Dr Clare Wenham discusses the state of global health security in 2020 and the governance of pandemics.

This is the third blog in the 12 Days of Global Health series.

2020 has been a year like no other. I am saying this as an academic who specialises in global health security and the politics of health emergency prevention and response. It seems but a few days ago that the first rumours were appearing about an outbreak in Wuhan, and as a global health security community we were avidly awaiting to see what China would do, what the World Health Organisation (WHO) would do and how the global community would respond. We waited to see whether the collective ideals of global health security, which have been fostered in previous decades in response to outbreaks such as SARS, H1N1, Ebola and Zika, would pay off and governments and global actors would rise to the challenge.

Instead, we saw something much sadder – at least from my perspective – several of the lessons from previous epidemics had not been implemented. The world remained unable to cope with a major epidemic, and perhaps most frustratingly, all the efforts which those of us working in this space had been shouting about were not listened to in any meaningful way. Though the systems for detecting outbreaks have improved immensely in recent years, and surveillance infrastructure and reporting mechanisms for sharing information and data meant that we knew about SARS-CoV-2 in a relatively short time scale, the problem was that we didn’t do enough next. I’d argue that the declaration of the Public Health Emergency of International Concern (PHEIC) for COVID within a month of notification of the pathogen to WHO, was fast and acted as the clarion call to action that the world needed to sit up and take action to mitigate the virus’ global spread. However, the problem was that governments didn’t listen, or listened and didn’t do much. More specifically, many governments in the global north didn’t realise the severity of the pathogen and downplayed the risk it would be to their more robust health systems. This was a mistake.

Though the systems for detecting outbreaks have improved immensely in recent years, and surveillance infrastructure and reporting mechanisms for sharing information and data meant that we knew about SARS-CoV-2 in a relatively short time scale, the problem was that we didn’t do enough next.

There are two issues here within the global governance of pandemics, governed by the International Health Regulations (2005) which stand out to me (and indeed, neither of which are new, but we could have predicted, and indeed the global health security community had predicted). Firstly, that the PHEIC notification didn’t come with any guidance for response and to implement a plan. There is no requirement for governments to do anything particular in response to a PHEIC declaration. This is problematic – it’s as if the fire alarm is ringing, but there is no fire evacuation plan detailed. Governments are not required to undertake risk assessments, to release surge capacity, to take steps or to strengthen point of entry control. By that, many states did start to take measures, but this began for the most part in the ceasing of trade with China (and then later Iran, north Italy etc) and repatriating nationals. Neither of such efforts suggested that governments thought that the outbreak would spread beyond these limited clusters and did not appear to think it was a problem for their population.

The second is that there is no financial mechanism to support governments to implement any response effort when a PHEIC is declared. This has been well evidenced before, that even if governments may pay attention to the PHEIC, low-income settings may have limited opportunity to activate response plans as the declaration doesn’t come with financial support. The World Bank’s Pandemic Emergency Financing Facility (PEF) mechanism, which was established in the wake of Ebola in West-Africa, was designed to provide financial assistance to Official Development Assistance (ODA) countries to be able to strengthen their health system to respond to a health crisis. However, as I argued last year (was it only last year?), this mechanism was fundamentally flawed, and indeed it didn’t begin to pay-out for COVID until May 2020, a good 5 months into the pandemic, where fast moving advantage so vital for pandemic preparedness was long since lost.

There is no financial mechanism to support governments to implement any response effort when a PHEIC is declared. This has been well evidenced before, that even if governments may pay attention to the PHEIC, low-income settings may have limited opportunity to activate response plans as the declaration doesn’t come with financial support.

So where does this leave us almost a year later? I think there will need to be a re-evaluation of the global mechanisms we have for responding to epidemics. The IHR (2005) will likely be revised, but the question which remains for me is: how will these be revised? Whilst from a technical public health perspective there are many suggestions which could be made to mitigate the risk of disease transmission. The political reality of governments agreeing to such regulatory changes, which will impede on their sovereign decision making and authority, at a time of fragile perceptions of international organisations and multilateralism, seems unlikely. There is a risk that in moving to update the regulations, we may be left in a worse position than when we started, as the geopolitical climate for global disease governance and cosmopolitan ideals of a global solidarity for outbreak response are delicate. So, the status quo remains and we remain in a position where we do not have the political buy in or tools to make states comply to reduce the transnational spread of infectious disease. The ultimate 2020 catch-22.

The views expressed in this post are those of the author(s) and in no way reflect those of the Global Health at LSE Blog or the London School of Economics and Political Science.

Photo: Suiting up to keep safe – the roving Ebola burial team in Freetown, Sierra Leone. Credit: Department for International Development UK. Licensed under creative commons (CC BY-NC-ND 2.0).