The Existing and Internationally Accepted Definition of Pandemics

The World Health Organization (WHO), conceivably the main global health authority, defines a pandemic as “the worldwide spread of a new disease.”Footnote ⁷ The Dictionary of Epidemiology provides further elements for the definition of pandemics by stating that a pandemic is “an epidemic occurring worldwide, or over a very wide area, crossing international boundaries and usually affecting many people.”Footnote ⁸ The Dictionary of Epidemiology further defines ‘pandemic’ as “a global spread of a disease” and ‘epidemic’ as “a widespread occurrence of a disease” that is more geographically limited than a pandemic.Footnote ⁹ The central element common in both pandemic and epidemic is therefore the idea of ‘spread.’ Although the Dictionary of Epidemiology has separate entries for the words ‘pandemic’ and ‘epidemic,’ scholars often use these words interchangeably.

The WHO and the Dictionary of Epidemiology provide the existing and internationally accepted definition of pandemics. The spreadability of the disease serves as the chief criterion of the definition (i.e., how widespread an illness is or can be). The WHO further refines this definition by creating six phases or stages of spreadability. The phases do not relate to the number affected by the outbreak nor the severity of the illness (e.g., the impact that a disease has on mortality, morbidity, and comorbidities). Instead, the phases of spreadability refer to the geographical location of the outbreak and how it may gradually disseminate across areas. Different phases require different responses, as follows:

The Conflation Problem

The existing and internationally accepted definition of pandemics posits that pandemic is the spread of a new disease, over a wide area, and crossing international boundaries. This definition can encompass a range of both communicable and noncommunicable diseases, with varying degrees of severity (e.g., the impact that a disease has on mortality, morbidity, and comorbidities), so long as they spread across countries. For example, the existing and internationally accepted definition of pandemics could include A(H1N1), Ebola, Zika, as well as obesity, tobacco addiction, diabetes mellitus, and substance abuse. The WHO has, in actuality, declared the 2009 A(H1N1), the 2014 Ebola, and the 2016 Zika outbreaks as PHEICs and global experts have had protracted debates on the pandemic threats related to these each of these three infections. Likewise, the WHO has warned against the global epidemic of obesity—or ‘globesity,’Footnote ²⁴ as they name it, and global health experts have extensively discussed the public health risks of the contemporary obesity pandemic.Footnote ²⁵ Both the WHO and global health experts have also dubbed tobacco addiction as a pandemic.Footnote ²⁶ Similarly, global health experts have also discussed the diabetes pandemic,Footnote ²⁷ the drug addiction pandemic,Footnote ²⁸ and substance abuse pandemic.Footnote ²⁹

All of these very distinct medical conditions, with varying degrees of spreadability and severity—and therefore varying degrees of urgency—have been conflated under the same label of ‘pandemic,’ in a way that it becomes difficult to differentiate between global health emergencies and nonemergencies within the specific context of pandemic preparedness and response. I will call this the conflation problem: a situation where two different global health realities are treated with the same degree of transmissibility, gravity, and emergency, because they fall under one same label (e.g., pandemic)—although one is much graver than the other.

A(H1N1), Ebola, and Zika have a degree of urgency that is distinct from the other examples named. The urgency attributable to A(H1N1), Ebola, and Zika is predicated on a combination of their high spreadability and high severity. The combination of high spreadability across national borders and high severity, which all these three communicable diseases display, justify their qualification as global health emergencies in the context of pandemic preparedness and response. Problems such as obesity are, in this sense, inherently different from A(H1N1), Ebola, Zika: although these noncommunicable diseases may affect populations across international borders, they would not spread as rapidly as infectious diseases do. Also, problems such as addiction or substance abuse may or may not be severe. However, because they are not infectious diseases, their form of spreadability is not sufficient to qualify them as global health emergencies that could be authentically equated with potential pandemics. Obesity, tobacco addiction, diabetes mellitus, and substance abuse fall outside of the narrower category of global health emergencies within the context of pandemic preparedness and response, and therefore integrate the broader category of nonemergencies, which cannot be authentically equated with potential pandemics.

