FIRST PUBLISHED IN INTERNATIONAL HEALTH POLICIES
At the beginning of this year, a somewhat nebulous period, when a little known disease was bubbling up in China, it was difficult to distinguish between politically motivated decisions from those taken solely based on evidence keeping public health concerns in mind.
A month ago, in her early assessment of the novel coronavirus outbreak that was then an evolving Public Health Emergency of International Concern (PHEIC) – a term that now sounds relatively unthreatening – Suerie Moon, Co-Director, Global Health Center at The Graduate Institute in Geneva said that in the prevailing hyper-politicised atmosphere, it is hard to say when governmental measures are based on science and in the interest of public health alone. At that time, in mid-February 2020, the epicentre of the outbreak had not yet shifted to Europe.
The unfolding of the pandemic in an already exacerbated trade-war environment, in any case had made diplomacy and negotiations difficult. Protectionist trade agendas had begun to seep into public health decision-making. The export bans within the European Union over the last few weeks, came as no surprise. Unprecedented factors including the scale of containment measures, interconnectedness of the Chinese economy, geopolitical transition and tension all contributed to the way this outbreak was being managed, Moon said at a gathering in Geneva when such events were still being permitted.
Earlier this week, both the UK and the US, belatedly shifted their positions and strategies on how to deal with the epidemic moving from containment to delay.
Now, when the gloves are off, clear evidence-based decisions shaping the responses to this pandemic are in stark contrast to those decisions which continue to be dictated by political compulsions. In short, it is now relatively easy to set the politics apart from the public health concerns driving the fight to contain the disease.
Like a dye helps detect microbes, the pandemic has now brought to fore our biases, our weaknesses, our propensity to disbelieve facts, our over-reliance on optimism and much else. All of this has made startlingly clear, the visceral motivations of governments across the world, even as it has, as an inevitable consequence, brought centerstage – frontline health workers, the public health specialists, the epidemiologists, the scientists and countless others. The battle to save facts has gone global and how.
Geneva, home to the World Health Organization and other international organizations, just happens to be a somewhat unique, deracinated and liberating city, a vantage point to see nationalists dictating public health decisions elsewhere. From this fertile zone where science and policy intermingle to produce guidelines and technical assistance to the most vulnerable countries affected by the disease, it is hard to fully appreciate the political impulses governing populations even at this hour. And of course, for the first time ever, key international actors such as WHO are operating in a country in lockdown, faced with the crisis in even more real terms (one WHO staffer tested positive for COVID19). (Given how ubiquitous the disease is, it will be interesting to see one potential impact of the pandemic, to what extent it “decolonizes global health”)
At this relatively early stage of the pandemic, of the many changes upending the rules in our pre-pandemic world, three key changes are beginning to emerge: one, WHO has decidedly reclaimed space at the center of global health decision-making, even as the pandemic reconfigures politics within countries to an extent; two, authorities and governments have to learn new ways to communicate if they want the public to trust them again; and three, inevitably new forms of governance to fight outbreaks will emerge.
CHANGE 1: THE POLITICS
WHO has effortlessly assumed centerstage in coordinating and leading the response to the pandemic as it should. One observer familiar with the developments of the last few weeks said, that WHO has cleverly focused on helping developing and vulnerable countries in providing technical assistance and guidance. WHO has been working backstage continuously with its richer member-states who have as much expertise as the UN’s health agency itself. But it has left those countries to publicly defend their strategies and decisions domestically.
In fact, the political tightrope WHO has had to walk, has little to do with which donor countries control its purse strings, the observer was of the view. “It is not as linear or simplistic as that. Donor countries are convinced and are willing to pay for WHO”. The political tightrope has basically meant remaining silent publicly and let the U.S. and U.K., for example, do what they want to do.
WHO has essentially put its head down, shipped testing kits to more than 120 countries, sending PPEs to nearly 60 countries, and dispatched missions to affected countries. These hugely important public health interventions do not generate as much interest as WHO praising China in its fight against COVID-19 in Wuhan and elsewhere.
The pandemic has had implications for domestic politics, the world over. As a result of the crises, a balance needs to be struck even within countries, on what many have called the limits of federalism at the time of a national emergency. The governments in Switzerland and Belgium, for example, were apparently pulled in different directions as a result of the greater powers at the cantonal/regional level. Chinese style central command is simply not possible in many countries, Outi Kuivasniemi, Deputy Director for International Affairs, Ministry of Social Affairs and Health in Finland said recently. Many countries are considering or are already militarising their efforts to fight the pandemic, because it is beyond the capacities of civilian administrations. In addition, there are cultural and legislative differences even within countries. (In India, the southern state of Kerala, more developed than its peers, has for example, been more systematic in finding and isolating cases than other states.)
CHANGE 2 – How we communicate
The pandemic is challenging our assumptions, and not just scientific ones. Take communication. Who would have predicted that a 71 year old institution, a large, international bureaucracy that WHO is sometimes perceived as – would rightfully, turn into, what one commentator said, the planet’s most important social media influencer driving awareness and engagement at the height of a pandemic? (The agency has held more than 30 press briefings since January 2020 on the outbreak alone. Anyone can log in and watch these updates.)
Misinformation and lack of trust in authorities are mixing in bewildering ways during this pandemic. While addressing misinformation is a collective effort, restoring trust in authorities squarely lies with governments and their institutions.
