The COVID-19 pandemic has laid bare the realpolitik of global health security. It has also illuminated some uncomfortable truths. For example, the pandemic has illuminated very different, and often hostile, interpretations of both “Western” (i.e., USA, UK, European) and Chinese pandemic perspectives and preparedness. Yet the reality is that few nations were prepared, with the Global Health Security Index not accurately predicting the current crisis landscape.
The pandemic has also provided a mirror to changing and complex geopolitical realities, including threats to human security. COVID-19 has reflected the “true colours” of how to conceptualise global health and what value sets to work by. And COVID-19 has also been a crushing additional weight on many already fragile national health systems, exposing fault lines across the geopolitics of global health and the rise of global health engagement by countries such as China that have traditionally shied away from this area.
In this blog, we explore China’s global health leadership, its international cooperation and lack thereof, and analyse what we see as the future of global health security. But perhaps the greatest difficulty in all of this will rest on how societies view their countries’ domestic responses, and how they see their duty to global health.
Geopolitics and information sharing
Treating China as a geopolitical competitor in the global health security space is strategic stupidity. The confusion surrounding the SARS-CoV-2 origin story, irrespective of the merits for or against the theory, threatens to drive a dangerous wedge in global health security. This wedge is not only between China and the West, but also across numerous countries within the sphere of influence through the Belt and Road Initiative (BRI).
This collaboration spoke to one of the most critical aspects that the pandemic has illuminated: accurate and truthful data sharing is king
One of the least reported cooperative actions of the pandemic, particularly in the early weeks and months of the outbreak, was the communication (at both a clinical and scientific level) between the West and China. Old friends and acquittances, particularly those who had worked on first SARS pandemic, were rapidly engaged to understand what was happening and what patient management strategies might work. This collaboration spoke to one of the most critical aspects that the pandemic has illuminated: accurate and truthful data sharing is king. But information by itself is not enough. It must be actionable intelligence. However, the foundations of such exchanges of data require long term exchanges, fellowships, and trusting friendships between individuals, not the creation of instrumental protocols that have little grounding in human empathy.
The history of US-China health exchange and collaboration, counter to the current political narrative, is an excellent example of what can be achieved.
There have been numerous examples significant relationship building that have been overlooked, like the US-China Joint Committee for Cooperation in Medicine and Public Health that started in the 1980s, through to major programs between US-China CDC which only ended relatively recently in 2017. The history of US-China health exchange and collaboration, counter to the current political narrative, is an excellent example of what can be achieved.
But relationship building cannot exist in a vacuum. Honesty is a pre-requisite for building global health security. Unfortunately, global health is rife with not just a lack of health data, but also a dishonesty over what is reported. Instead of helping to build proper national health data systems and connect these, policymakers seem more interested in giving hundreds of millions to make guesses under the guise of modelling. Both China, the West, and the countries with which they work to protect global health must rise to this challenge.
Global health security
Infectious diseases do not emerge in isolation. In most countries they are an integral part of wide spectrum of communicable and non-communicable diseases.
The pandemic has illuminated both the importance and dangers of global health security. Pre-pandemic global mechanisms such as International Health Regulations and the Alliance for Health Security Cooperation Joint External Evaluation programs have now been proven to be weak and ineffectual, products of wishful thinking rather than hard-nosed operational planning. And proposed policy solutions for future threats have been as varied and multiple as stars in the night sky—ranging from a pandemic “radar” system based on genomic analysis to an integrated global pandemic treaty. But these are solutions for very specific health security threats: epidemics and pandemics. Infectious diseases do not emerge in isolation. In most countries they are an integral part of wide spectrum of communicable and non-communicable diseases.
Security is crucial, but the securitisation of health in countries such as China presents some profound moral, ethical, and technical challenges. In a public health context, the use of signal intelligence (SIGINT) and other unique intelligence tools has become increasingly integral to epidemic and pandemic preparedness and response. While governments overtly refer to these as public health measures, national security doctrines are being expanded to include the pandemic threat. Health data (all types of data germane to public health or hospital clinical care) thus becomes of central importance to national security.
If health data is seen as a strategic advantage, then leaders will immediately be faced with significant barriers to cooperation. But the normalisation of global health security as an open source, cooperative domain of intelligence needs first to address cyber security and disinformation. If either China or the West exploits this system, it would erode the fundamental foundations for peaceful cooperation in global health security. The best version of this plan that I can suggest is a type of global health security oligopoly with China, with clear red lines around the critical areas of health security that have to be co-shared and managed.
COVID-19 is not the first, nor will it be the last, major global health security threat. While the continuing and futile accusations fly around the “lab leak” theory for SARS-CoV-2 origin, the bigger picture, which absolutely requires significant and deep cooperation with China, is being missed.
By far the largest and most dangerous “laboratory” is the natural world.
By far the largest and most dangerous “laboratory” is the natural world. Dramatic changes to the ecosphere and human encroachment into natural habitats are driving emergence of pathogens with epidemic, and ultimately pandemic, potential. Yet in many parts of the world, this issue remains under-explored, with few integrated human-animal-environment studies and even less systematic data collection and bio-intelligence.
COVID-19 has highlighted the importance of an integrated “One Health” perspective in evaluating how anthropogenic activities drive the emergence of novel zoonotic (animal) pathogens and provide the conditions for zoonotic outbreaks to achieve epidemic scales. One Health is a trans-disciplinary approach that identifying health threats at the human-animal-environment interface and acting upon them.
