The COVID-19 pandemic has exposed all the strengths and weakness of our respective health systems. It has illuminated some uncomfortable truths. From the weakness of global mechanisms such as International Health Regulations1 and the Alliance for Health Security Cooperation Joint External Evaluation programs through to individual preparedness of nation states for just such an eventuality2. It has also made us look at what the securitisation of global health actually means. The pandemic has also provided a mirror to protean therapeutic geographies and complex, bio-hybrid threats in an increasingly globalised, interconnected world. It has reflected ‘true colours’ of how we both conceptualise global health and what value sets we work by, as well as what diseases really ‘matter’ and to whom? And finally, the pandemic has been an additional weight on global health that has expanded existing fissures and created new ones. It has exposed fault lines across the geopolitics of global health that have been growing for some time. Faultlines between countries, ideologies of health (and disease), cabals and colonial constructs that still hold huge sway in global health and those growing divisions between vulnerable, deprived populations and the wealthy. The solutions proposed have been as varied and multiple as stars in the night sky; from the highly instrumental, e.g. pandemic ‘radar’ system based on genomic analysis to the highly abstract e.g. an integrated global pandemic treaty. But these are solutions for a very specific threat, namely epidemics and pandemics3. Infectious diseases do not emerge in isolation. In most countries now they constitute part of the double burden of disease with health systems having to adapt to significant rises in non-communicable diseases. Fragile and conflict impacted countries also create uniquely complex ecosystems for global health. Peaceful co-operation is the hallmark of good health and good disease management irrespective of setting. Peace is a bridge for health and health is a bridge for peace.
One of the least reported co-operative actions of the pandemic, particularly in the early weeks and months of the outbreak was the communication, at clinical and scientific level between the UK and China. Old friends and acquittances were rapidly engaged to understand what was happening and what patient management strategies might work. The more the respective communities understood, the better equipped we felt. This spoke to one of the most critical aspects that the pandemic has illuminated. Accurate and truthful data sharing is king4. But information by itself is not enough. It has to be actionable intelligence and as we, and others, have argued the Mertonian norms of science were not sufficient to deliver what was needed5. However, the foundations of such exchanges of data require long term exchanges, fellowships and trusting friendships. Examples abound of significant relationship building e.g. the US-China Joint Committee for Cooperation in Medicine and Public Health that started in the 1980s through to major programs between US-China CDC which only ended relatively recently in 2017. The history of US-China health exchange and collaboration, counter to the political interface, is an excellent example of what can be achieved6. The pandemic has illuminated very different and often hostile interpretations of both Western and Chinese pandemic preparedness. Yet the reality is that few nations were prepared, the Global Health Security Index proving to be a total myth7. Perhaps the greatest difficulty though will rest on how we as respective societies view our countries domestic responses and our duty to international obligations in global health. The UK, for example, has experienced catastrophic excess mortality not just due to pandemic but also due to shutting down/high friction of non-COVID healthcare which, for example in cancer, will lead to significant loss of life and economic impact over the next decade. The pandemic has also illuminated both the importance and dangers of global health security. The securitisation of health presents some profound moral, ethical and technical challenges. In a public health context, the use of SIGINT and other unique intelligence tools has become increasingly integral to epidemic and pandemic preparedness and response, even if not overtly referred to in these terms, as national security doctrines expanded to include the pandemic threat8. Health data and captured within this term is all types of data germane to public health or hospital clinical care, thus becomes, as we have said, of central importance. If health data is seen as gaining strategic advantage, then we are immediately faced with significant barriers to peaceful co-operation. But the normalisation of global health security as an open source, co-operative domain of intelligence needs first to address Scylla of cyber security9 and the Charybdis of disinformation10. Exploitation of either sides vulnerabilities or assets or manipulation of the info-sphere around global health erodes the fundamental foundations for peaceful co-operation in global health. The key is to become more intelligent about health security through better co-operation11.
The pandemic as mirror has reflected a proliferation of global health threats. Not least in the epidemic and pandemic space. Whilst the continuing and futile accusations fly around the ‘lab leak’ theory, the bigger picture, which requires massive co-operation, is being missed. The biggest and most ‘dangerous laboratory’ by log order difference is nature. Dramatic changes to the ecosphere, and human encroachment into natural habitats, are driving emergence of pathogens with epidemic, and ultimately pandemic, potential. Yet in many parts of the world, this issue remains under-explored, with few integrated human-animal-environment studies. COVID-19 has highlighted the importance of an integrated One Health perspective in evaluating how anthropogenic activities drive the emergence of novel zoonotic pathogens and provide the conditions for zoonotic outbreaks to achieve epidemic scales. A trans-disciplinary approach that fully integrates the human-animal-environment nexus is needed to understand the scope of the problem and identify ways to mitigate risks. Historically, the One Health research agenda has been mostly orientated towards continental Africa and SE Asia. But parts of the world, such as the Pantanal wetlands in Brazil, are a rapidly evolving foci for emerging zoonotic pathogens given land use and climatic changes altering fragile ecosystems. The same pressures are causing novel and increasing interactions between humans and domesticated animals with wildlife. These new contact rates provide increased opportunities for zoonotic disease transmission, and in the absence of a robust local healthcare system, there is insufficient protection to prevent small outbreaks from expanding to epidemic proportions.
