The global pandemic of coronavirus should be a clarion call to revamp global and national
health institutions and their approaches. This new virus exhibits high transmissibility
and with no medical countermeasures poses a risk to health systems worldwide. A few
months prior to this pandemic, the Global Preparedness Monitoring Board (GPMB) warned
that ‘there is a very real threat of a rapidly moving, highly lethal pandemic of a
respiratory pathogen killing 50 to 80 million people and affecting nearly 5% of the
world's economy [1]. Unfortunately, the world did not expect that this would strike
soon.
Health risk is interconnected with social well-being, economic forces, and human rights.
This requires a fundamental shift in understanding the complex nature of health to
build solid, cost-effective preventive actions and policies in the future. Unfortunately,
pandemics and epidemics are largely understood and dealt with from a biomedical approach.
The COVID-19 pandemic is a reminder to move beyond this reductionist perspective towards
an assertive institutional environment, especially when there is inadequate scientific
understanding and uncertainty prevailing in the event. An assertive institutional
environment is about the actors taking a step back from their predetermined concepts
and frameworks to take decisions as an external viewer for the welfare and security
of the humanity and their ecology nationally and globally. This requires stronger
international cooperation, adequate foresights, social solidarity, and optimized resources
with strong leadership and effective communication.
INTERNATIONAL COOPERATION
Governance during a pandemic is about setting formal and informal rules, mobilizing
public institutions, enacting regulations, reinforcing socially embedded norms and
values, and using market forces to integrate within and beyond nations to manage the
crisis. There are two international frameworks that guides national and international
cooperation during health emergencies. The first is the International Health Regulations
(IHR), which remain at the core for international cooperation with over 196 national
signatories, which came into force in 2007 and was updated in 2009 [2]. Yet, after
more than 10 years, the IHR and its revised version have proven to be inadequate and
have cast doubts on the effectiveness of the regulations. The second is the WHO Guidelines
[3] for influenza preparedness and response, which identifies five basic components:
(i) planning and coordination, (ii) situation monitoring and assessment, (iii) reducing
the spread of disease, (iv) continuity of health care provision, and (v) communications.
Interestingly, during the COVID-19 pandemic these frameworks only offered guidelines
for countries to share information on the characteristics of the virus to the international
community.
There were a few regional and bilateral initiatives during this pandemic, which offers
significant lessons for cooperation and sharing during the pandemics. The African
Union (AU) played an effective role in communicating about and shaping African responses,
with technical legitimacy provided through the Africa Centres for Disease Control
and Prevention (Africa CDC) [4]. The regional responses within AU reflected a spectrum
of cooperation, complexity, and the politics of diplomacy during pandemics – rising
from information sharing; to ‘nudging’ and guiding; to active coordination of state
responses, to collective action. Bilaterally, many countries were engaged in the dispatch
of personal protective equipment’s. China provided pandemic-related aid to personal
protective equipment, including 1000 for the New York city. Germany offered to provide
hospital beds to treat critically ill patients from neighbouring countries demonstrating
the European solidarity [5]. Despite these initiatives, international institutions
have an immense task to address the shared global problems that are likely to linger,
such as movement restrictions, high levels of unemployment, rising dissatisfaction
with governing institutions and growing civil liberties during pandemics. This requires
international institutions to strengthen international cooperation through adequate
foresight, building social solidarity, and enlightened leadership [6,7].
FORESIGHT
Foresight remains crucial for national- and international-level preparedness and response
during pandemics when there is uncertainty in the behaviour and unpredictably in the
scientific understanding of the pathogens. China realized the seriousness of the virus
to activate the Epidemic Prevention and Control Headquarters System (EPCHS), set up
the Joint Prevention and Control Mechanism of the State Council (JCMSC) and mobilized
heath work force [8], many of these measures were non-pharmaceutical interventions.
This was supported by transforming public venues to hospitals and make-shift hospitals
to ensure health security. In late January, when South Korea came to know about the
virus outbreak in China, the country’s health officials, and representatives from
more than 20 medical companies met to discuss the manufacture of testing kits and
the details of government support [9]. Their rapid response to COVID-19 was partially
a result of their previous experience with SARS 2003 and MERS. India, realizing its
inadequacies in health infrastructure in a highly dense and unequal society, invoked
the National Disaster Management Act-2005 to impose nation-wide lockdown as a non-pharmaceutical
intervention to contain the initial spread of virus [10]. When cases were reported
in China, Germany developed the diagnostic test kits for COVID-19 and mobilized the
country`s public and private laboratories to rapidly scale up testing capacity [11].
