Casualties of preparedness: COVID-19 and the global health security paradigm

Manjari Mahajan, co-editor of Pandemic Discourses, interviewed Andrew Lakoff, Professor of Sociology and Communication at the University of Southern California and author, most recently, of Unprepared: Global Health in a Time of Emergency.

Your book discusses how a global health security assemblage has emerged over the last two decades. Could you briefly tell our readers the main goals and dominant rationality that characterize this global health security paradigm?

There are two main strands to track: one comes from the world of international health, and the other from the world of US biodefense. First, the concept of “emerging diseases” arose from the field of international health, beginning in the late 1980s. The HIV/ AIDS pandemic had upended the assumption that infectious disease had been conquered by modern public health measures. Along with other novel diseases such as Ebola, the idea was that AIDS was a harbinger for a future in which ecological disruption, urbanization, and rapid global travel meant that there would be a continuous emergence and spread of new diseases to which humans had no immunity and which could have catastrophic consequences. The 2002 SARS outbreak seemed to confirm this prediction – and the sense among infectious disease experts was that the world had dodged a bullet because the disease had proven less easily transmissible than initially feared.

Second, in the late 1990s, US biodefense officials became increasingly worried about the threat of a bioterrorist attack. This was in the context of post-Cold War concern about the whereabouts of stocks of weaponized anthrax and smallpox from the former Soviet Union.  They argued that it was necessary to draw on techniques of preparedness from the world of security to address these new threats: these techniques included simulation exercises to learn about vulnerabilities in the response system, sentinel devices to provide early warning of a bioattack; and mechanisms – such as stockpiles or advanced purchase agreements with drug companies – to ensure the availability of medical countermeasures to address the disease. As an example, the “Strategic National Stockpile” managed by the US Department of Health and Human Services was established in 1999, and initially mainly contained stocks of anthrax vaccine, smallpox vaccine, botulism anti-toxin, etc.

The idea of bringing the rationality and techniques of preparedness to bear on the problem of emerging disease was proposed by figures like Donald Henderson – who had led the global smallpox vaccination campaign and was the initial director of a major biosecurity think tank in the late 1990s. In the wake of SARS, and as global concern about the possibility of an avian flu pandemic increased, the paradigm was installed in the World Health Organization through the revision of the venerable International Health Regulations in 2005. This had three key elements: first, an expansion of the kind of event that should be the focus of the regulations, beyond the three “classical” scourges of yellow fever, cholera and smallpox; second, the development of a decision tool to recognize the arrival of a “public health emergency of international concern”; third, the requirement – though unfunded – that all WHO member states have the capacity to detect and respond to potentially catastrophic disease outbreaks. The paradigm was articulated in a 2007 WHO report called “A Safer Future: Global Public Health Security in the 21^st Century.”

Now that we are a few months into the COVID pandemic, what would be your reflections on this global health security schema? I am here less interested in a scorecard of formally instituted mechanisms, and instead wondering about whether the logic of preparedness that undergirds this paradigm, and the infrastructure and expertise that gets privileged, have proven to be the most meaningful ways of addressing this pandemic.

It’s clear that this rationality of preparedness, and the mechanisms that were put in place to implement it, have proven insufficient on their own to deal with the COVID-19 pandemic. Let me give you a striking example: in 2019 two US-based think tanks put together a report called the “Global Health Security Index”, which ranked 195 countries in terms of metrics of preparedness such as: existing prevention measures, early detection capabilities, and the capacity for rapid and coordinated response. The two countries that were ranked as best prepared for a catastrophic biological event, according to the index, were the United States and the United Kingdom. With hindsight, we can now see that among the wealthy countries, the US and the UK in fact have had some of the very worst outcomes in the pandemic. And some of the countries that were lower down in the rankings – for instance, South Korea (#9), Germany (#14), Singapore (#24) or New Zealand (#35) – have fared much better. So the question then becomes: what did pandemic preparedness focus on, and what did it miss?

In your book, you note how this public health preparedness schema in significant ways originates in the United States and then becomes global. As you note, the US, in many respects, was considered ahead of other countries in the “preparedness” game. Sitting in New York, nothing could be more ironic. As we learn more about how different countries are dealing with the epidemic, it doesn’t seem as though a formal preparedness armamentarium of scenario planning, stockpiles, and surveillance infrastructure were necessarily the most important in handling this public health emergency well. What did the preparedness regime orient us towards? In the process, what did it end up having us ignore?  

The preparedness regime was very technically focused, asking questions like: are there detection systems in place that can signal the emergence of a new disease? Are there decision instruments that can enable officials to determine what counts as an emergency? Can we ensure the rapid production and distribution of medical counter-measures? But as we’ve learned in the COVID pandemic, the critical questions have turned out to be much bigger: how do social inequalities shape relative vulnerability?  What problems of response may be exacerbated by having a federal system of distributed responsibility? What happens if the President does not believe in the authority of expert knowledge?

