The world expects effective global health interventions: Can global health deliver?

ABSTRACT

The COVID-19 crisis offers unique challenges and opportunities for global health. The initial management of the pandemic was dominated by virologists, supported by epidemiologists who did not always meet indispensable scientific requirements. Interdisciplinary and complex global health concerns and expertise, however, did not have tangible impact on the COVID-19 debate, and even less on the strategies to contain the pandemic. As an explicitly political concept global health must safeguard its broad socio-political approach and counteract all tendency towards biomedical reductionism. Global health is universal and goes beyond health security. Above medical and biotechnological solutions, it requires the consideration of both downstream and upstream determinants of health such as the political, economic, ecological and social conditions that led to the crisis.

KEYWORDS:

• Global health
• COVID-19
• biomedical reductionism
• determinants of health
• health security

The COVID-19 Global Health threat

A dangerous plague is sweeping the world. Global health experts and practitioners are utterly preoccupied by the COVID-19 infection rapidly unfolding around the globe. The pandemic threatens people's health and evokes dramatic consequences in numerous countries. One could assume that the world's dependence on effective interventions to slow down the spread of COVID-19 would underpin and increase the importance of global health (Dalglish, 2020; Kickbusch et al., 2020; Pai, 2020). However, the crisis rather exhibits the existing challenges of global health, which can be seen as the consequent continuance of public health in today's globalised world. The long-term outcome of the COVID-19 crisis on humans’ health and the effect on global health – as well as on public health – remain therefore uncertain. Instead of strengthening Global Health, the current handling of the pandemic worldwide may rather become more of a challenge for global health.

Yet the COVID-19 pandemic has highlighted more clearly than ever the complex nature of global health. At the same time, it has revealed the extent to which biomedicine and biotechnology still dominate the debate. For weeks, politicians and the media continuously provided the populations in many countries around the world with a mix of meaningless epidemiological figures, threatening scenarios and deterrent images of overcrowded intensive care units. The Infodemics associated with the worldwide spread of COVID-19 did not only arise from the inappropriate nomenclatures as assumed by some authors (Hu et al., 2020) but rather exhibits the much more worrying fact that the intrinsic complexity of global health was unable to achieve sufficient impact in the media and general public (Nielsen, 2020).

The precipitous development around the pandemic undermined good epidemiological science being partly perverted even by a respected public-health institution, Johns Hopkins University in Baltimore, overwhelming the global public with ever new numbers of confirmed cases, deaths and recoveries (JHU, 2020). Likewise, the World Health Organization did not shy away from simply confronting and comparing absolute numbers among different countries and populations (WHO, 2020). Presenting and publishing absolute figures without the slightest idea of what the reference values are contradicts basic requirements of health sciences. Meaningful epidemiological data require both a numerator and a denominator; however, the latter is either missing or, at best, inconclusive as there is an unknown number of unreported cases (EbM Netzwerk, 2020), and data about the number of tests realised are usually inhomogeneous and incomplete. Moreover, even the numerator is doubtful due to a mix of under-reporting (people with or without symptoms who are not tested) and over-reporting (as not all patients who die with positive tests die from COVID-19).

In spite of all declarations about the relevance of global health in a pandemic outbreak, it was not global or public health experts that became the second group to enter the scene after virologists and epidemiologists. Instead, economists and business experts were the second on stage to create awareness of economic consequences of lock-down decisions, and law experts warned about the deep cuts of civil and human rights. Only at a later stage did global and public health experts make a noticeable appearance.

The experience during the early phases of the COVID-19 crisis has shown that the rapid succession of epidemic or pandemic outbreaks does not automatically contribute to shaping an awareness of global health. In contrast, the initial dominance of virologists and epidemiologists in media and political crisis management marginalised global health rather than strengthened it. The great importance decision makers attach to biomedical and biotechnical solutions compared to their determination to address social determinants of health is reflected in the huge amounts of money invested in developing COVID-19 vaccines (Schäferhoff et al., 2020) and the megatrial launched by WHO for accelerating the research on medicines to fight the current coronavirus pandemic (Kupferschmidt & Cohen, 2020). Strikingly, there is no comparable research fund in sight for investigating the obviously relevant upstream determinants of the pandemic (Holst, 2020).

