Evidence for Foreign Affairs Committee: Global Health Security (GHS0011)

Dr Clare Wenham (Department of Health Policy, LSE) has 10 years + experience of research and teaching in global health security and outbreak response. Her research has focused on the politics and policies of health emergencies including on pandemic flu, , Zika & COVID-19. Her research examines the global governance of health security, and the role of the International Health Regulations (2005) and WHO. She is an associate academic at Center for Global Health Science and Security, the Vice-Chair of ISA global health section. At LSE she is the Programme Director of MSc Global Health Policy and sits on the board of LSE’s Global Health Initiative. She has consulted for European Union, UN Women, Wellcome Trust, Asian Development Bank and formally worked in policy at an NHS Trust and the Faculty of Public Health. For COVID-19 she is co- PI on 2 projects funded by CIHR and Bill and Melinda Gates Foundation to understand the gendered effects of the outbreak.

COVID-19 reminds us of the importance of global health security

Global health security: transnational efforts to prevent, detect and respond to emerging pathogenic threats, relies on international cooperation. States, international organisations, non-governmental organisations and the private sector need to work together to ensure that appropriate surveillance, disease control and surge capacity mechanisms are in place across the whole life cycle of an epidemic, from preparedness through to after action review to ensure that population and economic health is protected. COVID-19 has brought this point home most acutely. We need global cooperation for; sharing data about the outbreak transparently; clinical learnings to have benefit elsewhere in the globe; treatment and vaccine candidates to be trialled, latterly distributed and implemented; and most fundamentally, each actor in the global health security landscape must realise that cooperation is the only way to have the most pertinent information and data available to decision makers to design and implement appropriate and effective strategies to respond to a pandemic.

Perhaps more importantly, given globalised capitalist flows, COVID-19 has also demonstrated that even if you eradicate the virus in your borders, you remain at risk of reintroduction of the virus (as seen in , New Zealand, Thailand, Vietnam), and global trade will continue to be limited until COVID-19 is controlled globally.

Remarkably, in spite of such knowledge, many governments (including the UK) have sought to turn their back on the cosmopolitan ideals of global health security during COVID-19, to shy away from WHO advice and chart their own course domestically. This has been at a cost of a significant number of lives and perpetuating widespread economic chaos.

UK’s current approach to global health security Over the last decades the UK has provided a vital role in global health security. The UK was at the forefront of recognising health as a security issue during HIV/AIDS, and notably launched the Health is Global Strategy in 2008,1 which was the first global health protocol published by a government which expressly recognised that epidemics occurring overseas can prove a security risk to national and international economic security. This has been a blueprint for many policies from other states in their global health activities2. This leadership of the UK to date in global health security is mirrored in the myriad of activities which the UK undertakes with frequency in preparing, detecting and responding to outbreaks globally. This includes, (but is not limited to): - Public Health England’s global health team engaged in numerous bilateral projects with low- and middle-income states to build capacity for surveillance and laboratory facilities (and more areas of global health security efforts)3

- NHS offering (and indeed exporting) a model of universal health coverage and working to support low- and middle-income states strengthen health systems, as well as sharing technical expertise, human resource and management guidance – all of which forms a key part of control protocols elsewhere

- Second largest state funder to WHO (and indeed with US suggested withdrawal would become largest)4. Second largest donor to Global Fund for HIV/AIDS, Tuberculosis and Malaria5. Significant support to CEPI, COVAX and other multi- lateral efforts

- Significant support to Sierra Leone during Ebola (2014-6) including deployment of PHE epidemiologists; UK military deployment to build Ebola treatment units; NHS volunteers as healthcare workers during crisis; DFID supported clinical trials of Ebola vaccines (in collaboration with UK universities and funding bodies)

- Creation of UK Public Health Rapid Response Team (UKPHRRT) to deploy to support outbreak response globally However, there is a tension between UK’s activity to date in global health security and domestic failures during COVID-19. Firstly, despite being a major funder to WHO, the UK government decided to depart from WHO advice in March 2020, and that the WHO’s recommended policy based on test, trace, isolate did not apply to the UK6. This is also contrary to findings of the Public Accounts Committee and International Development Committee in 2015/6 which found that UK delayed response during Ebola was as a result of WHO’s delayed activity (with the inference that WHO was only following WHO guidance)7.

