The definition of global health security may be debated depending on what are the various components one wishes to measure and integrate into a composite metric. Is it security of health services for all persons on earth? Or is it protection of all countries from major threats to global health? The former would embrace the vision of health promotion and disease prevention alongside universal health coverage through a continual supply of services assured by an efficient and equitable health system. The latter is a restricted and defensive construct that prepares nations to predict, prevent and promptly respond to acute threats that may periodically arise.
The current description of global health security, as adopted by the World Health Organization, is of the limited latter variety. It is defined as “activities, both proactive and reactive, to minimise the danger and impact of acute public health events that endanger people’s health across geographical regions and international boundaries”. The current Covid-19 pandemic exemplifies such a threat to global health security.
Indeed, the concept of global health security mainly gathered strength from the concerns of high-income countries that infectious disease epidemics that arise in low- and middle-income countries may cross over into their populations. The SARS-1 epidemic and the fear of bioterrorism heightened these fears towards the end of the last century. Along with the strengthening of International Health Regulations (IHR), there has been an attempt to build defences within and between countries to anticipate, avert and attenuate pandemics.
A measure to gauge the capacity of national health systems in contributing to global health security was developed by the Johns Hopkins Center for Global Health Security, the Economist Intelligence Unit and the Nuclear Threat Initiative. The Global Health Security Index (GHS Index), released in October 2019, used 140 questions to make this assessment, organised across six categories. They are: prevention of the emergence or release of pathogens; early detection and reporting for epidemics of potential international concern; rapid response to and mitigation of the spread of the epidemic; sufficient and robust health system to treat the sick and protect health workers; commitments to improving national capacity, financing plans to address gaps, and adhering to global norms; overall risk environment and country vulnerability to biological threats.
In a benchmarking exercise using these criteria, the report ranked countries according to their level of preparedness for epidemics or pandemics. The US was ranked number 1 and the UK was ranked number 2. High-income countries filled the lists of the ‘most prepared’, with only Thailand featuring as an exceptional middle-income country at number 6. India was ranked at 57.
Within a few months, the Covid-19 pandemic struck, subjecting the index to a reality check. Both the US and UK floundered badly, though the latter managed to rally intermittently. Higher ranked countries like Belgium (19), Brazil (22), Mexico (28) and Sweden (7) fared poorly in comparison to lower ranked but remarkably well-performing countries like New Zealand (35) and Vietnam (50). The index came in for trenchant global criticism as the pandemic unfolded and the errors in ranking became all too apparent.
Where did the GHS Index go wrong? As often happens, a reductionist technocratic approach to assessment of complex systems failed to take into account several factors that vary with changes in the political and social milieu. The political leadership in the US and Brazil gave shocking examples of poor political leadership. Even the political leadership in the UK vacillated over strategy for some length of time. The anti-science movement, fed on right wing rhetoric, opposed masks, social distancing, travel restrictions, testing and vaccines. Conspiracy theories abounded in both mainstream and social media. Denial of the pandemic or making light of its threat became the badge of right wing politics that misguided loyal followers. Social solidarity is critical to a unified national response. Public trust in an intelligent, decisive and compassionate political leadership may appear a non-measurable factor to technical modellers but is a vital ingredient in a country’s pandemic response. New Zealand is a shining example in this regard. The Titanic of technical modelling was sunk by the unsighted iceberg of political reality.
Comparative strengths of public sector health services, levels of universal health coverage and extent of social inequities were not taken into account. Even on the purely technical side, there are missing elements. The index is focused on prevention, detection and control of infectious diseases. No attention was paid to the fact that the clinical severity of infections by respiratory viruses is mostly determined by comorbidities like hypertension, heart disease, diabetes, obesity, chronic respiratory disease, cancer and mental health disorders. The ability of health systems in different countries to prevent, detect, control and care for these disorders needs to be measured and monitored as the designers of the GHS Index go back to the drawing board.
K Srinath Reddy
Cardiologist, epidemiologist and President, Public Health Foundation of India (PHFI)
(The author has written the book ‘Make Health in India: Reaching a Billion Plus’. Views expressed are personal)