This policy brief was originally published in Japanese as part of a series of papers produced by 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.
A year and a half has passed since the spread of COVID-19 was designated as a pandemic, and the fight against the virus still continues. As of November 2021, Germany and many other European countries are seeing an ongoing spread of infection, prompting the World Health Organization (WHO) to identify Europe as the current COVID-19 epicenter. Vaccines are a powerful weapon in the fight against the virus, but there is a large discrepancy in vaccine access among different nations. According to statistics published by Our World in Data, as of November 2021, the percentage of the populations in high-income countries that have been fully vaccinated is high, with 76% having received the required shots in Japan, 75% in Canada, and 68% in Great Britain. While middle-income countries have also achieved high vaccination rates, such as Argentina (61%), Malaysia (76%), and Cambodia (79%), those in developing countries such as Ethiopia (1.2%), Kenya (4.1%), and Ghana (2.4%) are markedly lower. Overall, the approximately 1.3 billion people who live in Africa have a vaccination rate of just 6% and are not expected to reach more than 10% by the end of 2021. Meanwhile, excessive stockpiling of the vaccines in advanced nations has resulted in a predicted surplus of 1.2 billion doses by year’s end, highlighting the large discrepancy existing in vaccine access.
This discrepancy will also lead to delays in economic recovery. According to the United Nations Development Programme (UNDP), the WHO, and Oxford University, if low-income countries had achieved similar vaccination rates to those of high-income countries, their estimated amount of GDP growth in fiscal 2021 would have been US$38 billion more than the current amount. Despite the objective data indicating that everyone would greatly benefit if the pandemic were handled as a global emergency, the international community has failed to cooperate appropriately to combat the COVID-19 crisis.
Why is this happening? Looking back at history, nations have promoted cooperation relatively easily to fight against infectious diseases in the past. Even recently, developed countries recognized AIDS and Ebola as serious threats to the international community and took the lead in mounting high-level responses. In contrast to these precedents, why has it been so difficult to mount a cooperative response to COVID-19? Here, I will attempt to decipher this question, discuss how we can prepare a robust response to the next crisis, and define the role that Japan will be expected to play.
High-Level Responses to Infectious Diseases
Responses to infectious diseases, which transcend national borders, have usually been supported by international coordination. The reason for this is simple: countries that cooperate can gain the information and tools they need to manage the spread of infection. In fact, even countries that are in political conflicts such as Germany and France before the World War I, Japan and the international community before World War II, and the United States and the Soviet Union during the Cold War cooperated in the fight against infectious diseases. In more recent years as well, high-level international responses have frequently been mounted. In today’s highly globalized world, infections spread very quickly and can turn into global crises that not only threaten people’s health but also have an impact on other domains, such as the economy and the functions of society. Reflecting a deepening recognition of this fact, infectious diseases are no longer considered to be the sole domain of the public health field, but rather are now viewed within the broader context that includes national security.
AIDS is a notable example of this trend. Having recognized that the spread of AIDS could have a negative impact on efforts to maintain international peace, for example through the deployment of peace-keeping operations (PKO) in Africa, the UN Security Council adopted Resolution 1308 in January 2000, which identified the need for anti-AIDS policies from a national security perspective. From about this time, infectious diseases such as AIDS and malaria became a topic of discussion at summits among the leaders of industrialized nations. When an outbreak of Ebola occurred in West Africa in 2014, US President Barack Obama took the initiative in hosting a UN summit, where a response to the global emergency was discussed. The UN Security Council adopted Resolution 2177, which identified Ebola as a potential threat to the peace and security of the international community. Subsequently, the UN Mission for Ebola Emergency Response (UNMEER) was established, which took an action against Ebola in cooperation with the PKO then underway in Liberia. Overall, it can be said that highlevel measures have been taken from a security perspective in response to recent outbreaks of infectious diseases precisely because of the wide-ranging impact that those outbreaks can have.
Treating COVID-19 as a National Crisis
COVID-19 has already had a tremendous impact not only in the health realm, but also on the global economy and the world’s poverty trends. Despite that, no high-level global response to COVID-19 has been mounted comparable to those that arose against AIDS and Ebola. Although the UN Security Council did adopt Resolution 2532 in July 2020, it was concerned with international conflicts related to the virus and did not, as was the case with Ebola, aim at ending the infection itself through international cooperation.
