No back to normal

The PHEIC – an alarm system that was not heeded

“The world simply cannot afford another period of inaction until the next health crisis.” This is a statement from the 2015 Report of the Ebola Interim Assessment Panel. It was not heeded. In September 2019, the Global Preparedness Monitoring Board was one of the many bodies and individuals that warned of a pandemic – stating it was not a question of if, but when. Since the Spanish flu, the world has seen a wide number of outbreaks but only a few have reached global dimensions and been defined a “public health emergency of international concern”. None has spread as far and had such impact as COVID-19.

A PHEIC is part of an "alarm system" and a "call to action". Since 2009, there have been six PHEIC declarations: the 2009 H1N1 (or swine flu) pandemic, the 2014 polio declaration, the 2014 outbreak of Ebola in Western Africa, the 2015–16 Zika virus epidemic, the 2018–20 Kivu Ebola epidemic, and the ongoing COVID-19 pandemic. Some outbreaks are automatically considered a PHEIC: SARS, smallpox, wild type poliomyelitis, and any new subtype of human influenza do not need an IHR decision to be declared.

The warning of the WHO when it declared a PHEIC on January 30^th, 2020 was not heeded by most countries. In early June 2021, the world has seen 172,980,867 corona cases, 3,719,064 deaths and 155,716,527 people recovered. The end is not in sight. As the world continues to be challenged by COVID-19 the number of proposals on how to “fix” the system of pandemic preparedness and response have increased. As always, they include proposals on how to reform the World Health Organisation, how to gain the higher-level interest of finance ministers and heads of state and how to improve global solidarity and financing. The frustration about action not taken – especially with regard to the implementation of and compliance with the International Health Regulations – remains high.

There is no lack of flowery statements on declaring health and pandemic preparedness and response as a “global common good” – but the situation in early June is still defined by high levels of vaccine inequity, a reality that the Director General of the WHO terms “vaccine apartheid”. Only 1% of the 1.3 billion vaccines injected around the world have been administered in Africa. In Latin America and the Caribbean, a region that accounts for only 8% of the world’s population but 30% of all reported Covid-19-related deaths globally, Peru, the country with the highest number of deaths, has only managed to vaccinate some 5% of the population.

The Geopolitics: the greatest threat to global health

There is something unique about this pandemic. Never has global health been subject to such extreme geopolitical stand-offs and competition. When our panel meets on 23 June further, debates will have taken place at the G7, the G20 and the BRICS as well as in many regional organisations – and consensus is ever harder to find. The pandemic and the WHO are pawns in this game at international and national level. Every issue is now a geopolitical race aiming to gain and show system and regime advantage: number of infections and deaths, percentage of vaccinated people, extent of vaccine donations. Vaccine diplomacy centres on gaining geopolitical advantage and sharing doses with friendly nations or in competition with others. Even the announcement of the US president to contribute 800 doses to COVAX included the statement: the US “will retain the say” on where the doses distributed through COVAX ultimately go. Similarly, there is the fear that a patent waver at the WTO would benefit Russia and China and give them access to Western innovation and technology. Geopolitics today is not driven primarily by weapon systems but by science and technology.

A new sharing mechanism established in April 2020, the ACT-Accelerator partnership, launched by WHO and partners, has supported a coordinated global effort to develop tools to fight COVID-19. With significant advances in research and development by academia, private sector and government initiatives, the ACT-Accelerator is contributing to fight the pandemic by deploying the tests, treatments, and vaccines. But it too has not been able to overcome regime competition in vaccine development and production.

A key political issue remains the knowledge on the origins of a virus. It is essential to avoid future outbreaks –but such knowledge can usually only be gained if it is not linked to assigning blame to countries or to groups within countries. 150 years of pandemic control and sanitary regulations have tried to address this problem – most recently the International Health Regulations that came into force in 2007. It aims to incentivise countries to share information and act responsibly with adhering to early notification: no one is safe until everyone is safe. The tense situation between the USA and China has made it extremely difficult to investigate the origins of COVID-19 – and the issue has only just this month reared its head again, probably for reasons of domestic policy and “being tough” on China. Part of this stand off includes the engineering of misinformation campaigns (on safety of vaccines for example) which as the WHO says spread faster than the virus. “Infodemics” have become a normal part of the geopolitics of global health.