1 HM Government (2008). Health is Global: a UK Government strategy 2008-13. London Retrieved from https://webarchive.nationalarchives.gov.uk/20130105191920/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPo licyAndGuidance/DH_088702 2 Gagnon, M.L., Labonté, R. Understanding how and why health is integrated into foreign policy - a case study of health is global, a UK Government Strategy 2008–2013. Global Health 9, 24 (2013). https://doi.org/10.1186/1744-8603-9-24 3 Public Health England,(2015). PHE’s Ebola response – the people behind the scenes. Retrieved from https://publichealthmatters.blog.gov.uk/2015/02/03/feature-phes-ebola-response-the-people-behind-the-scenes/ 4 Wintour, Patrick (2020). UK to become WHO’s largest state donor with 30% funding increase. The Guardian. https://www.theguardian.com/world/2020/sep/25/uk-to-become-whos-largest-state-donor-with-30-funding-increase 5 Global Fund. (2019). Global Fund Donors Pledge US$14 Billion in Fight to End Epidemics [Press release]. Retrieved from https://www.theglobalfund.org/en/news/2019-10-10-global-fund-donors-pledge-usd14-billion-in-fight-to-end-epidemics/ 6 Walker, A. (2020, 14th April 2020). England coronavirus testing has not risen fast enough - science chief. The Guardian Retrieved from https://www.theguardian.com/world/2020/apr/14/england-coronavirus-testing-has-not-risen-fast-enough-science-chief 7 Public Accounts Committee. (2015)>. The UK's response to the outbreak of Ebola Virus Disease in West Africa https://publications.parliament.uk/pa/cm201415/cmselect/cmpubacc/868/868.pdf; International Development Committee. (2016). Ebola: Responses to a public health emergency, Second Report of Session 2015–6 During the early months of COVID, the decision to move rapidly into “delay” and rather than push for “contain” is the antithesis of the approach the UK government had been promoting over the last decade within global health security rhetoric, whereby the aim of health security is to limit the outbreak at the source before it becomes an epidemic. This strategic wrong decision was compounded by consistently reduced spending in public health because of austerity measures8, multiple years without an outbreak in UK and thus a sense of complacency and indeed by Brexit planning9. It remains to be seen how these decisions made during COVID-19 might affect UK’s standing in global health security leadership in the future, or whether low and middle income settings which have responded more comprehensively to the outbreak may feel challenges in accepting advice. To re-establish leadership in global health security, the UK government has renewed its commitment to GAVI,10 increased funding for WHO, continued to fund CEPI, and hosted a virtual global vaccine summit in summer 2020. This all fits within the broad mandate of “Global Britain”. Indeed, continuing to demonstrate leadership to global health security is vital for the success of “Global Britain”. However, this remains a crucial time for UK within global health security to demonstrate that it understands effective global health security and commits to the normative agenda. Reforms to IHR One of the areas that the Prime Minister announced would be a focus of the UK’s G7 leadership was to devise protocols for what governments must do in the event of an outbreak with global reach in future. Such protocols exist already within WHO: The International Health Regulations (2005)11 lay out clear protocols as to how governments must develop or strenghten core capacity to “prevent, detect, respond” to epidemics through building surveillance and laboratory facilities; report emerging outbreaks to WHO in a timely manner; what governments should do at borders and within the transport industry to minimise spread; and what provision there is for WHO to make recommendations for trade or travel restrictions to minimise global disease transmission, doing so within efforts to reduce any potential impact on trade (that finely account for the balance between public health and the economy that is continuing to dominate policy decisions during COVID-19). A problem with these regulations is that, like many areas of international law, they are hard to enforce. The only punishment that states face for failing to adhere is to be “name and shamed” by WHO (which indeed rarely happens) and there are no meaningful deterrents (such as WTO sanctions). For some governments this is enough12, yet we have seen governments flouting IHR in previous outbreaks13, and during COVID-19 where many governments not only implemented travel and trade restrictions without WHO advice, but

