By Haruka Margaret Braun, HGHI Intern and Megan Diamond, HGHI Affiliate
In April 2020, the Access to COVID-19 Tools (ACT) Accelerator was launched by the World Health Organization (WHO) and its partners with the aim of providing innovative and equitable access to the most recent diagnostics, treatments, and vaccines. A fundamental initiative of ACT is the COVID-19 Vaccines Global Access (COVAX), a global collaborative created to accelerate the development, manufacturing and distribution of COVID-19 vaccines worldwide. The underlying hypothesis: if countries worked together, COVAX could provide equitable access to COVID-19 vaccines; critical for low and middle-income countries that are unable to self-finance vaccine deals. While COVAX was originally created to leverage global collaboration for good, the lack of funding, coupled with the hoarding of vaccines by wealthy countries has undermined that goal.
From the early stages of the COVID-19 pandemic, experts have emphasized the importance of global partnership and equitable access to COVID-19 diagnostics, treatments and vaccines. Global health governance refers to “the use of formal and informal institutions, rules, and processes by states, intergovernmental organizations, and non-state actors to deal with challenges to health that require cross-border collective action to address effectively”, and has long been proposed as an essential mechanism to facilitate effective international partnership in times of health crises and pandemics. In the context of an international public health emergency, such an approach is essential to mitigating the spread of disease and preventing future disasters.
Calling on global partnership in the context of a disease outbreak is not novel. From SARS to Ebola, global health governance has been a prominent approach to tackling the spread of disease. In some cases, such as the WHO Framework Convention on Tobacco Control (FCTC) it has resulted in incredible successes. In others, such as during SARS and Ebola, repeated failures to collaborate led to insufficient, and at times, harmful results. As global inequities in the allocation of resources to prevent and treat COVID-19 continue to widen, a careful examination of these lessons – both good and bad – can help strengthen pandemic preparedness.
The case for strengthening global health governance structures was made during the SARS epidemic in 2003. The absence of a functioning global governance surveillance system contributed to over 8,000 infections, and 700 deaths across 29 countries. After the initial outbreak of SARS in Guangdong province, China, the Chinese government failed to openly report the scale of China’s SARS outbreak to the WHO and the broader international community. This reporting failure was repeated by other countries as the virus spread, downplaying the extent of the virus’s toll and eliminating opportunities to adequately respond as a global community. Even if cases were more accurately reported, national pride and security consciousness would have acted as a secondary barrier, as they affected much of the political decision-making during the epidemic. SARS exposed failures within the global governance system, some of which were subsequently addressed, including the expansion of the WHO authority and regulatory power through the revision of the WHO’s International Health Regulations (IHR) in 2005. The expansion gave the WHO the power to declare a public health emergency of international concern (PHEIC).
Overall, minimal progress has been made in improving global governance systems, as many mistakes made during the SARS epidemic have been repeated during the COVID-19 pandemic response. Failures in transparency and communication regarding COVID-19 cases early in the pandemic contributed to the inability to contain the spread of disease across borders. The Chinese government did not immediately notify the international community about the outbreak of COVID-19 in Wuhan, China, and was reluctant to share raw data to WHO investigators. After the first reported case of a coronavirus disease in Wuhan on December 1, 2019, the WHO sounded its highest alarm by declaring the virus to be a PHEIC on January 30, 2020. Through this declaration, the WHO advised governments to implement public health measures such as testing and social distancing to curb the spread of the virus, a recommendation which was ignored by many countries. Preliminary investigations from the WHO and another independent panel point to the need for clearer communication regarding the immediate guidance and recommendations to countries once an event is declared a PHEIC. The failure of the PHEIC declaration to spark global action leads to the question of its power and enforceability and whether it’s creation post-SARS has been able to successfully alert countries of public health risks and create a coordinated international response to such crises.
Global surveillance reporting failures have been widely witnessed during the COVID-19 pandemic and have been largely discussed by researchers and journalists. In addition, these systems have failed to establish a clear precedent to push countries to monitor probable cases. Despite public health surveillance guidance from the WHO and US Centers for Disease Control and Prevention (CDC), many US states do not report such data of probable cases. Similarly across the globe, surveillance failures were witnessed because governments failed to build the capacities of IHR core health systems, including a system of surveillance and detection of diseases that is prepared for testing and national contact tracing efforts.
