“The same applies here as in the Ukraine, as with the humanitarian catastrophe in Syria and Iraq: if we do not act, the consequences – including for us in Germany – will be unforeseeable.” With these words, the then foreign minister of the Federal Republic of Germany, Frank-Walter Steinmeier summed up the danger of the Ebola epidemic in West African countries in September 2014. At that point in time, the virus had already been raging for nine months, and there was concern that the virus could also spread to Nigeria, the most densely populated country in Africa.
When the first suspected cases of Ebola appeared in other countries around the world, previously neglected questions suddenly became relevant: how well prepared are we for an outbreak in our own country? How can we prevent the virus from spreading to other countries? Who is responsible for – and capable of – containing the disease? How was it possible for such an outbreak to occur?
The Ebola Shock and the Expansion of the State Security Paradigm
The Ebola shock – an epidemic that killed 11,371 people between 2014 and 2016 – triggered a new awareness of the danger of a cross-border epidemic, even in Germany: in a country with sixteen international airports, ten seaports with an annual volume of goods of about three hundred million tonnes, and daily border traffic with nine directly neighbouring nations, the question arises of whether effective protection can be provided for the population. It became clear: the perception of security in a country so closely intertwined with the world had to change. The response – although a late one – to the Ebola fever epidemic became an important catalyst for strong German involvement in global health policy.
The Ebola crisis contributed to an expansion of the state security paradigm: citizens’ safety can no longer be guaranteed through actions on a national level.
For Germany, the policy field of global health is becoming an important pillar of multilateralism and the safeguarding of human rights. The topic is no longer merely a concern for the Ministry of Health. In her speech at the 2015 World Health Assembly, Angela Merkel emphasised that the World Health Organization (WHO) is “the only international organisation that enjoys universal political legitimisation in matters of global health”. To support the work of the WHO, the Federal Government consistently advanced global health security during its G7 and G20 presidencies in the years 2015 (Elmau) and 2017 (Hamburg), and launched and provided support for numerous initiatives at an international level. Additionally, the chancellor highlighted the connection between individual health security – through access to health services – and collective health security – by means of concerted actions by the community of nations in a globalised world –, and linked both with the human right to health.
The Ebola crisis considerably contributed to an expansion of the state security paradigm: citizens’ safety can no longer be guaranteed merely through actions on a national level; domestic and foreign policy must be combined in a new way to ensure the ability to act in crisis-related spheres of activity. This applies to global epidemics as well as the environment and the refugee problem. The challenge of having to take on increased international responsibility is also reflected in the coalition agreement. A large number of ministries specify their role in global health policy, including the Federal Ministry for Economic Cooperation and Development (BMZ) and the Federal Ministry of Education and Research (BMBF). The Federal Foreign Office consolidated the position of coordinator for the foreign policy dimension of global health policy, and the Federal Ministry of Defence (BMVg) has been working in the field with mobile laboratories in various Sub-Saharan African countries ever since the Ebola crisis. The Ministry of Health is responsible for devising the new edition of the Federal Government’s health strategy as mandated by the coalition agreement and has received additional resources for collaboration with the WHO.
Health Security, Convergence, and Inequality
The world is simultaneously characterised by rapidly growing health convergence and major health inequalities. The past decades depict unprecedented progress in human development and health: the number of people living in absolute poverty (less than US$1.90 per day) was reduced by more than half. Life expectancy has risen substantially: on average, people today live five years longer than in the year 2000 (in African countries, nearly ten years longer). Globally, a person reached an average age of 71.4 years in 2015. Eighty-five per cent of all children worldwide are vaccinated and polio has nearly been eradicated. Imagine if this progress were undone overnight through a flu pandemic.
The Strong Effect of Pandemics on the World Economy
Comparing the estimated economic impact of pandemics, climate change, and natural catastrophes on global economic performance.
The major gaps in health security put human lives, prosperity, and political stability at risk. The magnitude of an epidemic is closely connected to the level of development of the national health system, but only about fifty per cent of the global population have access to health services. The three West African countries that were affected by Ebola rank among the world’s poorest and most fragile countries. Poverty and inequality remain the biggest health risks, for every individual and for collective health security. According to World Bank estimates, the economic damage caused by the outbreak of Ebola in Guinea, Liberia, and Sierra Leone amounted to 2.2 billion US dollars. The dimensions of a pandemic with an even more infectious pathogen could have far more dramatic consequences. Even conservative estimates predict economic damage of a magnitude comparable to other global catastrophes such as climate change or natural disasters. The interdependence of poverty, health, and environmental crises is particularly significant.