To be clear, what I am defining here as a global health emergency in the context of pandemic preparedness and response is twofold: it has the spreadability component (i.e., it is a highly infectious disease) and it has the severity component (i.e., it is a grave communicable disease, with high impact on, e.g., mortality, morbidity, and comorbidities). This definition has two implications.

First, it means that a noncommunicable, yet severe (e.g., high impact on mortality, morbidity, and comorbidities), disease would not qualify as a global health emergency in the context of pandemic preparedness and response. Take, for example, the case of severe pain. Most recently, the WHO has warned against “the global pandemic of preventable pain,”Footnote ³⁰ calling for the imperative of universal access to palliative care. Although lack of universal access to palliative care qualifies as a grave human right violation that afflicts many populations across countries, it is not a pandemic.Footnote ³¹ It is not the degree of suffering that defines an emergency in the context of pandemic preparedness and response—even though suffering may very well be an adequate requirement to qualify emergency out of this context. Palliative care may be necessary as a medical treatment to PHEICs that have pandemic potential, but lack of universal access to palliative care alone cannot be considered a pandemic threat. Although pain can be very severe, it is not a communicable disease.

Second, if a global health emergency in the context of pandemic preparedness and response is predicated on both spreadability and severity, then communicable, but unsevere, diseases would also not qualify as a global health emergency that can authentically be equated with potential pandemics. For example, some seasonal flus can be high in spreadability, yet low in severity (e.g., low impact on, mortality, morbidity, and comorbidities). Although these types of seasonal flus can be highly infectious diseases that spread across countries fast, they should not be called a pandemic if they lack severity (e.g., high impact on mortality, morbidity, and comorbidities).

It has also been argued, in this respect, that certain seasonal flus cannot be truly called pandemics because, independently of their severity, they supposedly do not spread simultaneously in different WHO regions. As Heath Kelly, puts it: “seasonal epidemics are not considered pandemics. A true influenza pandemic occurs when almost simultaneous transmission takes place worldwide. (…) Simultaneous worldwide transmission is sufficient to define an influenza pandemic and is consistent with the classical definition of ‘an epidemic occurring worldwide.’”Footnote ³² For Kelly, therefore, the criterion of spreadability, on which the existing and internationally accepted definition of pandemics is predicated, is sufficiently clear to differentiate a pandemic from a nonpandemic. As such, the addition of the criterion of severity, for Kelly, is unnecessary, and the criterion of spreadability, as it is in the existing and internationally accepted definition of pandemics, is sufficient. In fact, for Kelly, even if the criterion of severity were useful for some decisions within the pandemic preparedness and response context, the severity index could be used, without the need to modify the existing and internationally accepted definition of pandemics.

Peter Doshi, however, disagrees. In arguing that the existing and internationally accepted definition of pandemics is elusive, he states that “the ‘pandemic’ label must of necessity carry a notion of severity.”Footnote ³³ In the same vein, when discussing the six phases of pandemics, Harvey Fineberg argues that a sole reliance the criterion of spreadability when defining those six phases leads not only to theoretical ambiguities but also to confusion as to when a situation should be treated as a pandemic because, in reality, the decisionmaking processes in the context of pandemic preparedness and response take into consideration both spreadability and severity, not just spreadability.Footnote ³⁴

In emphasizing the need of considering not only spreadability, but also severity, both Doshi and Fineberg are defending the views that (i) spreadability is a necessary but not a sufficient criterion; and (ii) severity is also a necessary criterion. Severity, alone, however, is not a sufficient criterion either, as I argued above when discussing the example of severe noncommunicable diseases, like severe pain and lack of universal access to palliative care. To be nuanced enough and avoid conflations between global health emergencies and nonemergencies, the standard definition of pandemics should, therefore, be predicated on both spreadability and severity. This new definition would solve the crux of the conflation problem and would therefore avoid definitional ambiguities that generate moral confusions, which lead to either divergent decisions or indecision in real life.