Historically, the One Health research agenda has been mostly orientated towards continental Africa and Southeast Asia. But parts of the world, such as the Pantanal wetlands in Brazil, are a rapidly evolving focus points for emerging zoonotic pathogens, because of land exploitation and climate change. These same pressures are causing novel and increasing interactions between humans and domesticated animals with wildlife. New levels of contact provide more opportunities for zoonotic disease transmission; and, in the absence of a robust local healthcare system, there is insufficient protection to prevent small outbreaks from expanding to epidemic proportions.
The future expansion of China through the Belt and Road initiative means it will be increasingly important global actor in strengthening One Health systems in a variety of countries. But even if this was not the case, China in itself is one of the most biodiverse countries in the world, with nearly 36 of the global biodiversity hotspots, a veritable cauldron of viral evolution that requires and deserves deep international study.
High threat diseases in conflict zones
High threat diseases, fragile health systems, and population displacement (including forced migration) increasingly coexist in countries with significant security issues. The recent histories of Ebola virus (EBOV) and Marburg virus, both well-known filoviruses which cause life-threatening viral haemorrhagic fever, in the Kivu regions of the Democratic Republic of the Congo are a case in point. As both China the West strive for ever greater global influence through development programs, there has been little pause or reflection by either on the impact that such development programmes are having on global health security risk.
For probably well over a hundred years, filoviruses have existed within these jungles across DR Congo, with outbreaks in human populations largely contained due to the areas’ relative geographic remoteness. However, conflict and (de) development are radically changing the disease geographies. As Hughes and Hunter discussed in their 1970’s paper, development is a double-edged sword when it comes to epidemics and pandemics. Development, plus conflict, plus ecosystem destruction, present entirely new and dangerous ecosystems for high threat diseases. Even on its own, conflict is a global health security threat which can rapidly breach borders. There are clearly mutual interests in supporting both health systems strengthening and emergency response to epidemic outbreaks in conflict regions to prevent them from becoming pandemics both in the west and in China.
Learning from COVID-19
There is mutual interest in a results-orientated joint investment in critical areas of health systems strengthening. China and other global powers should invest together in basic vital statistics, hospital information systems, and healthcare workforce development. There is a dangerous narrative that all that is needed to better prepare for the next pandemic is technical solutions like genomic surveillance. This is a fool’s paradise.
The failures in preparedness and response to the COVID-19 pandemic were systemic and specific.
What prevents epidemics becoming pandemics is the strength of national health systems. The failures in preparedness and response to the COVID-19 pandemic were systemic and specific. Likewise, the alarming and growing threat of anti-microbial resistance speaks to the need for serious cooperation to tackle the roots of this problem through a One Health approach. But global health security remains insufficiently country centred, and technical support is often disconnected or inappropriate for local policymakers. Joint country programs through Western-Chinese cooperation would provide not only significant confidence building platforms but also real focus at a time when global health has been seen by many as nationalistic and (neo)colonial.
The fault lines exposed and created by the weight of the COVID-19 pandemic cannot be repaired by either China or the West alone. Inequalities and the long-term impact of the pandemic on economic systems will have profound effects on the ability of governments to deliver universal health coverage and strengthen their health systems.
The global health economy is one of a few factors that will determine whether we are ready, or not, for the next major global health crisis. And it is in the corridors of economic power (IMF, World Bank, China Development Bank et al) that the greatest cooperative efforts are needed to provide the fiscal space for nations to build their health systems. It has been clear to those of us researching global health that fiscal headroom for countries to address their increasingly complex health financing transitions has been eroding for some time.
Even prior to COVID-19, there was serious doubt as to whether many countries could, even if they politically wanted to, achieve the necessary progression towards Sustainable Development Goals without sustained technical assistance in health governance. Already there has been substantial work in this field between the West and China, particularly around priority setting and the development of health technology assessments, one of the most essential tools in health systems planning. Strengthening global health security requires a wide range of both security sector and public health engagements, approaches and skill sets to be built into countries. To achieve such joint actions at scale peaceful cooperation is an absolute prerequisite.
Could better cooperation in global health security also help reduce conflict between the West and China? Despite their being significant scholarship on the role of development and peaceful cooperation, this research has rarely extended to a consideration of the global health space.
The most signiﬁcant attempt to bring together the concept of global health and peace came with the publication of the WHO “Consultation on Health as a Bridge for Peace” in 1997. Here, global health had a privileged position as a peacebuilding tool, something valued by all groups in society, transcending political differences. But this has not been without its detractors who argue passionately for an apolitical health space. In the harsh light of COVID-19, such a stance seems out of kilter with the new realities facing the world.
Global health security cannot be a zero-sum game nor unattainable ideological purity. Pragmatism in building a health security with both Western and Chinese characteristics needs to be the order of the day. Countries need cooperative health systems strengthening that is de-conflicted and mutually reinforcing. And when things do go wrong, there already needs to be in place global health intelligence systems that work despite broader geopolitical tensions. Relying on WHO to be the sole sentinel for future pandemics is a significant mistake. The diversity and complexity of the pandemic threat from inception to propagation demands parallelisation and co-operation of China and the West’s security and public systems that engages across disciplines and countries to develop indicator and warning systems coupled to robust response planning.