This was followed by its ability to manage the infection rates in hospital and long-term
care facilities [12]. It is this leadership during a pandemic with public awareness
of the prevailing uncertainty and bold decisions by considering the interests of public,
private, and civil society that played a significant role in the initial containment
of the disease spread.
Photo: From Unsplash (https://unsplash.com/photos/8BIy9ifXMtA).
SOCIAL SOLIDARITY
Motivating stakeholders to pay attention to foresight and assertive action requires
more than just sophisticated expertise in communication and building solidarity. Diverse
social organizations in China participated in the epidemic control through shared
expertise, promoting public health literacy, and through volunteering programs. This
helped to disseminate information and gain social support [8]. Solidarity can also
be aided by experiential backing. Having learnt lessons from the MERS and SARS epidemics,
people in South Korea gave a solid backing to their government. Similarly, when China
announced the pandemic, good social communication from the government and sub-national
agencies with the public played a significant role in containing and controlling pandemic.
The Indian prime minister took primary responsibility in reaching out to the common
public (where most of them are illiterate) through the weekly address on television
to highlight the seriousness of the pandemic and sort support from the citizens while
imposing the countrywide lockdown [10]. The Robert Koch Institute in Germany took
lead in publishing risk assessment strategy document, response plans, daily surveillance
reports and technical guidelines which formed the basis for public awareness and critical
decisions by stakeholders during the outbreak [12]. It can be a challenge for countries
to mobilize the public for massive state intervention, and this is often only possible
in a crisis like COVID-19. From the outset, decision-making in these countries has
been a collaboration between the government and the scientific community, solidarity
from their citizens and a highly modern testing system.
OPTIMIZING TECHNOLOGY
Technology and in-house resources have been useful for many nations in containing
the spread of the pandemic. For example, the Smart Management System developed by
South Korea to track and analyse the movement of infected individuals [13] was useful
to that country in containing COVID-19. The technology gave epidemiological investigators
real-time data about the patients, their contacts, and their movements to enable tracking
infection routes for effective containment and treatment. Countries that have maintained
low COVID-19 per capita mortality rates appear to share strategies that relied on
digital technology and integrating it into policy and health care [14]. The future
of public health is likely to become increasingly digital, and to succeed we need
for the alignment of international strategies for the regulation, evaluation and use
of digital technologies to strengthen pandemic management, and future preparedness
for COVID-19 and other infectious diseases [15].
CONCLUSION
The world has not experienced a simultaneous and indiscriminate social, health, governance,
and economic crisis to rival that experienced because of COVID-19 [7]. This has exposed
not only how far the world is from effective and unified global governance, but also
multiple crises of confidence in the institutions expected to guide international
action and cooperation [7]. The Viewpoint calls for revision of the international
guidelines and national approach towards facilitating an assertive institutional environment
for pandemic governance. An assertive institutional environment is about the actors
stepping back to take decisions as an external viewer for the welfare and security
of humanity and their ecology nationally and globally. It is not about having a proactive
policy with predictable concrete events but rather drawing attention to potentially
relevant developments on an everyday basis recognizing the prevailing uncertainty,
unpredictability, and availability of resources with strong leadership [16]. It is
about addressing them through the interplay of consolidated interests, political competitiveness,
and more urgent matters on the everyday agenda. This requires stronger international
cooperation, adequate foresights, stronger solidarity among citizens and governments,
and optimized resources with strong leadership and effective communication. It is
important that such a framework goes even further by integrating with diverse health
care systems; incorporating economic and market behaviour; regulating social behaviour
and resource transfer in their day-to-day movements, addressing socio-economic effects,
developing socially informed and acceptable measures, and ensuring equitable access
to health security through national and international cooperation. The pandemic also
presents an opportunity for country agencies to improve education regarding hygiene
and other practices, strengthen their health infrastructure, improve immunity-based
diet systems, improve housing, and enhance cooperation among nations and intergovernmental
agencies to help develop governance structures in alignment with other health-related
sectors.