https://publications.parliament.uk/pa/cm201516/cmselect/cmintdev/338/338.pdf 8 The Kings Fund, (2017). Does the NHS need more money? Retrieved from https://www.kingsfund.org.uk/publications/articles/does-nhs- need-more-money 9 Calvert, J. A., Leake A, (2020), 19th April 2020). Coronavirus: 38 days when Britain sleepwalked into disaster. The Times. Retrieved from https://www.thetimes.co.uk/article/coronavirus-38-days-when-britain-sleepwalked-into-disaster-hq3b9tlgh 10 GAVI. (2020). Gavi welcomes UK funding pledge [Press release]. Retrieved from https://www.gavi.org/news/media-room/gavi- welcomes-uk-funding-pledge 11 WHO. (2005). International Health Regulations (2005). WHO: Geneva. https://www.who.int/publications/i/item/9789241580496 12 Davies, S. The international politics of disease reporting: Towards post-Westphalianism?. Int Polit 49, 591–613 (2012). https://doi.org/10.1057/ip.2012.19 13 Worsnop, C.Z. Domestic politics and the WHO’s International Health Regulations: Explaining the use of trade and travel barriers during disease outbreaks. Rev Int Organ 12, 365–395 (2017). https://doi.org/10.1007/s11558-016-9260-1 further have failed to follow guidance of the Director General, and that of the IHR Emergency Committee as to how best to respond to the pandemic. Given this, it is hard to imagine what protocols the UK may devise which are not already included within IHR. These regulations took many years to craft in 1990s and early 2000s, as points of contention in the negotiations centred on the proposed authority given to the WHO and the challenge to sovereign decision making and power during an outbreak. These issues still remain fundamental to designing new governance arrangements for global disease control – and the question remains why would global governments collectively agree to have stricter protocols for pandemic preparedness and response, when they don’t abide by the ones that they have in place already?14 Instead, the UK should focus on revisions to the IHR, either through a rev-con model such as the Biological Weapons Convention15, or indeed, reopening the treaty. The risk of this latter approach is that more is lost, than gained. A further risk for the UK is the tension between extolling the IHR, a piece of international law amid the difficulties of UK policy towards international law with the Internal Markets Bill. Issues which need to be revised, where UK could lead normatively would be: - Declaration of the Public Health Emergency of International Concern (PHEIC). There has been much consideration as to why governments didn’t take action when the PHEIC was declared for COVID in January 2020. Several groups, including the Independent Panel for Pandemic Preparedness and Response, IHR Review Committee, and the Independent Oversight and Advisory Committee of the Health Emergencies Programme, as well as Director General Dr Tedros have suggested introducing a traffic light system as a tiered approach to declaring emergencies – i.e. to create warnings and then alarm when necessary, or indeed to introduce a regional PHEIC. Both suggestions would be counterproductive to global health security. Realistically, governments wouldn’t do anything for an “amber” alert, and would therefore bring little to no advantage for health security, not to mention introduce subjective indicator based tiering which will create further constraints on the progressive “all-risk” approach to health security reporting to date. A regional PHEIC risks a balkanised response, whereby only regional governments take action, and in the case of requesting assistance, only neighbouring governments would support, ensuring a quasi “post-code” lottery for international assistance for outbreak response16 .

- Gender is absent in IHR to date. It is well established that outbreaks have significant gendered effects17, the lack of recognition of this in the IHR means that governments may not seek to mitigate such effects. Gender consideration needs to be included in all stages of a pandemic life cycle, and exemplified in IHR, starting with gender mainstreaming efforts to strengthen core capacities, (and in parallel within the WHO

