On June 11th the leaders of the G7 will meet in Cornwall to ‘build back better’ from coronavirus. As would be expected, global health security is high on the political agenda, and Boris Johnson, who holds the G7 Presidency, has started to roll out his initiatives. This is not unusual, since the G7 has traditionally played an important role in global health policy, both for better and worse.
For better, at the Japanese Summit in 2000, the members of the G8 (before Russia was expelled for invading Crimea) committed $10 billion to launch both the Global Fund to Fight, AIDS Malaria and Tuberculosis (GFATM) and the GAVI Alliance. Although these institutions have been far from perfect, it would be churlish to dismiss their positive impact on global health security, since they are estimated to have saved millions of lives.
Yet, for worse, the G7 also has a history of being big on words and light on follow-through and well-integrated policies. For example, in 2015, the leaders of the G7 in Germany declared that Ebola had been ‘a global wakeup call’ for better pandemic cooperation. In response, the G7 backed the establishment of the Global Health Security Agenda (GHSA) and underwrote the World Bank’s Pandemic Emergency Financing Facility (PEF). Both initiatives were not fit-for-purpose and were nowhere to be seen during the pandemic.
In the case of the GHSA it has struggled to get members (only 69 countries), is poorly integrated with other global policies, and lacks funding and political commitment, particularly from G7 countries. PEF, which was meant to deliver $500 million within 72 hours of a pandemic threat, sat idle, and has now been terminated. As the former Chief Economist of the World Bank lamented, PEF was an ‘embarrassing mistake’, created by ‘goofy governments who wanted to have an initiative for the G-7’ and ‘officials who loved the phrase “private sector involvement”’.
The recently published 2021 Carbis Bay Progress Report, a G7 progress report on development commitments, focused heavily on how the G7 has helped to strengthen health systems, expand access to vaccines, to advance universal health coverage (UHC), while also promoting health security. However, when examined in detail, the report shows only minor gains and seemingly counts everything the G7 does as somehow advancing health security. This inflates the positive narrative while shifting the blame for emerging health risks on low-to-middle income countries.
That said, what is promising about the progress report is that it does recognise key shortcomings in current global health security policy, which has tended to narrowly focus on surveillance, vaccine discovery, and countermeasures, with little attention given to upstream determinants, prevention or preparedness. As the report suggests, ‘the foundational role of strengthening health systems to the goals of UHC and Global Health Security (GHS) has only become clearer, not least in the face of the COVID-19 pandemic that has challenged health systems across the globe. The case to look at UHC, GHS and health system strengthening together is clear, as is the need for continued leadership by the G7 and other partners in these priority areas’.
Nevertheless, there are worrying signs that key lessons learned from the 2021 Carbis Bay Report and from COVID-19 are being missed at this G7 Summit. Two stand out.
First, a major initiative by Johnson is the Pandemic Preparedness Partnership (PPP). This initiative aims to establish a public-private partnership that includes industry, international organisations and experts to help deliver vaccines, therapeutics and diagnostics more quickly, via co-operation on research and development, manufacturing, clinical trials and data-sharing. The ultimate aim, according to Johnson, is to ‘slash the time to develop vaccines for new diseases to 100 days’.
The problem with the PPP is that it merely continues our current obsession with vaccine discovery and immunisation as the primary means for health security. This approach got us here in the first place and often comes at the expense of other preventative and preparedness measures (as highlighted in the 2021 Carbis Bay Report).
This is concerning since an overreliance on immunization for health security does not appropriately reflect the empirical evidence, both in terms of general public health and, particularly, in the case of Covid-19, in which social determinants, age, comorbidities, and previous exposure to infections play a determining role in explaining the ‘transition’ from SARS-CoV-2 infection to severe forms of Covid-19. Given the epidemiological complexities, vaccine dominant strategies risk being suboptimal, when not strongly coupled with more ambitious preventative public health policies and investments in population health. If the lessons of COVID-19 taught us one thing, it was confirmation of the principle that ‘an ounce of prevention is worth a pound of cure’.
Moreover, it is not clear how the PPP’s 100-day target was selected and whether it is a case of putting the cart before the horse. At the moment, it looks arbitrary, better suited for political slogans and G7 speeches, than rooted in science. This raises several quality and control concerns, particularly if clinical trials and government approvals will be fast tracked in order to meet the target. As the lessons from COVID-19 demonstrate, hurried processes and speedy trails can restrict our evidence-base, which can leave significant gaps in our knowledge about who can receive the vaccine, how long the vaccine generates immunity, whether it reduces transmission, while also fuelling vaccine hesitancy and mistrust. Lastly, overreliance on vaccine strategies assumes that we can find an effective vaccine to future pathogens. This is not a given, since there are many diseases where vaccines remain elusive.
Second, although the G7 Health Minister’s communiqué on June 4th 2021 provided some positive words on revamping global health policy (whole-of society approach; One Health; intersectoral, health system strengthening, and gender), the communiqué was light on detail, and much of the language used could have been cut and pasted from the 2015 G7 communiqué. This is troubling if not backed with appropriate mechanisms, since historically the problem with G7 global health policies is that they are disjointed, increasing governance fragmentation, where financial commitments are scarce, coordination between institutions limited, and political leadership wanting.
Beside a few promises to establish expert committees (e.g. the Zoonoses Community of Experts & the New Variant Assessment Programme) there is little in the PPP or the Health Minister’s Communiqué that indicates real commitment to the political and financial reform mechanisms needed to address the counterproductive public health effects of ‘vaccine nationalism’, ongoing violations of the International Health Regulations, uncoordinated pandemic travel policies, meaningful attention to upstream zoonotic and environmental determinants, global health system strengthening, and/or the lack of political will and investment required to seriously reboot global health governance. In the case of finance, the numbers being discussed look meagre, and hardly an investment in global health, particularly when compared to the estimated $25 trillion COVID-19 has cost the planet in stimulus packages and lost GDP.
Furthermore, like the PPP, the Minister’s Communiqué again overemphasises surveillance, data sharing and immunisation as the mainstay of global health security. This symptom approach becomes precarious as the risks from emerging epidemics and syndemics are estimated to intensify with increased habitat encroachment, increased social inequality, degradation of living conditions, social environments and ecologies, urban density, and climate change. These upstream determinants require a much stronger focus on prevention and preparedness. Otherwise, we simply let pathogens emerge and lockdown until vaccines can be discovered, produced and globally distributed.
As an alternative Britain should be more ambitious with its G7 Presidency to push a broader continuum of strategies that includes vaccine discovery and equitable immunization, but also strategies promoting better global population health and healthy lifestyles, targeted prevention on other determinants of health, adequate primary care and monitoring, early treatment, health system strengthening, enhanced health regulations, and sufficient national, regional and global system policy preparedness for emerging epidemics.
These reforms will require a paradigm shift in our thinking about global health, where health becomes an investment, not a line-item expense, and where preventive measures beyond siloed vaccine strategies are taken seriously – and there are already frameworks being developed elsewhere that can promote this approach, such as the Health Systems for Health Security framework being finalised at the World Health Organisation. Without this more holistic approach we are doomed to repeat the failed lessons from the G7 Summit in 2015 and COVID-19. Thus, merely elevating yet another set of misaligned, uncoordinated, half-hearted, and under-resourced global health and pandemic preparedness partnerships and policies. We must ‘build back better’ than that.