Eighteen Doors, and a Statute of 1908

Part IV of the International Health Regulations (2005), Articles 19 to 22 with Part B of Annex 1, governs the places where a country meets the world. A “Point of Entry” is a passage for international entry or exit of travellers, baggage, cargo, containers, conveyances, goods and postal parcels, together with the agencies and areas serving them. Article 19 requires the Annex 1 capacities to be developed at every designated point and the competent authority at each to be identified. Article 20 requires the designation of airports and ports and the issue of Ship Sanitation Control Certificates and Exemption Certificates under Article 39 and Annex 3. Article 21 permits the designation of ground crossings and invites neighbouring States to consider joint designation of adjacent ones. Article 22 then lists the nine duties of the competent authority, among them the supervision of deratting, disinfection, disinsection and decontamination, the control of the discharge of sewage, refuse and ballast water, the maintenance of effective contingency arrangements, and communication with the National IHR Focal Point.

This is the limb of health security where Pakistan’s law is most obviously mis-allocated, and the reason is constitutional rather than technical: the border is federal while health is devolved.

Eighteen, and not twenty-eight

Pakistan has 18 designated points of entry: nine airports, six ground crossings at Chaman, Khokrapar, Sost, Taftan, Torkham and Wagah, and three seaports at Bin Qasim, Gwadar and Keamari, the last three being those on the World Health Organization’s list authorised to issue Ship Sanitation Certificates. That itemisation is the one given by the Joint External Evaluation of Pakistan’s IHR core capacities, on the mission of 15th to 24th May 2023, published by the World Health Organization on 28th March 2025.

A word of caution to anyone drafting from the Pakistani secondary material. Two reports in wide circulation, the In-depth Analysis of IHR-Related Laws in Pakistan of 18th November 2024 and the second part of the Evidence for Health legal research report, both reproduce the World Health Organization’s passage verbatim and then print the total as twenty-eight. The itemisation they carry is word for word the itemisation above, and it sums to eighteen. The twenty-eight is a transcription error, and since a figure of that kind travels from report into submission and from submission into a bill, therefore it should be corrected wherever it is met.

Capacity at those eighteen places is recorded as developed but not sustained. The six ground crossings have no isolation facilities and no diagnostic capacity at all. There is no memorandum of understanding between the points of entry and the health facilities behind them. There is no national multisectoral mechanism for risk-based decisions on travel measures, which is why state functionaries during the times of COVID-19 simply followed the advisories of the National Command and Operation Centre, a body created by a letter of the Prime Minister’s Office and by no statute. The Travellers Surveillance Management Information System depends on operators funded by the World Health Organization. And illegal animal crossings bypass the system entirely.

The Act which says nothing about health

The Ports Act, 1908 contains no sanitary provision whatsoever. Port health rests instead on the Pakistan Port Health Rules 1974 and on the Pakistan Aircraft (Public Health) Rules 1965, whose list of quarantinable diseases has been frozen since 1965 at yellow fever, plague, cholera, smallpox, typhus and relapsing fever.

Smallpox was declared eradicated in 1980. It is still on the list. Mpox, which killed a man at the Pakistan Institute of Medical Sciences in February 2026, is not.

The position in the air is no better, and in one respect it has gone backwards. The Pakistan Civil Aviation Authority Act, 2023 mentions public health only at Section 4(2)(g) and Section 4(2)(k), and in doing so it dropped the express enforcement power which stood in Section 9 of the Ordinance it repealed. A statute passed in 2023, three years after the Honourable Supreme Court of Pakistan was told that no national public health law existed, removed a health enforcement power from the aviation regulator and put nothing in its place.

The traveller, and what is owed to him

The Regulations are not one-sided, and the duties they impose towards the traveller are the ones a Pakistani officer at Torkham is least equipped to discharge. On arrival or departure a State may require information as to destination and itinerary and may apply the least intrusive non-invasive medical examination; but no examination, vaccination or prophylaxis may be carried out without prior express informed consent, save under Article 31(2); ships and aircraft may not be refused free pratique for public health reasons; and Article 32 requires that a traveller placed in “Quarantine” or “Isolation” be treated with dignity and given food, water, accommodation, communication and medical care.

Since there are no isolation facilities at any of the six ground crossings, therefore an officer at Chaman who detains a sick traveller cannot comply with Article 32 whatever his intentions, and an officer who lets that traveller pass has complied with nothing at all. The choice the law leaves him is between two breaches.

Whose door is it

Border Health Services told the Evidence for Health team what the problem is in one sentence: legislation should make health measures at the border unambiguously federal. That is right, and it is the whole of the difficulty. Health was devolved to the provinces by the Constitution (Eighteenth Amendment) Act, 2010, while entry into and departure from Pakistan remained federal; and hence at every one of the eighteen doors a federal officer stands upon a provincial subject, holding rules of 1965 which do not name the disease in front of him.

The cure is not a new agency. In the light of the above, it is urgently required that three things be done. First, that the Draft National Health Security and Infectious Disease Contingency Act 2026 name the competent authority at each designated point of entry, as Article 19 requires, and vest in it the nine duties of Article 22 expressly, with the Federation answering for them and the provinces bound through endorsement by the Council of Common Interests under Article 154 of the Constitution of the Islamic Republic of Pakistan, 1973. Secondly, that the Pakistan Aircraft (Public Health) Rules 1965 be replaced by rules whose schedule of quarantinable diseases is amendable by notification, so that the list never again stands still for sixty years. Thirdly, that Pakistan take up the invitation in Article 21 and put the cooperation practised at Torkham and Chaman on a footing of joint designation under Article 57, since the traffic across those crossings is not going to wait for the statute book.

Eighteen doors, six of them without so much as a room to isolate a sick man in, and behind all of them an Act of 1908 which does not mention health. The next importation will not arrive because the science was not understood; it will arrive because nobody at the door held a power worth the name.