But the problem also reflects itself in the need to give virus mutations abstract names so as not to discriminate and endanger members of certain population groups – Chinese and Indians for example. Still countries like to look to military examples – weapons inspections – to address the issue of pandemic preparedness. There is no reason to believe that a model based on a military security paradigm would be more successful than one based on a public health paradigm. One need only look back at the experience with UNSCOM and UNMOVIC and the Iraq war.

The reviews – what will follow?

In 2020 the member states of WHO – then under pressure from the Trump administration – set up two important review committees even though the pandemic was far from over. One to – yet again – review the International Health Regulations and an Independent Panel to assess the performance of WHO and the larger global health system, including the member states. Other organisations and bodies as well as non-governmental organisations have also been concerned with “what went wrong” and have commissioned reviews and/or provided proposals for change. And of course, there is no lack of media investigation and commentary as well as academic and think tank analysis.

As mentioned above The Global Preparedness Monitoring Board was one of the mechanisms that was established following the Ebola Crisis. The GPMB’s call for more political commitment, support of WHO, better financing and better compliance through an international framework has been taken up by the recent review committees in different ways, calling for example for high level political commitments and councils at the UN (a global health threats council), a pandemic framework treaty negotiated at the WHO, new financing mechanisms for global public goods discussed at the G20 and a strengthened WHO. The World Health Assembly in May 2021 did not find a consensus on any of these proposals.

The system failure

The Independent Panel stated: “The initial outbreak became a pandemic as a result of gaps and failings at every critical juncture of preparedness for, and response to, COVID-19”. But looking back at these experiences and the cycle of panic and neglect we must begin to see the devastating impact of the pandemic not only as a feature of lack of compliance with existing instruments and an outcome of geopolitical tensions but as a deeper system’s failure that requires a bolder response, reaching out beyond health. Frequently review committees tend to recommend creating new institutions and mechanisms thus contributing to the already considerable fragmentation of global health. What we require are political leaders with a vision and a willingness to address the system failures in an interconnected but deeply divided global risk society.

Five such system failures should be addressed:

- the lack of foresight and undervaluing preparedness at national, regional and global levels,
- the closing of the mind that leads to the weakness of multilateralism and to strong nationalism in times of crisis,

- the charity model of global health that has fragmented global health, is not fit for crisis and reinforces the unwillingness to share and pay for global public goods, in particular the WHO,

- the lack of recognition of the multi sectoral nature of pandemic origins and response, neglect of ONEHEALTH and planetary health,

- the geopolitical decoupling and provision of support – such as vaccines - not based on need but foreign policy priorities.

No matter what the geopolitical intentions and positions of countries and big powers - we require reliable multilateral collaboration on tackling three issues: climate change, pandemics and global health, and deep inequalities. All of them will require a new mechanism of fair financing of global public goods. This must be the approach that underlies all reform efforts, only then will they be transformative and ensure peaceful development.

We require the realisation that these global priorities are deeply interconnected and destroy lives and livelihoods if not addressed in new ways. The SDGs were the first call to change thinking – but they were not able to create a sense of urgency – 2030 seemed a long way off. It is a tragedy if it needs a health crisis on the scale of the present pandemic to get action by the United Nations, the G7 and the G20. But it would be an even greater tragedy if the pandemic does not lead to charting a bold way forward.

Professor Ilona Kickbusch is the Director of the Global Health Programme at the Graduate Institute of International and Development Studies, Geneva, Switzerland. Before returning to Europe, she was head of the global health programme at Yale University, New Haven, CT, United States of America.

Professor Kickbusch has had a distinguished career with the World Health Organization, at both the regional and global levels, and was responsible for the Ottawa Charter for Health Promotion, a seminal document in public health. She developed the “settings” approach and initiated programmes such as Healthy Cities, health-promoting schools, healthy workplaces, health-promoting hospitals and health in prisons. She also initiated WHO’s Health Behaviour in School-aged Children (HBSC) Study. She has contributed significantly to developing the concept of health literacy and most recently has spearheaded the field of global health diplomacy.