By Richard Coker (London School of Hygiene & Tropical Medicine)
An epidemiological tsunami is sweeping the world. The most vulnerable will succumb directly from infection and, often forgotten, indirectly from being unable to access health care services. As this pandemic unfolds, it may be difficult to see any positive consequences. But there may be.
All pandemic infectious disease threats are zoonotic, that is, they emerge from animals that then exploit a new ecological niche, humans. They test our social, political, cultural, economic and moral norms. Global crises may test these norms to destruction. The Black Death in the 14th century decimated the global population with profound social and economic consequences. For the survivors of the Black Death, wages rose, land became more abundant, and the feudal system was destabilised. World War 1 (along with the Spanish influenza pandemic) transformed the economies and polities of Europe. Working lives, especially for women, were transformed, universal suffrage became widespread,and political systems changed, most notably with the emergence of communism. WW1 also led to the League of Nations, the precursor to the United Nations. Chernobyl, according to Mikhail Gorbachev, helped trigger the collapse of the Soviet Union. When each of these seismic events started, the consequences would have been difficult to predict. Seismic events result in unexpected consequences.
The COVID-19 Pandemic
This pandemic will test how we look after our neighbours. Protecting our societies’ most vulnerable will test our social contract, perhaps to breaking point. And nowhere is this test likely to be more profound than the United States of America (USA). This exceptional country has the notion of rugged individualism proudly embedded in its DNA. It has, however, also resulted in a health care system especially unsuited to enhancing social solidarity, to risk sharing, or to enabling population-based behavioural measures to prosper. Worldwide, the configuration of health systems reflects political and social values. When private insurance schemes dominate, as in the USA, health systems are ‘individualised’, that is, when you’ve paid your premiums, you demand and expect a service. In times of pandemics such individual-focused systems are likely to falter because your health becomes more dependent on your neighbours’ health. Everyone is in this together. But the US system is engineered to avoid what are perceived to be ‘free-riders’. In a pandemic there’s no such person as a ‘free-rider’. If social solidarity is a necessary pre-requisite for an effective response to this new threat, what does this mean in terms of shifts to our communal values?
The values undergirding health systems eventually, in times of health resource shortages, test moral and ethical norms. Who should get access to ventilators? Ventilators now, therapeutic pharmaceuticals perhaps in 6 months, and vaccines in 12-18 months. Should it be the insured, the rich, the politically connected, the old, the young, the economically active, soldiers, health care workers who gains access preferentially?
Scarce resources test social, institutional, and political systems. Today’s coronavirus is highlighting a fear that some countries will be left in the cold when it comes to drugs and vaccines. Global pharmaceutical supply chains are highly interconnected and there is talk of blocking the export of basic pharmaceutical ingredients from China and India in anticipation of future domestic demand, or some countries getting preferential access to future vaccines. Political self-interest is a powerful motivator. Few politicians will be brave enough to put others, outside their jurisdiction, to the front of the queue.
Belonging to a regional bloc (EU, ASEAN etc) or sizeable manufacturing country (China, India) matters if you don’t want to be left out in the cold. The temperature for those residing outside powerful blocs with pharmaceutical and vaccine manufacturing capacity could get decidedly chilly. Pandemics are not only a public health matter, they are also a matter of power and security.
This power matters at national, community, and individual level. Witness, for example, in Southeast Asia how limited surveillance capacity, including intentionally limited testing, has resulted in woeful under-representations of COVID-19 cases. This has resulted in policy decisions that have, in all likelihood, threatened the health of some of the poorest and most vulnerable in society. Enormous migrations of people from cities undergoing ill-thought out ‘lockdowns’ to their villages and neighbouring countries would challenge even the best resourced and best performing public health systems. Those in SE Asia and much of the world were already challenged ahead of this pandemic. The poorest or the poor, whether migrant workers, refugees, prisoners, or the indigent are at greatest risk, and these risks are magnified in low- and middle-income countries around the world.
Scarce resources always raise moral and political questions. In the US the collision between the political, cultural and the values underpinning the health care system are most stark. The US is the place to watch as this pandemic unfolds. Its traditional ‘exceptionalism’, increasing political isolationism, cultural individualism, and largely for-profit health care system mean it is exceptionally unprepared for what is to come. The demands for change to the social contract in terms of social security and health care are being heard more loudly in the US. This pandemic will raise the volume of the American people’s call for greater social and health care support from a shout to a scream. And when the US screams, the world listens.
The scream for reform needs to be heard by our multilateral global institutions, the successors to the League of Nations. These institutions are meant to serve global welfare. The World Health Organization (WHO) has become a shadow of what it was when it led the global eradication of Smallpox in the 1970s. This has been, in part, by design. The organisation is the tool of governments largely unwilling to give it greater authority. This informs the choice of WHO’s leaders, its bureaucratic and administratively chaotic regional offices, the vulnerability of commitments made, an ever-expanding mandate that is not financed adequately, and increasingly, budgets tied to specific activities of interested parties rather than funding ‘core’ functions. There has long been an insistence by governments to ensure that WHO’s authority doesn’t stray into realms of national sovereignty. The International Health Regulations (2005) that resulted directly from the SARS epidemic highlight this perspective. The regulations lack real teeth. They encourage countries to enhance their risk assessment capacity. But they stop short of mandating countries to improve their risk management capability. Risk management remains a sovereign state issue. But, as the cliché goes, emerging infectious diseases know no borders. The weakest link in global preparedness, once an epidemic has emerged, is the inability of any single country to prevent or contain the emergence of infectious diseases. The world needs a robust WHO, focused on infectious disease control, and armed with the technical, administrative, financial, and legal authority to do its job in a timely fashion.
Perhaps this crisis will cause us all to reassess our values, our sense of social solidarity, national, regional and global. Perhaps too we can see how interconnected and interdependent we are on each other and our relationships with the animal kingdom. All pandemics, after all, emerge from animals. The conversations we have during this emerging time of crisis should constructively inform what sort of society we want to live in and the institutions that enable and support that vision.
Image credit: Wikipedia Commons/OpenMyanmar Photo Project