High threat diseases, fragile health systems and population displacement (forced migration) are increasingly co-terminus in countries with significant (in)security issues12. For example, the UK and China are jointly working in many parts of fragile and conflict-impacted Sub Saharan Africa countries such as DR Congo with a history of Ebola virus (EBOV) and Marburg virus, well-known filoviruses which cause life-threatening viral haemorrhagic fever13. As both the West and East strive for ever greater global engagement through development programs there has been little pause or reflection as to the consequences on global health security. For probably well over a hundred years filoviruses have remained sequestrated within the deep jungles of central Africa, outbreaks in human populations were essentially contained because of the very remoteness and disconnection. Development as Hughes and Hunter discussed in their 1970’s paper is a double-edged sword14. This by itself could probably be managed. But add in radical and unpredictable human behaviour changes due to conflict, the impact of climate-induced ecosystem destruction and entirely new and dangerous scenarios present themselves. In and of itself insecurity and conflict is a global health security threat which can, as we know now, rapidly reach across borders. There are clearly mutual interests in supporting both health systems strengthening and emergency response. And here we do talk about health systems strengthening from a generic foundational perspective including basic vital statistics, hospital information systems, workforce, etc. There is a dangerous narrative that all that is needed is to better prepare for the next pandemic. The failures in preparedness and response in this COVID-19 were systemic not specific. Likewise, the alarming and growing threat of anti-microbial resistance also speaks to the need for serious nation-nation co-operation to tackle the roots of this problem through a One Health approach. Beyond pandemics new therapeutic geographies have created a post-Westphalian health system(s) as patients cross national boundaries seeking care or because of forced migration. Cancer patients from Afghanistan travel huge distances to access care in Pakistan. All this speaks to the continuing issue that despite decades of Overseas Development Aid and other domestic and international strengthening programmes through World Bank IMF etc, many, if not most health systems are fragmented and weak. Yet global health is insufficiently country centred and technical support is disconnected or inappropriate for local policy-makers15. Joint country health systems strengthening programs would provide not just significant confidence building platforms but also real focus at a time when global health has been seen by many as nationalistic and (neo)colonial.
The fault lines exposed and created by the weight of the COVID-19 pandemic cannot be repaired by any single nation. Inequalities and the long-term impact of COVID-19 pandemic on economic systems will have profound effects on the ability of governments to deliver progressive universalism and strengthen health systems16. The economics of global health is one of the super-currents that will determine whether we are ready, or not, for the next major global health crisis Sparkes SP, Bump JB, Ozcelik EA, Kutzin J, Reich MR. Political Economy Analysis for Health Financing Reform. Health Syst Reform 2019: 1-12.17. And it is here in the corridors of economic power that the greatest co-operative efforts are needed to provide the fiscal space for nations to build their health systems. It has been clear to those of us in the trenches of global health that fiscal headroom for countries to address their increasingly complex health financing transitions has been eroding for some time18. Even prior to the COVID-19 pandemic there was serious doubt as to whether many countries could, even if they politically wanted to, achieve the necessary progression towards SDG goals that were affordable, equitable and sustainable19. Already there has been substantial work in this field between the UK and China20, particularly around priority setting and the development of health technology assessments, one of the most essential tools in health systems planning21. Strengthening health systems and improving global health security requires professionalisation of national planning and operational implementation that has been largely ignored by the global health communities. To achieve such joint actions at scale, peaceful co-operation is an absolute prerequisite.
Despite there being significant scholarship on the role of development and peaceful co-operation, this has rarely included global health22. The most signiﬁcant attempt to bring the concept of global health and peace together came with the publication of the WHO’s ‘Consultation on Health as a Bridge for Peace’ in 1997. Here, global health had a privileged position as a peace-building tool as something valued by all groups in society that could transcend political differences. But this has not been without its detractors. As Rushton and McInnes23 observed, there has been doubt over the efﬁcacy of global health activities as a peacebuilding tool but this critique has really been centred on humanitarian actions rather than normative global health co-operation24. The COVID-19 pandemic has, if anything, shown that prevention, early warning, mitigation and responses to global health threats be they acute or long term cannot be treated as a global zero-sum game. Peaceful co-operation is needed to study and prevent new zoonosis, AMR and other trans-national disease threats. Mutual and decolonialised bio-sampling and data sharing need to be the norm for effective early warning. Countries needed co-operative broad health systems strengthening that is de-conflicted and mutually reinforcing. And when things do go wrong there already needs to be in place global health intelligence and response systems that work outside or rather in spite of broader geopolitics25. Achieving these lofty ideals and practical solutions is not amenable to a grand solution, but rather careful construction of modest deeds to build, in time, great acts.
Professor Richard Sullivan is Professor of Cancer and Global Health at King’s College London, Director of the King’s Institute of Cancer Policy and co-Director of the Conflict and Health Research Group. Richard’s global cancer research covers cancer systems strengthening, financing, political economy, and cancer care in conflict. He also leads major programs on conflict and health across the Middle East and Sub-Saharan Africa, global health security & intelligence and a wide range of clinical areas, including impact of explosive remnants of war on public health.
He was worked on issues of biosecurity and bioweapons for the last twenty years including deployments during recent Ebola outbreaks in West Africa and DRC. Professor Sullivan trained in surgery gaining his PhD in Biochemistry from University College London. Richard was Clinical Director of Cancer Research UK for nearly ten years. Richard is a WHO advisor, former UK director of Council for Emerging National Security Affairs and founding member of the civil-military Global Health Security Alliance.