The global governance of pandemics

On 17 March, 2020, exasperated by the unilateral measures of many EU member states to close borders and restrict free movement of essential healthcare goods, the editorial board of the Financial Times asked "whether public health should continue to be a sovereign responsibility." On May 29, President Trump announced that the USA would terminate its relationship with the World Health Organization, citing its subservience to China and mismanagement of the coronavirus pandemic. And on July 1, critics charged that the USA was undermining international cooperation by buying up most of the next three months' supply of remdesivir, one of two drugs believed to shorten the recovery time for COVID-19 patients (BBC News, 2020b). This pandemic has thrown into sharp relief questions that have long bedeviled policymakers responsible for controlling disease. What is the appropriate distribution of powers between international organizations and nation states in the governance of global health? And to what extent is international or "global governance" in the health sphere feasible? To shed light on these questions, I will consider the recent history of efforts to cope with cross-border health threats that set the stage for responses to the current pandemic, and then review the record of international cooperation in the face of COVID-19. I focus on two institutions at the center of such efforts, the European Union and the World Health Organization, and I close by drawing some conclusions from this record about the appropriate division of responsibility between national and international institutions and the factors conditioning the effectiveness of responses in each sphere. As the most developed of supranational organizations, we might expect the European Union to be at the forefront of international cooperation in matters of health. But the disease outbreaks of the last 35 years have tested its competence in public health because decisions in this realm depend heavily on agreement among the member states. As the European Community grew from 6 states into a Union of 27, that agreement became harder to achieve, not least because national governments preferred to address social issues domestically (Greer et al., 2019: 29). Bovine Spongiform Encephalopathy (BSE) in cattle was the first health threat to challenge European unity (Judt, 2001). In 1996, despite years of British denials, "mad cow disease" was linked to human health creating alarm about food safety across Europe. The German government finally agreed to slaughter its suspect cattle in order to control the outbreak within its borders only on condition that Brussels would share the $300 million bill. But the European Community budget was dependent on member states' contributions, and countries like Finland, which claimed that its herds were BSE-free, were reluctant to finance what they termed Germany's complacency. Europe had limited powers to enforce its injunctions: even when the Commission lifted its embargo on the export of British beef, France refused to remove its ban. Yet the BSE crisis had significant effects on the European governance of health: it increased public distrust of EU food safety regulation (Lynch & Vogel, 2001: 25) and agricultural policy and revealed that economic and political interests could trump health considerations and give rise to regulatory capture. This experience brought changes, namely an overhaul of the "ad hoc approach" to food regulation (Vos, 2000), the establishment in 2002 of a new regulatory agency, the European Food Safety Authority (Vincent, 2004), and the promotion of the precautionary principle in risk regulation-that "the absence of scientific certainty no longer justifies delaying the introduction of measures that could prevent potential harm" (Noiville, 2006: 307). The next significant test case for European governance was the appearance in 2004-2006 of a potential pandemic-avian flu, which is extremely virulent in poultry and was transmitted to humans (mainly children, through backyard poultry) in Vietnam, Cambodia, and Thailand. There was little person-to-person transfer of the disease, but the suspicion that viral mutation might create it caused global panic. This time vaccines and treatments were the issue that put pressure on European solidarity. Several EU countries generated pre-orders for influenza vaccines but declared that they would impose export limitations on vaccines manufactured within their borders (Bielitzki, 2007: 61). In the event, the pandemic did not materialize, but efforts to mobilize a collective response were unsuccessful. The EU Commission proposed the creation of a strategic stockpile of antiviral drugs, but three member states disagreed and most of the others refused to fund it, with the result that "each country must act for itself" (Ljunggren, 2006). The H1N1 or "swine flu" epidemic in 2009 saw similar resistance to sharing vaccines and medications and concern about this lack of cooperation produced an EU joint procurement mechanism 5 years later to provide for "medical countermeasures for different categories of cross-border health threats" (European Commission, 2014). Framework contracts for (only) pandemic influenza vaccines were signed in March 2019, but many member states did not sign up immediately to this voluntary mechanism (European Commission, 2019). The threat of avian flu did lead to calls for "pandemic preparedness," but readiness entails preparation of a certain kind. That has become evident in the context of the current pandemic. Take ventilators, for example: when the coronavirus arrived, no European country had enough to meet the challenge except perhaps Germany, and it had