Project for a beneficial epidemic

In 1998, the Dutch sociologist Abram de Swaan wrote these lines1:

Sometimes it takes a disaster to prod people into action which they had refrained from taking until then out of ignorance, indifference or lack of confidence in their peers. Thus, preventive measures are usually adopted only when the catastrophe they are supposed to prevent has already occurred, once. Usually, the discussion centres about the question of what should be done to make sure that disaster will not strike again. Here, I will ask the reverse question: what kind of catastrophe does it take before people will adopt the policies that would have been feasible and beneficial all along.

With that reverse question in mind, de Swaan wrote a ‘Project for a Beneficial Epidemic’. What would it take to prod ‘concerted action by the wealthy countries to eradicate the conditions of poverty that caused the spread of a disease on a world scale?’ According to de Swaan, an infectious disease that is airborne, very harmful, if not lethal, and that would ‘continue for some years so as to allow governments and international organisations the time to overcome their dilemmas and effectively coordinate their actions’.

Abram de Swaan may not be a household name for the readers of BMJ Global Health. However, his study of the emergence of welfare systems in Europe and the USA2 is of relevance to the study of global health. The kind of solidarity on which public healthcare and welfare systems are built has few altruistic spores. Common and overlapping interests by key actors are the foundations of such systems.

As you will have guessed, the question we want to raise is whether COVID-19 may turn out being the beneficial epidemic de Swaan had in mind. While it may sound cynical—anyone with global health concerns would prefer that COVID-19 never occurred—we believe it is of utmost importance and urgency to raise the question. Spiriting COVID-19 away is not one of the options we have. Let us try to use the opportunities.

At first sight, an unlikely candidate

COVID-19 is airborne, lethal (for many people) and obviously very harmful. It ticks at least two out of de Swaan’s three boxes. But will it continue long enough for governments and international organisations to get their act together?

The unprecedented speed at which effective COVID-19 vaccines were first announced and later also developed may have turned this epidemic into an unlikely candidate to become a beneficial epidemic. Even before the first vaccines went into clinical trials, vaccine nationalism emerged—or re-emerged.3 Although we wholeheartedly agree with the Director General of the WHO decrying vaccine nationalism as a ‘catastrophic moral failure’,4 Oye warned us a long time ago that ‘cooperation under anarchy’—that is, in the absence of a global government—typically occurs in ‘the absence of gains from defection’,5 like trade, climate and nuclear agreements.

This warning actually predicted rapid defection from the COVID-19 Vaccine Global Access Facility (COVAX).6 Wealthier states seemed to have a lot to gain from defecting from COVAX: negotiating priority delivery with pharmaceutical companies while keeping the vaccines they pay for to their own people, thus being able to open up their own economies faster than other states could. Furthermore, COVAX alone would not be enough to free the world from COVID-19: some of the poorer states would need additional forms of international cooperation to strengthen their health systems to be able to vaccinate everyone—while keeping the system running for other health priorities.

On that issue too, defection from earlier commitments—for example, continuing to actively recruit health workers from poorer states—may seem to come with gains for wealthier states. If COVAX cannot work because states think they will gain from defecting from it, hoping that COVID-19 will prompt all states into creating some kind of international health systems fund, as suggested by Gostin,7 seems grossly optimistic. Defecting saves them their financial contribution.

What if we never achieve vaccine-induced herd immunity?

However, the assumptions on which rapid defection from COVAX was based may be wrong. In July 2020 already, Bollyky and Bown warned,

It is not clear yet whether achieving herd immunity will be possible with this coronavirus. A COVID-19 vaccine may prove to be more like the vaccines that protect against influenza: a critical public health tool that reduces the risk of contracting the disease, experiencing its most severe symptoms, and dying from it, but that does not completely prevent the spread of the virus.8

Recent findings seem to confirm Bollyky and Bown’s concerns. COVID-19 now seems more likely to become endemic, and governments will need to switch from emergency measures to policies that are economically and socially sustainable, and back to emergencies, indefinitely.9 To avoid that, all countries will have to work together to control SARS-CoV-2 mutations, wherever and whenever they occur, while keeping in mind that health systems in most parts of the world are not prepared for that challenge—and have other health issues to deal with. This may be in the form of COVAX, an international health systems fund or a global fund for health10; a deep revision of the International Health Regulations, as well as reforming the Agreement on Trade-Related Aspects of IntellectualProperty Rights (TRIPS), focusing on obligations of doing no harm and international cooperation11; or even—considering how climate change increases the risk of pandemics—a green and social climate fund.12 We may well have to consider all these ideas to engineer a major shift in the global governance of health and its inequities.

Giving hope a sporting chance

Optimism and hope are two different things, or so argue Bury et al whose research ‘aims to identify the unique nature of hope, suggesting hope is invoked in particular when expectations of positive outcomes are low’, while ‘with greater probability hope tends to align with optimism’.13 We are not optimistic. But we are hopeful.

A quarter of a century ago, wealthier states started providing AIDS treatment. It took almost a decade between the development of effective AIDS treatment and the creation of an international mechanism that allowed hoping that all people living with HIV will benefit from AIDS treatment: the Global Fund to fight AIDS, Tuberculosis and Malaria. Twenty-five years ago, the leadership of WHO did not decry a catastrophic moral failure because of unequal AIDS treatment policies.14 Grotesque inequalities in global health are no longer tolerated; wealthier countries pushing their vaccine nationalism to extremes will pay a cost in terms of legitimacy and reputation.

We broadly agree with Davies and Wenham: International Relations scholars—and political scientists more broadly—are crucial for the global COVID-19 response15 and to help us find ways ‘so as to allow governments and international organisations […] to overcome their dilemmas and effectively coordinate their actions’. However, while global health governance studies have focused, among others, on governance resilience and institutional innovation in the face of health security threats,16 we argue that one of the major reasons for states having difficulty to promote and join international collective action is a deep core of neoliberal policy ideas and values that has functioned as the foundation of international cooperation for more than 30 years.17 Another reason may be the shrinking of democratic space because of security interests and the power of transnational capital.18 At least the people of the UK seem to disagree with their government’s vaccine nationalism.19