Valdai Club

COVID-19 has not only influenced all global healthcare development plans but also has substantially changed the entire context of how healthcare operates. The current pandemic has accelerated the gradual fusing of the global healthcare agenda with the rhetoric and challenges of international relations, which began in the early 2000s. In a way, the current crisis finalises the emergence of a new system governing global health and international relations, with the concept of “one health” as a focal point. 

The increased mediatisation of public health policies and the global nature of the existing medical threat have played a big role in this process. In recent months, we have observed a transformation of global health based on two mutually exclusive trends in the area of international communications. While there are new attempts to unify the globe by disease, there are also efforts to form a new structure of the world based on the “semipermeable membrane” model consisting of several boundaries related to different spheres of the world economy and international relations. In this model, state borders are open to some types of activity and closed to others. Today, this model has even greater potential owing to the rise of digital technologies. Its strength lies in its ability to protect nation states from disease spread across borders, while at the same time allowing them to continue expanding their international influence. 

A new interpretation of pandemics

In May 1980, 40 years ago, the 33rd World Health Assembly declared that the world and the entire population had gained freedom from smallpox. This was an inspiring medical victory for international healthcare under Cold War conditions, made possible by the WHO partnership between the two rivals, the USSR and the USA. At that time, scientists seemed to think that epidemics were a thing of the past. Shared victories by the antagonistic superpowers encouraged global optimism and the belief that many diseases could be eradicated through collaborative efforts. 

But following the end of the Cold War in the 1990s, the processes of globalisation contributed to the emergence of a new discourse. Infectious diseases came to be perceived as outside threats to the international and domestic policies of great powers, in response to the emergence of additional risks of medical and biological threats to their populations being imported from developing countries. A new stage in the integration of healthcare and international relations began to take shape in academia and politics. 

In 2004, a leading expert on global health and international law, David Fidler noted that 21-century public health would experience a revolution that would be political rather than technical in practical terms. According to Fidler, “the previously obscure and neglected policy area of public health shed obscurity and neglect to become the subject matter of intense national and homeland security, foreign policy, and global governance debates.” 

SARS (Severe Acute Respiratory Syndrome) emerged as the first such threat in 2003. Medically speaking, it was nothing new. From the point of view of the post-Westphalian global health governance system, however, its spread and disregard for borders occurred in a new environment for public health governance. 

The international situation was radically different than during previous global epidemics. Later, the 2000s were marked by epidemic outbreaks in various corners of the planet. The world was gripped by new concerns regarding the proliferation of diseases, both “classical” pandemics such as flu and many previously unknown ones like MERS (Middle East Respiratory Syndrome), Ebola, and others.

David Fidler’s prediction is coming true. Currently the world is witnessing the redefinition of international politics and communications in global health.

New border models are being developed around the concepts of quarantine and vaccination passports. New narratives are emerging, including “diplomacy of medicine” and “diplomacy of health,” which are related to the global security discourse. What we are seeing, in fact, is a series of global changes taking place over the past one and a half year, whose main thrust is the fusing of global health and international relations. This is a new stage in the evolution of 19th-century problems of international regulation of public health. 

Analysing this focus area requires interdisciplinary research at the interface of the history of medicine, healthcare organisation, international relations, international law, global healthcare policy and its ethical implications at different stages. It also requires a command of skills needed for a political and cross-cultural analysis of health. 
 
The present article will outline two key trends underlying research and public discussions in this area: 

(1) COVID-19 has reshaped the global health narrative, imbuing it with new elements of meaning that earlier were largely associated with international affairs, and has reinvigorated the globalisation discourse from the health perspective.

 (2) The existing political challenges in international relations have become consolidated as part of the fight against the pandemic, with international communications centered around the theme of global health. 

Currently, public health lies at the intersection of two narratives – medicalisation and securitisation. International quarantine has become a global lockdown. Instead of the smallpox eradication programmes of the past, there is a programme to prepare for and prevent future medical threats. And the WHO motto of the 1970s, Health for All, has been converted to One World One Health. International healthcare has gone global, with vaccination emerging as the basis of public health, the main tool of global security and the principal global public good.

What is “global health?” 

In his 2013 essay, Harvard professor Alan Brandt writes that “the AIDS epidemic has provided the foundation for a revolution that upended traditional approaches to ‘international health,’ replacing them with innovative global approaches to disease. Indeed, the HIV epidemic and the responses it generated have been crucial forces in ‘inventing’ the new ‘global health’.” These terms have been updated since the mid-1990s, which Colin MacInnes explains in two ways. First, the new term has provided a political impetus for public health problems, which were neglected for a long time and became more visible under the influence of globalisation. Second, it is a reflection of a paradigmatic shift that has occurred in response to how globalisation is changing human health. In total, this “rebranding” has shaped a new political dimension, where popular health in developing countries was linked to a new global security and international politics agenda, environmental issues and climate change. Taken together, all of this has reinforced the political component of healthcare development.

