Commentary COVID-19: time for paradigm shift in the nexus between local, national and global health 1,2 3 4 Elisabeth Paul , Garrett W Brown, Valery Ridde To cite: Paul E, Brown GW, INTRODUCTION Key messages Ridde V. COVID-19: time for The WHO declared the novel coronavirus paradigm shift in the nexus between local, national and disease 2019 (COVID-19) an ‘emergency of ► The COVID-19 pandemic has triggered unprece- global health. BMJ Global Health international concern’ on 30 January 2020 dented measures worldwide, which have often been 2020;5:e002622. doi:10.1136/ and a pandemic on 11 March. According to adopted in an ‘emergency’ mode and are largely bmjgh-2020-002622 WHO’s Situation Report - 79, as of 8 April reactionary 2020, the epidemic has caused 79 235 deaths ► Alternatively, COVID-19 needs to be appraised as 1 part of a much bigger health picture, adopting a EP and GWB contributed equally. worldwide. While it is seemingly nearing its end in China, where it was first reported, “systems approach” that enables interactions with EP and GWB are joint first it is still on the rise in Europe, in the USA other acknowledged and preventable health con- ditions, which often receive disproportionately low authors. and in other parts of the world, including in attention many low-income and middle- income coun- Received 9 April 2020 ► To do so requires a paradigm shift in global health Accepted 13 April 2020 tries (LMICs). The pandemic has triggered governance, from a specific reactional paradigm to a unprecedented measures worldwide. Many systemic, coordinated and preventive paradigm countries have installed travel bans, confine- ► It is necessary to adopt a holistic approach to health ment and lockdown policies. These responses reflecting both a security approach and a health de- have been adopted in an ‘emergency’ mode, velopment approach, tackling upstream causes and and are largely reactionary, aimed at miti- determinants, aimed at helping populations reduce gating the spread of the disease while waiting their individual risk factors and augment their nat- for a specific cure and/or vaccine to be devel- ural immunity oped. ► Such preventive health policies must be tailored to local specificities and local environments, and health Here we do not want to underestimate the systems must be strengthened at the local level so risks caused by the pandemic, nor to question as to be able to respond to population needs and the measures taken by the WHO and govern- expectations ments. But we would like to express our ► The current crisis calls for a paradigm shift in public concerns regarding four COVID-19-related and global health policies; and in the in the nexus issues, and advocate for a ‘paradigm shift’— between local, national and global health policies © Author(s) (or their employer(s)) 2020. Re- use that is, a scientific revolution encompassing and systems permitted under CC BY- NC. No changes in the basic concepts and experi- commercial re- use. See rights mental practices of a scientific discipline2—to and permissions. Published by prepare for future crises. BMJ. in particular, one million die annually from 1School of Public Health, chronic obstructive pulmonary disease; Université Libre de Bruxelles, pneumonia kills millions of people annually Bruxelles, Belgium A SHIFT IN FOCUS: COVID-19 IN THE BROADER and is a leading cause of death among chil- 2Tax Institute, Liege University, GLOBAL HEALTH PICTURE dren under 5 years old; each year 1.4 million Liege, Belgium It is important to remember other acknowl- die from tuberculosis; and lung cancer kills 3Global Health Theme, POLIS, edged and preventable health conditions, 1.6 million people a year and is the deadliest University of Leeds, Leeds, UK 3 4CEPED (IRD- Universités when compared with the focus that COVID-19 cancer. The WHO estimates that seasonal 4 de Paris), INSERM, Institut has triggered at global and national levels. influenza kills up to 650 000 people a year. de recherche pour le Respiratory diseases have been leading In 2018, an estimated 405 000 people died developpement, Paris, France causes of death and disability in the world of malaria.5 In 2017, about 295 000 women Correspondence to before COVID-19. It is estimated that, glob- died during and following pregnancy and Dr Elisabeth Paul; ally, four million people die prematurely childbirth—that is approximately 810 women Elisabeth. Paul@ ulb. ac. be from chronic respiratory disease each year; each day.6 In the USA alone, a lower limit of Paul E, et al. BMJ Global Health 2020;5:e002622. doi:10.1136/bmjgh-2020-002622 1 BMJ Global Health 210 000 deaths per year was associated with preventable represents far less money than the PEF (which, in theory, harm in hospitals.7 should come after the CFE, if you happen to prequalify Whereas infectious diseases seem to inspire the for the loan).16 The ‘One Health’ approach, which was most terror among the public and policymakers, non- meant to offer a more responsive research and policy communicable diseases are responsible