COVID-19 is currently getting the full attention and distracting public health and consequently global health from existing long – and medium-term health crises (Cash & Patel, 2020; Horton, 2020). The major threats facing today's world, the climate emergency, ecological degradation, armed conflicts, inequality, and a growing epidemic of non-communicable diseases fuelled by predatory commercial practices are being pushed to one side by COVID-19. For increasing its reputation, relevance, and strength, global health must become more tangible and political.

In fact, the prevailing biomedical reductionism tends to supplant calls for more community health efforts (Aggleton & Parker, 2015), despite increasing evidence regarding the important role of socioeconomic and sociodemographic factors such as deprivation, population density, ethnicity, and chronic diseases, being associated with a higher likelihood of positive COVID-19 tests (de Lusignan et al., 2020), and more severe outcomes (Chen et al., 2020; Ho et al., 2020). Growing evidence confirms unhealthy lifestyles increasing the likelihood of COVID-19 related hospital admissions (Hamer et al., 2020).

This finding shows that the risk factors for severe COVID-19 infections are the same as for non-communicable diseases, which are again closely related to low socio-economic status (Whitehead et al., 2016). Thus, the predominant concentration of global health policies on both cross-border health problems and the spread of dangerous infectious diseases often lacks an in-depth understanding of political, social and economic conditions and requirements (Chan, 2020). Policies and health strategies are often lacking the intrinsic complexity and universality of global health, most recently in the context of the coronavirus pandemic, diverting the focus from the broad and universal approach of the Sustainable Development Goals (Aggleton & Parker, 2015).

Implications for future global health strategies

Global health is increasingly determined by cross-border relations, policy priorities and particularly by security concerns; the securitisation of health is meanwhile considered a key feature of health governance (Labonté & Gagnon, 2010). Multiple agents at national and international levels interact to target and fight cross-border threats to health (Bengtsson & Rhinard, 2019), as acute epidemic outbreaks are often regarded as predominant symptoms of globalisation. All too often, global health – as well as public health – pays less attention to potentially curable or preventable long-term diseases like tuberculosis and obesity, and even less to the structural causes of bad health and health inequalities (Yong Kim et al., 2005).

It is increasingly becoming obvious that the measures taken to fight the spread of COVID-19, particularly the lockdowns, are causing and will cause enormous social, economic and other indirect costs (Karlson et al., 2020). Preliminary OECD estimates suggest that every month of pandemic-related restrictions will shrink the economies of high-income countries by two percent, summing up to an overall yearly shrinkage of about 25 percent for countries such as France, Germany, Italy, Spain, the United Kingdom, and the United States (OECD, 2020).

However, the gross domestic product (GDP) the OECD refers to is not telling the whole truth. The impact of recession is unequally distributed among and within societies. Unemployment is likely to rise to levels unheard of since the 1930s – deepening social divide and boosting authoritarian and nationalist movements and populist political parties. It will take several years to tally the total number of deaths, bankruptcies, layoffs, suicides, mental health problems, losses to GDP and investments, and other costs attributable not just to the virus but to the measures used to fight it. A mix of economic expertise, political requirements and social aspects provides increasingly convincing reasons for countries to begin easing their restrictions.

Meanwhile, after the rapid implementation of lockdowns, global health has hesitated too long and not fully used the potential to supply policymakers with sound, evidence-based practical recommendations of how to adjust the measures and reduce dubious decisions produced during the initial stage of the outbreak. Despite the persisting dearth of evidence on the efficacy or effectiveness of non-pharmaceutical interventions for pandemic outbreaks (Aledort et al., 2007) a number of precipitous measures are rather questionable from a clinical and infectious point of view. As a matter of fact, the effect of travel restrictions as an isolated intervention is doubtful, at best (Errett et al., 2020), as evidence is lacking for its potential to contribute to the effective containment of infectious diseases (Mateus et al., 2014). Complete curfew prohibiting leaving the home except for very few cases, spending leisure time or doing sports outdoors is likely to be as exaggerated and ineffective as the complete closure of office buildings, in comparison with the implementation of the minimum requirements of physical distancing in order to maintain both recreational and labour activities. Likewise, more evidence is needed for underpinning the indiscriminate recommendation to use facial masks in the community as long as the general public is unaware of the correct use, minimum hygiene requirements are unknown and different types of masks with different levels of protection are available.

