Complaints against the trend toward compulsory vaccination and the manner in which WHO is promoting it are being directed, in the United States, to Congress and to the American delegations to the U. N. and the world health assembly. Comparable channels exist in other countries.

Remedial action could take the form of amendments to the WHO constitution, efforts to persuade WHO to amend the international sanitary regulations, or— in the last analysis—withdrawal from WHO through congressional action. The United States made provision for such withdrawal when it approved entry into the organization.

Much will depend, it is agreed, on the manner in which the 115 articles of the new convention are interpreted by the governmental health authorities who will enforce them.

Great latitude is given to health administrations. They will administer the law directly, and deal directly with WHO, bypassing heads of State, cabinets, and legislative authorities.

Medical officers at ports and airports are given wide discretionary power. Among other things, compulsory medical examination of incoming or outgoing travelers is authorized whenever a frontier health authority anywhere in the world considers it necessary. Even if a "healthy" ship merely stops at a port and a passenger or crew member does not get off, health authorities may come aboard and subject him to compulsory examination.

The provisions applying to smallpox vaccination are contained in article 83. It is one of the permissive articles. It provides:

1. A health administration may require any person on an international voyage who does not show sufficient evidence of protection by a previous attack of smallpox to possess, on arrival, a certificate of vaccination against smallpox. Any such person who cannot produce such a certificate may be vaccinated; if he refuses to be vaccinated, he may be placed under surveillance for not more than 14 days, reckoned from the date of his departure from the last territory visited before arrival.

14-DAY PERIOD

2. A person on an international voyage who during a period of 14 days before his arrival has visited an infected local area and who, in the opinion of the health authority, is not sufficiently protected by vaccination or by a previous attack of smallpox, may be required to be vaccinated, or may be placed under surveillance, or may be vaccinated and then placed under surveillance; if he refuses to be vaccinated, he may be isolated. The period of serveillance or isolation shall not be more than 14 days, reckoned from the date of his departure from the infected local area. A valid certificate of vaccination against smallpox shall be considered as evidence of suflicient protection.

Legal authorities say this article is loosely drafted and susceptible of more than one interpretation.

Paragraph 1, it is agreed, applies to persons who are not considered to have been exposed to smallpox, while paragraph 2 applies to those who are considered to have been exposed.

The question of whether a traveler is considered to have been exposed or not turns on whether he has visited an infected local area. The regulations define this phrase as a local area where there is one case of smallpox derived from a nonimported case or two cases derived from an imported case.

The word, "local," however, is not precisely defined. It may refer to an area as small as a port or airport. But in at least one instance where a smiliar problem arose, a quarantine officer of the United States Public Health Service interpreted it to mean an entire country-England.

UNDER SUSPICION

Thus if there is anywhere in England a single case of smallpox thought to have been caused by an infected person within the country, all travelers who have visited any part of England, no matter how remote, may be faced with a choice between forcible vaccination and 2 weeks' quarantine at the next frontier. Even if a person is considered to have been exposed, medical authorities do not agree that vaccination after exposure serves a useful purpose so far as protecting others from contagion is concerned.

Doctors say the smallpox vaccine-which they describe as the virus of cowpox, a cattle disease-ordinarily has no curative power, and, indeed, may have ill effects.

They say an exposed person who thereafter is vaccinated will develop the disease in a milder form and be a menace to society in much the same fashion as one who is not, unless he is vaccinated almost immediately after exposure.

Thus the provisions of article 83, paragraph 2—for vaccinating a person who has been exposed-appear to observers to be a form of discipline rather than a protective measure.

INTERPRETATION VITAL

If a traveler has not visited an infected local area and thus is not considered to have been exposed, his treatment will depend upon the interpretation health authorities place under paragraph 1 of article 83.

The first sentence provides, without any qualification, that a health authority may require any person arriving in the country to have a vaccination certificate if the person has not had smallpox-and the next sentence says he may be vaccinated if he does not have such a certificate.

There is then a semicolon and the phrase "if he refuses" is used. Whether the traveler is unconditionally free to refuse is not made clear.

