After major crises and wars, the world tends to recompose itself. One such crisis is Covid-19. The pandemic is exposing deep inequalities within and between countries that question the current model of globalisation. This piece argues that the pandemic is so widespread and disruptive that it is bound to bring significant changes in the world order. Covid-19 is already altering the balance of powers in global health, provoking a rethinking of a new legal and policy framework to prepare and respond to future global health threats, and inspiring a popular movement to treat global health as a global public good. A critical question is whether these changes will combine to address economic, environmental, and social inequalities rendering globalisation more legitimate, transparent and accountable; or whether the new order in global health will perpetuate inequality
By Enrique Restoy, PhD
Head Evidence: Frontline AIDS
Associate Researcher: University of Sussex, UK
A Global Health Crisis To Shape a New Globalisation
Ironically, the biggest global health threat since AIDS might have certified the demise of globalisation as we know it.
We have witnessed a fragmented, disorganised and unequal response to the Covid-19 pandemic.
Can you recall any special session or resolution by the UN Security Council or the G-20 on the pandemic? Do you know what the World Bank or the International Monetary Fund did over the first months to help countries prevent the epidemic from becoming a pandemic with massive economic impact?
As the pandemic broke out, essential supplies such as ventilators and PPE were sold to the biggest bidder, with supplies turning last minute to whatever country paid the highest price. Big pharmaceutical companies rushed to develop vaccines with public funding from Western states that pre-ordered the vast majority of doses. It took months to set up the global initiative on vaccines (COVAX). The initiative will only deliver widespread distribution of vaccines to most low-income countries well after they have reached most people in the rich ones.
Governments constantly undermined World Health Organisation’s guidelines, imposing their own versions of what measures needed to take place. For months, Sweden allowed near normal life, while the rest of Europe was confined. For a few days, the US banned travel from Europe, but not from the UK, apparently because the UK government was a friend.
The coronavirus also provided the perfect canvas for nationalists and populist to show their true colours.
Brazilian president Jail Bolsonaro, first denied out rightly that there was even a pandemic killing hundreds of thousands of Brazilians. Then he told his people to ‘toughen up’. Late Tanzanian president, John Magufuli, rejected vaccines and invited the population to pray instead.
Some countries expelled migrant workers who had lost their jobs due to the pandemic thus fuelling discrimination against returnees in their country of origin.
This pandemic has indeed erased any belief that our globalised world was equipped to deal with a major planetary crisis.
Globalisation as we knew it
Since the end of WWII, globalisation has increasingly opened international borders to the exchange of goods, services, finance, people and ideas. It created institutions and policies at global and national levels to facilitate such movement.
Both neo-liberals and conservatives on one hand, and progressive thinkers on the other, loved to hate globalisation. But loved it somehow.
For the neo-liberals, globalisation broke down trade barriers, expanded the power of multinational corporations, and protected the global financial sector during economic crises, bringing the biggest global economic growth in GDP terms in history.
Any young graduate from a middle-class background in the rich West could choose in which country to work, where to go the next weekend on a city break abroad, what new gadget to buy that would be home in a matter of hours. A life of opportunity and open doors. Alas, not for all.
For the progressive proponents representing the interests of the most marginalised, globalisation brought about a strong human rights system underpinning its universal values, epitomised by the Human Rights Council, which since 1989 has periodically scrutinised the human rights record of almost all countries on the planet.
Globalisation made possible an unprecedented global health response to HIV and AIDS with its own global governance facilitating the access to affordable lifesaving treatment to now over 24 million people living with HIV across the world.
Globalisation framed the Millennium Development goals (MDGs), a set of state commitments that have led to a drastic reduction in maternal and child mortality and severe poverty, and a dramatic increase in girls’ access to education and among other huge advances in human development over the past few decades.
The Sustainable Development Goals (SDGs) which replaced the MDGs went further to underpin the respect for human rights in the pursuit of development; and the Paris Agreement represents a legally-binding recognition by many states that they need to take decisive action against climate change.
There were therefore positives in globalisation from all perspectives of the development debate.
Covid-19: globalisation as it really is
Anti-globalisation sentiment however, has been strong and mounting in the past few years. Although it traditionally came from the left side of the argument, it has also been highly criticised by the right.
The coronavirus and its inadequate response across the globe has exposed most brutally and to most people two critical problems globalisation has exacerbated to perhaps, a point of no return: inequality in treatment and opportunities, and an insatiable pursuit of economic growth to the detriment of the Earth’s limited resources.
These two problems are interdependent. Without strong social protection systems and measures to address inequalities in society, economic growth tends to multiply such inequalities while destroying the environment. And vice versa, societies with large inequalities need much greater economic growth to reduce poverty, thus decimating the Planet even further. Inequality hurts economic growth and the Earth.