My argument that the standard definition of pandemics is not nuanced enough because it conflates two different realities of global health (namely, the much narrower cohort of global health emergencies, on the one hand, and the all-encompassing cohort of global health nonemergencies, including all other diseases, communicable or noncommunicable, severe or not, which spread across national borders, on the other hand) could raise at least two objections.

The first possible objection against my argument is that the standard definition of pandemics is nuanced enough, and the evidence of its sophistication is the fact that it is six-folded. Certainly, this manifold and complex definition of a pandemic would seem to be nuanced and presumably able to guide a gradual yet close surveillance with proper responsive measures to each stage of pandemic spread. However, the fact that a definition is complex and manifold does not necessarily entail that it is nuanced enough. The existing and internationally accepted definition of pandemics with its six phases is overly complex and repetitive.Footnote ³⁵ As discussed in section 1, there are more phases than necessary because not each phase corresponds to a specific and different response: there is no distinction among Phase 1, Phase 2, and Phase 3 in terms of required actions, and likewise there is also no distinction between Phase 5 and 6 in terms of pandemic response. Fineberg argues that the phase structure was “needlessly complex” and “less suited to operational management.”Footnote ³⁶ Because the existing internationally accepted definition of pandemics with its six phases has been considered problematic and ineffective, the IHR Review Committee has called for the simplification of the pandemic phase structure.Footnote ³⁷

The second possible objection against my argument is that the standard definition of pandemic is nuanced enough because it does acknowledge the existence of global health emergencies under the so-called PHEIC. Certainly, in doing so, the WHO would seemingly acknowledge the distinction I am arguing for between global health emergencies and nonemergencies in the context of pandemic preparedness and response. However, the fact that the WHO has produced the definition of PHEIC in parallel to its definition of pandemic (with no clear correlation between these two definitions) does not solve the conflation problem I am alluding to between global health emergencies and nonemergencies in the context of pandemic preparedness and response. As argued above, the crux of the conflation problem is that the existing and internationally accepted definition of pandemics is not nuanced enough because it is predicated on the criterion of spread alone, rather than on the criteria of spread and severity conjointly. As discussed in section 1, the definition of PHEIC is predicated on the criterion of spreadability, rather than severity. As article 1 of the IHR puts it: “‘public health emergency of international concern’ means an extraordinary event which is determined, as provided in these Regulations: (i) to constitute a public health risk to other States through the international spread of disease, and (ii) to potentially require a coordinated international response” (emphasis added). Also, as discussed in section 1, although the IHR acknowledges severity in general terms, it mentions the word only once in its article 13.4, regarding the additional provision of severity assessment, because the purpose and scope of the IHR are “to prevent, protect against, control, and provide a public health response to the international spread of disease in ways that are commensurable with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade” (emphasis added).Footnote ³⁸

The Solution to the Conflation Problem

Section 2 established that, in order to be nuanced enough and avoid conflations between global health emergencies and nonemergencies, the existing and internationally accepted definition of pandemics (discussed in section 1) should be predicated on two criteria: spreadability and severity. Neither spreadability nor severity alone would solve the crux of the conflation problem: only spreadability and severity together can adequately address the moral confusions that lead to divergent decisions and indecision in real life, regarding pandemic preparedness and response.

The adequate solution to the conflation problem would clarify the standard concept of pandemics by highlighting the moral value and distinctiveness of pandemics, with the purpose of better guiding and facilitating the decisions in pandemic preparedness and response. Pandemic is a morally valuable and distinct idea, thus: pandemic is a global health emergency that not only spreads rapidly but also is severe (e.g., has high impact on mortality, morbidity, and comorbidities), and these justify resource allocation priority over and above nonemergencies that are not as urgent within the context of pandemic preparedness and response. Global health emergencies and nonemergencies are not, as argued in section 2, on a moral par. These are two distinct global health realities, and putting them together under the same label of pandemics causes moral conflation that leads to practical confusions in decisionmaking.