14 Wenham, C (2020). If the UK wants to lead in global health, it must demonstrate a commitment to international laws which underpin global governance. BMJ Opinion. https://blogs.bmj.com/bmj/2020/10/07/if-the-uk-wants-to-lead-in-global-health-it-must-demonstrate-a- commitment-to-international-laws-which-underpin-global-governance/ 15 Katz, R. (2019). Pandemic policy can learn from arms control. Nature, 575(7782), 259-259. 16 Wenham C, Phelan A, Eccleston-Turner M, Halabi S. Reforming the Declaration Power for Global Health Emergencies. International Law Impact and Infectious Disease (ILIAID) Consortium IHR Reform White Paper Series (1).(November 2020) 17 Wenham, C., Smith, J., & Morgan, R. (2020). COVID-19: the gendered impacts of the outbreak. The Lancet, 395(10227), 846-848. Joint External Evaluation (JEE) and National Health Security Action Plans (NHSAPs); to have the IHR expressly recognise gendered effects of outbreaks (as a new article, or within article 3 on human rights); gender parity within IHR Emergency Committee, and inclusion of gender advisors; ensure sex-disaggregation for all data; include gendered concerns in risk assessments to be undertaken by states; and ensure that after action reviews consider the gendered effects of a particular epidemic18. The UK’s recognition of the gendered effects of COVID-19 internationally in the UK government’s COVID-19 recovery strategy19, alongside the efforts that DFID has purported for years around gender equality stands them in good stead to push for such revision. Normative commitment to Global Health Security and multilateralism Beyond IHR Revision, UK also must play an important role in normative commitment and support to WHO, and to the norms of global health security. It can do so in a number of ways: - The UK is a considerable donor to WHO, GAVI, CEPI, COVAX, UNICEF, as well as multiple non-governmental organisations which it funds for global health related activity. This not only provides much needed resource for global health, but simultaneously signals an important commitment to the norms of global health security. As a well trusted donor, this can carry considerable weight in signalling the importance of global cooperation through multi-lateral institutions within global health.

- However, beyond funding these institutions, UK government must also ‘play by the rules’ and follow the guidance issued by such institutions. In the absence of enforceable international law for health security, the system relies upon normative commitments and expectations of states to behave in a certain way. This ranges from following WHO guidance in responding to an epidemic (which UK has not done consistently during COVID); ensuring routine global health programmes are not diverted or suspended as a consequence of COVID; and ensuring that there is equitable distribution of vaccines to those who most need it globally, rather than for those who can afford to pay.

- Within this normative commitment, UK should also agree to strengthen the institutions which already exist in global health security. The reason for the failures during COVID has not been because of a lack of institutions with the technical capacity to manage the response. The problem has been with governments veering away from internationalism and collective action for global health security. This is the time for UK to signal firm commitment to the systems which currently exist, not only through funding, but through championing them publicly, following their guidance and encouraging others to do the same. With the opportunity to have leadership of G7

18 Gender and COVID-19 Project and Women in Global Health. Sumegha Asthana, Sara E Davies, Roopa Dhatt, Ann Keeling, Arush Lal, Alexandra Phelan, Maike Voss and Clare Wenham (October 2020) Strengthen gender mainstreaming in WHO´s pandemic preparedness and response, Policy Brief. 19 HM Government (2020). Our plan to rebuild: The UK Governments COVID-19 recovery strategy https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/884760/Our_plan_to_rebuild_The_UK_G overnment_s_COVID-19_recovery_strategy.pdf 2021, this is a propitious opportunity to show such normative leadership and commitment to the systems which exist, rather than seeking to recreate the wheel.