The term “global health” means a new interpretation of health that is far more integrative than traditional notions of international health. Its main distinction is the supranational nature of health- and disease-related problems, as well as the fact that no single country can adequately fight disease given how interconnected the world is, encouraging free movement of people and goods and, as a consequence, a more rapid spread of illness. Global health implies the participation of scientists, politicians and international independent actors in discussions of how to finance healthcare and how to distribute medical equipment, medicines and services in a global collaborative environment. The introduction of this notion was followed by the emergence of new ethical and moral precepts that recognise public health as the supreme value.

Transforming global narratives

“This year's World Health Assembly will play a vital role in shaping the global health architecture of the future, and in strengthening WHO to fulfill its mission and mandate,” WHO Director-General Dr Tedros Adhanom Ghebreyesus told the WHA meeting in May.

Global health today means “post-Westphalian public health.” This term describes a form of public health governance that departs from the Westphalian healthcare model emphasising the principles of national sovereignty and non-interference. It is a response to the growing influence of globalisation that combines the interests of multinational corporations and international organisations and prioritises multilateral activity and alliances. In many regards, this is distinct from the history of international cooperation during the Cold War (poliomyelitis, smallpox and other international health programmes). At that time, it was a matter of nations’ collective efforts, whereas today the focus is on evolving a supranational system to govern global health and respond to medical threats to health by creating a global analogue of an “air defence system.”

These trends have all been on display during the COVID-19 pandemic, and more specifically the international health events that occurred in May and June 2021, including the 74th Session of the WHA, the G20 Global Health Summit, and a G7 meeting. The pandemic theme was also taken up at the Russia-US summit held in Geneva on June 16, 2021. Speaking at his news conference following the meeting, US President Joe Biden traced the trajectory of the fight against global health threats, saying that it was necessary to develop a global physical mechanism for identifying future pandemics. 
 
Interestingly, it was at these WHO-sponsored meetings that world leaders formulated new global health narratives. The main targets of the global health governance system are “prevention,” “detection,” “response,” and “recovery” in the face of pandemic threats to health. In addition, there are new transnational global health actors, such as GAVI and UNICEF, CEPI, Global Health Security Agenda Bill & Melinda Gates Foundation , WTO, WEF and others, which are developing new public-private business partnership models. The WHO has also advanced some additional initiatives, including the Independent Panel for Pandemic Preparedness and Response (IPPPR), technical recommendations, the Solidarity clinical trials, a UN supply task force, an initiative to accelerate access to anti-COVID-19 resources, including those offered by COVAX partnership and the COVID-19 Solidarity Response Fund. 

These meetings have also consolidated the “one health” concept that was formulated in the 2010s and is now reflected in the One World One Health slogan of the global health campaign. This concept is associated with the strategic global security discourse. Politicians, scientists and international organisations and funds were focused on the “build back better” plan aimed at promoting global immunisation programmes, developing strategies for ending the ongoing pandemic crisis, and looking for common approaches to head off future threats to global health. Thus, the pandemic has resulted in a new attempt to unify the globe through disease, with a global immunisation programme likely to be the end result. 

Strange though it may seem, the international dialogue during the COVID-19 pandemic suggests parallels with discussions at the 19th-century International Sanitary Conferences convened amid cholera epidemics, construction of the Suez Canal, and an upsurge in world trade. Historians agree that despite great strides in international cooperation, relations between countries were growing increasingly antagonistic at that time. We observed similar trends at the start of the pandemic, when tensions were on the rise between the US and China, the US and the WHO, etc., against the background of developing countries’ appeals to the WHO to “draw up a global agreement for rapid and universal access to quality-guaranteed vaccines and treatment.” Efforts undertaken by nations were chaotic and inconsistent.

This focus on supplying and protecting individual countries has led to the coining of a new term, “vaccine nationalism,” which is undermining global solidarity in the fight against the common threat. In other words, representatives of the 21st-century global healthcare system suggested, like the delegates of the 19th-century Sanitary Conferences, a model of the world as a “semipermeable membrane” rather than that of a “world without borders” or a “world of total borders.” What we are witnessing is the evolution of a 150-years-old idea.

Conclusion

The COVID-19 pandemic has challenged traditional perceptions of public health. For the majority of states, it was a domestic policy matter and an important element of their national security systems. At the global level, health policies were always relegated to the “low politics” category below strategic matters like nuclear arms. This has necessitated a dramatic revision of the idea that medical knowledge takes precedence in decision-making on public health. 

It is difficult to make even an interim assessment of the pandemic’s influence on the system of international relations due to the coalescence of the medicine and healthcare agenda with the politics of international relations. Narratives in world public politics are getting jumbled, creating additional tensions, with military terminology popping up in the purely humanitarian context of the socially meaningful objectives pursued by medicine and healthcare. “Health,” a highly personalised term, has been subsumed by global security. This is causing not only tensions between cooperating states that regarded this matter as a zone of their influence and responsibility but also at the level of communities and individuals, for whom this is the first global encounter with the overarching ethical duty to “remain healthy” as opposed to the “right to health.”

The past year and a half has seen the rapid integration of global security and global governance rhetoric (international relations) with health issues (medicine and health protection as part of domestic policies). The important thing for Russia is not to miss this trend and remain in the “game” on the global health field, where we were the first to provide the world with a vaccine and can offer our not insubstantial historical experience.