This policy brief series is the product of a joint research project conducted by the Japan Center for International Exchange (JCIE) and the Tokyo University Institute for Future Initiatives (IFI) to provide analyses on global and regional health governance systems and structures and to offer concrete recommendations about the role Japan should play in the field of global health.
The novel coronavirus has shaken not only conventional global health systems, but also the international order itself. The conventional global health framework has been considered to be part of the liberal international order,1 centered on the World Health Organization (WHO) and the International Health Regulations (IHR). The WHO and the IHR seek to achieve a degree of international solidarity, placing the interests of humanity ahead of national interests. This framework is based on the fundamental value of having the international community unite and work together to take a stand against infectious diseases and other diseases that pose a threat to humanity.
Usually, the conduct of nations in the international community is intended to maximize their own interests, and when problems arise in other countries, the general rule is that they should be dealt with by that country. However, infectious diseases traverse national borders and spread, and if they are not prevented from occurring in other countries, then they will reach one’s own country. In other words, these circumstances present a unique value of emphasizing international solidarity whereby acts of self-interest are achieved through altruistic acts.
Furthermore, the IHR, which has become part of the rules-based international order, requires that public health responses “avoid unnecessary interference with international traffic and trade.” This concept has become a fundamental value of the international community through free trade and the free movement of people. In addition, the IHR also provides fundamental principles in such areas as information-gathering and sharing, WHO leadership in emergency responses, and science-based decision-making, etc. Those principles respect national sovereignty but also seek to ensure that the restrictions authorities place on social activities are as minimal as possible and take human rights into consideration.
In addition, the international distribution of and support for testing, vaccines, and therapeutics have become viewed as important activities that embody international solidarity in the framework of the WHO- and IHR-centered global health governance system. The Access to COVID-19 Tools (ACT) Accelerator, in which Japan has been actively involved, is a foundational activity for realizing this type of liberal international order, and efforts such as the COVAX AMC Summit (AMC: Advance Market Commitment), which Japan co-hosted with the Gavi Vaccine Alliance and other organizations, was also aimed at realizing international solidarity.
However, these activities have faced a major challenge from the novel coronavirus. This essay examines the impact of the pandemic on the rules-based international order and how it will change the global health regime.
Infectious disease countermeasures as national security
One of the major challenges that COVID-19 posed for the global health regime was that, while many previous outbreaks of infectious diseases have occurred primarily in developing countries (or countries with low core capacity), COVID-19 has struck developed countries (or countries with high core capacity) as well. Western countries that traditionally have been at the forefront of research on infectious disease have been gravely affected, and due to the spread of the disease in countries with high drug discovery capability in areas such as vaccines and diagnostic agents, the global health regime’s underlying schema of “developed nations supporting developing nations” has collapsed, and advanced countries have had to put all of their efforts into dealing with their own infectious disease countermeasures. As a result, we have seen the emergence of the phenomenon known as “vaccine nationalism,” and not only have developed countries hoarded vaccines that they developed and manufactured for themselves to carry out domestic vaccinations, but they have also impeded the distribution of vaccines to developing countries by securing enough doses to vaccinate their populations several times over. In addition, there have been cases, as seen in the EU and India, where measures were taken to restrict vaccine exports due to worsening infection rates within their own region or country.
Furthermore, despite the fact that IHR is not supposed to interfere with international traffic and trade, many countries stopped the movement of people or strengthened immigration controls as border measures to prevent the inflow of infections from other countries. Even in the EU, where up until now people had been allowed free movement across national borders under the Schengen Agreement, many nations have taken action to temporarily restrict the movement of people based on the Schengen Borders Code. These restrictions have been eased and re-applied several times, and some European nations still have border controls in place currently. This mechanism for controlling the movement of people is an unavoidable issue with infectious diseases where person-to-person transmission is occurring, and for future infectious disease countermeasures too, this will likely be accepted when there is a certain degree of rationality behind it.
The fact that such exceptional measures have continued to be introduced, which differ from the traditional global health regime, is probably due to the perception of COVID-19 as a “national security crisis.” States have often “securitized” certain specific issues related to global governance, giving them a higher political priority and strengthening the relevant government authority.2 However, in the case of COVID-19, rather than governments intentionally trying to make it into a national security issue, it has become a national security problem out of necessity because the transmission and mortality rates of this disease are at levels rarely experienced in many countries.
However, the securitization of infectious disease has given rise to a new form of international relations, as seen in “vaccine diplomacy,” whereby vaccines are being used as diplomatic tools to impose one nation’s will on others, and in the use of vaccines as a means of so-called “economic statecraft.”3 On the one hand, providing vaccines to countries that lack doses appears to be creating international solidarity, but on the other hand, these vaccine donations are being used as strategic diplomatic tools, which was not envisaged under the original global health regime. Moreover, this kind of behavior can be seen strongly in authoritarian regimes (particularly China and Russia) that have prioritized the export of vaccines over domestic inoculation. With China and Russia advancing their “vaccine diplomacy,” other countries have been left with no choice but to counter it. The Quadrilateral Security Dialogue (the “Quad”), which consists of Japan, the United States, Australia, and India, has established a working group on vaccine development and international delivery as an urgent matter. That being said, the Quad is providing doses by utilizing the COVAX Facility, an international framework for vaccine distribution, and thus this is not being used as a means of strategic “economic statecraft.” However, the recipients of the vaccines can be adjusted to meet certain requests, and these countries are providing vaccines bilaterally as well, separately from COVAX.