However, across the globe, the quest for economic growth has meant weaker policies to ensure a more equitable distribution of wealth, and inadequate measures to reduce the environmental impact of such growth. Globalisation contestation has failed to stop this self-destructive trend.
But Covid-19 has had an unprecedented impact on the entire notion of globalisation. It has brutally exposed the underlying inequalities of globalisation both in the more economically developed countries and in the less economically powerful ones.
Inequality within countries is fuelling the pandemic and putting those left behind and everybody else around the world at higher risk.
People from all layers of society in the most unequal countries (whether rich or poor), with inadequate public health services for less affluent people, have suffered the most. Middle class people have descended into situations of near destitution and poverty. This is happening in countries with large GDPs (the great pursuit of globalisation as we now it), such as the UK, as well as countries with low GDPs.
Covid-19 has also exacerbated inequality between countries as illustrated by the huge concentration of vaccines in richer economies while the rest of the world watches on.
Yet, this is a global health crisis involving an air-borne virus that travels the world around thanks to globalisation. In this case, the cliché is real and resonates among people the world over: nobody will be safe from the coronavirus until all people in all countries are.
Globalisation has gone so far that the question might not be whether it will survive, but rather, what will make it work for all. According to Joseph Stiglitz, globalisation could promote equality provided it was transparent, legitimate and accountable.
The challenge is to make globalisation favour full employment, social protection policies to protect living standards against economic shocks, universal quality health coverage, and perhaps most important of all, policies that reduce inequalities within and between countries.
Global health is so embedded into the engine of globalisation that it will be at the core of any reform of the economic order that might ensue from the pandemic.
I see three critical areas of positive change if global health was to reform because of Covid-19: a new global health balance of powers, a change in the laws and practices of international cooperation on health, and a popular movement for equality in the access to vaccines and equitable access to health in all countries.
- A new balance of powers in global health
According to WHO and UNAIDS, global health should be treated as a public universal good, with global governance structures which should not be dominated by the richer, more powerful countries. Yet, these very agencies are indeed at the mercy of the biggest economies that fund them. The dependency is even greater in the case of the Bretton Woods institutions: the IMF, the World Bank, and the World Trade Organisation (WTO). In global health, there is the additional dependency on multinational pharmaceutical companies, who control key global health supplies with patents largely protected under Intellectual Property regulations, a regime set out by WTO.
These dependencies contradict all the principles of change that would render globalisation a framework of equality. They do not favour transparency and these institutions are mostly only fully legitimate for and accountable to rich countries.
I wouldn’t hold my breath that powerful countries would want to give away their power in global health decisions. However, the balance of powers in global health may be changing. For example, the vaccine diplomacy of China (Sinovac vaccine) and Russia (Sputnik V vaccine) is making their Covid-19 vaccines available to lower income countries faster than vaccine-producing countries in the West. This diplomacy is increasing the popularity of these no longer emerging superpowers across many regions. Yet, as of early 2021, most countries were still negotiating with very little bargaining power their access to Vaxzevria (formerly AstraZeneca), Pfizer-BionTech, Moderna, and Johnson & Johnson Janssen, all of which were produced by Western multinationals with heavy public investment from European countries and the USA governments.
The new vaccine diplomacy might simply signal a change in who is dominating global health rather than a more equal distribution of powers across the board. But Mike O’Sullivan also sees a new multilateralism bringing countries together around shared values or interests. This has led to interesting initiatives such as Nordic countries and Southern Hemisphere countries acting together against climate change. These initiatives could be more transparent and accountable for more people living outside rich countries.
This trend could facilitate the creation of alliances among countries for which public health is a true public good and these countries could establish new global, albeit not universal, agreements and frameworks that advance global health as a public good in a good number of countries. Could there be room for an improbable alliance for health as a public good involving Cuba, the UK and Japan, for example?
- Changing laws and practices in global health cooperation
Reforming the laws and practices of international cooperation on health seems more straightforward given how abysmal such cooperation, or lack of, has been when confronting the Covid-19 pandemic. However, this might prove tricky. Global health legal and policy instruments are riddled with red lines set by states and corporations. In the end, big pharmaceutical companies’ interests, border control, and geopolitics often have the upper hand over public health needs, let alone the human right to health.
There is already a battery of legal instruments to regulate global health and foster collaboration to address health risks with the potential to threaten global security. These are mostly encapsulated in the WHO health regulations (IHR) introduced in 2005 and currently under review.
The IHR include requirements for the development of States Parties’ capacity to rapidly identify, report, and respond to potential public health emergencies of international concern. They also state that the responses must avoid unnecessary interference with human rights (although the IHR contemplate temporary derogation of human rights under some public health imperatives).
The IHR have not really worked well to respond to the Covid-19 pandemic.