New zoonoses represent a key risk factor: the World Bank estimates that these infectious diseases alone caused direct economic damage amounting to twenty billion US dollars and indirect economic damage (for example to food production, trade, tourism) to the amount of about two hundred billion US dollars between 2000 and 2010. The frequency with which these damages cross borders can be seen in the case of the Zika virus. Although the virus originally broke out in Brazil, it is expected to lead to economic costs of half a billion to two billion US dollars in six southern US states. Already today, epidemics are threatening food security, destroying investment incentives, and burdening the trade of goods and services.
Poverty and inequality remain the biggest health risks, for every individual and for collective health security. Vast funds are needed to cover access to health services in countries with low to medium incomes – one calculation estimates that these amount to an annual sum of 134 billion US dollars (to begin with) and will amount to 371 billion US dollars in the year 2030 for a group of sixty-seven countries. For this reason, global health – just like global climate policy – is increasingly resorting to a smart combination of national funding, development aid, and joint financing for global public goods. The World Bank has also presented a financing plan for national health security.
The effects of epidemics are disastrous for every development process. This is where the interest of forums such as the G7, G20, the World Economic Forum, and the Munich Security Conference in global health security stems from: because nations that are growing increasingly closer, both economically and in terms of health, not only face joint risks, but also an increasing obligation to initiate joint preventative measures. This is also the message of the Sustainable Development Goals adopted in 2015.
Substantial Increase of Disease Outbreaks
Disease outbreaks in animal and human hosts.
Health Security in the Twenty-first Century
Ever since the 2014 Ebola crisis and increasingly so following the new outbreak in the Democratic Republic of the Congo in 2018, an intensified awareness of the possibility of a global epidemic – a pandemic – has prevailed. In a new report, the WHO mentions the probability of “Disease X” – a natural or manmade threat. The organisation also emphasises that the question is not if the next epidemic will break out, but instead simply when this will happen and how well prepared we are to face it. In the years between 2005 and 2010 alone, there were more than 3,000 outbreaks of infectious diseases worldwide, and the trend is rising. More and more frequently, parallels are drawn to the worst flu pandemic in the history of mankind, which took place one hundred years ago. Within just two years (1918–1920), between fifty and one hundred million people died from the so-called Spanish flu – nearly 2.5 to 5 per cent of the global population at the time. The pathogen back then was a derivative of the influenza virus A H1N1. Today, it is also assumed that the next great epidemic will be caused by an influenza virus. Bill Gates has pointed out that an airborne pathogen could kill more than thirty million people in less than a year.
The reference to a currently unknown “Disease X” shows that policy in the area of global security challenges is becoming increasingly anticipative, but that at the same time it is forced to act on the basis of an insecure knowledge foundation. This also explains the cycle of panic and neglect that characterises this area of health policy. The risk dynamics of global health security are multidimensional and driven by diverse spatial, temporal, and social factors. These include sociodemographic factors such as the growing world population, more than half of which lived in cities in 2015. Compared to the year 2000, today’s urban population has increased by over one billion people. One-third of the people do not have basic sanitary provisions. The increasing volume of tourist and freight traffic (approximately 3.7 billion airline passengers were transported in 2016, compared to 1.7 billion in 2000) provides evidence that humanity is as connected as never before in our history. A highly contagious virus would require only about thirty-six hours to spread around the world.
Environmental changes also play an important role. As a result of global climate change, the spread of disease-carrying insects (for example, Aedes aegypti) is also changing. Analyses on global hotspots for emerging zoonotic diseases – infectious diseases that are transmitted from humans to animals or vice versa – show that the risk of an outbreak in tropical regions with high biodiversity and simultaneous change of land use (for example deforestation, mining, and dam or road construction) is particularly high.
Health Security has Many Dimensions
Eight different aspects of health security.
Not least of all, political and military conflicts are also taking their toll: the probability of health systems being incapable of fighting outbreaks of infectious diseases is considerably higher when conflicts are causing the public infrastructure to erode over the years. Before the start of the Syrian Civil War, vaccination rates in the Mediterranean region were above ninety per cent. In 2014, polio, measles, and whooping cough emerged in Syria and spread to Iraq. Another example is the conflict in Yemen: in February 2017, comprehensive vaccination campaigns had to be conducted because the country was facing the risk of polio – which had been declared polio-free in 2009 – becoming endemic again. Global interdependencies extend the logic according to which the system is only as strong as its weakest links.
