CHILD-PROOFING GLOBAL PUBLIC HEALTH IN ANTICIPATION OF EMERGENCY.

• Author: Abbott, Frederick M.

1. THE TRAGIC RESPONSE TO COVID-19

   To put things in perspective, the human race has made considerable progress. The first outbreak of the Black Death or bubonic plague in mid-1300s Europe killed an estimated 30-50% of Europe's population, tens of millions of people, in about four years. (1) By that standard, the international community as a whole has done a pretty great job responding to COVID-19, which as of February 11, 2021, has killed 2,362,735 people according to Johns Hopkins data. (2) That is about 0.03% of a global population of 7.8 billion people. (3) We do better than the middle ages.

   By almost any other assessment methodology, we are hard-pressed to give the international community high marks. The response has been characterized by a lack of transparency, substantial gaps in scientific understanding, inconsistent communication, lack of capacity for the manufacture of vaccines, substantial gaps in preparedness for diagnostics and personal protective equipment, absence to date of an effective treatment, and political conflict. (4) What makes most of these problems the more glaring is that we understood the gaps well in advance, but we were not prepared to address them. This may be a general problem with lowprobability, high-risk events because competition for resources within government budgets gives an advantage to immediate needs. (5) For each government administration, the hope is that tenure in office will pass without a public health crisis. That potential for crisis is passed on to the next administration.

   Regrettably for the international community, the pandemic struck during a confluence of political trends that culminated in strong nationalist and anti-science political movements. (6) It remains hard to explain the ascendancy of Donald Trump to the apex of political power in the United States, and his continuing support from a large segment of the US population, notwithstanding that he has been voted out of office. The leader of the most militarily powerful nation on earth, still a dominant force from an economic standpoint, used his office - and the capitulation of his political party - to deliberately subvert measures to curtail the spread of the virus, publicly rejecting science along the way. (7) He was not alone. In late November it was reported that President Bolsonaro in Brazil announced that he would refuse to be vaccinated, potentially undermining a vaccine roll-out in that country. (8)

   At the other end of the political spectrum, we have governments, such as in China, that have done well in their internal control of the coronavirus through the imposition of strictly enforced social control measures, (9) but where concerns arc raised regarding the longer-term consequences from the standpoint of individual rights involving privacy, family life, speech, and freedom of movement. (10) This entails the delicate boundary between elevated government authority during a health emergency, and assurance that individual rights are restored as exigent circumstances dissipate.

   Nationalist trends and political conflict have dramatically affected international institutions - a case in point being the World Health Organization. Yes, an imperfect institution, but it plays a key role in facilitating cooperation, particularly for those countries and governments with limited capacity to develop their regulatory framework and to create robust health infrastructures without assistance.

   Where does international law fit into this maze? Realistically, international law does not remove ineffective or even malevolent national leaders from political office except in the most extreme circumstances following armed conflict. But can international law provide a more resilient framework in which the decisions of national leaders during crisis are less likely to cause harm? A framework in which we are less susceptible to ad hoc and incoherent decision making?

   In a way we are asking whether international law can child-proof the working space of global public health, making it less susceptible to the transient ebb and flow of national political leaders. A fully functioning global public health system would prepare us in advance to address viral and other pathogenic outbreaks in terms of robust R&D platforms and sound manufacturing infrastructure; it would alert us to an outbreak at the earliest possible date; and it would instruct us regarding the appropriate interim protective measures to take, (11) all without triggering perceptions of personal insecurity that lead to social unrest and conflict. (12)

   If the international architecture worked properly, we would not get to where we reached during the COVID-19 pandemic. Of course, we face similar questions in other domains. If the IMF worked better, recessions might be avoided and countries would be less likely to default on their debts. If the World Bank worked better, more countries would move from low to middle-income, and from middle to high.

   Business and economics perhaps more than disease and death may cause the international community and the governments within it to address pandemic preparedness more seriously. Widespread economic recession, unemployment, diminished trade, and ballooning government deficits worldwide seem more likely to capture the attention of budget drafters and to encourage additional financing for urgent needs like vaccine production capacity.

   Perhaps the idea of a child-proofed global public health system is a fantasy, and we accept continuing to be knocked around. But we might at least consider the question whether an improved international framework could be...