COVID-19 hit the world like a sucker punch. Without a treatment or a vaccine, the pandemic triggered an unprecedented global wave of economic and social devastation. The numbers are staggering. At the time of writing, COVID-19 has infected over 40 million and killed more than one million. The economic and social hardship triggered by COVID will plunge millions more into poverty. Its impact will be felt for decades.
The world spent years preparing for a pandemic. Countries signed on to the World Health Organization’s International Health Regulations designed to detect and respond to outbreaks that could go global. These regulations created a transparent mechanism for the declaration of a “Public Health Emergency of International Concern.” And here at home, we designed the Public Health Agency of Canada in the wake of the SARS 2003 outbreak to ensure we would be better prepared.
Despite all that planning, COVID-19 caught Canada and much of the world off guard. As outlined below, missteps and mismanagement plagued the response, which was underpinned by an overconfidence in flawed institutions and a narrow group of experts. In just a few short months, COVID and the bungled response to it has planked the wrong curve — the arc of human progress.
COVID-19 has created a challenging global landscape where weakened global institutions and diplomacy are ill prepared to address escalating poverty, inequality and deepening humanitarian crises. Canada needs a clear vision of our place in this COVID-19 world. Through our diplomacy, development assistance and economic engagement, Canada should push for a renewed appreciation of our common humanity and advance an agenda for global human dignity.
We must also put in place the institutional capacity to promote this vision. Global health policy needs a more open and collaborative approach to foreign policy deliberations and decision making, one that reaches across disciplines, incorporates the voices of affected communities and listens carefully to its fiercest critics. Only with this vision and the institutional structures to support it can we effectively minimize the impact of the pandemic and ensure we do not repeat the same mistakes we made in our initial response to COVID.
So what went wrong?
Why was the world unable to contain this pandemic? The nature of COVID-19 is a big part of the problem. It’s a new pathogen and is deceptively dangerous. Vaccines can be quickly developed for novel influenza strains. But prior to the COVID-19 outbreak, no human vaccine for coronaviruses made it past early clinical trials. Without a vaccine, the only methods of control are masks and physical distancing to prevent the virus from spreading from one person to another. Controlling COVID is not an easy task. There may be significant numbers of asymptomatic cases as COVID-19 generates mild or no symptoms in most people, yet an infected person without symptoms can transmit COVID. Moreover, the relatively low fatality rate is misleading. COVID-19 causes severe illness and death among the elderly and those with pre-existing conditions. Hospitals can be quickly overrun when the virus circulates broadly in the community.
China also initially gave the false impression that it had COVID under control. Reports of a mysterious pneumonia trickled out of Wuhan in December 2019. While many health experts cautioned it could result in a global spread, policy makers were optimistic it would be contained, like earlier outbreaks of the Middle East Respiratory Syndrome, which was also a coronavirus. China had strengthened its health monitoring systems since the SARS epidemic in 2003. The government appeared to take swift action. It imposed a lockdown in Wuhan and other cities in Hubei province. And countries in the region, like Taiwan and Thailand, quickly identified cases and controlled COVID’s spread.
Although China initiated public health measures, it also undertook action to control the flow of information about the outbreak. COVID was spreading rapidly in early January, but China only confirmed sustained human-to-human transmission on January 20. Health workers and intelligence experts had warned of the extent of the outbreak in Wuhan, but these voices were excluded from the WHO’s decision-making processes. The WHO waited until January 30 to declare COVID-19 a global health emergency — a delay that impeded global prevention and preparedness.
The virus quickly hitched rides around the world. By early February, COVID-19 spread to Iran. While public health alerts focused on China, the virus travelled from Iran to northern Italy. In early March, New York City was hit, although evidence suggests that the United States experienced limited community transmission in January and February. By March the global pandemic was well underway.
Canada was not ready. Our pandemic preparedness muscles had atrophied. Government errors, clearly documented by Wesley Wark, a visiting professor at the University of Ottawa’s Graduate School of Public and International Affairs, characterized our response. Stockpiles of critical pandemic supplies expired and were destroyed without being replenished. Even in late February, when COVID cases were rising around the world, our health minister, Patty Hajdu, told Canadians that COVID-19 posed a low risk. Our public health infrastructure was ill prepared. Protocols to check and track travellers returning home from countries with COVID-19 cases lagged far behind the spread of the disease. And most provinces had limited capacity to test even symptomatic individuals for COVID.
Although the government rapidly funded sophisticated outbreak models, our low testing capacity meant we did not have sufficient data to guide public health measures in communities. Without good data, public health officials could not target interventions towards the most affected communities and groups. Given the lack of consistent gathering and reporting of data by race and socio-economic status, the disproportionate impact of COVID on racialized and economically vulnerable groups was not initially tracked, understood or addressed.
