Society after Coronavirus essay #5: International Healthcare Co-operation

This is the fifth in a series of essays exploring the economic, social and cultural effects upon the daily lives of persons living in the United States, western Europe and more broadly around the world, as we emerge from the global Covid-19 lockdown pandemic.

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By Matthew Parish

Behind the scenes, the European Union has been playing a major role in coordinating the responses to the Covid-19 pandemic across Europe. This has been achieved not by way of legislative decrees emanating from Brussels; the policy consequences of ordering that people remain locked down in their homes are too devastating for an international organisation to harbour responsibility for. Nevertheless there is logic in a coordinated international response. For example if each country within a geographical area imposes differential lockdown rules to seek to slow the spread of the virus, but those countries allow free movement between them, then there is a risk of a race to the bottom in standards because people can travel from places of higher infection to places of lower infection, bringing their infections with them and undermining the benefits of a more rigorous lockdown regime. At least that is the theory. Therefore when one is looking for the intellectual source of successive European countries in March 202 having rapidly imposed similar lockdown measures across borders, one will find a guiding hand of Brussels soft power imposing uniformity across different countries. This includes not just healthcare measures, but also associated industrial and social policy: for example.

Across Europe, the rule that states would pay 80% of furloughed employees’ wages to businesses was a constant Brussels prescription, reinforced by European Central Bank lending promises. The 14-day quarantine rule, at the time of writing in late May 2020 being largely aborted as unworkable, was an EU prescription, as was the also aborted requirement to travel with a negative 72-hour old polymerase chain reaction test. Social distancing rules of two metres are a quiet Brussels invention, copied uniformly. It is not had to see how intergovernmental cooperation became possible over such a short time period in the context of a crisis.

Democratic governments rarely like doing things quickly. Accountable to the people and the media, they like to test the waters, consult with people, and make decisions amongst the options available to them that they think the most people will look or the fewest will dislike. But in crisis, actions may need to be taken quickly and without adequate time for reflection or collection of data, and this is where the Brussels Executive excels. Its technocrats are not responsive to political pressures in the usual ways, and they can just make decisions. Those decisions need not even be given the force of law; governments will eagerly adopt them because in the absence of a process of accountability a government will fall back on a precedent. One country has adopted these measures, and therefore all the others will soon follow suit. The logic of governmental herds is remarkably attractive during the rapidly unfolding crisis timescale of a Coronavirus pandemic.

Now death is the new normal, and we no longer have a crisis. People just continue to die, and  governments massage statistics about it as in wartime. Nevertheless in the face of death there is a habit for governments to follow one-another in the way the deal with it, and this is why countries are unlocking their societies in step. The European tradition of ever-aligning proximity of their political and legal systems since 1957 makes this happen because individual governments lack knowledge or direction and this is one field in which, for the most part, they are happy to delegate their decision-making to international (European) standards. Governments can take the credit for acting decisively in front of their domestic audiences, whereas in fact what they are doing is following the suggestions of an international authority. Governments have not been forced to do this; some countries, Sweden and Belarus, have not done so. But most have willingly gone along with the sense of collective action when it suited them because they had no policy of their own.

This is not the way that most proponents of central action through international institutions like to think of their efforts: as a means of arbitrary policymaking in times of crisis because no domestic authority wants to take responsibility for difficult decisions. Nevertheless that is the role the European Union found itself unwittingly playing. The question now is whether international cooperation is important and necessary in the management of pandemic crises in the future. Advocates of renewal of international institutions argue that domestic healthcare research has not been sufficiently fruitful, and therefore research efforts should cooperate across borders to develop vaccines, reliable testing and research on prevention and treatment. Efforts in different countries have been inconsistent and haphazard, they say. There is truth in this latter assertion; but that does not automatically entail that cooperation between countries through the use of international institutions such as the World Health Organisation is desirable. Everything depends upon a close analysis of what one is trying to achieve.

In some medical contexts, international cooperation may be imagined to achieve economies of scale. Hence where a research project requires more money than any one country can afford or is prepared to pay, efforts may pooled internationally (as for example has been the case with CERN, the large hadron collider experiment outside Geneva, Switzerland). Covid-19 vaccine research is not in this category, however. The profile of the disease is so high that there is far more money available for vaccine research than anyone knows what to do with. The patent premium available upon an eventual vaccine is so high that there is not a huge incentive upon pharmaceutical companies to cooperate. Nor is there a clearly identifiable need; indeed competition between major pharmaceutical companies may speed up the process of eventually finding a vaccine (if indeed one can be found).

Recent notions of pushing back of global patent law to permit a vaccine once found to be distributed cheaply are not only misconceived but entirely pernicious. If pharmaceutical companies anticipate lower levels of legal protection of their inventions, they will be proportionately disincentivised to continue their current imperative research. The way to deal with the problem of unequal access to pharmaceuticals across nations with differing levels of wealth is the same as it always has been: wait until a new invention has been tested and works, and then subsidise or negotiate reductions in its market price in the developing world. There is no point anticipating a problem such as price restraining circulation of a pharmaceutical and pre-legislating for it, before the pharmaceutical has even been invented. By doing so, international institutions are reducing the likelihood that it ever will be invented. Unfortunately it is precisely this idea that was recently touted in the hallways of the World Health Organization. Officials in that body ought to know better. Global pharmaceutical research is driven using a competitive market between giant companies, and the middle of a crisis is not the time to tear that system up.