Despite the uneven literacy of news world over, it is frightening how universal the threat of misinformation is. WHO is sanitising misinformation around this pandemic by working with technology companies and much else.
But whatever WHO does to contain the “infodemic”, these efforts can be reversed within countries. While appearing to control or interfering with communication from scientific experts, governments end up sowing the seeds of distrust in the minds of people at the time of a grave public health crisis. Science must be allowed to take control of the narrative on the public health emergency. When governments lose trust, it worsens public health crises. [See Iran, for example, where lack of trust in the government continues to haunt the public health response. Or India, where a northern province is planning to go ahead with a huge religious congregation over the coming days, despite scientific advice against the same. ]
A pandemic in the 21st century means, giant dashboards flickering with real-time information with numbers and maps depicting crises ballooning in different parts of the world. But beyond the numbers, we need stories. As Vinh-Kim Nguyen, an Emergency physician and medical anthropologist, also a professor of anthropology and sociology at The Graduate Institute noted recently, “Building narratives and telling stories are more effective than merely stating numbers.” In a pandemic, stories have the power to galvanise support and empathy, equally for the overwhelmed doctors of the rich Italian North and health workers in China’s Hubei province.
To be sure, stories are important, for they change community behaviour. Communities respond to stories. During the Ebola crises, a change in community behaviour broke the chains of transmission that became “a game-changer” in West Africa, experts have noted.
CHANGE 3 – New forms of governance
Policymakers and legal experts are already working on how to calibrate the system of international alerts for outbreak response. When the dust settles in a few months, questions will be raised on whether WHO should have declared the outbreak a PHEIC earlier than it did, and as a consequence perhaps hastened the formal announcement of the pandemic that followed. There is no doubt, the immediate momentum that was generated soon after WHO declared COVID-19 as a pandemic on March 11, 2020 when the disease had reached more than 110 countries and had left more than 4,000 people dead.
But the current system perhaps did not allow for more nimble-footed decision-making – WHO and other specialised health agencies acted within the constraints of what prevailing frameworks allowed.
While we are yet to come to terms with the potentially staggering cost of human lives as a result of COVID19, forensic analysis is necessary to examine how politically motivated decisions impacted trade and travel restrictions in the early days of this outbreak. Rules that need countries to transparently respond to an outbreak without the fear of facing unnecessary trade and travel restrictions, are encapsulated in the International Health Regulations. How these rules will be reworked in the context of a pandemic is unclear, but they do need an overhaul – at least to address, why countries fighting the pandemic are imposing export bans on a range of goods from Personal Protective Equipment (PPEs) to Active Pharmaceutical Ingredients (APIs).
Now more than ever before, silos in international development must break surely and swiftly. Take trade and health, for instance. The International Health Regulations in its current form, is perhaps not a strong enough mechanism to insulate the effect of protectionist politics on trade at the time of a health emergency.
This will be an area where trade and health institutions must work together not just during outbreaks but at all times, without defending their respective regulatory and policy turfs.
New forms of governance could and should emerge from what the pandemic leaves in its wake. After the Ebola crisis in 2014, new forms of voluntary assessment on country preparedness were put in place. Experts are already working at an incredible pace, adapting to new information and urgency. This has given rise to an unprecedented rate at which information is being shared. Experts believe greater sharing will be needed on data around epidemiological information, clinical trials, genomic sequencing, pathogen samples, and quite simply local intelligence and strategies.
Leadership during ambiguous times
Even an unforeseen pandemic can have a silver lining – remaking of institutions, emergence of new leaders, new cultural mores of working and sharing.
The pandemic may have given WHO, inadvertently a shot in the arm, amplified its importance, and laid to rest fundamental concerns raised by its critics on the need for a decisive multilateral institution providing leadership. (New “hubs” for global health, must also prove that they are able to forge solutions and bring neighbors together at the backdrop of a worsening health crises and inward-looking trade policies)
How much this will transform into flexible funds for WHO, remains to be seen. As much as $675 million was costed for the Strategic preparedness and response plan for the new coronavirus for a period of three months. A number of different agencies and actors are coming together to fight back the pandemic.
Early beaters of the disease – at least for now – including China, South Korea, Singapore may well emerge as new leaders in public health, alongside traditional ones like Thailand. The laggards in responding to the disease, have also been countries with the most expertise, and those who had sufficient lead time to prepare for the crises.
The crises demonstrated what global health can offer to the world, apart from its technical expertise. A defining lesson in leadership – how to act decisively in times of ambiguity – certainly with facts, but also with intuition and courage. Dr Mike Ryan, WHO’s emergencies operations chief, steering the outbreak in these tumultuous times, said recently “Perfection is the enemy of the good when it comes to emergency management. Speed trumps perfection, and the problem in society we have at the moment is everyone is afraid of making a mistake – everyone is afraid of the consequence of error. But the greatest error is not to move. The greatest error is to be paralyzed by the fear of failure.”
During my recent interview with Dr Ryan, he also spoke about each government’s unique understanding of social contracts – what is acceptable in a society and what isn’t. When was the last time we spoke about social contracts? Politics may perhaps finally come around to issues that matter – not exclusion or identity politics – but health and the planetary emergency.
Can a virus topple a government? Maybe. “It is a new society,” Swiss health minister, Alain Berset declared at a press conference last week.