The world has just passed an important anniversary. A year ago, on the eve of 2020, a municipal office in Wuhan, China, reported that 27 people in the city had come down with a strange and unidentified “viral pneumonia.” The next day, the World Health Organization picked up on the report and reached out to the Chinese government for more information. No one realized at the time how significant this new pathogen—later named SARS-CoV-2, the virus that causes COVID-19—would become. One year later, it has changed the world in unimaginable ways.
The past year has seen nearly 86 million cases of COVID-19 and more than 1.8 million deaths. In the immediate aftermath of the virus’ global spread, economies around the world were sent reeling, with the World Bank estimating that the global economy would shrink by 5.2 percent by the end of 2020. More than 20 million people lost their jobs in the United States alone, where unemployment reached 14.7 percent in April—the highest level of unemployment since the Great Depression. Just last month, the United Nations warned that the loss of jobs and income threatens to push a billion people—nearly one-eighth of the world’s population—into extreme poverty, erasing decades of progress on poverty reduction in an instant. Reports of discrimination and xenophobia, against people of Asian descent, refugees and other groups inaccurately perceived as being more likely to spread COVID-19, are on the rise and hampering disease control efforts, according to the United Nations. The pandemic has also strained governments at all levels and impaired the work of international organizations.
In better news, the world has also learned a lot over the past year—although some countries much more than others—about how to deal with the coronavirus and manage the worst pandemic in a century. At the start of 2020, scientists had never seen this coronavirus before, and did not even know if it could be transmitted from person to person; within months, they confirmed that the virus is transmitted via respiratory droplets and aerosols. Throughout the year, we saw how governments that took quick, decisive and science-based actions were able to effectively stop COVID-19’s spread. Perhaps most impressively, scientists developed not one, but two highly effective coronavirus vaccines in less than a year, with a third—from AstraZeneca and the University of Oxford—now being distributed in the U.K. This is the shortest time that it’s ever taken to create a vaccine for a disease, beating the previous record, the mumps vaccine, by a full three years.
In the coming months, countries will continue to learn a great deal more about COVID-19. Even so, as we pass this anniversary, it’s worth taking a moment to step back and evaluate what we can take away from this crisis to guide our collective response to the next one. Several important lessons are already clear.
Lesson 1: The Global Health Governance System Is Both Fragile and Robust
Infectious disease outbreaks require a coordinated response—but there is no single, coherent system for putting one into motion. The World Health Organization may be the most prominent actor in the global health space, with its near-universal membership and mandate to act as an international coordinating authority for cross-border health issues. But this U.N. agency is far from alone. The global health governance system relies on an assortment of other actors, too, leveraging their talents in a complementary fashion. These include national governments, nongovernmental organizations like Medecins Sans Frontieres, philanthropies like the Bill and Melinda Gates Foundation, public-private partnerships like Gavi, and other intergovernmental organizations with health-related operations, like the World Bank, UNICEF and the United Nations Development Program.
When COVID-19 emerged, this system was already strained. The WHO’s budget was small and largely out of its own control, making it hard to dramatically change its operations when the pandemic first broke out. Despite the lessons of past disease outbreaks, the WHO remained understaffed and in need of deep reforms to its safety protocols and accountability measures. If that were not enough, the top funder of global health initiatives, the United States, was being led by a president, Donald Trump, who repeatedly called the value of multilateralism into question and expressed significant reservations about the very existence of global health programs, undermining the efforts of the WHO’s director-general, Tedros Adhanom Ghebreyesus, to reenergize member states and renew their commitment to the organization.
Learning does not have to wait until a pandemic ends. We can and should use these lessons to adjust our policies as we enter the second year of COVID-19.
Nevertheless, the global health governance system has proven its resilience and adaptability. It took only one month after that first official report from Wuhan for the WHO to declare COVID-19 a “Public Health Emergency of International Concern,” an important designation that signals the severity of a crisis to the global community and allows the WHO to call for additional resources and coordinate responses across borders. That was a big improvement from its response to the outbreak of Ebola in West Africa in 2014, when it was roundly criticized for waiting a full eight months to raise the status of the epidemic to that level. The delay allowed the disease to spread even farther and made it that much harder to bring the outbreak under control. This time, the WHO’s relatively quick action led the global community to begin work much sooner.
