COVID-19 and the Future of Global Health
This article is adapted from a presentation given by Dr. Ok Pannenborg, retired World Bank Chief Health Advisor, to the Washington Institute of Foreign Affairs on September 30, 2020. The analysis and recommendations presented are those of Dr. Pannenborg. Adapted by Cassidy Childs, UNA-NCA Advocacy Fellow and Research Assistant.
While COVID-19 has impacted nearly every minute aspect of our lives in the U.S., an analysis of COVID-19 in the broader context of foreign affairs and the global health regime is valuable. The consequences of COVID-19 will dictate the future role of international institutions when facing global health challenges. However, the COVID-19 pandemic is not an unprecedented crisis. Indeed, a history of diseases dating back centuries can offer insight as to what long-term impacts may shape our future.
Pathogens and Pandemics
First, let’s establish a basic understanding of COVID-19 and how it spreads through communities. Pathogens are agents that cause disease. In increasing size, pathogens are prions, viruses, bacterium, fungi and parasites. Viruses are submicroscopic agents that replicate only in living cells. Polio, HIV, smallpox and dengue are examples of viruses that replicate in a similar manner to COVID-19. COVID-19 enters living cells, fuses with the endosome’s membrane, releases its RNA genome to replicate, and infects other cells.
Two primary features of pandemics are the high transmissibility and lethality of a virus. Together, the reproduction factor (R) and the level of infectiousness determine the transmissibility. The proportion of those infected that die, known as the case fatality rate (CFR), determines the lethality. COVID-19 spreads quickly and is fairly lethal with an R factor of about 2.6 and a CFR of 1–5%. A hypothetical pandemic that has the transmissibility of COVID-19 and the lethality of Ebola has the potential to wipe out 50–70% of the world’s population.
Pandemics have the potential to be significantly more deadly than conflicts and wars. However, political officials and the general public tend to have collective amnesia about pandemics and the threats they pose for public health. For example, the 1918 Spanish Flu killed at least 50 million people, while deaths directly attributed to WWI are estimated to be 16–40 million people. In the U.S., the 1918 Spanish Flu killed more people than all of the 20th century war casualties combined.
Pandemics and epidemics can significantly change the course of history through their devastation. The Antonine plague (165 A.D.) killed 5 million people, the Justinian plague (541 A.D.) killed 50 million people, the Black death (1350) killed 25 million people, and the Colombian pandemics (1500s) killed up to 90% of indigenous populations in the Americas.
The geopolitical impacts of these diseases have lasting legacies today. The Antonine plague catalyzed a change in the balance of powers in Europe, the Justinian plague prevented the reunification of the Late Roman empire, and the Black Death ended the English Feudal system. The ramifications of the COVID-19 pandemic could be as significant as the geopolitical consequences of previous diseases.
In January of 2020, the World Health Organization (WHO) announced that a new coronavirus had begun to spread from Wuhan, China. By February, COVID-19 was still largely localized in China, but the first cases were rapidly being detected around the world. By late March, COVID-19 overwhelmed Italy and Iran, beginning to spread rapidly in Europe, the Americas, and Asia. By late summer, the entire world needed to address community spread of COVID-19.
There are three ways to address the threat of a pandemic. First, there is prevention. Prevention measures include lock-downs, social distancing behaviors, facemask requirements, and the closure of national borders. Second, there are medicines, such as Oseltamivir for influenza A and B and antiretrovirals for HIV/AIDS. In 2005, developed nations stockpiled Oseltamivir during the H5N1 avian flu pandemic that originated in Southeast Asia, leading to shortages of the drug. During COVID-19, these same discussions of equity, fairness, and access to medication continue as developed countries buy out stock for potential medicines to combat the severity of the virus. Lastly, vaccines can be an effective response to pandemics. The science for vaccines has progressed quickly over time from first generation vaccines of chicken/duck embryos to recombinant vaccines that we use today to the possibility of mRNA vaccines in the future. Because of this quick progression in technology, vaccines have become a more feasible response for pandemics. For COVID-19, the invention of vaccines using mRNA technology has been successful. The Pfizer vaccine has a 95% efficacy rate against symptomatic COVID-19 cases after 2 doses, the Moderna vaccine has a 94.1% efficacy rate against symptomatic COVID-19 cases after two doses, and the Johnson & Johnson vaccine has 66% efficacy rate against symptomatic COVID-19 cases after one dosage. However, challenges remain as, for example, scientists have not been able to produce vaccines for some diseases, such as HIV or leprosy.
While these three strategies are recommended to prevent the spread of COVID-19, there have been varying levels of success in countries around the world. State capacity and policy have been crucial to the success or failure of COVID-19 containment. Success in the context of COVID-19 would be low case counts, low death rates, and test positivity rates below 5%.
The U.S., Sweden and Britain attempted to support herd immunity, hoping that the exposure to a significant, less vulnerable part of the population would create a buffer for more vulnerable populations. However, all countries that attempted this strategy have now backtracked and called for social distancing. Instead, state capacity to conduct population testing, promote social distancing and contact tracing has led countries to success. After having the most amount of COVID-19 cases at the beginning of the pandemic, South Korea implemented strict testing and contact tracing systems which prevented the worsening of COVID-19 cases. After accounting for population differences, the U.S. has 79 times more deaths and 47 times more cases than South Korea.