to order an additional 10,000 ventilators from a domestic supplier (Buck & Ghiglione, 2020). Being prepared on this front would have required three things. The first is advance planning. But anticipating the need for equipment such as ventilators, and then budgeting for that need, is not a simple matter: these are expensive machines; they require maintenance and also trained staff-respiratory therapists-to operate them. Keeping enough on hand, therefore, entails both ongoing expenditure and manpower planning. In March it was revealed that none of the UK Government's key preparedness plans for pandemic influenza, published in 2011, 2012, and 2014, mentioned ventilators (Lambert, 2020). Moreover, no matter how forward-thinking plans are at the national level, crucial decisions about equipment often fall to hospitals and local health planners who may baulk at including high-priced items of this nature in their annual budgets. And, during periods of austerity, which a number of European nations have experienced in recent years, longer-term considerations inevitably give way to more immediate priorities. Ensuring an adequate supply of ventilators would also have required an expansion of domestic manufacturing capacity which the anticipated demand for ventilators did not produce. Italy's sole manufacturer of ventilators, used to producing only 125 per month, canceled all orders from abroad but that was not enough to supply domestic needs. Finally, this challenge demanded a mechanism for sharing scarce goods among EU states. The EU Civil Protection Mechanism of 2001 is such a mechanism but, when it was activated in March by Italy's request for additional protective equipment, no member state responded (Braw, 2020; see also De Pooter, 2020). As one advisor to the EU Commission said: "It is back to the future, where Italy is left on its own" (Hall et al., 2020). By mid-March European solidarity was faltering. Germany, long a proponent of the EU single market, announced on March 4 that it was banning the export of protective medical supplies (Reuters, 2020). It then closed its western borders except for commercial traffic (BBC News, 2020a). Despite Commission pleas that such measures were "undermining collective efforts to contain the coronavirus" (Espinoza, 2020) every EU member state, except for Ireland, closed or put restrictions on its borders, which threatened to render the Common Travel Area meaningless (Herszenhorn & Wheaton, 2020) and created transport paralysis and long delays in moving food and healthcare supplies. Proposed initiatives to prevent an economic downturn, such as "coronabonds," or shared European debt, were resisted initially by Germany, revealing the same fault lines in the union that had emerged during the eurozone crisis 10 years earlier (Rankin, 2020). The choice of protectionism over cooperation was not surprising; as an EU official observed, "at a certain point solidarity no longer works because everyone is preoccupied with responding to their own emergencies" (Stockton et al., 2020). Eventually, border restrictions were relaxed, export bans lifted, import duties on medical equipment suspended, and sharing of resources improved. France and Germany were able to broker an agreement on an EU recovery fund composed of both grants and loans (Fleming et al., 2020). Retrospective analyses of Europe's failure to contain COVID-19 have begun, designed to yield recommendations about how to forestall or protect against a future crisis. Yet Europe's experience with this pandemic so far mirrors the history of its attempts to contain disease: initiatives proceed in fits and starts, often precipitated by crises in specific areas, and generate reforms that address the administrative landscape in that area but do not lead to an overhaul of the system of governance (see Grönvall, 2001; Lezaun & Groenleer, 2006). Moreover, cross-state "preparedness" for a pandemic may involve complex strategies some of which cannot be implemented by Europe alone. At the global level, the principal organization entrusted with the task of coping with pandemics is the World Health Organization (WHO). And it is under fire. In addition to US charges of a cover-up and manipulation by China, the accusations against it include: failing to heed Taiwan's warnings (Manson & Cookson, 2020) in late December 2019 about the risks posed by the new virus (this in part because China has ensured that Taiwan is not treated in the WHO as an independent state and has had no "observer status" since 2018), refusing to advise China to close the live animal markets that were believed to be the source of the outbreak (Sengupta, 2020), waiting too long to recommend the wearing of masks, and asserting that the risk from asymptomatic carriers was low (although WHO then reversed itself on this issue). Such allegations miss the essential point-the terms under which WHO was established mean that it is only as effective and interventionist as its member states allow it to be. Like the EU it is sustained by the contributions of its members, and it is hampered by its organizational structure. It is headquartered in Geneva but authority for response to an epidemic is vested in regional authorities and governed by the World Health Assembly (WHA), a cumbersome one-country, one-vote legislature that squabbles over budgets and policies. Its capacities are enshrined in a Constitution (1948) which permits certain actions and forbids others: WHO is instructed only to promote, assist, propose, standardize, maintain, stimulate, foster, furnish, establish, study and, above all, coordinate. These directives circumscribe what WHO can do. It cannot enter a country to investigate the sources and spread of