Over a decade after the SARS outbreak, the 2014 – 2016 West Africa Ebola outbreak yet again highlighted weaknesses in global governance structures as a mechanism to mitigate disease spread. Ebola highlighted the implications for when a country does not have the minimum core capacity to detect, report, and rapidly respond to outbreaks. The three most affected states, Guinea, Liberia, and Sierra Leone had a historically vulnerable public health infrastructure, and were in the aftermath of a civil war that had devastated the healthcare system and access to basic sanitation. While the WHO declared the epidemic to be a PHEIC in August 2014, little was done to mobilize resources to support WHO recommendations for treatment centers, personal protective equipment, and health worker compensation. Second, Ebola highlighted the need for transparent and open collaboration on new therapeutics and vaccines to support low- and middle-income countries. While the WHO provided technical leadership regarding the ethical use of unproven therapies during Ebola, there lacked guidance about how limited quantities of drugs should be delivered and rationed. Because of this, West African health workers and patients were often denied access to the available drugs that were at times available to international staff, highlighting the inequity in securing access to such resources. The Ebola crisis demonstrated how unprepared the multilateral system was to respond in fragile states and highlighted the need for rapid responses to emergencies and long-term capacity-building for infrastructure, a health workforce, and increased healthcare funding.
Again, clear comparisons between the Ebola response and COVID-19 response can be made. Global governance systems failed to inform the production, procurement and distribution of resources needed to test and treat COVID-19 infected individuals; revealing vulnerabilities within health systems globally. The lack of global supply chain oversight of essential frontline medical devices and PPE has highlighted the need for a new governance system that supports intervention by public-health authorities during critical emergencies. For resource limited states, the shortage of intensive care beds, ventilators, and specialist staff have revealed challenges in the capacity to care for COVID-19 infected individuals. As of May, 2021, amid an unrelenting surge in India with reports upwards of 350,000 cases per day, a national shortage has caused India to rely on global partners for medical devices such as oxygen concentrators and ventilators. While the Biden administration announced last week that they would make available the raw materials needed for India’s vaccine production, wealthy nations continue to be accused of hoarding COVID-19 vaccines.
The inequitable distribution of resources during the COVID-19 pandemic has not been limited to testing and treatment. Since the development of COVID-19 vaccines, LMICs have been pushed to the back of the line with regards to vaccine access, and vaccine nationalism in the form of hoarding vaccines has undermined global vaccine equity efforts. Despite global calls for vaccine equity, wealthy governments partnered with pharmaceutical companies and purchased a surplus of supplies, creating a reality in which ninety percent of the 400 million vaccines delivered by March 2021 went to wealthy and middle-income countries. This points to the repetition of past global health governance failures and has exacerbated inequities during the COVID-19 pandemic.
Despite failures seen in past epidemics, there are success stories that clearly demonstrate the power of global governance for health. The FCTC has proven that a unified and evidence-based approach to health crises can result in incredible global successes when the role of actors are clearly defined and accountability measures are put in place. It is estimated that nearly 22 million premature smoking-attributable deaths were saved due to the strong implementation of tobacco demand-reduction measures enforced by countries between 2007 and 2014. As an international treaty the WHO FCTC is unique, as Article 19 details the concept of liability, which had yet to be included in the provisions of any other framework convention. Under this article, parties agreed to consider taking legislative action or promoting their existing laws to deal with liability and collaborate to keep the tobacco industry liable for its abuses, creating a clear accountability system. Success stories such as this and others should be critically examined to inform how multinational organizations can strengthen collaboration and accountability, both in chronic and acute public health crises.
Overcoming failures in global health governance structures will be no easy feat. Growing nationalism and the politicization of scientific rhetoric continues to threaten the capabilities of global partnership and effective global health governance. Many point to the rise of far-right politicians and leaders in the contribution to nationalism, and that the crisis has heightened nationalist attitudes. As noted by the rise of the term ‘vaccine nationalism’, the current pandemic has shed light on countries who have foregone multilateral partnerships to more immediately protect their own citizens. This is a dangerous reality as COVID-19 vaccine inequities worsen, virus variants continue to flourish, and global herd immunity becomes a more distant dream.
Moving forward, it is critical that global governance structures are built under the framework of social and health equity, and that they enable the global community to more readily respond to health crises. To this end, key questions remain: Is global health governance inevitably set up for failure? How can we better learn from the past? Will we continue to fail at establishing global equity in times of public health crises due to nationalistic attitudes and failures of global governance? Addressing past failures and preparing for future global health crises will require a unified strategic international response to disease outbreaks that center transparency, collaboration, and equity.
