The pandemic has made us painfully aware of our common vulnerability to disease outbreaks. New communicable diseases originating in one part of the world can spread quickly and widely, underlining that health is a global concern. But this is old news.
The advent of the concept of “global health” is well established in both the academic literature and policy discussions, reflecting the consensus that we have seen a fundamental change in the nature of the causes and outcomes of ill-health in recent decades.
This change is rooted in the effects of globalisation and seen not only in the spread of communicable diseases, but in other developments – the globalised pharmaceutical market, the emergence of global civil society, new international health actors with a global perspective (such as the Bill and Melinda Gates Foundation), and the migration of health professionals. These developments combined to create a powerful sense of change, such that as long ago as 2008, the UK government declared that “health is global”.
COVID-19 appears to reinforce this narrative. Most striking, of course, is the spread of the disease. It has touched almost everyone. Within 18 months of its appearance, the WHO has identified only 14 countries reporting zero cases, 12 of which were Pacific Islands which had implemented strict travel restrictions, reinforcing sea borders.
The pandemic has also demonstrated the global nature of the marketplace for health products. From the often desperate search for PPE in the early months of the pandemic to the development, production and supply of vaccines in 2021, it is clear that states cannot rely on national suppliers alone.
The liberal vision
But the global health narrative was always more than simply an analysis of a new reality. It was also a call for new ways of working to address both new diseases, like COVID-19, and existing health inequalities. Underpinning this was the argument that if health was global, then responses needed to be global too, and that a consequence of globalisation was that the health of one state or population group was linked to the health of all.
This liberal vision of global health – one which held that the rich had responsibilities to the rest of the world, and progress was possible through cooperation – was already in trouble prior to COVID.
For all of the stated concerns about inequalities from the G7 and others, the global health agenda originated in high-income countries and reflected their concerns (especially over the spread of disease from other countries).
As a result, proposed responses prioritised their interests, including an emphasis upon dealing with the effects of disease – through pharmacological solutions – rather than addressing the causes, which might have been disruptive to their economic interests. That is why there were so many calls to decolonise global health before COVID emerged.
COVID-19 has thrown into sharp relief the current weaknesses of the global health project. During the most serious pandemic in living memory, the response has been dominated by national concerns and policies.
In the years leading up to the pandemic, the emergence of unashamedly nationalist governments in G7 and G20 states challenged visions of globally shared interests. Most obviously, Trump’s “America first” stood in stark contrast to the Obama administration’s global health security initiative and the Bush administration’s massive programme for AIDS relief, which helped transform the course of HIV infections in Africa.
During this time, optimists pointed to the continued engagement of other countries in global health initiatives, and argued that this new nationalism might only be a transitory phase, with business-as-usual returning post-Trump. Pessimists suggested that what we have seen is a more fundamental shift in the zeitgeist, with the global “haves” turning away from the humanitarianism and cosmopolitanism of the 2000s. The jury may be out as to who is correct, but at the very least the consensus of that era over the benefits of globalisation appears much less convincing now.
Global health gone missing
In contrast to the 2002-3 SARS outbreak and the 2009-10 swine flu pandemic when the WHO was central to a global response, or the 2014-15 West African Ebola outbreak when the organisation was widely criticised for not playing a leading role, this time around there has been no question that leadership on COVID-19 would come from anywhere except national governments.
Stark policy differences between states have appeared over basic issues such as face masks, lockdowns and social distancing. The WHO has criticised high-income countries for a “catastrophic moral failure” over allocation of vaccines, and questions of safety have been largely addressed at the national level despite clear advice from the WHO.
Although COVAX, the global vaccine sharing facility, had delivered more than 38 million doses to 100 economies in the first quarter of 2021, by mid-April it was warning that supplies were tight and additional stocks were unlikely to be available to it beyond those already reserved. This was despite accelerating production of vaccines, and appeared to be because of prior agreements by manufacturers with (usually high-income) states on supplies for their national needs. Joe Biden’s recent announcement of an additional 20 million doses for the rest of the world, although welcome, is but a drop in the ocean given the billions likely to be needed in India alone.
The catastrophic increase in COVID cases in India was exacerbated by the lack of critical health products, from PPE and oxygen to vaccines. If there ever was a global health system, then it had gone sadly missing when we needed it most.
COVID-19 has demonstrated that, in a time of crisis, the rich and powerful fell back to national approaches with only secondary concerns for the global health good. But since national health outcomes appear still to be inextricably linked to global developments, the need to rebuild global health after COVID is more pressing than ever.