As a minimum, however, if a person has a conscientious objection to vaccination, he can be placed under surveillance, a form of medical probation. He will not be isolated and may move about freely, according to article 27 of the code governing surveillance. But he may be required to report to the health authority at specified intervals and subjected to "medical investigation."

Dr. Calvin Spencer, Chief of the Division of Foreign Quarantine of the United States Public Health Service, the man immediately in charge of enforcing vaccination laws at American ports, is one of those who place a strict interpretation on the code.

Dr. Spencer said in a recent interview that article 83 "does appear to contravene" present exemptions from vaccination in American law. A departmental legal team is studying the code with a view to tightening United States Public Health Service regulations, if necessary, he said.

The relevant portion of the health-service regulations is section 71. As it now stands, this section provides that persons arriving at an American port may satisfy the smallpox vaccination requirement by presenting a statement from a local or national health authority at the place of embarkation, affirming that they were not in an area where smallpox was present in the 14 days, immediately prior to embarkation for a port under the control of the United States.

These certificates ordinarily are accepted. A quarantine officer, however, is not bound to accept them in all circumstances. Such travelers may be held under observation for not more than 14 days if the quarantine officer has reason to believe they have been exposed to smallpox within 14 days prior to arrival.

COVER WIDE RANGE

The International Sanitary Regulations cover a very wide range of topics. They lay down standards for the control of plague, cholera, yellow fever, typhus, and relapsing fever, as well as smallpox. They apply to boats, automobiles, trains, and all other media of transporting as well as to persons.

Vaccinations against plague, typhus, and relapsing fever, the code provides, shall not be required as a condition of entry into a country. WHO officials say the ban on typhus injections will require removal of this requirement by some countries.

Vaccinations against yellow fever shall be required—that is, are mandatory— for travelers leaving an infected local area and proceeding to a yellow-fever receptive area. The latter area is defined as one in which yellow fever does not exist but where conditions would permit its development if introduced.

Persons without yellow fever vaccination certificates who are traveling from an infected area to a receptive area may be isolated for as long as 6 days. WHO officials say this period is shorter than some countries have required.

With regard to cholera, even a vaccination certificate will not protect a traveler from surveillance, if he has come from an infected local area. If he does not have a certificate, he may be isolated for up to 5 days.

TIMETABLE TRACED

The regulations establish a vast clearinghouse for information about disease. Health authorities in all countries are required to notify the World Health Organization daily, weekly, monthly, and annually, sometimes even hourly, of the

number, type, and symptoms of diseases in men and animals; of the countermeasures taken; and of important changes in its health laws and practices.

The timetable followed by WHO in enacting the sanitary regulations was as follows:

May 25, 1951: WHO assembly voted them unanimously.

June 6, 1951: Dr. Brock Chisholm, Canadian Director-General of WHO, formally notified the health administrations of member governments. (He was not required to notify heads of state or foreign ministers; the code authorized him to bypass usual channels.)

June 6, 1951 to March 6, 1952: 25 countries submitted reservations; thereupon, the 9-month period having elapsed, no further reservations could ever be offered (except for colonies, in which case the deadline is extended to December 6, 1952). March 6 to October 1, 1952: The reservations were discussed in WHO committees; all but four countries withdrew them, modified them, or convinced WHO they should be accepted as minor.

October 1, 1952: The regulations will come into effect, having the force of domestic law in all member countries except Australia, Argentina, Burma, and Saudi Arabia.

UNUSUAL POWERS

No organ of the United Nations except WHO has the power to legislate for member governments. Article 22 of the WHO constitution entitles this specialized agency to make regulations within its field of operation which shall come into force for all members after due notice has been given of their adoption by the World Health Assembly except for such members as may notify the Director-General, of rejection or reservations within thhe period stated in the

notice.

"Due notice" is not defined. In the case of the Sanitary Regulations, it was 9 months. WHO may decide in each instance how much notice it chooses to give. WHO also may decide whom to notify. In the present case, it decided that any notification or information sent by the Organization to the Health Administration shall be considered as having been sent to the state.

Thus no governments, let alone legislatures, were notified directly that the Sanitary Regulations had been enacted on their behalf.