Nevertheless the United Nations, and the World Health Organization, one of the United Nations’ specialised agencies, are in search of a role in the midst of the current pandemic. While they talk about the need for global cooperation, seldom are they sufficiently specific as to identify in what way states ought to cooperate. One area in which international institutional cooperation, whether through the United Nations or otherwise, has been successful is in international standard setting. This underlies the relative successes of the International Postal Union and the International Broadcasting Union. The thought is that where there is more than one legitimate way to undertake an important activity, more often than not it is best that all nations undertake that activity the same way or with the same rules.

This applies for example to testing and measuring Covid-19 cases. The data on infections and deaths with which we are currently bombarded daily come from different countries using different methods of counting. Or, in some cases, we find different methods being used even within the same countries. This is a particular problem in large federalised countries that do not have national public healthcare systems, such as the United States. In order to keep track on statistical issues as varied as the effectiveness of lockdown techniques; infection hotspots; and disproportionate influence upon different population groups within a society, it is important that countries and indeed regions within a country all use the same testing techniques.

The World Health Organization understood this at an early stage of the Covid-19 crisis, advocating that governments test as much of the population as possible. This was undoubtedly sage advice, because without effective cross-sectional population testing all data is unreliable. That is because the only people who end up being tested for Coronavirus are hospital patients and their carers, neither of which groups are cross-sectional of the population as a whole nor are in the same risk profiles as the typical man (or woman) in the street. Therefore infection and death statistics become at best proxies for the capacity and effectiveness of national healthcare systems. Countries with inferior healthcare systems simply do not record all the people being infected or dying. Without cross-sectional population testing, that very few countries have even attempted, the various statistics emerging from different countries’ health ministries are incommensurable.

The World Health Organisation should have continued to recommend full healthcare testing as the most rational course, and prescribed international standards on how to do it so that every country that did undertake it could comply with a common norm. That way, infection and death rates would be intelligently comparable and we would now have a much more accurate picture of how Covid-19 has spread across the world and how deadly it is. We would therefore be in a far better position than in fact we are to assess the effectiveness of lockdown measures, about which we are currently just guessing. In this aim of international cooperation, therefore, our international institutions have failed us. Organisations that harbour ambitions to serve as standard-setters have to set standards; and this is what the World Health Organization has failed with sufficient clarity to do. As a result, countries went down the quarantine and lockdown route rather than the testing route, and this may turn out to have caused damage to the economy.

The World Health Organisation is now close to dissolution, in the face of policy squabbling between its two largest members, the United States and China. The United States has announced that it intends to defund the organisation forthwith by reason of dissatisfaction with its Chinese-leaning Ethiopian Director-General who is expected by the United States to resign for bias. It is unclear how this dispute will be resolved, as the United States is the largest donor to the World Health Organization that is looking at substantial cuts to its operations should Washington, DC carry out its threat. The World Health Organization has been the subject of repeated criticism throughout its lifetime; a series of other international health organisations, including UNAIDS, the Global Fund and GAVI, have been created by the UN member states as a result of dissatisfaction with the inability of the World Health Organization to respond to crisis. Those renewed organisations have not, on the whole, performed effectively either. Grant funds have been wasted across the world, and the institutions’ headquarters have been infected with inept and ineffective management.

The aspiration for increased cooperation to face global healthcare crises turns out to be a chimera: it sounds like a good idea, but the international institutions already in existence lack the capacity and independence to do anything useful. There is still plenty of scope for international organisations to set useful common standards for countries, in particular relating to testing because there is not enough testing but there ought to be and it ought to be standardised. There is little for the World Health Organization to do in terms of encouraging research into vaccines or cures; that is for international pharmaceutical companies, with their massive resources, to undertake. Recently the World Health Organization has taken to articulating its ideas about such routine matters as whether there is value in wearing face masks; but member states and private citizens alike are not taking much notice of it. The United States, behind the scenes, is now demanding that the Director-General of the World Health Organization resign for failing to provide sufficient weight within the organisation to the interests of its biggest donor. Should the WHO not comply, then US withdrawal of financing, expertise and lobbying power many mean the organisation has no credible future as an international institution representing a balanced cross section of its principal funding members’ interests.

One temptation we ought to resist is to establish yet another international coordination body for overseeing pandemic diseases or similar health emergencies. There are already too many such institutions. The World Health Organization and its sister institutions has ample expertise; a substantial proportion of its employees are doctors, and some of them are amongst the best in the world. There is a standard-setting function for the institution to undertake. The problem is that it is too dysfunctional in its current condition to be undertaking that effectively. If this role is needed for the global fight against pandemic diseases, then the World Health Organization will have to be reformed from within and this will require coordinated pressure from all the member states. The member states must themselves understand the desirability of having common testing and measurement standards for fighting pandemic diseases, and they must insist that the organisation they fund undertakes these roles properly. That should arguably be the sole subject of the next World Health Assembly resolution.

Matthew Parish is an international lawyer and scholar of international relations based in Geneva, Switzerland. He is an Honorary Professor at the University of Leicester; was elected as a Young Global Leader of the World Economic Forum; and has been named as one of the three hundred most influential people in Switzerland. An expert in UN reform, he is the author of several books and over three hundred articles.

The views expressed in this article do not necessarily reflect those of TransConflict.

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