It is therefore tempting to advocate for the current overhaul of IHR or the establishment of a new legal framework on pandemic suppression to radically change how the world responds to global health threats. For that, this instrument would have to uphold the principle of health as a global common good, embracing the right to equality as the key paradigm for the prevention of pandemics.
For this to work, there needs to be wide political consensus across countries and have teeth: to be legally binding, to come with considerable funding to help countries collaborate and prepare for future pandemics and distribute the medical response to them equitably; and to set up strong accountability mechanisms to ensure monitoring and compliance.
If such new mechanism underpins the principles of health as a public good, and the human right to development, not just to health, it could help frame a response to the economic, social and environmental inequalities within and among countries that are the root cause of health inequality. With that framing, the mechanism could be particularly ambitious in the medical preparedness and response to pandemics, for example, with the suspension of vaccine patents in times of pandemic crisis and fair pre-established vaccine production and distribution schemes and economic recovery stimulus. If the mechanism is clear in its definitions, principles and enforcement measures, it has the potential of bringing levels of transparency and accountability that have not existed to date in global health.
Some countries are already calling for a Pandemics Treaty for preparedness and response. They demand an instrument that ensures “universal and equitable access to safe, efficacious and affordable vaccines, medicines and diagnostics for this and future pandemics”. This is a good starting point to make things change. But it sticks to the idea of promoting just health equality. Yet again, advancing a medicalised response to pandemics that falls short in addressing the root causes of health inequality: social, environmental and economic inequality within and between countries.
- A people’s movement to change priorities in global health
The problem with the two first areas of positive change I just mentioned is that they both very much depend on governments’ will. In the international arena, bold ideas often end up watered down by conflict of priorities, corporate interests, internal public opinion and diplomatic disputes.
Here is where the example of HIV and AIDS is most compelling. It was a global human rights campaign initiated in the US and Europe, but followed suit soon after in South Africa, India and many other countries that sparked the biggest global respond to a health threat ever to be seen. Herein lied a great deal of the legitimacy of the global HIV movement.
The argument that won this response was an outcry for the human right to live. Hundreds of thousands of people filling the streets and demanding access to treatment for those living with AIDS. A case for AIDS as a global security risk made at the UN Security Council and as a major public health threat warning by WHO came when the movement was well underway.
However, even though the HIV movement created its own global governance and has mobilised billions of dollars to safe millions of lives, it has not ended health inequality, and stigma, discrimination and human rights violations against marginalised populations affected by HIV: people who use drugs, the LGBT community, sex workers, young women and adolescent girls, among others.
This time, it will take a much bigger social movement to make the profound shift to bring about global equality in health. It will need to be an overwhelming force demanding accountability at all levels of the global health architecture. A truly global movement with legitimacy the word over, not a campaign dominated by civil society in the global north.
Will it be the #Peoplesvaccine campaign? It is early to say. In favour of this initiative, this pandemic is affecting every single person around the World. That was not the case with HIV. The campaign message is also compelling: ‘pharmaceutical corporations must allow the Covid-19 vaccines to be produced as widely as possible by sharing their knowledge free from patents. Governments must facilitate such transfer of knowledge so that, when safe and effective vaccines are developed, they are produced rapidly at scale and made available for all people, in all countries, free of charge.’
Conclusion: time to make globalisation promote global health equality
Covid-19 and globalisation are inextricably linked. The virus has travelled all around the world at lightening speed facilitated by the free flow of people, a trait of globalisation. The pandemic has become a global health threat of utmost concern for the institutions governing globalisation, especially the Bretton Woods organisations, WHO and other UN agencies, and multilateral governmental fora, such as G-20.
Yet, Covid-19 is having a devastating impact on the lives of billions of people in both high and low-income countries. The pandemic has exacerbated deep economic, social, environmental and health inequalities within and between countries. It has also brutally exposed deep weaknesses in the current globalisation model and its instructions.
Critical changes are already underway in three key areas of global health with the combined potential of revolutionising globalisation as we know it. The balance of power in global health is changing with a new vaccine diplomacy; a growing number of governments are calling for a review of laws and policies framing preparedness and responses to global health threats, and a mounting mobilisation of civil society for a reconsideration of global health as a global good.
We have a historic opportunity to ensure these changes combine with the long-term objective of eliminating global economic, social, health and environmental inequalities. For that, the new globalisation institutions and legal and policy frameworks must be transparent, legitimate and accountable.
However, if governments, civil society, private actors and other key stakeholders take a short term, narrow vision, these changes are bound to perpetuate the inequalities that the current globalisation model has created. That will be the case if the new balance of power simply replaces exiting dominant governments and corporations for new ones, if the new legal and policy framework for pandemic preparedness just focuses on medical aspects ignoring economic, environmental and social inequality, and if the peoples’ vaccine campaign fizzles out once Covid-19 is under control in most countries.