I was pleased to see my letter to the editor published in The Economist (3 June 2023 edition). I wrote it in response to an essay written by Dr. Tedros Adhanom Ghebreyesus, the Director General of the World Health Organization. His essay “on the lessons from covid-19” had appeared “by invitation” in the 20 May 2023 edition of The Economist (available here). Here is what I wrote:
“Although Dr. Tedros necessarily must avoid offending any of his member governments, I am disappointed with how cautious he was in his reflections on the lessons from covid-19. The disproportionate initial impact of the pandemic on the developed world was strikingly more than the underfunding of public health (mostly a US problem). It ignores the significance of mobile populations and other factors related to the way the disease spread so quickly. I would have had more to say, too, about “vaccine nationalism” and the failure of the visionary COVAX Facility, as well as the continued impasse on intellectual property rights.
Regardless of the claims to the contrary about the relevance of this issue, the fact that the NGOs and the pharmaceutical industry are at such logger heads on the issue discourages the kind of consensus building on multi-stakeholder collaboration in global health policy that is so sorely needed. And, of course, Dr. Tedros also avoided criticizing the way the Chinese have continued to stonewall information-sharing about its origins.”
In this commentary, I take the opportunity to elaborate on the main points in my letter. Clearly, Dr. Tedros was avoiding being confrontational with any member state of the WHO, including both US and China. But he also used the invitation to build the case for universal health care as one lesson learned from the pandemic, rather than to describe the broader range of lessons learned regarding the evident lack of global cooperation.
The underfunding of public health services was the main focus of Dr. Tedros’s essay, and especially the inadequate funding of community-level health services. One cannot disagree with his advocacy for strengthening community-level public health measures as a priority to combat any future pandemic. The point, though, is that one might have expected more than this in an essay on “lessons from covid-19”. The impression from this line of argument was that the Director General was choosing to avoid alienating any of his member states by diverting attention from more controversial issues to this less controversial one.
And yet, one could also get the impression that he was in fact criticizing one of his member states without specifically naming it. After all, he did observe that “the world’s biggest economies and highest-income societies were the hardest hit” by covid-19. To develop his point about the underfunding of public health, then, he asserted that “many” of these high-income countries were “caught out by their historic under-investment in public health”. My reaction was a certain amount of confusion.
How many high-income countries had been caught by this? True, as a resident in France, I recall that the government was heavily criticized early in the pandemic for its mishandling and undersupply of masks for the general population, as well as an undersupply of ventilators for hospitals. But was that proof of an under-investment in public health? My impression is that France and most of the other high-income countries were not guilty of under-investing in public health. After all, it is those high-income countries of Europe that have consistently been ranked as providing the most comprehensive publicly funded health systems, including primary health care. In contrast, it was clearly the case that the US stood out for its appalling under-investment in public health and that Dr. Tedros’s remarks on this point were really directed at the US.
I have no complaint with his not specifically mentioning the US as such, but he continued in his essay to suggest that it was the “public-health know-how” of many low- and middle-income countries that proved his point that they were better positioned to respond to covid-19 at the community level than those high-income countries who didn’t have community-level public-health measures in place. It was even this lack of community level capacity, he argued, that forced the “many” high-income countries to “introduce more severe restrictions, including stay-at-home orders”. My recollection is that these kinds of restrictions happened in lots of places, including some not so high-income countries. And what is more, some of those low- and middle-income countries did have surges in covid-19, in spite of their public health know-how, while others seemed to escape the worst of it for reasons that went beyond their “muscle memory” (as Dr. Tedros described it) of community-based public health programs.
The focus on the importance of making “strategic investments in health” at a time when governments are more inclined to cut back on pandemic preparedness is indeed commendable. It also sets the stage for the forthcoming high-level meetings at the UN General Assembly in September on both universal health care and pandemic preparedness and response. But I remain hopeful that the varied efforts to draft a new instrument or to amend the International Health Regulations will be part of a broader awareness of the other “lessons” one should have learned from this pandemic and not just the importance of investments in public health and primary health care.
Vaccine nationalism and the politicizing of pandemic policy responses were disappointing developments over the course of the pandemic. It was horrific to see the ease with which anti-scientific misinformation and anti-vaccine rhetoric were spread in places like the US. The export bans and travel restrictions that became so widespread were not helpful either, especially where they resulted in the hoarding of surplus vaccines in rich countries that could have been distributed more equitably elsewhere in the world. I was especially disappointed by the failure of the COVAX Facility to transform itself into a global sharing platform, above and beyond its failure to meet its commitments to developing countries in a timely fashion. The furor over intellectual property rights was also very disruptive, with many NGOs criticizing the COVAX Facility for its defense of the patent system. It was interesting to see the shift in many developing countries to a demand for diversification in manufacturing facilities and technology transfer as an alternative to the original COVAX idea of pooling existing vaccine sources.
Finally, my own vision continues to be a multi-stakeholder one. The Global Fund seems to be in a place of its own on this, but I am still hopeful that the phenomenal early signs of collaboration in response to the covid-19 pandemic will bear fruit in the future. I notice that other coalitions are coming together – the Coalition of Partnerships for Universal Health Care and Global Health seems to be a good example of this. The traditional hostility between NGOs and the private sector that has reinforced the tensions over intellectual property rights may ultimately fade in importance with these broader efforts to work together.
But let’s also keep in mind that partnering needs to produce globally collaborative policies and programs to counteract the populism and politicizing that were so rampant in the response to covid-19. Something like a Global Health Threats Council does encompass the significance of multi-sectoral collaboration beyond the health sector, too. But such an approach will also a whole lot more transparency than we witnessed – whether that was from the pharmaceutical companies or the NGOs or the governments themselves – on subsidies or costs or prices or, for that matter, the real origin of the pandemic. Dr. Tedros might have had a point, after all, for concentrating on the kind of issue – universal health care (along with more funding for community-based public health) – that does seem to be ripe for consensus-building.