Observers consider this circumstance especially significant in the case of the United States, which exercises great if not decisive influence in WHO, as in most other U. N. organs.

The United States Congress, like other legislatures, agreed to a partial delegation of sovereignty when it approved the WHO constitution in 1948. Those who recall the debate, however, say they doubt that Congress realized how broadly the grant would be interpreted.

STOP, LOOK, AND QUESTION

(An editorial)

In 1948 when Congress debated joining the World Health Organization efforts were made to insure that the United States would not be inadvertently committed to a program of compulsory insurance for medical care. Reasons for this caution and for a reservation enabling the United States to withdraw from WHO are now becoming more apparent.

For on October 1 WHO regulations incorporating even greater infringemen's of individual rights than are involved in compulsory insurance will go into effect. An article describing this situation appears on the first page of our second section today. We believe it should cause a sharp questioning of WHO's procedures and results.

The purpose of cooperating to prevent the spread of disease is a wholly laudable one, and we have the greatest respect for all unselfish efforts to that end. But we believe mistaken methods are being used, not only in the treatment of disease but in the disregard of constitutional procedures and civil liberties.

We do not question the right of those who desire vaccination and inoculation to have it. We do not question the right of those who declare such treatment that provides immunization to force it on others for their own protection. Moreover, we strongly question procedures which permit WHO to bypass the government of any country and place very great discretionary power in the hands of an administrative agency.

The rather remarkable constitution of WHO gives it the power to legislate for member countries unless they object. And in setting up the new regulations on international travel WHO did not even trouble to notify the State Department or Congress-which presumably could exercise a veto. One remedy would be for Congress to curb the arbitrary authority now exercised by the Public Health Service, which appears to be acting both as promoter and agent of WHO. Another remedy would be to insure by constitutional amendment that limitations be placed on so-called self-executing international agreements. This newspaper does not wish to be alarmist. As we understand it, WHO is alone among United Nations agencies in its power to legislate for member nations. We believe that the rights of individuals and states under the American Constitution can be protected from infringement by an international organization or through treaties. But the situation now precipitated by WHO indicates that a properly framed constitutional amendment may be required.

THE NATURE AND PURPOSE OF THE WHO INTERNATIONAL SANITARY REGULATIONS The story under the caption “Pattern for Compulsory Medication," and the editorial under the title "Stop, Look, and Listen," which appeared in the Christian Science Monitor of September 26, 1952, reveal a basic misunderstanding of the nature and purpose of the international sanitary regulations to which they refer, and of the procedures under which they were adopted. They also fail, unfortunately, to relate the provisions of these regulations to quarantine practices in which the United States and other states have been engaged for many years.

The reader of this story and editorial is told, in effect, that an international organization, the World Health Organization, in adopting the international sanitary regulations, usurped the power of sovereign states and, purposely bypassing normal channels of communication between the World Health Organization and member governments, conferred wide discretionary power directly upon the health administrations of national governments which could readily be used to infringe upon individual liberty--for example, by requiring vaccinations. The reader is told, among other things, that "the U. N. World Health Organization, acting largely at the instance of the United States, has launched what one official calls a terrific drive' for worldwide smallpox vaccination of travelers"; that "considerable new power also falls into the hands of national health authorities such as the United States Public Health Service"; that “in an extreme case, if Congress were not alert, the present powers assumed by WHO and the national health authorities could be stretched to cover the enactment of compulsory national health programs or the imposition of mass medication in a form which the Congress might disapprove if presented in the normal way— as a bill to be acted upon"; that "no governments, let alone legislatures, were notified directly that the sanitary regulations had been enacted upon their be half." and that “WHO did not even trouble to notify the State Department or Congress."

The purpose of this memorandum is to explain the nature and purposes of these regulations, and to describe the way in which they were drafted, reviewed, and adopted.

To begin with, it might be pointed out that international sanitary regulations, or quarantine regulations, as they are sometimes called, are not new. They have been in existence for 50 years in the form of treaties. These treaties were concluded to unite states on measures to prevent the international spread of epidemics of cholera, plague, smallpox, typhus, and yellow fever, and at the same time to prevent undue interference with the movement of persons traveling outside the borders of their own countries and of goods, ships, and aircraft in international commerce. Without regulations of this kind, ships and airplanes as well as United States nationals traveling abroad, might be subjected to all sorts of restrictions on their freedom of movement through the arbitrary application by other governments of their own quarantine laws.

