On June 1, 2024, the World Health Assembly reached consensus on a package of amendments to the 2005 International Health Regulations (IHR). These amendments follow nearly two decades of implementation and an intensive multilateral process prompted by the global struggle against COVID-19. This article critically examines whether the amended IHR reflect lessons learned from the pandemic, potentially ushering in a new era for global health law in pandemic preparedness and response, or if they deflect attention from the need for deeper structural reforms. While the IHR remain the only near-universal legal framework for preventing and addressing the international spread of disease, these amendments emphasize equity and solidarity, and potentially shift the IHR from a technical instrument to one focusing on inherently political issues. This analysis examines key IHR amendments and their implications for the future of global health law, particularly in the context of equity, financing, and implementation.

In low- and middle-income countries, fewer than 1 in 10 people with mental health conditions are estimated to be accurately diagnosed in primary care. This is despite more than 90 countries providing mental health training for primary healthcare workers in the past two decades. The lack of accurate diagnoses is a major bottleneck to reducing the global mental health treatment gap. In this commentary, we argue that current research practices are insufficient to generate the evidence needed to improve diagnostic accuracy. Research studies commonly determine accurate diagnosis by relying on self-report tools such as the Patient Health Questionnaire-9. This is problematic because self-report tools often overestimate prevalence, primarily due to their high rates of false positives. Moreover, nearly all studies on detection focus solely on depression, not taking into account the spectrum of conditions on which primary healthcare workers are being trained. Single condition self-report tools fail to discriminate among different types of mental health conditions, leading to a heterogeneous group of conditions masked under a single scale. As an alternative path forward, we propose improving research on diagnostic accuracy to better evaluate the reach of mental health service delivery in primary care. We recommend evaluating multiple conditions, statistically adjusting prevalence estimates generated from self-report tools, and consistently using structured clinical interviews as a gold standard. We propose clinically meaningful detection as ‘good-enough’ diagnoses incorporating multiple conditions accounting for context, health system and types of interventions available. Clinically meaningful identification can be operationalized differently across settings based on what level of diagnostic specificity is needed to select from available treatments. Rethinking research strategies to evaluate accuracy of diagnosis is vital to improve training, supervision and delivery of mental health services around the world.

During the COVID-19 pandemic the international community repeatedly called for the equitable distribution of vaccines and other medical countermeasures. However, there was a substantial gap between this rhetoric and State action. High-income countries secured significantly more doses than they required, leaving many low-income countries unable to vaccinate their populations. Current negotiations for the new Pandemic Treaty under the World Health Organization (WHO) attempt to narrow the gap between rhetoric and behaviour by building the concept of equity into the Treaty's substantive content. However, equity is difficult to define, much less to operationalize. Presently, WHO Member States appear to have chosen ‘access and benefit-sharing’ (ABS) as the predominant mechanism for operationalizing equity in the Treaty. This article examines ABS as a mechanism, its use in public health, and argues that ABS is fundamentally flawed, unable to achieve equity. It proposes other options for an equitable international response to future pandemic threats.

Background: Burkholderia multivorans are gram-negative bacteria typically found in water and soil. B. multivorans outbreaks among patients without cystic fibrosis have been associated with exposure to contaminated medical devices or nonsterile aqueous products. Acquisition can also occur from exposure to environmental reservoirs like sinks or other hospital water sources. We describe an outbreak of B. multivorans among hospitalized patients without cystic fibrosis at 2 hospitals within the same healthcare system in California (hospitals A and B) between August 2021 and July 2022. Methods: We defined confirmed case patients as patients without cystic fibrosis hospitalized at hospital A or hospital B between January 2020 to July 2022 with B. multivorans isolated from any body site matching the outbreak strain. We reviewed medical records to describe case patients and to identify common exposures. We evaluated infection control practices and interviewed staff to detect exposures to nonsterile water. Select samples from water, ice, drains, and sink splash zone surfaces were collected and cultured for B. multivorans in March 2022 and July 2022 from both hospitals. Common aqueous products used among case patients were tested for B. multivorans. Genetic relatedness between clinical and environmental samples was determined using random amplified polymorphic DNA (RAPD) and repetitive extragenic palindromic polymerase chain reaction (Rep-PCR). Results: We identified 23 confirmed case patients; 20 (87%) of these were identified at an intensive care unit (ICU) in hospital A. B. multivorans was isolated from respiratory sources in 18 cases (78%). We observed medication preparation items, gloves, and patient care items stored within sink splash zones in ICU medication preparation rooms and patient rooms. Nonsterile water and ice were used for bed baths, swallow evaluations, and ice packs. B. multivorans was cultured from ice and water dispensed from an 11-year-old ice machine in the ICU at hospital A in March 2022 but no other water sources. Additional testing in July 2022 yielded B. multivorans from ice and a drain pan from a new ice machine in the same ICU location at hospital A. All products were negative. Clinical and environmental isolates were the same strain by RAPD and Rep-PCR. Conclusions: The use of nonsterile water and ice from a contaminated ice machine contributed to this outbreak. Water-related fixtures can serve as reservoirs for Burkholderia, posing infection risk to hospitalized and immunocompromised patients. During outbreaks of water-related organisms, such as B. multivorans , nonsterile water and ice use should be investigated as potential sources of transmission and other options should be considered, especially for critically ill patients.