Global Risks Require International Cooperation and Strong Institutions
A look at the outbreaks of the past thirteen years shows how present the threat of an epidemic is: SARS, the H1N1 flu, Middle East respiratory syndrome coronavirus (MERS-CoV), Ebola, and the Zika virus. They all represent serious dangers to health security. Only after analysing the Ebola outbreak did the limitations of both global coordination as well as the funding of countermeasures become clear – despite an existing international agreement. This was a wake-up call for the community of nations, and the Ebola crisis was addressed at the UN Security Council in September 2014. In January 2015, the member states placed their trust in the WHO to serve as the central organisation for global health security. The International Health Regulations (IHR), adopted in 2005, represent the core of shared responsibility in health security and are introducing a new standard for global health security. Their origins date back to the year 1851, when the necessity for cross-border action – due to cholera, yellow fever, and the plague – arose for the first time. In 1969 – at this point already under the WHO umbrella –, the IHR were updated and expanded. But it was not until 2005, in view of the aftermath of SARS, that the regulations took their current shape. Three key elements point beyond national sovereignty in a ground-breaking way:
- In the case of a common global threat, cross-border solidarity has priority over national sovereignty.
- The WHO’s authority is considerably increased in that it can declare a Public Health Emergency of International Concern (PHEIC), if necessary even without the cooperation of the affected countries. The coordinating role of the WHO in cases of crisis is also expanded.
- All countries are obligated to implement a defined catalogue of measures to preserve health security, including reporting.
After the Ebola crisis, the WHO set up the WHO Health Emergencies Programme in July 2016 which follows, a fundamentally new approach. The programme enables the WHO to provide operational support directly to countries affected by an outbreak. In 2016, the programme was active in several crises, including Lassa fever in Nigeria, the outbreak of yellow fever, and the Zika virus in Brazil. Another new aspect is the Contingency Fund for Emergencies, for which Germany continues to be the largest donor, even after its restocking. Both the new WHO programme and the funding have stood the test during the 2018 Ebola crisis in the Democratic Republic of the Congo.
Germany supported the ex-post analysis of the Ebola crisis with the High-Level Panel on the Global Response to Health Crises and the Global Health Crises Task Force run by the United Nations, as well as the World Bank’s Pandemic Emergency Financing Facility (PEF), launched together with the WHO and Japan, which acts as an insurance for a country. Global interdependencies extend the logic according to which the system is only as strong as its weakest links. It is aimed at paying out emergency funds to governments, multilateral organisations, or NGOs if countries are confronted with dangerous outbreaks, before these turn into pandemics. In contrast to the Contingency Fund for Emergencies (CFE), the PEF therefore fills the financial gap which had previously emerged after initial responses. The World Bank also supports pandemic simulations with finance ministers of supported countries and assists in building laboratory networks in West and East Africa. At the start of 2017, Germany joined forces with Japan, Norway, and the Wellcome Trust to launch the new research and development initiative Coalition for Epidemic Preparedness Innovations (CEPI) – a public-private partnership focusing on the research and provisioning of vaccines. By now, the initiative has received financing commitments to the amount of 670 million US dollars, to be used for researching vaccines for MERS-CoV, Lassa fever, and Nipah viruses. The World Bank conducts pandemic simulations with finance ministers from supported countries and helps building laboratory networks in West and East Africa.
In order to improve many countries’ weak capacities for implementing the IHR and the standards of the World Organisation for Animal Health (OIE), the US initiated the Global Health Security Agenda (GHSA) in 2014, a partnership of countries now numbering sixty-five nations and seven multilateral organisations (including the WHO). In June 2014, the GHSA was also endorsed by the G7 states. It was complemented by the Joint External Evaluation (JEE) in 2016, which picked up on one of the IHR’s weaknesses. The self-reporting approach is enhanced by a jointly conducted evaluation. Since February 2016, seventy-two JEEs have already been conducted in six regions. Thirty-one additional JEEs are planned for 2018 and 2019. A similar process exists for the OIE’s animal health regulations, the so-called Performance of Veterinary Services Pathway (PVS), which evaluates the quality of national veterinarian and animal health systems; however, funding for implementing the recommendations is still missing.
