swine flu) virus epidemic, and in 2014, because of the Ebola virus threat, national governments issued guidelines and took measures similar to those suggested by the US Centers for Disease Control and Prevention, another example that demonstrates the increasing interconnectedness of health care management authorities in various countries.

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II.  Structure of Public Health Crisis Management Systems

In the countries surveyed, the systems of health care and health crisis management are governed by statutory and regulatory measures that reflect general constitutional principles concerning the protection of the public and the health of an individual.  Responsibilities for dealing with health crises are distributed among the central or federal governments and regional and municipal authorities to prevent, monitor, and respond to public health emergencies.  This distribution prevails regardless of the cause of the health emergency.  In the case of terrorism, the intervention of other government authorities may be required.  In Germany the legislative power for public health remains with the states; however, the German Federation has concurrent legislative power over measures to combat most public health threats.  Decision-making powers and the authority to declare emergencies appear to be concentrated in the hands of specified officials, who are assisted by civil servants from the agencies involved.  The participation and cooperation of different agencies and of special units, if they exist, appear to be a common feature in the countries surveyed where the minister responsible for health issues plays a leading role.  The appointment of a special commissioner may be an option in certain cases.    
Reporting systems for notifiable diseases have been widely adopted so that authorities with decision-making powers can monitor the situation in order to take the appropriate measures.  Almost every country reviewed has its own classification of infectious and contagious diseases, depending on disease severity, as well as relevant national action plans to respond to an outbreak of such diseases.

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III.  Powers of Public Health Authorities

In the majority of the countries surveyed, the Ministry of Health is the central authority in public health crises and takes appropriate emergency measures to confront such crises.  In many countries, separate agencies dealing with epidemic surveillance and sanitary control are subordinated to the Ministry of Health for the duration of a crisis.  While in the majority of the countries reviewed such agencies are usually responsible for planning, coordinating, and implementing the response to a crisis, in some countries (e.g., Brazil and Russia) they have the actual power to mobilize resources.  In Canada, the Prime Minister and provincial premiers have the authority to declare emergencies for all types of crises, including public health crises.  In England, the Secretary of State has broad powers with respect to a health crisis.  The power to proclaim a state of emergency is vested in the president in Nigeria and Kenya, according to their constitutions. 
In several countries, depending on the type of health crisis, other departments (such as the Departments of Agriculture, Justice, Interior, and Environment), in cooperation with the Ministry of Health, may be involved in the decision-making process.  This cooperation is often in addition to the involvement of other agencies’ special units, where existing.  Public health services at any level are primarily entrusted with the bulk of the measures needed to prevent and control a health crisis.  These measures are often preventive in nature, including the power to enter private homes and coercive powers to carry out precautionary measures, including the right to quarantine infected individuals, conduct mandatory inoculations, and examine and monitor diseased persons.  In Japan, provincial governors may order the hospitalization of patients, whereas the report on England indicates that public authorities do not have the power to force a quarantined, diseased person to undergo treatment. 
A number of reports point out that during a simultaneous outbreak of an infectious disease in several countries, as was the case with SARS in 2003, avian flu in 2005, and the A/H1N1 virus in 2009, or when a threat comes from a disease outbreak outside of the country, as during the 2014 Ebola epidemic, health authorities can impose stricter controls on travelers coming from high-risk areas and require air carriers to provide detailed information regarding their passengers’ itineraries.  Heath authorities exercise control with the help of health questionnaires, sanitary monitoring, and the mandatory hospitalization of infected persons.  Measures necessary to curb a public health crisis may include compulsory health procedures, such as vaccinations, disinfection, quarantine, and travel restrictions.  Most of the reports illustrate that measures taken during health crises are, in many instances, in conflict with the constitutional and legal rights of individuals, such as those concerning the inviolability of person and home, freedom of movement, the use of property, peaceful assembly, and the ability to conduct business.  In most of the surveyed countries, the constitution permits intrusions into these constitutionally guaranteed fundamental rights to the extent that the intrusive measures are specifically authorized in statutory provisions and are in the public interest, such as for the protection of public health.  In Brazil, the government may issue a compulsory license for the use of a patent if a patent holder does not comply with a request for its use, in order to secure the reserve of medicines needed to fight a public health crisis.  
The failure to comply with measures taken in a crisis generally results in administrative or criminal sanctions.  Medical personnel who fail to provide assistance in emergency health situations, or to act on or report a case, may be more severely penalized.  These sanctions are not only set forth in the body of the legislation authorizing the specific measures, but are also included in the criminal codes of a majority of the countries surveyed.

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IV.  Transparency of Public Health Crisis Management System

Recognizing that a well-informed public is better prepared to deal with an emergency and minimize its impact, education and the disclosure of public health information appear to be important components of the response to public health crises.  The need for transparency is emphasized in many of the surveys.  The duty to supply information concerning public health finds its basis (with some exceptions) in the countries’ constitutions or special laws.

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V.  Cooperation with the WHO

Recognizing the important role of the WHO in helping its Member States to confront and overcome health crises, the countries surveyed generally cooperate with the WHO.  All of the countries have agreed to implement the WHO International Health Regulations of 2005 and are making efforts to comply with the requirements prescribed by that document.    

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Prepared by Peter Roudik
Director of Legal Research*
February 2015

* This comparative summary was originally prepared by Giovanni Salvo and Karel Wennink, former Foreign Law Specialists, in August 2003; it was updated for the purposes of the present report.

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Last Updated: 04/07/2016