There were also innovative approaches right away to the challenges that COVID-19 posed. Almost as soon as the virus began its global spread, public health experts voiced serious concerns that once a coronavirus vaccine was developed, it would be financially out of reach for low- and middle-income countries. In response, the WHO, European Commission and French government launched COVAX, a public-private partnership that brings together nearly every country on the planet—representing more than 90 percent of Earth’s population—to pool resources for vaccine development, negotiate with manufacturers to decrease costs, and ensure that all states get access to eventual vaccines. To date, however, the United States is still not part of it.
Under this COVAX plan, no country will get enough doses of the vaccine to inoculate more than 20 percent of its population until all countries in the partnership have been able to reach that threshold. Wealthier countries will subsidize access for poorer countries, and manufacturers will benefit, too, from the guaranteed market COVAX provides. This is a great example of countries working together to recognize their shared interests and vulnerabilities, while also using existing institutional structures as a starting point to launch new and innovative projects.
Unfortunately, the global response to COVID-19 has also highlighted the system’s undeniable fragility and vulnerability to larger geopolitical tensions. The United States has been the top funder of global health projects annually for nearly 30 years. That record was threatened under Trump, who proposed cuts to that spending every year in his budget proposals. If Congress had not resisted those efforts, the international health governance system as we know it would have had to undergo a radical restructuring to reorganize staff and source new funds—a significant undertaking at any time, let alone during a global pandemic.
Coronavirus aid items being prepared for shipment at a WHO facility in Dubai, March 5, 2020 (AP photo by Kamran Jebreili).
Beyond the financial elements, though, Trump’s decision in July to withdraw the United States from the WHO and cede its global health leadership role has created a vacuum within the system. There is nothing that states that America has to be the global health leader, but its active and collaborative leadership has been a strong and powerful norm, and no other country has the financial resources nor the political legitimacy and authority to guide this tricky policy landscape.
In America’s absence, China has attempted to take up the mantle. At the WHO’s annual assembly in May, Chinese leader Xi Jinping pledged to donate $2 billion to COVID-19 relief efforts over the next two years. He also spoke of making a Chinese-developed vaccine widely available as a global public good, and announced a partnership with African states to bolster the development of the African Centers for Disease Control and Prevention. These sorts of efforts could bolster China’s soft power within the international system, signaling a shift in the larger geopolitical balance that has traditionally favored the United States.
Even if President-elect Joe Biden has America rejoin the WHO on his first day in office, as he has pledged, the experience of the past four years under Trump has undermined trust and led allies and partners to doubt Washington’s long-term commitment to multilateralism. The erosion of these norms puts in peril a system that is reliant on the good graces of its member states, rather than on punitive sanctions or international legal requirements.
Lesson 2: There Is No One-Size-Fits-All Pandemic Response
The decisions that governments make—or fail to make—can, of course, have a tremendous effect on the contours of an outbreak within a country’s borders. Simply compare how New Zealand’s Jacinda Ardern and Brazil’s Jair Bolsonaro have responded to COVID-19, and it is clear how decisive and effective policy responses can alter the disease’s course. Even among the pandemic’s best-performing countries, though, it is tricky to figure out exactly which policy responses made the greatest difference—particularly since we are still in the middle of this outbreak.
Take one set of policy responses: travel bans and border closures. Last January and February, the WHO repeatedly advised against international trade and travel restrictions, except as a very short-term measure to give a country time to bolster its response capabilities. Under the WHO’s International Health Regulations, member states were not supposed to implement border closures or travel restrictions that were more restrictive than those recommended by the WHO.
Nevertheless, more than 70 countries introduced strict international trade and travel restrictions in the first few months of the coronavirus pandemic. This is an understandable impulse; policymakers believed that if they could prevent infected travelers from entering the territory, they could lessen the likelihood that the virus would be imported. Such thinking prevailed again last month, when more than 40 countries banned travelers from the United Kingdom after its government announced that a new, more contagious strain of the coronavirus was spreading rapidly in the country.