One feature of COVID-19 that makes it very different from previous infectious diseases is the fact that it has spread in areas around the world simultaneously, thus creating competition and confrontation among nations over the resources needed for response and arguments over what and whom is to blame for the pandemic. Of course, this is deeply connected to the decline of the liberal international order, which had been noted since before the pandemic occurred, but the simultaneous global nature of the outbreak has also played a major role. In the cases of AIDS and Ebola, a relatively limited number of countries were affected, and countries that were not directly touched by the outbreak were able to mobilize and dispatch resources to help combat the threats—funds, medical staff, and even military personnel—to the affected areas. In the COVID-19 case, however, nearly all countries were affected at the same time, and only a limited number of countries had the ability to develop and manufacture the medical supplies and vaccines that were needed. This sparked competition among nations as they vied to get the materials and medicines they required.
In the United States, then-President Trump quickly invested great sums of money in vaccine development, and anticipating that there would be limited production capacity, he tried to leverage that investment in order to secure preferential access to the vaccines for US citizens. India initially manufactured vaccines for use by developing countries, but after the number of domestic cases exploded in April 2021, the Indian government limited all the vaccines to domestic use and banned their export. Generally speaking, the simultaneous outbreaks of COVID-19 around the world prompted each country to first and foremost view the pandemic as its own “national emergency.” They were not able to view it as a “global emergency,” as they had in the Ebola and AIDS cases, and even if they did see the COVID-19 pandemic as a global crisis, they were unable to emphasize that aspect of it, making it ultimately impossible to mount an appropriate response to this virus on a global scale.
COVID-19 Responses as Politics
Because each country approached COVID-19 as its own national emergency, its response took an extremely political form. One notable example is what happened between the United States and China. In early February 2020, in a telephone conversation with President Xi Jinping of China, then-President Trump praised the Chinese government for its excellent handling of the situation, and immediately afterward he tweeted: “We are working closely with China to help!” However, from March 2020 on, with the number of cases in the United States rising dramatically and the presidential election looming in the fall, Trump began referring to the novel coronavirus as the “Wuhan virus” and strengthened his criticism of the WHO for being biased toward China. This was an attempt to deflect criticism away from his own administration. Meanwhile, China aimed to expand its political influence through active sales, donations, or manufacturing support of its own vaccine in Central and South America, the Middle East, Southeast Asia, and other regions incapable of developing or manufacturing vaccines.
The politicization of the COVID-19 response could also be observed within each country. Because the novel coronavirus could be spread through routes such as via contact, respiratory droplets, and microdroplets, it was necessary to curtail person-to-person interaction to some degree. Many countries implemented lockdowns and either closed or restricted the operating hours of restaurants and commercial businesses. Naturally, these policies brought about serious economic and social damage. The longer the fight against the virus took, the more political leaders were forced to pursue the contradictory goal of containing the virus while minimizing the damage to economic and social activity. In Japan as well, medical personnel who were stretched to their limits called for lockdowns and the declaration of a state of emergency, while business owners increasingly lamented that they could not accommodate any more mandates to stay closed or shorten their operational hours. Faced with the task of trying to handle these many different demands that were irreconcilable with the pandemic response, the leaders’ responses became extremely political.
Unfortunately, it appears that the fight against COVID-19 will continue. Reports of “breakthrough infections” among fully vaccinated people are on the rise, and many developed nations including Japan have begun to recommend booster shots. Given that context, one issue of immediate concern is how to expand vaccinations in developing countries while promoting booster shots in developed countries. As long as infections continue somewhere in the world, the virus will continue to mutate, leading to an ongoing vicious cycle in which each country plays cat-and-mouse with the disease while pursuing self-interested policies. Of course, in times of crisis it is only natural for national governments to attempt to secure the safety and health of their own citizens. That being the case, what should be done to break this vicious cycle?