an epidemic unless invited to do so by the affected state. The 2003 SARS epidemic caused international consternation because China refused to admit that cases existed within its borders, and WHO thus had no power to investigate. Much of the criticism directed at the WHO Director's praise for China's actions over COVID-19 was based on a misunderstanding of its mandate. Without the power to force nations to provide information, "it is obliged," argues James Meek (2020), "to fall back on consensus, persuasion and flattery - in other words, diplomacy." The organization does, however, have one important instrument in its arsenal-it can issue travel advisories. But though they carry considerable weight, WHO has no power to enforce them, and they have downsides. Canada was infuriated when WHO issued an advisory against travel to Toronto in May 2003 because of SARS, despite that city's claim to have limited the outbreak to hospitals (Kondro, 2003). Although the advisory was lifted a week later, it adversely affected trade and tourism and, some argued, made Toronto an international pariah (Mackay, 2003). What, then, are WHO's core functions and how have they evolved over time? Are they fit for purpose in the face of a global pandemic? SARS was the epidemic that literally rewrote the rules of global health governance, no mean feat in that this entailed changing a treaty, the International Health Regulations (IHR), governing the spread of infectious disease. The revisions stipulated that states would no longer be the sole authorities on disease outbreaks within their borders and that WHO could consider nongovernmental sources of information ranging from scientific reports to social media. The revised IHR was adopted in 2005 and entered into force in 2007. Some commentators heralded these changes as ushering in a new "post-Westphalian" era of scientific cooperation and human rights in which public health would be recognized as a global public good (Fidler, 2003). But responses to the epidemics that followed suggest that this may have been overoptimistic.1 State sovereignty over information is not the only barrier to building collective knowledge about the potential sources of a pandemic. One of the most poignant examples appeared in a letter to the New York Times in April 2015 titled "Yes, we were warned" (Dahn et al., 2015). Officials from Liberia's Ministry of Health described how during the 2014-2015 Ebola epidemic they had come across a 1982 study that analyzed frozen blood samples taken in 1978 and 1979 from 433 Liberians (Knobloch et al., 1982). The paper concluded: "Liberia has to be included in the Ebola virus endemic zone." But the results were published in a European journal and not disseminated in West Africa. The letter argued that "had the virologists' findings been linked to long-term efforts to train Liberians... to identify and stop epidemics... the outcome might have been different." In recent years, pressure against such "parachute research" has grown in the global scientific community, but the recommended solutions, including open source publication and the inclusion and crediting of local collaborators, may not be enough to break down long-standing practices created by the norms of scientific publication and career-building pressures. Yet, this pandemic has gone some way to break down these barriers, at least for the moment. As an American researcher observed, "the ability to work collaboratively, setting aside your personal academic progress, is occurring right now because it's a matter of survival" (Apuzzo & Kirkpatrick, 2020). The updated IHR regulations and the global community's censure of China for its handling of SARS did prompt faster revelations about the new coronavirus. There had been scattered reports in December 2019 of patients with lung conditions and pneumonias at different hospitals in Wuhan. An internal alert was posted by local health officials on 30 December. At the same time a Chinese doctor who was director of a hospital emergency department received a SARS coronavirus diagnosis in a patient, which she circulated to colleagues (McCarthy et al., 2020). This news spread online and on social media, so that by the next day international newspapers were reporting a cluster of 27 cases of an unusual pneumonia at a local seafood market. WHO also learned of the outbreak from ProMed the nonprofit network of disease spotters. It activated its incident management system on January 2, issued a warning on January 4 and followed up with a detailed report the next day. On 12 January, China submitted the genome sequence of the virus to the WHO. On January 20-21, a WHO field team visited China and reported that human-to-human transmission was occurring (Kuo, 2020). The main brunt of criticism leveled at China, and therefore at the WHO which was relying on its information, concerned the timing of these last two measures, namely, that China knew in late December but did not admit that human to human transmission of SARS-CoV-2 was very likely (Yong, 2020), and that it could have sequenced the genome sooner (AP, 2020) so that a diagnostic test would have been available at least a week before Germany produced one on 16 January. These delays soon became for President accusations that China had the pandemic on the To be was not WHO was at the of information, and was made of China's to the of a who later of COVID-19. the of the of the pandemic an advance in international WHO power from the of the IHR in states were required to the organization of that might a public health emergency of international concern misunderstanding about the of a This is not a for the WHO to into a country and enforce actions or impose but to and the global