- It is important to recognise that the landscape for global health security has traditionally been very Western-centric, with the raison d’etre of global health security rooted in protection of Western borders & economies from pathogens starting in low and middle income settings. This understanding is outdated, both in the reality of COVID transmission and achievements, as well as in policy circles. Low and middle income states have demonstrated that they have been able to manage COVID- 19 more effectively than many states in the global north, including the UK, meaning the UK should seek to learn from such states, and ensure that global health security must be led by those who have demonstrable success, and from whom the world can learn. Moreover, this comes at a broader time within the global health policy landscape to decolonise global health. The UK must learn that British exceptionalism and UK leadership in global health can only go so far and the future of global health security governance does not lie exclusively in the global north. FCDO should support such efforts and ensure a more inclusive and horizonal governance mechanism for global health security. Global Pandemic Early Warning System Early warning is vital to global health security. Being able to know about a circulating pathogen as soon as possible allows for a timely response. Under the IHR, governments must strengthen capacity to be able to detect an outbreak through improved surveillance and laboratory infrastructure, and must report any outbreak which might pose risk of international spread to the WHO within 24 hours. Indeed, this acts as an early warning system through the state-based system. On top of this, the WHO runs the Global Outbreak Alert and Response Network (GOARN) to detect outbreaks through state reporting, non-state reporting, and horizon scanning through media sources and social media scraping. This allows early identification of an emerging pathogen so relevant investigations can be launched. Beyond WHO there are a number of digital disease surveillance platforms which provide early warning for outbreaks, including ProMED-Mail, a horizon scanning platform collecting real-time information from clinicians, vets and public health officials across the world and HealthMap, which provides a crowd-sourced real time picture of emerging pathogens from the media. These are both open access and, indeed, are well used by governments and WHO in their disease surveillance activities20. Indeed, it was these systems which first detected COVID-19 and Ebola in West Africa prior to WHO reports21. Thus, the pandemic early warning system already exists within and outside WHO. Global health actors have a habit of inventing new institutions rather than strengthen the ones that exist, but this seems fundamentally flawed in this instance. We have the tools at our disposal

20 Brownstein, J. S., Freifeld, C. C., & Madoff, L. C. (2009). Digital disease detection—harnessing the Web for public health surveillance. The New England journal of medicine, 360(21), 2153. 21 Cook, Emily. 2020. How AI systems detected the first COVID-19 case. Healthcare Global https://www.healthcareglobal.com/technology- and-ai-3/how-ai-systems-detected-first-covid-19-case-1 for an early warning system – there are two challenges to having them work effectively to prevent the next pandemic: - Funding: WHO GOARN (and the broader Health Emergencies Programme within WHO) are chronically underfunded, restricting their ability to scale up response efforts during a crisis. As we saw earlier in the year with WHO’s Strategic Preparedness and Response plan which needed $675m which the organisation was unable to raise from member states, so it was left to establish a COVID-19 Solidarity Fund, asking the global public to help their efforts22. This is not a sustainable way to manage pandemic preparedness.

State Compliance: The major problem with global health security isn’t knowing about a circulating pathogen – with the methods above, within a day or two WHO (and the global community) knows about any emerging threat, so outdated concerns of government concealment are somewhat moot. The problem is getting governments to do something to mitigate against the disease risks. Even when COVID-19 was declared a Public Health Emergency of International Concern on 30th January 2020, and later a Pandemic on 11th March, many governments (including UK) did not take strong enough action compared to the risk posed23. Thus, the problem isn’t the lack of “early warning” about an emerging infectious disease threat, it’s national politics creating apathy. Instead of pushing for a new early warning system, the UK should strengthen the mechanisms in place through WHO and digitally, and simultaneously push global governments to commit to working with WHO (through whatever reforms are required of the institution to engender trust and compliance), and ensure that governments take outbreaks seriously and prepare when they have the chance, rather than when it’s too late. To do so, research is desperately needed to understand why governments have sought to detract from global norms of global health security during COVID-19, and why many defaulted from their obligations under IHR. A first step would be to invest in such research to understand the actual problems within global health security, rather than try to find solutions for problems which do not exist (such as an early warning system for pandemics). This is a snapshot of my analysis of the UK’s role in global health security (I have a number of ongoing projects in this area). I am very happy to elaborate in written or oral evidence in relation to other aspects of the call for evidence.

22 Davies, S. E., & Wenham, C. (2020). Why the COVID-19 response needs international relations. International Affairs, 96(5), 1227-1251. 23 Wenham, C. (2020) We should strengthen existing institutions rather than create a new international body for virus surveillance. BMJ Opinion https://blogs.bmj.com/bmj/2020/07/21/we-should-strengthen-existing-institutions-rather-than-create-a-new-international-body-for- virus-surveillance/ December 2020