As countries continue tightening travel and trade restrictions in an attempt to control the global coronavirus outbreak, 328 Americans who’d been stuck on a cruise ship in a Japanese harbor for nearly a month were finally flown home yesterday, some sick with the virus, and the rest headed for two weeks of quarantine.

According to a University of Maryland researcher who studies how countries adhere—or not—to international health regulations, their time in shipboard limbo is a symptom of a system of global health governance with serious gaps.

In an interview with Maryland Today, public policy Assistant Professor Catherine Z. Worsnop talked about how governments coordinate responses, what they can do to prepare for the next outbreak, and the forces that drive them to make bad decisions.

What’s your assessment of how the global coronavirus response is being handled?
If country adherence to World Health Organization (WHO) guidance is a measure, then not very well. This situation really has revealed urgent gaps in the operation of the International Health Regulations (IHR)—the binding agreement under WHO that coordinates country responses during outbreaks like this. These cruise ships are a great example—the IHR offer  no clear guidance on what to do. You don’t want healthy people stuck with sick people on a ship for obvious reasons, but if no country is willing or able to take those people and quarantine or isolate them on land, what are you supposed to do? It’s not a good option to put them on planes and disperse them without being able to track people closely. There are no great options here.

What are some of the other potential effects of these gaps in the regulations?
Another issue is that around one-third of all countries are imposing some kind of travel restriction, when WHO has recommended against doing so and countries are supposed to follow that guidance. There’s a lack of scientific evidence for many of these travel measures, and because in spending energy and money on these measures, they're not putting those resources into effective measures, including investing in diagnostic capacity, hospital worker training, communication—things we know work that are not as flashy as travel restrictions. Some of these travel restrictions are also potentially counterproductive since they disrupt medical supply chains, especially problematic during an outbreak, and can harm economies more generally.

These kinds of measures are also harmful to outbreak preparedness and response because they can encourage countries to not be transparent about outbreaks, now or in the future. No country wants to report if the response is going to be that they get targeted by a bunch of travel or trade restrictions, which are very costly.

Why are countries doing the wrong things?
The intense uncertainty surrounding this and every major outbreak should not be discounted. It plays a role in why we see countries and companies imposing a range of measures that may or may not be effective. It’s very hard to just say that, you know, no travel restriction will ever be beneficial at all, when at the same time you’re saying there's a lot we don't know about this outbreak.

This gets to the role that public pressure and fear plays. The public often supports travel restrictions during an outbreak, and governments want to be seen as “doing something.” Until governments face real costs for not following WHO guidelines, or they have another politically useful and effective policy option, we are likely to keep seeing countries ignore WHO advice about border measures.

What can be done to get countries to follow the rules?
In addition to better messaging and communication about why border measures may not be the best option, governments would need to face real costs. This is most likely to come in the form of public “naming and shaming.” I'll first say WHO is in a very bad spot here. They rely on member countries for funding and support, especially during an outbreak, and when you need the cooperation of key countries, it can be problematic for them to publicly criticize. Countries could hold each other accountable, domestic groups harmed by restrictions could hold their own governments accountable. Countries could increase funding to WHO so that the organization felt less vulnerable and had more resources to marshal during outbreaks like this.

Even though it’s still early, have we learned anything lasting from the coronavirus outbreak?
We’re relearning many of the same lessons we learned in previous outbreaks, but didn’t take to heart; one somewhat new thing is about the prevalence of misinformation. It has seemed worse this time, for reasons I think we’re all familiar with, and which have shown up in other areas of policy as well. WHO has been taking new measures in communications to try to deal with that, and there has been some cooperation from social media companies on it, but it’s a difficult problem, clearly.

Secondly, we really need to focus on domestic health infrastructure and preparedness in between outbreaks. A reason why many countries can't rapidly adopt the domestic measures that are actually effective is because they haven’t put the attention and resources into this when an outbreak isn't happening.