Disclosures: None

Equity is a foundational concept for the new World Health Organization (WHO) Pandemic Treaty. WHO Member States are currently negotiating to turn this undefined concept into tangible outcomes by borrowing a policy mechanism from international environmental law: “access and benefit-sharing” (ABS).

This article deals with the rehabilitation of economies in post-conflict states, paying particular attention to the role played by the state in this process. Using the example of Cambodia and its policies on rice production and export, the article shows the prominent role that may be played by the state in prioritised areas of economic development where there has been market failure. In the Cambodian case, the government targeted rice production and export as these had great potential for promoting the major aims of national development policy – economic growth and poverty alleviation. Using a whole-of-government approach and a combination of direct involvement and the creation of an enabling environment, the government appears to have contributed to vastly increased rice production and export.

This article traces the role of the state in developmental theory and practice, paying particular attention to public sector management. The early orthodoxy of modernisation theory put the state at the centre of development, giving it prime responsibility for generating development. Realisations of the shortcomings of modernisation theory and disappointment with its results led to the rise of neoliberal approaches in development thinking and action, with a focus on the shrinking state. However, in turn, the efficacy of neoliberalism has been questioned, and its human toll has been critiqued. Coupled with evidence of the success of the East Asian developmental states, the result has been a rethinking of the state and a new acknowledgment of its central role in development. Strong institutions and efficient, effective and responsive public sector management have been identified as key ingredients of capable states that made development happen. In outlining this trajectory, the article introduces the case studies that comprise this symposium.

An integral component of public management reform in Korea has been e-government, a field in which Korea has been a pioneer and in which it is the world leader. This article examines the Korean model of public management reform in the context of the developmental state and democratisation to describe and explain the emergence and expansion of e-government practices. The growth of e-government is tracked and the crucial role of the Ministry of Public Administration and Security delineated. Also covered are Government for Citizens initiatives, the provision of particular services, the mushrooming use of smart phones and emerging patterns of citizen participation, especially as related to local-level governance. The article demonstrates how much can be achieved in e-government and provides a model from which other countries can choose appropriate practices.

Democratic cooperation is a particularly complex type of arrangement that requires attendant institutions to ensure that the problems inherent in collective action do not subvert the public good. It is perhaps due to this complexity that historians, political scientists, and others generally associate the birth of democracy with the emergence of so-called states and center it geographically in the “West,” where it then diffused to the rest of the world. We argue that the archaeological record of the American Southeast provides a case to examine the emergence of democratic institutions and to highlight the distinctive ways in which such long-lived institutions were—and continue to be—expressed by Native Americans. Our research at the Cold Springs site in northern Georgia, USA, provides important insight into the earliest documented council houses in the American Southeast. We present new radiocarbon dating of these structures along with dates for the associated early platform mounds that place their use as early as cal AD 500. This new dating makes the institution of the Muskogean council, whose active participants have always included both men and women, at least 1,500 years old, and therefore one of the most enduring and inclusive democratic institutions in world history.

Monitoring of cryptic or threatened species poses challenges for population assessment and conservation, as imperfect detection gives rise to misleading inferences about population status. We used a dynamic occupancy model that explicitly accounted for occupancy, colonization, local extinction and detectability to assess the status of the endemic Critically Endangered Bermuda skink Plestiodon longirostris. During 2015–2017, skinks were detected at 13 of 40 surveyed sites in Bermuda, two of which were new records. Ten observation-level and site-specific covariates were used to explore drivers of occupancy, colonization, extinction and detectability. Sites occupied by skinks tended to be islands with rocky coastal habitat and prickly pear cacti; the same variables were also associated with reduced risk of local extinction. The presence of seabirds appeared to encourage colonization, whereas the presence of cats had the opposite effect. The probability of detection was p = 0.45, and on average, five surveys were needed to reliably detect the presence of skinks with 95% certainty. However, skinks were unlikely to be detected on sites with cat and rat predators. Dynamic occupancy models can be used to elucidate drivers of occupancy dynamics, which in turn can inform species conservation management. The survey effort needed to determine population changes over time can be derived from estimates of detectability.