One pressing issue is to quickly establish a system that can increase vaccine production to accommodate both the booster shot demand in developed countries and the initial two-shot vaccine protocol in developing countries. Since last year, at the World Trade Organization (WTO), India, South Africa, and others have been proposing that the intellectual property (IP) protections on COVID-19 vaccines be waived. However, many developed countries are against this idea, and it appears unlikely that such a waiver will be achieved any time soon. The manufacture of the COVID-19 vaccine requires advanced technology, and some believe that, rather than seeking a patent waiver, it would be more practical to ask drug companies to cooperate voluntarily by offering technology transfer as well as cooperation and support for local vaccine production in developing countries.
In October 2021, the American drug company Pfizer and the German biotechnology company BioNTech announced that they would build manufacturing plants to produce mRNA vaccines in Rwanda and Senegal that, beginning in fiscal 2022, will produce a targeted 100 million vaccine doses for exclusive use in Africa. Similarly, Moderna has announced its intention to establish a localized manufacturing facility to produce vaccines solely for African use. The technology transfer hub established by WHO unfortunately failed to attract the cooperation of any pharmaceutical company, but we are still seeing those companies take the lead in expanding production capacity in developing countries. It will probably be necessary for pharmaceutical companies and developed nations to remain engaged in supporting the expansion of vaccine production capacity.
From a long-term perspective, the response to infectious diseases should be considered a security problem on multiple levels and dealt with systematically. On a global level, it will be necessary to address problems in WHO governance and strengthen inadequacies in the International Health Regulations (IRH2005). In light of the current antagonism between the United States and China and the lack of leadership, however, systemic reform will not be easy. Therefore, preparations on the regional and national levels will become all the more important. The current crisis has revealed the need for revising border control policies and vaccine development and manufacturing capabilities at the national level. It is also necessary to review regional preparations. Because the response to COVID-19 has revealed a variety of flaws in global cooperation, there has been an active movement to review regional cooperation. Before the pandemic, the EU was not actively pursuing regional cooperation in the public health sphere. Since the fall of 2020, however, it has started to change direction and is moving toward establishing a European Health Union. They aim to enforce preparation for and response to public health crises within the EU through such means as monitoring the supply of phramaceuticals and medical equipment, coordinating clinical trials of vaccines, establishing surveillance systems, and sharing data such as bed occupancy rates in hospitals and the number of medical personnel. The COVID-19 crisis has also spurred African countries to reaffirm the need for intraregional cooperation.
In Asia, some piecemeal responses are progressing such as cooperation between Japan and the ASEAN countries in establishing an ASEAN infectious disease center. But reflecting rising tensions between Japan and South Korea and antagonism between the United States and China, the creation of a comprehensive, regional cooperative framework seems to be still a long way off with virtually no progress made among Japan, China, and Korea. Given that many new infections have emerged in Asia in recent years, it would obviously be desirable to share information among neighboring nations, jointly develop therapeutics and vaccines for infectious diseases that might arise, and to put some type of mechanism in place for imposing travel restrictions and creating a supply network for medical supplies and pharmaceuticals in times of emergency. Japan’s National Institute of Infectious Diseases already has been engaging in regular research exchanges with the Chinese Center for Disease Control and Prevention and the Korea Disease Control and Prevention Agency. It might be a good approach to build upon such unofficial international cooperation among researchers and work to establish some kind of comprehensive framework in the region.
Once an infectious disease spreads, it poses a threat to all nations. If we take a wider view, however, it also poses a threat to regions and to the peace and stability of the international community. Many advanced nations seem to have believed that infectious disease is a problem that only affects developing countries that lack adequate sanitation, and they failed to recognize that it could in fact have a direct, adverse impact on them as well. Of course, that attitude must be revised, and nations must review their command systems for border measures and healthcare and their production systems for vaccines and medical supplies in the framework of national security. Also, at the regional and global levels, agreement frameworks must be rethought from various angles and the establishment of new systems should be discussed with regard to situation appraisal, supply networks for medical supplies and pharmaceuticals, and standards for travel in times of emergency, and so on. Unfortunately, given that we live in an international community that lacks a world government, even if rules and systems are created, their effectiveness cannot be guaranteed. This is precisely why we need to make up for each other’s deficiencies on multiple levels.
About the Author
Kayo Takuma is a Professor at Tokyo Metropolitan University.