A sound, effective and successful strategy to fight a pandemic requires the multidisciplinary perspective of global health to provide robust evidence in order to prevent the negative effects from outweighing the positive. If global health is to be taken seriously, it must always address potential collateral damages of anti-pandemic strategies and monitor the undesired effects of the fight to contain the pandemic spread. This will ultimately put the prevailing focus on health security into perspective. The COVID-19 pandemic has impressively revealed the trend to consider health security as a means for protecting the industry from the consequences of bad health rather than as a strategy for protecting people's health from infectious diseases, not to mention the harmful effect of industry on people's health (Holst, 2020). Global health has to go beyond health security and therefore question the ongoing securitisation of health in national and international policies.

Politicising instead of securitising global health

The desire for security is well understandable in an increasingly inequitable, unstable and frightening world. However, it often remains unclear what is meant by security, who defines security and how it is to be created. Security-oriented policies focus on safeguarding the status quo, however inequitable and unfair it may be, as long as essential global health concerns such as pandemic outbreaks do not put social balance and integration across national borders in the forefront. Neglecting these such crucial determinants of health threatens to undermine what politics should be geared to: the rights and legal entitlements of people, as laid down in human rights and in the WHO constitution. Unlike human rights, striving for security does not enforce the idea of universality. Current security strategies are not necessarily aimed at the protection of those who are most in need – the poor and the marginalised, whereas overcoming poverty, inequity and social injustice is key for social cohesion and better health and therefore a crucial objective of global health.

Instead of putting the actual causes of global health crises such as the social, economic and political determinants of health in the centre, the debate revolves on how to efficiently manage the crisis without having to tackle the underlying causes. Avoiding the question of how to combat risks at their origin, global health tends to focus on how to deal with future risks in such a way that they do not threaten the status quo or put vested interests at risk. As continuance of public health, global health should be largely concerned with the question of how to identify and contain the health problems resulting from the living and environmental conditions as early and far as possible (Foldspang, 2015). However, these upstream determinants of health are neither high on the health agenda, nor are political priorities, power relations or the influence of stakeholders (Moon, 2019).

Global health is by no means immune to being instrumentalised for economic and political interests, it is rather interspersed with power relations (Labonté & Gagnon, 2010), which health-related policies need to explicitly acknowledge (Shiffman, 2015). Indeed, the existing power interests determine the predominant understanding of global health to a much greater extent than generally assumed or often discussed. The whole debate about global health governance, governance for global health and global governance for health (Kickbusch & Cassar Szabo, 2014) falls short in regard to analysing underlying power and power relations (Lee & Kamradt-Scott, 2014).

It has to be stressed that the root cause of the COVID-19 outbreak is not so much linked to the globalisation in itself but rather to the capability of transnational companies in imposing their business model thereby making microeconomic efficiency the lead dogma of global market economy. The prevailing economic system is man-made, and public policies worldwide, instead of prioritising national and social benefits, have accepted the predominance of transnational corporation profit interests vis-à-vis macroeconomic efficiency or sustainable economic acting. Unemployment, vulnerability, socioeconomic inequalities and weakened public services, in particular the health services, are not problems in themselves but inevitable consequences of the dominant economic system. More equality requires the question of power and power relations to be adressed and put on the agenda. All attempts of the last forty years to change the prevailing economic model will inevitably clash with powerful players and vested interests, as it touches the core of today's worldwide economy, the unrestrained growth model and the distribution of resources.

However, the recent reactions to the COVID-19 crisis have also exhibited an interesting policy shift: The resurgence of the strong state. Even the Financial Times, one of the world's leading business newspapers and certainly neither a progressive nor a very critical publication, states ‘Radical reforms – reversing the prevailing policy direction of the last four decades – will need to be put on the table. Governments will have to accept a more active role in the economy’ (FT Editorial Board, 2020). The daily further underpins the need to implement ‘policies until recently considered eccentric, such as basic income and wealth taxes’ (FT Editorial Board, 2020). Directly after these rather radical claims, however, the newspaper read by the richest and most powerful players in the globalised world, falls back into more conservative thinking patterns when it comes to the conclusion that ‘redistribution will again be on the agenda’ (FT Editorial Board, 2020). The increasingly accepted demand for redistribution does not go far enough; instead, the question of distribution needs to be addressed. The global reaction to the COVID-19 crisis must go beyond corrective interventions and retroactive compensations.