into have been only with In the WHO was of moving too and a when the epidemic was in of a of influenza The European argued later that some WHO officials had to international that to from a of pandemic And, this warning countries to of of vaccines and which when H1N1 to be suggest that this caused the WHO to the coronavirus a pandemic, its officials claimed 2020) that they to the in case it governments and to give up the In despite the to heed reports of outbreaks from nongovernmental WHO was to a during the Ebola epidemic in West Africa. Although the issued warnings that a was not issued have been for the some that WHO disagreed about the of the epidemic and that to Ebola would the affected ability to with other health like others claim that the organization a could the of the affected countries and thus an effective response 2020). The WHO the coronavirus was a on January. of the IHR of international in the of disagreed about was enough to but a week later and the to do At the same they recommended that the WHO should continue to the of an of alert in a way that not require on the of the January 2020). WHO had learned from its experience with epidemics and was but its response was to some by the terms of the IHR and by about the or nature of the of travel the organization with countries not to impose travel or trade restrictions and actions that or and health measures that with international that in such of to for under the terms of the IHR to the WHO the public health for such actions within of their with the that the WHO might to But many countries these and to close their borders, that the WHO can only with its member states and the power to enforce its were the key to controlling the pandemic and two first the and of drugs and vaccines and, a of their distribution both within and among significant to global is no global authority that has the and the to what the - the - will a of the WHO on global & 2020). Yet the last have a of initiatives to do These initiatives were by in part by the of drugs for in the The of these drugs was set initially at per per which made in nations and even for many patients in the developed As a a of and were to the of agreement of designed to protect By 2003 two to countries to international in the of public health by producing or drugs under certain Although international over did not proceed in epidemics to drugs for the Ebola epidemic of 2014-2015 an of international norms and regulations was in when COVID-19 In April 2020, at the of the European WHO a to COVID-19 to and new drugs, and for COVID-19 2020). by this the USA had announced plans to to WHO and to this international of and nongovernmental organizations, its preferred of et al., 2020). The of is perhaps the most of how American in this case over can global is an antiviral developed in 2009 by an American as a for it was then as a potential Ebola but to be effective other that it had antiviral in against et al., and in January it was as one of the to COVID-19. In was in the USA under an for in cases 2020), an that was in for and Finally, was on for COVID-19 patients over 12 years of The of this is that had results one that appeared to shorten recovery for and the WHO based on of a of patients in hospitals spread 30 posted results on that the had no significant on of hospital or need for among patients 2020). the for a week later the international global test of how in complex Moreover, knew of these results but the European Commission did not when it signed a joint procurement with the on for a supply of up to of & 2020). The US of Health and had refused to that for COVID-19 would be on the that restrictions would in such Despite the that the of on 2020), was able to set a of for a for patients with In the USA is no mechanism to a for see also 2020), and is often as what the will in May made a key to the for through a number of with in and a the received its and before government had even the for emergency 2020). These the to and in and countries and, the risk to of of could be to high-priced markets like the USA 2020). therefore, some of the international designed to drugs for nations were used in this to a for a that international authorities had of International of for COVID-19 has similar WHO a in the global to the on in of international and including the the and the the International for and the Health (see also The WHO and that in the so that every is a for But in the international system were revealed in when refused to its human of avian flu to the WHO on the that the had not developed to that countries would be or a share of pandemic vaccines that would rights were a to creating such 2020). years of international agreement was on a pandemic influenza preparedness that states to share and provide to The was by the in May 2011, but it is not it to influenza, and was about it would provide a so that countries could when vaccines against other were In the it did the most of this pandemic has been the way in which international for and distribution into a of 2020) and a among governments to the first and for their own & 2020). in May at the for a COVID-19 that "the and works or is a more where every country is to for itself" & 2020). into the for a the for had been set up in to finance vaccines against infectious and in April it with and WHO to one of the of the This was designed to the and of COVID-19 vaccines as as their through to all countries of 2020). nation would enough to of its The was immediately when the and China to be members, in China that it did so to its sphere of its to the USA of global 2020). And the to as most their to national governments supply for global distribution

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