The best lesson for the next pandemic is probably that the right policy interventions will constantly shift, and that there is no one-size-fits-all approach.
Were these closures and restrictions really a bad idea? That question remains fiercely contested. The WHO argues against blanket closures because they are unsustainable in the long term and can prevent the flow of goods necessary to stop an outbreak. As Vox put it, they are more “political theater” than effective policy, because by the time a country introduces these sorts of restrictions, the virus is likely already circulating within its borders. On the other hand, many of the countries that successfully addressed COVID-19 have relied at least in part on stringent border control policies. New Zealand has won plaudits for its impressive and aggressive response to the pandemic, and closing its borders to foreigners was a key element of its strategy. The same is true for Australia, which similarly banned foreign nationals early in the pandemic.
Scientific researchers, too, have yet to reach a consensus. A study published in the journal Science in April found that travel restrictions did delay the coronavirus’ international spread, but concluded that “early detection, hand washing, self-isolation, and household quarantine will likely be more effective than travel restrictions at mitigating this pandemic.” In contrast, a study by the International Institute for Applied Systems Analysis, published in August, found that countries that restricted international flights early in the pandemic significantly reduced COVID-19’s prevalence; their governments, the authors wrote, “did in fact do the right thing to prevent the spread of infection.”
What should a policymaker take away from these findings? Other aspects of the early pandemic response—like the guidance on whether to wear face masks, download contact-tracing apps or disinfect surfaces—have also been complicated or even reversed as the months went on. The best lesson for the next pandemic is probably that the right policy interventions will constantly shift, and that there is no one-size-fits-all approach. The right policy response in the first days of an outbreak may not be useful a year later. At the same time, recognizing which policies need to change, and when, can be difficult, if not impossible, in the middle of a pandemic. A second lesson, then, is that it is vital for governments to explain their decision-making processes to the public. Without clear and regular communication, the public can lose trust in their government and in health experts—and that lost trust can imperil the effectiveness of public health responses.
Knowing this, governments need to have structures and processes in place to allow policymakers and public health officials to continually evaluate the impact of their decisions and update their regulations and recommendations based on the data. Focusing, for example, on whether closing borders is right or wrong misses the bigger picture that no single policy can exist in isolation during a pandemic. A successful strategy is widescale and must make use of a full range of measures, including rapid and mass testing to detect cases, mask-wearing, physical distancing and the economic support necessary to maintain them.
Lesson 3: We’re Not All Equally at Risk
Viruses know no borders, or so we have heard time and again during this pandemic. In one sense, it is true. Passport checkpoints and lines on a map will not prevent a disease from spreading—especially in a globalized world, where goods and people can travel across borders with relative speed and ease. So long as a virus is circulating anywhere, any country is theoretically vulnerable to it. That is one of the most compelling reasons for global cooperation to address outbreaks of new diseases like this one.
In another, more profound sense, though, COVID-19 has exposed and reaffirmed that, in fact, we are not all equally at risk from infectious diseases. Instead, outbreaks often reflect and exacerbate the social cleavages that divide societies by race, ethnicity, gender, class and other variables. When people have unequal access to health care, live in conditions that increase their exposure to pathogens, or have reason to doubt that the government is looking out for their health needs, that increases their chances of getting sick.
Mexican army health workers wait to be vaccinated against COVID-19 in Mexico City, Dec. 29, 2020 (AP photo by Marco Ugarte).
These are what sociologists and epidemiologists call the social determinants of health: the conditions in how and where people live, work, learn and play that have direct and indirect effects on their lifelong health outcomes and health risks. Research has shown that today, and throughout history, these factors are of crucial importance for understanding health outcomes. As a result, if we implement health policies on the assumption that everyone is equally at risk, we gloss over the very real divisions that combine to determine a person’s overall health.