for almost 70% agenda to combat zoonotic diseases, remains sluggish at of all deaths.8 Depression affects 300 million people glob- best and underdeveloped in terms of including environ- ally and is the leading cause of disability worldwide, and mental factors, such as soil and water, which play a crucial nearly 800 000 people die from suicide every year.9 The part in AMR and other threats.17 global boom in premature mortality and morbidity from In terms of pathogen monitoring and response, the non- communicable diseases has now reached a point 2005 International Health Regulations, which are meant where some have even suggested it to be a pandemic.10 ‘to help the international community and governments Moreover, climate change (through increased heat waves prevent and respond to acute public health risks that and disasters) and atmospheric and environmental pollu- have the potential to cross borders and threaten people tion are expected to increase deaths and injuries, espe- worldwide’,18 are not fully implemented by many coun- cially in LMICs.11 In some debates, climate change has tries due to limited financial resources and political will, become more than a risk factor, with increasing calls for and have been violated in response to the COVID-19 the WHO to declare it a public health emergency.12 outbreak.19 What is more confounding is that many high- From a public health perspective, COVID-19 needs to income countries like France have failed to fully imple- be appraised as part of a much bigger health picture. For ment the International Health Regulations, particularly instance, beyond the lethality and direct mortality rates in their overseas territories.16 In addition, other disease of COVID-19, attention should be paid to the interac- control mechanisms, like the WHO Global Influenza tion with other pathogens, as well as to the more indirect Surveillance and Response System (https://www. who. effects of its mitigation measures.13 Indeed, the pandemic int/ influenza/ gisrs_ laboratory/ en/), remain inade- and its containment measures interact with, and impact quate and underfunded, with too few WHO laboratories on, other health conditions and will have system-wide and a market- based model where a global public good effects, highlighting the importance of adopting a (pooled influenza knowledge) is turned into a private ‘systems approach’ to its resolution.14 good (pharmaceutical profit), with historical inequities in terms of public health.20 Moreover, many countries, like China, are incentivised not to raise the epidemic A PARADIGM SHIFT IN GLOBAL HEALTH GOVERNANCE alarm too soon due to fears of diminished direct foreign The global health community, national security agencies investment (like with severe acute respiratory syndrome, and all governments have known that a pandemic like H7N9 and now COVID-19) and fears that the govern- COVID-19 was likely to come, yet global health policy has ment will be perceived as weak.21 remained woefully unprepared nor fit-for- purpose. In These conditions of incapacity at the international level 2015, the G7 members proclaimed that Ebola had been are exacerbated by a weakened WHO, whose budget has a ‘wake- up call’ for the need for better global coopera- been radically reduced and ring-fenced. For example, the tion. It was also recognised that antimicrobial resistance WHO used to receive three- quarters of its financing from (AMR) threatened to kill 300 million people by 2050, assessed contributions levied on members. However, a thus demanding urgent action. Yet little has been done change to a zero real growth policy for its regular budget to address these existing global health governance short- in the 1980s has meant it now only receives a quarter comings.15 of its budget from member contributions. As a result, For example, the lauded G7 and G20 response, the the WHO is dependent on extra-budgetary ring- fenced Global Health Security Agenda (https://ghsagenda. ‘pet project’ funding from donors to fill an increasingly org/), continues to speak in the terms of costly ‘counter- shrinking budget.22 As the money flows to other multi- measures’ versus prevention and health system strength- lateral health initiatives, the WHO’s authority dissipates, ening. Moreover, the Pandemic Emergency Financing with numerous organisations like the Institute for Health Facility (PEF) (https://www. worldbank. org/ en/ topic/ Metrics and Evaluation, the Bill and Melinda Gates Foun- pandemics/ brief/ pandemic- emergency- financing- dation and Médecins Sans Frontières able to command facility), meant to deliver up to $500 million in epidemic greater epistemic authority,23 financial influence24 and assistance to curb expansion into a pandemic, sits idle response effectiveness.25 However, this expansion of as a complicated ‘loan mechanism’ at the World Bank, initiatives creates a condition of policy fragmentation, available to only a few countries (eg, China and India do which significantly weakens coordinated global public not qualify for the money).