Taking the basic content and essential concerns of global health (Koplan et al., 2009) seriously leads to the conclusion that, due to its explicit political nature, it cannot avoid getting involved in key social and societal questions such as the distribution of resources, equality of opportunities, political power relations, social justice, vested interests, human rights – all of them being relevant levers for people's health. In practice, global health policies all too often end up reproducing inequalities and perpetuating social injustice. This is particularly true for pandemics in past decades that have raised income inequality and exacerbated unemployment with widely disparate impact according to educational attainment (Furceri, Loungani, & Ostry, 2020). Long-lasting effects due to diminished employment prospects or job loss, other income shocks, lower remittances, and the resulting impoverishment are particularly tangible for those with only a basic education whereas people with advanced degrees are scarcely affected (Furceri, Loungani, Ostry, & Pizzuto, 2020). The economic impact of lockdowns is most detrimental to people who work in the informal economy and barely survive on precarious livelihoods. As this will further widen the existing socioeconomic gap in all countries and societies around the world, it definitely underpins the urgent and pressing need for effective universal health protection (Yates, 2020), including access to health care and the right to sick leave (Heymann et al., 2020). The COVID-19 outbreak dramatically stresses the necessity to set up a global social protection fund or similar financing mechanisms in order to allow particularly the low-income countries to protect their citizens from the immense costs of the current as well as of future pandemics (Burrow, 2020).

Global health policy and politics

The recent health security agenda, particularly the policies to fight infectious disease outbreaks such as COVID-19, has exhibited a twofold effect on public policies. One was the relapse into olden times in the form of a strong isolation of nation states even in those regions where integration had already reached a relatively high level or even appeared irreversible like in the European Union; the other was the at least short-term return of the strong state. After many years of spreading the neoliberal ideology and evicting the State from its responsibilities, the latter reasserted its claim to political control with surprising clarity and decisiveness. Governments decided to intervene in individual and social life and to restrict economic and entrepreneurial freedom. For protecting people's health, the lock-down and the interventions of the reinvigorated state appeared comprehensible, as they were scientifically justified.

The state's regained strength vis-à-vis the private sector and even transnational corporations should be basically maintained beyond the COVID-19 crisis. The state is the only authority capable of guaranteeing and enforcing the right to health as it ultimately the only one accountable for human rights violations (Friedman et al., 2020). For improving and safeguarding people's health, public policies must safeguard the human rights and legal entitlements of people. Global health requires protecting those who are most in need – the poor and the marginalised – from health risks and bad health by overcoming poverty, inequities and social injustice. As important as good medical care is, it has less influence on people's health than their living, labour, income and environmental conditions, education, equal opportunities and social cohesion. Even in times of pandemic outbreaks, global health must consistently follow its broad socio-political approach instead of being deviated towards biomedical reductionism (Holst, 2020).

It would be detrimental to global health if researchers shy away from questioning the biomedical predominance in managing the pandemic or even from researching critical subjects outside the mainstream. In a world turned upside down due to a pandemic outbreak, it would be wrong to reduce global health to the search for medicines, vaccines and health security measures. Rather, it must advocate a health policy that addresses the social, economic, political and environmental causes of dangerous virus infections and all upstream determinants of health. In a nutshell, global health must first and foremost make a strong case for health-in-all policies. This will inevitably clash with powerful players and vested interests, as it touches the core of today's global economy, the prevailing growth model and ultimately the distribution of power. To emerge stronger and more visible from the current COVID-19 crisis, global health must become more explicit, more straightforward and ultimately more politicised.

Acknowledgements

The author is grateful to Ms Saskia Jaenecke for careful proofreading.

Disclosure statement

No potential conflict of interest was reported by the author(s).