Casualties of Preparedness: Rethinking the Global Health Security Paradigm

By Manjari Mahajan

The calls for a new pandemic treaty, like the genesis of the International Health Regulations (IHR), have been anchored within a paradigm of “global health security.” Before undertaking new projects of international lawmaking, it behooves us to examine this dominant paradigm and assess whether it actually leads to the goal of pandemic preparedness across countries. At stake are the future contours of a global normative, legal and infrastructural machinery and whether its animating logics are historically informed, evidence-driven, and geographically equitable.

The prevailing global health security paradigm was institutionalized in international law through the IHR, a policy centerpiece that was most recently revised in 2005 in response to a series of new infectious diseases including AIDS, SARS, and Ebola. At its foundation, the schema identifies the problem at hand as outbreaks of emerging infectious diseases, which become global security threats as they travel across borders. The focus is very much on new and re-emerging infectious diseases, and not ongoing health-related problems in a population. Moreover, this framework is animated by a special anxiety about contagion from poorer, purportedly primordial and volatile countries in the global South to the North.

The emphases on new infections and preventing their travel from the South to the North have resulted in a politics of control and enforcement that carry with it particular normative and infrastructural demands.

First, it has required that member states invest in building surveillance and reporting systems that allow for rapid reporting of infectious outbreaks to a global machinery. The global health security paradigm has not focused on building national capacities to address existing diseases or overall public health in a population. However, the COVID-19 pandemic has vividly illustrated that making a stark distinction between capacities to address new infectious outbreaks and routine public health is a costly mistake.

Second, the global governance of health security has demanded some ceding of national sovereignty, with member countries required to adhere to a common template of surveillance and reporting systems. States have to put into place a suite of narrow technical and administrative measures for biosafety and biosecurity; a country’s pandemic preparedness has been judged based on their having met these universal benchmarks. This has produced a disproportionate burden on poorer countries.

Especially from the point of view of a developing-country government, it might be less effective to use limited resources to add narrow technical capacities to feed a global machinery of surveillance, than to invest in overall scientific infrastructure that is integrated into a national system of research and innovation reflecting local needs. The one-size-fits-all benchmarks set by global managers has disallowed consideration of domestic imperatives and political judgment about resource allocation.

Moreover, one of the striking lessons of COVID-19 has been that countries that have provided relatively sustained and competent responses to the pandemic have not followed any single template. Successful public health action has been enabled by diverse assemblages of institutions, policies, historical legacies, and socioeconomic resources that have been necessarily highly contextual to each country. These heterogenous responses belie the convenient notion that it is possible or necessary to have neat templates of preparedness that can be applied uniformly across countries.

Third, much emphasis has been put on individual governments reporting to a larger international machinery. Here, a government’s accountability is not to its own people or to achieving particular health outcomes or adhering to national laws. Rather it is conceptualized as a government’s capability to assure a global apparatus.

Accountability becomes equated to a performative visibility where a government has to frontstage and show its preparedness capacity in a way that can be easily measured by indices and checklists of the global machinery. The privileging of reporting echoes secular trends within global health, where audits of governments and NGOs to donors anchor definitions and procedures of accountability. Inevitably such a framework creates perverse incentives for organizations to invest in producing information that can be captured by indicators, often at the cost of more meaningful work.

The limitations of this conceptualization of accountability are vividly illustrated by the fact that before the current pandemic, the United States and the United Kingdom were considered the “most prepared” by multiple global health security indices. Even though both countries tick-marked many of the requisite boxes in the preparedness checklist, they have since had a disastrous track record in managing the pandemic.

Ironically, even as extant accountability measures privilege national reporting to a global machinery, they completely elide any enforceable commitment by the international community to ensure equitable access to technological countermeasures, such as vaccines and medicines. Similarly, this understanding of accountability doesn’t include a global commitment to increasing capacity for knowledge and technological development across countries determined by sovereign priorities.

Lessons from history and a commitment to global equity require that our analytical frameworks and ensuing international governance systems move away from the overwhelming focus on centralized reporting and generic templates. Rather they have to include divergent approaches that speak to different countries’ historical experiences, social needs, and political imperatives.

Abandoning a universal templatized approach to control and enforcement is a significant challenge for global governance of health, which has long relied on modeling countries on generic templates and metrics, and tick marking through common checklists. Nevertheless, COVID-19 has starkly illustrated the urgent need for more sophisticated narratives and frameworks that embrace complex understandings of health and preparedness. This will undoubtedly require more complex and “messy” analyses; yet it is necessary — the alternative prevailing global health security paradigm is an emperor without clothes.

As the international community debates a new pandemic treaty or another legal instrument, the history of the last several decades of international health, and the more proximate experiences with COVID-19, should force a reckoning of the limitations and unintended consequences of the dominant global health security paradigm. The lessons do not point to the need for an exclusive and overwhelming focus on surveillance and reporting infrastructure, nor stricter enforcement mechanisms managed by global authorities.

Rather, there is a need for a different conceptualization of global health security that is anchored in frameworks that contextualize health in broader historical narratives and political and social determinants. State capacities, social resilience, economic imperatives, and political culture have to be understood not as ancillary sideshows as much as inextricable determinants of preparedness. Accordingly, the governance of global health security must systematically integrate different kinds of expertise and meaningfully represent states around the world. It must go beyond rhetorical gestures to participation toward a substantive consideration of the complex underpinnings of health and its varied national trajectories.

Manjari Mahajan is an Associate Professor in the Julien J. Studley Graduate Programs in International Affairs and the Starr Professor and Co-Director of the India China Institute at The New School.

The Petrie-Flom Center Staff

The Petrie-Flom Center staff often posts updates, announcements, and guests posts on behalf of others.

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