Infectious disease countermeasures and “time”
COVID-19 has also raised the issue of “time” when it comes to infectious disease countermeasures. Until now, it was believed that vaccine development takes two to three years, but the development of COVID-19 vaccines was achieved much faster than expected due to the new mRNA technology. Within a year of the virus being identified, vaccines were developed that have greater than 90 percent efficacy. The speed at which vaccines can be developed using these kinds of new technologies will be a crucial point in regard to future measures to combat infectious disease. If vaccines can be deployed quickly as a trump card to fight infectious diseases, then that will change the type of nonpharmaceutical interventions needed.
In contrast, in Japan it took a considerable amount of time for vaccines to be approved. This was due both to a revision to the Preventive Vaccination Law that meant it took a considerable amount of time to confirm the safety of vaccines and to the fact that Japan does not have a framework like the US Emergency Use Authorization (EUA). This led to the criticism that vaccination progress in Japan was slow even in the global context. In particular, as the Tokyo Olympics were scheduled to be held in July 2021, this delay resulted in domestic and international debate over whether the Olympics should go ahead, be postponed again, or be cancelled.
In addition, when the Diamond Princess, a cruise ship with more than 3,000 passengers and crew members, entered Yokohama Port in February 2020, in the early phase of the pandemic, Japan was forced to quickly implement infectious disease countermeasures. At that time, the number of available tests was extremely limited (they were only able to conduct about 300 tests per day), and it was not possible to test all passengers and crew at the same time. Consequently, testing was divided up, with a few hundred people tested per day, and the number of cases of infection detected were then announced every day, which led to the mistaken impression that infections were spreading onboard the ship. As a result, the international community became critical of Japan’s infectious disease countermeasures.
In this way, infectious disease countermeasures always represent a battle against time. Although the “timeframe” for what types of measures should be implemented at what stage measures should be implemented is extremely important, that was not adequately recognized by the international community nor within Japan. It is crucially important for infectious disease countermeasures that there be a rapid response, flexible decision-making in response to conditions, and public notifications about such decisions in order to promote behavioral change. Establishing a timeframe also gives people an image of working toward the resolution to an infectious disease, and will likely have a more stable effect on social intervention by giving a sense of how long lockdown and stay-at-home measures should last.
“Value” in the post-corona era
COVID-19 has served as a reminder that the global health regime must be rebuilt in a form that adds the two new elements of “securitization” and “time.” In other words, it has reminded people that it is no longer enough to just think about a framework in which developed countries support developing ones on the premise of international solidarity.
However, the nature of infectious diseases has not changed. Regardless of the extent to which a country “securitizes” an infectious disease, even if that country adopts thorough countermeasures on its own and completely vaccinates its population, if infections continue in other countries and if virus variants continue to appear, then the virus will eventually resurface as a re-emerging infectious disease. Consequently, that relationship of acts of self-interest being achieved through altruistic acts remains unchanged—to ensure one country’s “security” ultimately requires global infectious disease countermeasures. In other words, the traditional concept of international solidarity has been an important theme in the case of COVID-19.
However, what became crystal clear with COVID-19 was the question of who would be the first recipients of medical tools such as PPE and test kits, and what the order of priority should be. A global health regime needs to be established on the premise that the order of priority should be that nations first take care of their own infectious disease countermeasures and then, once they have carried out domestic vaccinations, they should provide vaccinations to an international distribution framework such as the COVAX Facility.
Moreover, as can be seen with vaccine diplomacy, it should also be assumed that international power relations and confrontational structures that are outside of the global health regime will be brought into the regime. This implies that whereas global health regimes have traditionally been thought of as extremely scientific and technical, from now on political bargaining and confrontations will enter into future pandemic responses. In this regard, rather than assuming that the global health regime will involve all countries and will act in a concerted manner, it may be necessary in some cases to seek solutions by utilizing coalitions of the willing and frameworks such as the Quad. Another option that should be considered is to build a global health regime in cooperation with regional institutions such as the African Union, and to strengthen infectious disease control capabilities as a regional security measure.
Looking to the future, there will be discussions of pandemic treaties and how best to secure the supply chain for vaccines and other relevant tools. It will be important that these discussions tackle the question of how national security issues can be recognized as global security issues, or in other words, how to ensure recognition that altruistic acts result in, and are connected to, one’s self-interest. By doing so, we can create a global health regime that contributes to the creation of a stable, rules-based international order for the international community.
About the Author
Kazuto Suzuki is Professor of Science and Technology Policy at the Graduate School of Public Policy at the University of Tokyo, Japan, and senior fellow of the independent policy think tank Asia Pacific Initiative (API).
- Ikenberry, G.J. (2006). Liberal Order and Imperial Ambition: Essays on American Power and International Order. London: Polity Press.
- Ken Shimizu, “The Securitization of Migration in Sweden: Recognition of a Non-Traditional Security Threat.” International Politics 172(2013): 87–99.
- Kazuto Suzuki, "Economic Statecraft and the International Community," in Yuzo Murayama, ed., U.S.-China Economic Security Strategy: New Competition for Emerging Technologies (Fuyo Shobo Shuppan 2021, 9– 32).