These treaties were considered to have certain disadvantages, however, stemming largely from the relatively slow procedure involved in bringing them into effect or in getting them modified. Thus, long delays occurred in bringing into force any new regulations designed to take account of scientific discoveries and technical advances in the control of communicable diseases as well as in transportation facilities. Some 40 countries, many of them important in air traf30572-53--20

fic, never became parties to any sanitary convention for aerial navigation and could therefore deal with planes and passengers as they pleased. This caused considerable difficulties to the American airlines operating abroad. Moreover, considerable confusion concerning the application of quarantine measures has existed because of the continuance in effect for some countries of the outmoded regulations in old treaties, even when newer treaties to bring the regulations more up to date were concluded and became binding on many more countries. Consequently, even a minimum of the uniformity of sanitary controls which was sought could not be obtained.

Hence, those entrusted with the responsibility for the administration of national quarantine measures, those in command of ships and aircraft which were subjected to these measures, as well as governments, were anxious to find a procedure which would facilitate the adoption of up-to-date regulations without long delays. In this connection, attention might be called to the following statement in the Report of the United States Delegation to the International Health Conference in 1946, at which the constitution of the WHO was formulated: "The concept underlying the regulatory power of the Organization [WHO] was developed jointly by the Department of State and the Public Health Service, ** in an effort to create a mechanism in the international field which would permit rapid general application of new scientific techniques in the international control of the spread of disease. This was done in pursuance of a suggestion made in the Senate Foreign Relations Committee that some way be found to accomplish this without requiring that committee to consider highly specialized technical matters. It is felt that the mechanism incorporated in the constitution can accomplish this result. In most cases, it will only be necessary to modify existing domestic regulations, within the scope of the executive branch of the Government, to meet the requirements of international health regulations. When more is required the Government can reserve its position pending necessary reference to Congress."

To meet this generally recognized need, therefore, there were included in the WHO constitution two articles (arts. 21 and 22) drafted so as to provide a simpler mechanism to facilitate the adoption of international regulations which are needed in certain limited technical fields. Thus, article 21 of the constitution of the WHO provides that the health assembly shall have authority to adopt regulations concerning, inter alia, sanitary and quarantine requirements and other procedures designed to prevent the international spread of disease. According to article 22, regulations which the assembly may adopt shall enter into force for all members of the Organization except those as may notify the Director General of the rejection or reservations within the period stated in the notice to member governments of the adoption of the regulations.

The authority granted to the WHO in its constitution to adopt regulations was brought to the attention of the Congress when it was considering United States membership in the World Health Organization. In the report, submitted by Senator Vandenberg on behalf of the Committee on Foreign Relations to the United States Senate (No. 421, 80th Cong., 1st sess.), it is stated that "The health assembly may adopt regulations concerning sanitary quarantine requirements which in the past have been embodied in conventions and could be changed only by customary treaty procedures. *** The adoption of such regulations and standards requires a two-thirds majority vote of the health assembly. This power is similar to that which has been granted to other international organizations in technical fields, such as the International Civil Aviation Organization. Each government will be free to reject such regulations and standards and their assent is not necessary to bring them into effect. The committee recognizes the safeguards to national sovereignty in the provisions of the constitution which confer these powers on the health assembly." It might be pointed out that the safeguards referred to are : (1) The limitation of the WHO's regulatory authority to certain specified subjects, such as sanitary and quarantine requirements, and (2) the right of any member government to reject the regulations which the health assembly may adopt or to make reservations with respect to such regulations.

The report of the Committee on Foreign Affairs (No. 979, 80th Cong., 1st sess. ) to the House of Representatives, which was presented by Congressman Judd, in describing the benefits to the United States of membership in the WHO refers specifically to those expected to be derived from the Organization's power to adopt regulations;

"Improved control of disease at epidemic centers abroad will give the United States increased protection against incursion of disease.