Canada was not alone in its struggles with this pandemic. The effectiveness of government approaches to COVID-19 has varied considerably. Steep rises in the number of cases in North America and Europe have sparked renewed restrictions. However, some countries have done much better. As pointed out by a scientific consensus published in The Lancet, COVID-19 can be controlled with public health measures. Many countries in Asia have out-performed much of the world. They implemented robust public health responses to control the initial outbreak, and then managed subsequent spikes in cases. Such measures allowed those countries to minimize COVID’s social and economic disruption.
There are other rays of hope. Global research networks have enabled scientists to rapidly share data, methods and research findings. Chinese scientists published the virus’s genome sequence online within days of its identification. This sequence enabled the quick development of diagnostic tests and kickstarted the creation of “mRNA vaccines.” These use a synthetic version of the virus’s genetic information to trick the immune system into a response — unlike traditional vaccines, which trigger a response by introducing inactive components of the virus. Both traditional and mRNA COVID-19 vaccines have quickly moved into final Phase Three trials. Concerns remain over the roll-out, effectiveness and sustainability of vaccines, as well as how to ensure their equitable global distribution. However, the speed of progress is unprecedented.
Scientific collaboration has clearly outperformed public health policy. Cooperation by researchers extended beyond vaccines. Epidemiologists shared models of the outbreak that detailed the potential consequences of delayed public health measures, prompting lockdowns around the world. Journals have facilitated both the rapid peer review and the open sharing of research.
The impact of policy failures
The catastrophic consequences of the failure of many countries to control COVID-19 are clear. While COVID has and will continue to kill many people, many more will suffer from the indirect effects of the public health lockdowns. COVID interrupted critical treatment and essential services — including comprehensive reproductive health services and immunizations. Women around the world are experiencing a “she-cession,” with impossible choices between childcare and employment, and higher job losses. Intimate partner violence and child abuse rates have risen at alarming rates around the world.
The economic costs have yet to be fully calculated. The International Monetary Fund predicts a 4.4 per cent drop in economic growth, pushing millions into extreme poverty. Remittances have plummeted. Organizations have interrupted development and humanitarian programming. Given the inevitable global recession triggered by COVID, the future levels of development assistance from rich countries are uncertain. In some countries, governments are using the pandemic as a cover for political repression. Migrants and refugees face heightened restrictions on movement and asylum. Global inequality is dramatically increasing, deepening divides between rich and poor regions. In short, vulnerable communities around the word are bearing the brunt of COVID’s impact.
Why did it go so wrong?
Policy makers designed pandemic responses for the world as we want it to be — a world in which health monitoring systems are effective, governments value and reward transparency, and institutions exist to oversee global health security.
As COVID has shown, the reality is far different.
China was less than forthcoming about the extent of COVID’s spread. In the future, such reticence and information failure should be anticipated. Policymakers should also expect that some countries may be unable to share outbreak information with the WHO because they don’t have the necessary public health monitoring systems. They should recognize that officials concerned for their livelihoods or reputations may cover up a local outbreak, and that some countries may also fear the economic, social and political disruption of a notification to the WHO.
The WHO itself lacks the tools to make sure states provide outbreak information. It has a vast, ambitious and critically important global agenda. This agenda includes the promotion of universal primary care, the coordination of health services in emergencies and the development of global regulations and guidelines on medicines and technologies. The WHO needs the cooperation of member states to advance that agenda — particularly the cooperation of powerful countries like China. It may be reluctant to risk depleting its political capital by confronting such states, especially in the early days of an outbreak when the pandemic potential of a disease is still not completely clear.
COVID-19 also emerged during the decline of the American health security umbrella. The U.S. Centers for Disease Control and Prevention has a long history of effective global infectious disease surveillance. Yet this surveillance capacity diminished when the Trump administration cut its funding and reduced its staff in China.
Despite signing on to International Health Regulations, countries funding international assistance did not prioritize their implementation. Global health programs focus on HIV/AIDS, malaria and tuberculosis, childhood illnesses and efforts to reduce maternal mortality. This health spending is understandably directed towards the high burden of existing diseases — not potential ones. The Institute for Health Metrics and Evaluation at the University of Washington reports 2019 development assistance spending for health at US$41 billion; pandemic preparedness received less than one per cent — a paltry US$370 million.
In Canada, the existence of our Public Health Agency may have led to a complacent belief among policy makers that Canada had the right bureaucratic machinery in place. Yet the agency does not have an explicit global mandate: its focus is on the health and safety of Canadians, and the mandate letter of the minister of health contains no reference to global health. Without a global mandate, warning signals from outbreaks overseas could be missed. Within the department, global health experts, including those participating in Canada’s Global Public Health Intelligence Network, were sidelined, leading to what two retired senior medical experts described to The Globe and Mail as “a steady erosion of scientific capacity.” This devaluing of scientific expertise and experience at the Public Health Agency of Canada reflects a worrying trend throughout the public service. Employees are incentivized to move around the bureaucracy, rather than remain in one area to develop deep expertise. While both are important, the knowledge of bureaucratic processes often trumps expertise for promotion and new appointments.