The precise definition of pandemics, as Daniel Barnett contends, matters because it has practical implications, and these moral distinctions are “not a minor semantic distinction, but rather one of enormous bearing on planning priorities.”Footnote ³⁹ Beyond planning priorities, however, lack of conceptual clarity also leads to communication challenges in pandemic responses. In discussing the defects of the IHR, Fineberg highlights the “difficulties in decisionmaking under conditions of uncertainty: associated with typical “challenges in communication”Footnote ⁴⁰ in the context of pandemic response. In this sense, some global health experts add that lack of conceptual clarity erodes communication and this, in turn, erodes the trust in the WHO and their global health authorities.Footnote ⁴¹ For Barnett, the erosion of communication and trust, not only reduces “compliance with essential protective guidance in the face of future threats,” but also enhances “complacency among frontline responders.”Footnote ⁴² As Doshi points out, the WHO has eroded the trust in its global health authorities by having continually exaggerated its pandemic predictions and by not conveying the truth about the outbreak situation.Footnote ⁴³

Some other global health experts, however, disagree that conceptual clarity is relevant. For Luc Bonneux and Wim Van Damme, for example, theoretical definitions are useless because “decisions must be based on adaptive responses to emerging powers, not on definitions,” and therefore the field of global health should need, they claim, “fewer, not more ‘pandemic preparedness’ plans and definitions.”Footnote ⁴⁴ Bonneux and Van Damme seem to be putting forth a Wittgenstinian claim that definitions do not need clarity for meaning and therefore one shall not be fixated on meticulous definitions of words, because language is adaptive according to the context.

Certainly, context is relevant for the adequate interpretation of terms. Yet, that is not to say that the clear definitions do not matter at all for the meaning of words. In this respect, Timothy Endicott, in How to Speak the Truth, discusses the role of language in the specific context of law. Endicott argues against what he calls “the dispositional theory,” according to which the meaning of words depends on how people are disposed to use those words. He gives the example of the word ‘friendship.’ In a “dispositional theory of friendship,” Endicott argues, the true meaning of the word friendship “would be misshapen because of the distracting prejudices and biases that distort people’s dispositions – so Aristotle says that the form of friendship that people are most disposed to recognize is that based on usefulness of others.”Footnote ⁴⁵ It is not difficult to come up with concrete examples where one calls someone a friend chiefly because such person is useful for one’s life goals. However, according to Endicott, this dispositional meaning of friendship distorts and misshapes the true meaning of friendship. There is, I think, an even clearer instance of a dispositional meaning of friendship that is misshaped and distorted. Take, for example, the contemporary phenomenon brought by Facebook. The way people are disposed to use the word ‘friend’ has changed after the emergence of the broad term ‘Facebook friends.’ Best friends and acquaintances alike are conflated among different realities and degrees of personal relationships. Conflating words also conflates the moral value and the meaning of different realities.

To counter such conflation, Endicott proposes an Aristotelian solution to the problem of understanding the true meaning of words like ‘friendship’ which can also be applied to the word ‘pandemic.’ In order to elucidate the true/focal meaning of words, Endicott spells out a three-fold legal interpretation method for selecting concepts through evaluative judgments. This method shows that conceptual clarity is not useless: there are important practical implications deriving from definitions and the meaning given to words. However, Endicott’s argument is compelling because it explains why the need for conceptual clarity goes beyond a mere consequentialist argument that focuses exclusively on the implications of language use and interpretation. His Aristotelian method helps identify the purpose for which the word is best understood to have been used as well as its context.Footnote ⁴⁶ It shows the moral distinctiveness of the true/focal meaning of words, and the ethical necessity of correctly defining pandemics. I use Endicott’s three principles of the meaning of words and apply it to explore the idea of the word pandemics today:

1. a) the analogy principle: when the WHO uses the word ‘pandemic’ to qualify the contemporary phenomenon of the spread of obesity across the globe, the WHO does so based on what the organization perceives as a similarity between a ‘true’ pandemic and obesity. As discussed in section 2, when the WHO calls obesity (or ‘globesity’),Footnote ⁴⁷ tobacco addiction, diabetes mellitus, substance abuse, and preventable pain ‘pandemics,’ this makes the meaning of the word ‘pandemic’ expand. As discussed in section 2, however, it would be improper to call any of these noncommunicable diseases a ‘pandemic’ because they so fundamentally lack what makes a pandemic a pandemic that the point of using the word is lost. And the point is lost because ‘globesity,’ tobacco addiction, diabetes mellitus, substance abuse, and preventable pain are insufficiently similar to a paradigm (or central case) of pandemic to merit being called ‘pandemic.’ This leads us to the next principle.

