Declaring monkeypox an international emergency, WHO chief rejects expert panel’s advice

The World Health Organisation (WHO) today declared the global spread of monkeypox a Public Health Emergency of International Concern (PHEIC), even though a special advisory committee has declined, again, to recommend the action. This is the first time since the PHEIC system was created in 2005 that the agency has made such a declaration without the panel’s endorsement.  

“This is big, unprecedented decision-making by the director general,” says Clare Wenham, a global health expert at the London School of Economics who has studied the history of PHEICs.

WHO’s Emergency Committee, which met on 21 July, did not reach a consensus on whether to declare the burgeoning monkeypox outbreak in more than 70 countries a PHEIC; a narrow majority voting against doing so. But Tedros Adhanom Ghebreyesus, WHO’s director general, invoked a PHEIC at a press conference this afternoon in Geneva. “We have an outbreak that has spread around the world rapidly, through new modes of transmission, about which we understand too little and which meets the criteria in the International Health Regulations,” he said.

“I am glad that the WHO director made the decision to declare MPXV a PHEIC despite the inability of the advisory committee to reach a consensus,“ Boghuma Titanji, a virologist at Emory University who works at a sexual health clinic, wrote to ScienceInsider. “It is the right thing to do at this time and was the right thing to do a month ago – many of us were frustrated by the delay.“

The committee first recommended against declaring a PHEIC in June, a move that was widely criticized by epidemiologists and global health experts but that WHO accepted. Tedros reconvened the group this week and asked it to reconsider the question, which they did in a 7 hour meeting. At the end, 9 members were against declaring a PHEIC and 6 in favor, Tedros said at the press conference.

“I find this baffling,” says Lawrence Gostin, who specializes in global health policy at Georgetown University Law Center. He says it’s “crystal clear” that the monkeypox outbreak meets all of the criteria for a PHEIC outlined in the International Health Regulations governing WHO members, including the risk of spread to other countries and the need for international coordination. Moreover, “the window for containing monkeypox outside of endemic areas in Central and West Africa is rapidly closing, if it’s not already closed,” Gostin says.

The Thursday meeting of the expert panel was followed by tense exchanges via email and text messages between those who had taken part, Science has learned.

Among the objections to a PHEIC raised by members of the committee was that the disease had caused few deaths so far and was not spreading in the general population, along with fears that a PHEIC could lead to further stigmatization of men who have sex with men (MSM), the group primarily affected.

Many advocates for gay rights and sexual health in MSM have advocated for a PHEIC, however, to help raise awareness and protect those most vulnerable, as some members of the committee noted. “Although I’m declaring a public health emergency of international concern, for the moment, this is an outbreak that’s concentrated among men who have sex with men, especially those with multiple sexual partners,” Tedros said. “That means that this is an outbreak that can be stopped with the right strategies in the right groups.”

Those in favor of declaring a PHEIC also cited the rising number of monkeypox cases, more than 15,000 so far, and countries affected, and that many cases are likely still being missed. They also pointed out the risk of the virus permanently establishing itself in the global human population. Indeed, just yesterday the CDC noted that two children in the U.S had the illness.

Sources familiar with the deliberations of the committee said the votes for a PHEIC were driven by those with expertise in monkeypox and LGBT health, and those against by more generalist global heath voices.

A PHEIC gives WHO some additional powers but it is also the loudest alarm bell the organization can ring. “Declaring a PHEIC makes governments and the global public sit up and take notice,” Gostin says. “It raises the political stakes for government leaders, and it raises the level of accountability for them to act.” Since the tool was created as part of the International Health Regulations in 2005, a PHEIC has been declared six times: for outbreaks of H1N1 influenza, polio, Zika, COVID-19, and twice for Ebola outbreaks. The PHEICs for COVID-19 and polio are ongoing.

That the committee could not agree on declaring a PHEIC even though the legal criteria for one have clearly been met, shows how inconsistently the process works, says Wenham. “That is a problem,” she says. “For it to have the power we want it to have, to be the clarion call for government to do something, governments need to trust that the process is the same each time.”

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