The Covid-19 pandemic will have a profound impact on global health GETTY
In a short span of 3 months, the COVID-19 pandemic has changed the world, impacting everyone, everywhere. As I write this, nearly 1.3 million people have been confirmed to have the infection and nearly 70,000 people are known to have died from the coronavirus.
When the pandemic is eventually brought under control (hopefully soon!), I believe, along with a dozen experts I interviewed, it will profoundly change the field of global health. In some ways, the pandemic will make global health easier. In other ways, the pandemic will make global health much harder. Much harder.
The positive fallout
The pandemic has made global health easier because we don't have to show the world is interlinked. Even a school child today knows what happens in Wuhan can profoundly affect the health of New York City. “Everyone in the world now understands that their health and sheer life can be put at risk by things far on the other side of the world - health interdependence,” said Sridhar Venkatapuram, a global health professor at King’s College, London. We don't have to make a case for investing in health – every country has learnt the hard lesson that pandemics can destroy the global economy and cost trillions. Investing in health is investing in the economy. “We will see a renewed attention to and re-positioning of health on the political agenda, as people become more clearly aware of the role of governments in health, and as governments will have a hard time reversing the positive measures they’ve put in place to respond to COVID-19. Calls for universal health coverage (UHC) may become more and more compelling,” said Seye Abimbola, Editor of BMJ Global Health, and professor at the University of Sydney.Yap Boum, a researcher at MSF EpiCentre in Cameroon echoes this. “As shown by the pandemic, a large majority of people have no access to quality healthcare. After the pandemic, I hope global health will be characterized by access to quality care for all,” he said. Coronavirus makes clear what has been true all along. Your health is as safe as that of the worst-insured, worst-cared-for person in your society. It will be decided by the height of the floor, not the ceiling.
Public health has never been a ‘sexy field’, but, after COVID-19, we might not need to 'sell' public health. In particular, the pandemic has underscored the critical importance of social determinants of health, and the need for social investments. “What most people in low- and middle-income countries (LMICs) know, and now Americans experience is protecting health is not just about healthcare,” said Venkatapuram.
Further, we no longer need to justify why global solidarity and international collaboration is fundamental to keeping the world healthy and safe. Global health is already popular among young people. After the pandemic, I suspect global health will become more popular and attract large number of trainees to disciplines such as public health, epidemiology, modelling, infectious diseases, and data science.
As Jane Philpott, the former Canadian health minister put it, “The finest motivation for global health education is the recognition of our common humanity, our shared destiny, and the interconnected determinants of health.” We should train students “for a global state of mind,” she wrote. The COVID-19 pandemic has made it imperative to train all students for a global state of mind.
Will the pandemic help reverse colonial trends?
Before the pandemic, and currently, every aspect of global health is dominated by experts (mostly men) and institutions in high-income countries (HICs), and global health is failing in equity, reciprocity, and genuine bi-directional partnerships.
Will this change after the pandemic? Historically, LMICs have always dealt with epidemics. And HICs have been the saviors. With the COVID-19 pandemic, LMICs seem to be handling things better than HICs which have more resources and global health experts. But are HICs willing to learn from LMICs?
“Will there ever be a time when the North learns from the South?” asked Catherine Kyobutungi, Director of the African Population and Health Research Centre. “I am angry at why the world has not yet woken up to a new reality that LMICs are doing a decent job with the pandemic, but we are still being fed with the same stereotypical narratives. In the past, with outbreaks such as Ebola, the world would descend on the affected country with experts and funding. Now, each country is on its own. For now, LMICs are holding on for dear life. That's a lesson in itself,” she added.
Abimbola agrees. “The realization that all health systems are vulnerable and inter-linked, and that expertise is much more widely distributed than the current global leadership on global health, may inspire humility in HICs and respect for LMICs, increase the possibility of mutual learning between countries of different income groups, and also potentially broaden the pool from which global leadership is drawn in global health organisations,” he said. In particular, it is critical to include women in any public health response.
“I think – or at least I hope – that after the pandemic, global health will truly be global. That we will realize our interconnectedness as humanity and that we are ‘one whole’; and when one part of that whole suffers, we all suffer. I hope this revitalizes our need to champion even more vigorously for equity in health for all people worldwide regardless of gender, colour, race, creed, sexual orientation or any other social construct,” said Kui Muraya, an expert at the KEMRI-Wellcome Trust Research Programme in Kenya.