In the United States, for example, a white man with a high level of education, a professional job that can be done from home and comprehensive health insurance can still contract COVID-19—but his odds of getting sick are greatly decreased by the nature of his career and means. By contrast, Americans working in essential industries, who are more likely to be members of minority groups, do not have the luxury of working from home, in no small part because our modern societies depend on them showing up for work. Essential workers are also paid relatively little and have few employer-provided benefits. All this increases their potential exposure to the virus and their ability to go to the doctor if they fall sick—either because they risk losing their job by taking time off, or because they lack insurance. It is precisely for these reasons that the United States saw large COVID-19 outbreaks in meatpacking plants, and why low-wage workers have suffered disproportionately during the pandemic.
These divisions are not unique to the United States. Minority and lower-income communities in the United Kingdom, Spain, South Korea and Germany, among other countries, have borne a disproportionate burden of the pandemic—and this understanding should inform government policy.
Blanket lockdown policies, for example, are far less effective if they do not also provide income support to low-wage workers, because otherwise they force essential workers to decide between the risk of contracting a feared disease and the threat that they will be unable to provide for themselves and their families. Many countries provided direct payments or wage subsidies early in the pandemic, and these strategies offered much-needed financial support, keeping many people from falling into poverty even amid spiking unemployment rates. The United States initially expanded unemployment benefits in the CARES Act, the $2.2 trillion relief and stimulus package passed in March. When those additional funds expired in July, though, businesses and individuals were incentivized to return to work to replace that financial support. It then became harder for state and local governments to follow public health guidelines about closing high-risk businesses and schools.
Not only do these issues have an effect on individual and societal health, but they also play out geopolitically. Now that vaccine distribution is underway, after the rapid development of several promising vaccines, hopes are high that the end of the pandemic is near. Yet vaccines in and of themselves are not important; vaccination is important. A vaccine that relatively few people can obtain will actually do little to end the pandemic, and will only serve to further widen the gap between the health “haves” and “have-nots.”
A vaccine that relatively few people can obtain will do little to end the pandemic, and will only serve to further widen the gap between the health “haves” and “have-nots.”
The effectiveness of the vaccine rollout programs that began work last month has been mixed. The U.S. and France, for instance, are both well behind schedule due to logistical problems and a lack of leadership from their national governments. Israel, on the other hand, is leading the world, having already vaccinated about 14 percent of its population outside of the West Bank and the Gaza Strip. Low- and middle-income countries, in contrast, might not get access to the vaccine until 2023.
Since the WHO can only offer general guidance on best practices and cannot force countries to implement specific measures to contain and eradicate the virus, it is incumbent upon national governments to recognize how disease outbreaks spread through their societies. This is even more true in countries where public health systems are decentralized to subnational and local governments, where the dynamics at play are that much harder to untangle, and where coordination between jurisdictions becomes even more crucial.
Going forward, addressing inequalities needs to be central to pandemic responses. This could include having broad-based, consultative processes that ensure that marginalized communities can express their needs. Other solutions could target relief efforts toward the most vulnerable groups first, or expand social protection programs to cover people working in the informal sector, who were often overlooked by emergency lockdown and stimulus measures in the spring.
In the words of U.N. Secretary-General Antonio Guterres, the COVID-19 pandemic has exposed the need to establish a “new social contract” between governments and their citizens that will prioritize gender equity, educational opportunity, expanded access to digital technology, labor protections, universal access to health care, inclusive governance and sustainable development.
If there is a potential positive that comes out of this pandemic, it is the growing recognition that greater economic equality is one of the most powerful policy interventions possible to improve the health of a society. The coronavirus pandemic could be an opportunity for the international community to better account for the interconnectedness between health and other global challenges, from hunger and poverty to climate change.
The coronavirus has tested the global community in nearly every dimension of social, economic and political life. What’s important now is whether we learn the lessons from this pandemic—and those in the past—to improve our responses to future health crises, which will come. Learning does not have to wait until a pandemic ends, though. We can and should take these lessons in hand now and use them to adjust our policies as we enter the second year of COVID-19.
Jeremy Youde is the dean of the College of Liberal Arts at the University of Minnesota Duluth and a political scientist who specializes in global health politics. His most recent book is “Globalization and Health” (Rowman and Littlefield, 2019). Follow him on Twitter at @jeremyyoude.