Canada is additionally undermined by the absence of global health among our foreign policy priorities and the weakness of our global health bureaucracy. Canada has no overarching global health strategy, and there is no secretariate at the Privy Council to coordinate the global health activities of relevant departments. Global Affairs Canada includes health in its humanitarian and development activities yet lacks a cadre of experienced global health experts to support broader and informed engagement. Moreover, Global Affairs does not draw on its extensive network of missions abroad to provide systematic reporting on global health. As a reflection of the government’s low prioritization of global health, Canada broke a longstanding tradition and did not host a G7 health ministerial meeting on the margins of the World Health Assembly during its 2018 presidency.
What does this mean for Canada’s foreign policy?
COVID-19 has changed the priorities of every country around the world. Governments now face two essential policy questions: How can they minimize the pandemic’s impact on health and socio-economic wellbeing? And how can they ensure that they are better prepared for the next pandemic?
As governments navigate those questions, they must also confront the pandemic’s impact on international diplomacy, alliances, institutions and global governance. The outbreak has confirmed in stark terms the decline of American leadership and the lack of candidates to take its place. Despite the fact that COVID-19 is a global problem requiring collective action, many countries are retreating from their commitment to multilateralism to pursue narrowly defined self-interests. The WHO has been weakened by its shaky response to COVID-19 and previous infectious disease outbreaks. Governments are understandably reflecting on the risks of economic integration, the need for economic security and the protection of their supply chains. But there is less reflection on where more protectionist policies may leave the world’s vulnerable populations. Globalization is perceived as the problem rather than the solution.
This pivot from international collaboration and cooperation could not happen at a worse time. Gains made on key social and economic indicators, such as poverty rates, maternal health and childhood mortality, are quickly being reversed by the impact of COVID-19. The cost of food and other essential items is rising while job losses soar. Many countries face the double burden of COVID-19 and the impact of climate change on food security and livelihoods. The education of millions of children and young people has been interrupted around the globe, undermining future human capital. Without leadership and assistance, some countries will face humanitarian crises and risk descending into conflict.
Global health and foreign policy are now intertwined. Given this reality, how can Canada best navigate the COVID world?
First, Canada needs a clear and realistic vision built on the idea that health is critical to equitable socio-economic development around the world. Canada’s advocacy regarding the structural barriers that devalue and diminish opportunities for women and girls continues to be crucial. However, we need more than a “pedestal” foreign policy. We need a broader vision for global governance structures, economic security and diplomatic engagement. As part of this vision, a feminist lens is critical to ensure gender and racial equality are promoted through our response to COVID.
Second, Canada needs to ensure that it has the organizational architecture to implement this new vision. We must ensure that our institutional structures are staffed with professionals that have expertise beyond a narrow focus on health. These professionals should include development practitioners and seasoned diplomats, as well as experts in fiscal policy, innovation and trade and supply chains.
Canadian global health policy also needs to be realistic about the reforms needed to support this vision. The WHO is critical to global health governance, yet the WHO’s inability to effectively respond to infectious disease outbreaks has undermined its credibility and weakened it. Canada could constructively contribute to the debate by showing its support for WHO but also for global health reform. One option might be a more nimble and responsive institution dedicated to infectious disease surveillance and outbreak response. Such an organization would be less constrained by the diplomatic maneuvering in which the WHO is forced to engage.
And third, that organizational architecture must be supported with networks of researchers and civil society advocates that are able to engage and provide constructive and critical feedback. The scientific response to COVID shows that international networks can facilitate the sharing of information needed to improve policy decisions. New networks must include diverse representation across disciplines and communities and ensure the voices of the most affected communities and marginalized groups can reach policy makers.
Canada also needs some humility. We have proclaimed “Canada is Back.” We “Canada-splain” how the world could be a better place if others would just adopt Canadian values. As part of our United Nations Security Council campaign, we touted our ability to steer the world out of the pandemic. We would be well placed to do a little less preaching and little more listening to learn from other countries and engage with our critics.
Societies best navigate these complex questions when they have a clear vision for what they want to achieve. Institutional structures must support that vision with expertise in both the process of policy making and the content of that policy. Moreover, these institutions must connect with open, collaborative networks that reflect the perspectives of various disciplines, diverse populations and critics. But most of all, we need policy leaders with intellectual curiosity and expertise, an openness to new ideas and a willingness to collaborate with others to find solutions. The COVID-19 pandemic will be with us for some time yet. Canada still has time to apply the lessons it has forced us to learn.
Interested in participating in the discussion about how global health policy could play a more central role in Canada’s global engagement? Join Valerie Percival and other global health policy experts at the inaugural event of the Global Ambition Project on November 9, hosted by the National Capital Branch of the CIC. Register here