Yap Boum thinks the pandemic might make LMICs more self-reliant. “African countries can no longer benefit from the expertise of experts coming from western countries as they cannot travel and are busy handling COVID-19 in their own country. It is therefore an opportunity for African countries to tap more into their own human and material resources to find homegrown solutions to address their challenges,” he said.
The COVID-19 pandemic might also help fix the current broken pharma model that results in inequitable access and profiteering. Several groups, including Médecins Sans Frontières (MSF) and Universities Allied for Essential Medicines (UAEM), have called for no patents or profiteering on drugs, tests, or vaccines used for COVID-19. They have also called upon governments to take any measures required to ensure availability and affordability. What we learn from COVID-19, must be carried forward to all products of global health importance.
Time for a stronger WHO?
The World Health Organization (WHO) has been the global coordinator of the pandemic response. For years, WHO has struggled to get adequate funding from countries. The resultant lack of capacity was exposed during the Ebola outbreak in West Africa. Even during the current pandemic, Trump proposed cuts to the US contribution to WHO. In fact, WHO has been forced to raise money by creating a COVID-Solidarity Response Fund. What WHO asked for, in the end, will be drop in the bucket, compared to the trillions in economic losses.
(FromL) World Health Organization (WHO) Health Emergencies Programme Director Michael Ryan, WHO ... [+] AFP VIA GETTY IMAGES
“The world will need a WHO with a stronger mandate and reliable funding. Its role in preparedness and response - by ensuring common goods for health - must be expanded. In turn there must be an accountability mechanism created that holds the global system as well as countries to account,” said Ilona Kickbusch, founding director of the Global Health Centre at the Graduate Institute of International and Development Studies in Geneva.
“I hope that there will be further investment in WHO especially in its work supporting countries in enhancing local surveillance and capacities, and investment in bringing together at country level the two agendas of health systems strengthening and global health security,” said Devi Sridhar, Chair of Global Public Health at the University of Edinburgh.
“The WHO could find itself in a difficult place after the COVID-19 crisis, in relation to a range of competing expectations and demands. Currently, global, non-state funding has been allowed to play an important role, in the face on falling state contributions for special projects. If government funding does come through, this may well be an opportunity for more responsive member states, where global funders are allowed to come in on a case-by-case basis, contributing to programs that regional groupings or countries consider important (rather than skewing national budgets and priorities with their own pet ideas and demands),” said Sanjoy Bhattacharya, Head of the WHO Collaborating Centre for Global Health Histories, and professor at University of York.
The negative fallout
I worry that Covid-19 might make global health much harder. The pandemic is now starting to affect many LMICs. It is disrupting every aspect of healthcare. Even basic services like routine immunization have been impacted, and diseases like measles and polio might stage a big come back. The pandemic has made it incredibly difficult to script an endgame for TB, AIDS and malaria, the “Big Three” killer epidemics.
LMICs will therefore need more funding than usual, to deal with the aftermath of the pandemic, and to rebuild health systems and economies. At the same time, the pandemic could deplete the economies of LMICs, and make them more dependent on international aid. HICs, having suffered huge economic losses, could use Covid-19 as the excuse to cut development assistance for health, and recast global health as a narrow mandate focused on ‘national security’.
“Economies worldwide will be substantially weakened, so the evolution of low-income to middle-income country status will slow down or reverse, and - even while more is needed - broader development assistance will be at risk, said Amanda Glassman, vice president and senior fellow at the Center for Global Development.
Gavin Yamey, Director, Center for Policy Impact in Global Health at the Duke Global Health Institute, agrees. “Yes, there will sadly be huge austerity programs in HICs and I fear that development assistance will be cut. Right now, we are seeing emergency aid for pandemic control, but after this phase, I fear austerity will kick in”.
“Global health and development budgets tend to be zero-sum and have been flat or even decreasing for several years,” said Katri Bertram, a Senior Global Health Consultant, and former Head of External Relations at the Global Financing Facility at the World Bank. “We will most likely see donors strained between their national responses and announcing a minimal few million dollars for various UN organizations, global health funds, and research initiatives,” she added.