The COVID-19 pandemic has demonstrated how institutional trust, cultural differences, and social norms can affect the success or failure to control the spread of the virus. For example, mask wearing is already common in Asian cultures, particularly when an individual has allergies or is recovering from an illness. Some countries such as Spain or Italy greet with a kiss on the cheek or handshake, while people choose to bow without personal contact in Japan. The U.S. may have fared worse in terms of case and death numbers during COVID-19 because of its individualistic values, while Asian countries are more collectivist and have social solidarity. Individualist societies celebrate personal freedoms, personal successes, and personal uniquity, while collectivist societies celebrate individual embeddedness in groups and social cohesion. While this has not been definitively proven in an academic setting, there is a slight positive correlation between individualist countries and COVID-19 deaths. Baniamin et al. 2020 argues that institutional trust, not societal values, may be the reason why the U.S. and other Western institutions have fared worse. 85% of Chinese citizens reported high confidence in their governmental institutions while only 39% of Canadians responded the same.
While there are three main ways to address pandemics and COVID-19, the political, social, and economic circumstances of each country have ultimately determined its ability to contain the spread of COVID-19.
The History and Future of Global Health
The latter half of the 20th century saw a swift rise in the academic field of global health with a large variety of actors. However, the COVID-19 pandemic may mark the beginning of its decline. The most prominent definition of global health is “an area for study, research, and practice that places a priority on improving health and achieving health equity for all people worldwide.”
In foreign affairs, global health is a relatively new topic. The first international convention on global health was the International Sanitary Conference, starting in 1851,led by France. A collection of prominent European governments ratified the first international sanitary convention in 1892 to address cholera and another international sanitary convention was ratified in 1897 to address the plague; conventions were consolidated into a comprehensive International Sanitary Convention in 1903. After WWI, the League of Nations included a clause “to take steps in matters of international concern for the prevention and control of disease,” solidifying public health as a matter of foreign affairs. During WWII, public health in foreign affairs came to a halt, resuming with the creation of the WHO in the UN in 1948.
A shift came from the 1970s onwards to increase attention and funding towards public health in foreign affairs. With decolonization, UN expansion, and the end of the Cold War, the geopolitical dynamics allowed for more global collaboration on health and medicine. Development assistance for health increased from $6 billion in 1990 to $40 billion in 2017. With additional funding for global health, there were some clear health victories, such as the eradication of smallpox, the near eradication of polio, new vaccines for a host of infectious diseases, and advances in research for HIV/AIDS.
The diversity of actors in global health has increased. From health academia and global health ambassadors to the globalization of pharmaceuticals, global health solidified itself as a significant aspect of foreign affairs. Since the 1970s, the U.S. has been the most prominent actor in global health in terms of financial contributions, however non-Western institutions have begun to rise in relevance too. ASEAN, the African Union, and health institutions such as the Africa CDC, universities in Asia and Africa (e.g., the National University of Singapore), the Chinese Center for Disease Control and Prevention, the India biomedical research and development community, and the International Vaccine Institute in South Korea have become powerful actors in global health in terms of research contributions, spending, and vaccine production capacity. Other non-Western sources of funding have become crucial for global health work;the Asian Infrastructure Investment Bank, the New Development Bank, the Road-and-Belt Initiative, the Silk Road Fund, and the Islamic Development Bank have been providing billions of dollars in grants and resources to global health projects.
However, this new global health regime may have reached its peak, partly due to COVID-19, the pandemic playing a role in the repositioning of the global powers, with China’s economy continuing to grow robustly (due to early control of the pandemic), the U.S. recovering and remaining the major global player due its dominant position in technology, innovation and finance, and Europe seemingly falling behind with the second pandemic year playing havoc among its members.While currently the pandemic priority seems to remain paramount, other global public good priorities likely will dominate global foreign affairs. Among the SDGs (as opposed to the MDGs before) global health already took somewhat of a backseat and concerns such as climate change, new technologies and innovations and trade regimes among the new global powers in Asia and elsewhere are increasingly defining the global agenda. While historically the U.S. has been the largest financial actor in global health, U.S. spending for global health decreased 40% from 10 billion to 6 billion in 2020 alone. Additionally, traditional donor sources for global health have been decreasing in relative terms and health affairs have shifted focus from the public to the private sector. While R&D for global health is still U.S. and EU dominated, there is a shift underway towards Asia and non-Western regions, including in production of medical technology capacity to China and east Asian countries, India, Brazil and Africa (e.g., the Serum Institute, the Gamaleya Institute, the Fiocruz and Butantan institutes, and others). Additionally, the active ingredients for pharmaceutical products (APIs) sourcing has largely become dependent on India and the bulk of COVID-19 vaccine production will soon be from Asia. Established and upcoming biomedical institutes, health and medical education, and biomedical research will no longer largely be located in the U.S., but instead will grow significantly and be found in developed and developing countries throughout the world.
COVID-19 has the potential for a restructuring of global power and a fall in U.S. dominance in global health. In the longer term, depending on the evolution among the great powers over the coming thirty years, even the UN global charter system might be repositioned with weak cooperation and international disorder if and when more pandemics were to happen and the global community would fail to establish a new global and supranational effective, efficient, equitable and fair pandemic and bio-hazard risk early warning and management system. While we do not know the long-term impacts of the COVID-19 pandemic, a history of pandemics suggests that these consequences will be significant to the international system. The global health regime may well change as non-Western institutions rise in power in the wake of the pandemic, challenging the U.S. to either reaffirm its international leadership or continue to recede to protectionism.