Moreover, the preparedness regime focused mainly on the stage of early detection and response, with a goal of “containment.” It did not have a lot of tools in its armamentarium for dealing with a disease once it was prevalent around the world: for instance, how to know when to institute lockdown measures? How to make policy decisions around reopening schools and businesses?

While it is not easy to generalize, it seems that having a functioning welfare state is one precursor to avoiding massive social and economic disruption as a deadly pandemic unfolds. That also wasn’t among the capacities measured by the “Global Health Security Index.”

What does the existing global health security paradigm mean for poorer countries?  So much of the COVID discourse in the United States and Europe has been about ventilators and ICU beds.  But these might not be the best points of entry if you are a poorer country.

This is a question we need to investigate further as we see what unfolds in the coming months. As part of the debates around global preparedness for an avian flu pandemic, circa 2008, there was a lot of discussion among WHO member states about issues like: how to ensure access to a vaccine to populations in poor countries. And currently global health philanthropies, as well as the multinational drug industry, are working on this. But yes, many of the medical issues we have been discussing in the US, such as the availability of ICU beds and expensive medical equipment like ventilators, are much less relevant in places where basic medical supplies and personnel are generally scarce.

As you know, there have been controversies about the WHO’s role in the pandemic, with the Trump administration among others complaining about it not calling the pandemic early enough. You have elsewhere pointed out that the WHO actually declared COVID to be a “Public Health Emergency of International Concern” by January 30th, and that this was the most important call it could have made to galvanize member states to put into action their pandemic emergency plans. It would be helpful for our readers to understand why this was the important clarion call, more so than the later March announcement of COVID as a pandemic. 

But there was also another point regarding the WHO that I was hoping you would reflect on.  Your book outlines the history of the WHO’s emergency declarations around recent large epidemics – H1N1, Ebola, Zika, etc.  What I took away from this history was that it is really difficult “to get it right.” What does this history tell us about how to think about uncertainty, and about our expectations from the WHO and other such institutions? 

On the first question: WHO’s declaration in late January of a “Public Health Emergency of International Concern” was a clear notice that member nations should immediately put themselves on emergency footing, activating preparedness plans, closely tracking cases, etc. Of course we know that at the highest levels, the Trump administration mostly ignored this alert, hoping the disease would go away, and only later – in March – when it was too late, claiming that WHO had not issued adequate warning. Whereas the official declaration of a “pandemic” in March was more descriptive, indicating that the global spread of the disease had passed the point where local containment was possible.

But, to address your second question: it is true that in recent years, from H1N1 (swine flu) in 2009, to Ebola in 2014 and Zika in 2016, the WHO has continually come under fire for inadequate response – either for exaggerating or for under-emphasizing the threat posed by a new disease. One lesson is that in the early stages of an outbreak of a novel disease, it is often very difficult to know for certain just how dangerous the disease is. This was true as well of the early weeks of after the emergence COVID-19 in China, in which the problem was to gather enough epidemiological data to understand what the threat was. However, it would be a mistake to address inadequacies in the WHO response by dismantling the organization or abandoning it. Rather, it needs to be strengthened since there is no other institution that can substitute for it.

Many scholars have written about a transition from international health to global health, the latter being marked by a move away from the centrality of nation states and national governments as the primary repositories of authority and responsibility for health of populations. What is striking in the COVID pandemic is how central governments are proving to be, both to the success and failures in managing the epidemic. Questions of borders, sovereignty, national competition have superseded any discussion of global commons or humanitarianism. Corporations, philanthropies, NGOs, and activist and humanitarian aid organizations are relatively at the margins. Circumventing the state, be it in sharing data, resources, or expertise, is rare. Are we entering a new period that not only brings the state back in, but puts it in the center?

Whether or not we are entering a new era (and we may well be), it does seem in retrospect that in discussions of the rise of “global health” – not only the role of WHO, but also that of global philanthropic organizations like the Gates Foundation or MSF, there was an overemphasis on the “global” at the expense of the ongoing salience of the national. We are certainly seeing, as your question suggests, that in terms of COVID response, national-level leadership and national-level economic and public health resources have been critical factors in successful management of the disease. On the other hand, as we enter the next phases of the pandemic – for instance, as countries that have successfully minimized rates of incidence try to avoid new outbreaks, or as we consider means of distributing limited doses of a vaccine – questions of global governance will remain salient. Of course – especially given the current weakness of WHO – it is far from clear how those questions will be negotiated.