The UN has already called for a $2.5 trillion coronavirus crisis package for LMICs. How will this be feasible, if HICs were to cut back on development assistance?
COVID-19: the new excuse for nationalism, isolationism, and fragmentation
The pandemic is already becoming the new excuse for nationalism, isolationism, xenophobia, denial of science, and racism. These are not new trends, and have been predicted to create a fertile ground for pandemics to emerge.
A striking aspect of the COVID-19 pandemic is how governments have responded with unrestrained nationalism - closing borders, imposing lockdowns, banning exports, and hoarding products. “Public health was long thought to be inextricably linked with human rights, yet governments have responded to this pandemic by restricting individual freedoms in disproportionate ways (most prominently the freedom of movement) and neglecting human rights that underlie health (including medical care, housing, food, water, and sanitation). These human rights infringements, compounded by the rise of international divisions, threaten to unravel the post-war system of human rights that has been a bedrock of global health governance since WHO first declared that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being,” said Benjamin Mason Meier, a professor of global health policy at UNC, Chapel Hill.
“Global health will become a key component of national security from now on — not an afterthought or a charity project, but a pressing, macro-critical concern that all governments and economies will be taking seriously. Governments and inter-governmental organizations like the WHO will be central in this effort, but their structural shortcomings will generate large-scale private efforts to independently track risks and preparedness more accurately, in the same way that multiple private entities do their own estimations of economic growth and risks in high-income countries,” said Amanda Glassman. She believes China will take its place at the global policymaking table for good, and the US and Europe will need to make space.
After every crisis, new agencies and initiatives are created, and these can often weaken already existing agencies and institutions. “We are already seeing new initiatives being born. And we know from experience that these then compete - also in the long-run - in the global health and development architecture with existing organizations, because their mandates, budgets, and permanent Secretariats keep growing with time,” said Katri Bertram. Turf and budget battles might become more brutal, she worries.
Extreme securitization of global health
Abimbola worries that the pandemic might make countries “over-optimize our health systems for global health security, that we develop health systems that are so finely tuned to responding to emerging infectious disease outbreaks but at the same time become less able to do other things as well as.”
Deisy Ventura, a professor of global health at the University of São Paulo, has been studying the growing securitization of global health. “It is indisputable that our current lifestyle and legal framework (e.g. International Health Regulations [IHR]) does not enable us to contain the international spread of diseases. Therefore, a swing towards security seems inevitable,” she said.
In 2014, the US led the foundation of the Global Health Security Agenda (GHSA) with 67 members. If WHO does not get strengthened, Ventura expects GHSA might become the center for a new surveillance system, due to its institutional minimalism and the room for North-American leadership. “The difference between GHSA and WHO/IHR is essentially that the latter, in order to be complied, depends on strong national health systems and locally prioritized health authorities. GHSA, for its turn, may fund countries to set up surveillance systems, which are able to sound the alarm and contain diseases or health threats at their epicenter, without necessarily improving the health of their population,” she said.
Can we use the crisis to re-imagine global health?
It is clear that the COVID-19 pandemic will profoundly affect global health. While there are some positive developments, the negative fallout list is too long. Everyone who cares about global health must find a way to minimize the negative consequences.
The crisis, however, does provide a chance to improve global health. The optimist in me hopes humanity will come out of the pandemic choosing global solidarity against isolationism. Solidarity will be critical, if humanity is to successfully deal with this crisis, and the next big one coming our way - climate change.
Covid-19 has taught us that health is the basis of wealth, that global health is no longer defined by Western nations and must also be guided by Africa and Asia, and that international solidarity is an essential response and a superior approach to isolationism. We may emerge from this with a healthier respect for the environment and our common humanity.
I hope all countries will now invest in universal health coverage and re-affirm health as a human right. Global health must be more than just fighting one epidemic after another. And global health leadership must be more than men in HICs driving the agenda.
I hope investments in public health and developmental assistance will no longer be viewed as a drain on resources. That countries will understand the need to build a social safety net for all, even within high-income countries. That countries will be more transparent with data and equitably share scientific knowledge and products.
Learning from Covid-19, I hope governments will invest in a stronger and more capable WHO, curb profiteering by industry, and ensure affordability of global health technologies, as a social good.
Most importantly, I hope that we all become kinder and compassionate, having suffered and survived, together.
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