2. b) the paradigm (or central case) principle: when the WHO uses the word ‘pandemic’ to qualify the growing number of obese people, smokers, diabetic individuals, drug addicts, and people suffering unbearable pain for lack of access to palliative care, the purpose of the WHO is to draw people’s attention to these escalating global health problems. This, however, is not the purpose for which the term ‘pandemic’ is to be used: the word ‘pandemic’ is not to be used as a mere rhetorical tool to emphasize the global spread of all kinds of problems. Rather, the true/focal meaning of the word ‘pandemic’ is identified by an evaluative judgment on both the purpose (i.e., the moral value or distinctiveness) and the context of the word ‘pandemic.’ And the moral value or distinctiveness of a pandemic is in the fact that a pandemic is a global health emergency that not only spreads rapidly but also is severe, and that justifies priority resource allocation over and above nonemergencies that are not as urgent.

3. c) the context principle: in order to properly elucidate the purpose of a ‘pandemic,’ the context where the word is used needs to be taken into consideration. And because the context principle builds on the paradigm (central case) principle, the context cannot be established without the previous examination and identification of purposes for which the term ‘pandemics’ is used. In view of that, the question here will be: what is the purpose for and the context in which the word ‘pandemic’ is best understood to have been used? As argued in sections 1 and 2, it would be a misuse of language to call obesity, tobacco addiction, diabetes mellitus, substance abuse, and preventable pain ‘pandemics.’ These are not central cases in which the word ‘pandemic’ is used. Instead, the central case of pandemics is global health emergencies that not only spread rapidly but also are severe, and that justify priority resource allocation over and above nonemergencies that are not as urgent.

In light of Endicott’s theory of legal interpretation, if conceptual clarity is not useless and if it does matter for practical reasons, why would the WHO and some global health experts be reluctant to use the words ‘pandemic’ exclusively to refer to its true/focal meaning (i.e., to refer to global health emergencies that not only spread rapidly but also are severe)? Is there a reason why the WHO and some global health experts are reluctant to add precision to the existing and internationally accepted definition of pandemics, by adding the criterion of severity to it?

Some speculate that the WHO has political and financial reasons to keep a broader definition of pandemics, rooted in spreadability alone.Footnote ⁴⁸ The addition of the severity criterion in conjunction with the spreadability criterion would drastically narrow the instances of pandemics declaration. In this way, they claim, by keeping an all-encompassing definition of pandemics, the WHO can obtain more resources: every time a communicable or noncommunicable disease spreads across international boundaries, the WHO rouses governments and the public, and receives extra financial support for pandemic preparedness and response. Were the criterion of severity to be added to the existing and internationally accepted definition of pandemics, the WHO would then substantially limit the incidences of pandemic declarations and therefore get less capital. And this could be fatal for the WHO, given “the highly competitive market of health governance, [where] the struggle for attention, budgets and grants is fierce.”Footnote ⁴⁹

It might be true that the WHO has political and financial reasons to keep a broader definition of pandemics, which does not include the criterion of severity. However, a less speculative and therefore more robust reason for the WHO to keep the standard definition as it is would be the fact that, arguably, it is too difficult to measure severity and find evidence for it. This, it is argued, would disqualify severity as a good and feasible criterion. However, severity indices do exist.Footnote ⁵⁰ Also, the fact that something is difficult or even unfeasible does not mean that it is necessarily unimportant. In fact, many difficult things, which can be thought of as unfeasible, are morally required. Conceptual clarity might be difficult to achieve; it might even be considered an unfeasible enterprise. It is however, morally required, not only for practical implications but also for the moral value and distinctiveness of the true/focal meaning of words such as pandemics.