Challenges also exist in the use of digital technologies for preventing and combating epidemics. Approaches such as HealthMap aggregate and visualise up-to-date information on outbreaks – in this way, HealthMap managed to identify the Ebola epidemic nine days before the WHO officially announced the outbreak. But such technologies are also important in the case of an outbreak: during the Ebola epidemic, the app mHero (Health Worker Electronic Outreach) was used. The app simplified the coordination of information between health workers as well as monitoring and reporting. This possibility to remain in constant contact enables knowledge transfer in difficult situations as well as the transmission of important yet relatively simple information, such as lab results.
Global health security is becoming increasingly important, but it needs a strong political advocate, especially in times when there is no current crisis. Germany is more committed to multilateralism and the international organisations than many other countries. And in the aftermath of the Ebola crisis, Germany, under the leadership of the Chancellor, has initiated a new foreign policy of health security. This policy continues to this day, but must be further strengthened and expanded.
Connecting Health Systems and Security
Strategic connection between elements of health systems and health security.
Global health security has become a central topic for heads of government as well as foreign and finance ministers. Foreign Minister Heiko Maas also broached the issue of this necessity at this year’s Global Solutions Summit in Berlin:“the Federal Government believes we can only tackle the tasks which will define our future, such as protecting the climate and oceans or combating epidemics, if we work with rather than against one another.”. This political foundation opens up the possibility for Germany to be an important trendsetter for global health security; as an integral part of the peace and development projects of the Sustainable Development Goals on the one hand, and the specific health goal (SDG 3) on the other. Germany can thereby assume a central role in one of the most important areas of international crisis prevention, preparedness and response.
Germany can assume a central role in one of the most important areas of international crisis prevention, preparedness and response.
The inherent message of Germany’s engagement should be that global health security cannot be entrusted solely to the security sector or the health sector. Instead, it requires an integrative concept that unites actors from many different sectors under civil leadership in order to be able to cover the diverse and interdependent dimensions. Germany’s positions in foreign and health policy are is less likely to be suspected of pushing a narrow understanding of national security and a military foreign policy – in contrast to the US, who define many global risks primarily from the perspective of national, military-oriented security interests. The ‘securitisation’ of health should not be the solution. Instead, a future concept of health security needs to bring together individual and collective security understood as joint responsibility of many actors and policy areas. This is particularly relevant for non-governmental organisations and humanitarian actors. Germany could stand for ‘concern for the entire globe’ – considering also its seat in the Security Council – and push for linking health security to the UN system, human rights, international regulations, joint financing, and transnational cooperation. This will also require a new financing model for health security as a global public good – and Germany must be willing to make a significant intellectual and financial contribution. Taking on such a leadership role in establishing a new integrative understanding of health security within the framework of SDG 3 can build on the many years of Germany’s WHO and health development policy, which has consistently preferred systemic solutions. What is required is the strategic connection between building health security structures and health systems (UHC). After all, the responsible handling of health risks includes preparedness. On the one hand, this is ensured through the consistent enforcement of the IHR regulations; on the other hand, through building and consistently strengthening public health institutions as part of a comprehensive health system. J. Quick illustrated this crucial connection as follows. To advance these priorities, a strategy for international health security is required with which the capacities of the German Ministry of Health and its related organizations – for example, the Robert Koch Institute when it comes to fighting outbreaks, disease monitoring and prevention, the Paul Ehrlich Institute as a Federal research institute for vaccines and biomedical drugs, the Federal Institute for Drugs and Medical Devices, and the Bernhard Nocht Institute for Tropical Medicine – can be pooled capacities of with actors in development cooperation, humanitarian aid, research, and defence. By initiating, financing, and contributing to new research alliances (CEPI) and collaborations (GARDP, AMR HUB), first steps have already been taken. Since the majority of dangerous epidemics have zoonotic origins, One Health approaches are increasingly important, as they recognise that humans, animals, and ecosystems are closely interconnected. This includes a coordinated, collaborative, and multidisciplinary as well as cross-sectoral strategy which can counteract potential or actual risks from this the human-animal interface.
I would like to sincerely thank Christian Franz for his support in writing this text.
How We Must Act
Three main focal points can be derived for an international health security strategy to encourage active foreign policy in health:
- Implementing an integrative and non-militarised health security policy in connection with the German seat on the UN Security Council: Germany can thereby assume a pioneering role in one of the most important areas of international crisis prevention and management. For example, guidelines could be developed to determine the conditions under which the Security Council should address health crises.
- Defending multilateral solutions and strengthening international organisations – particularly the WHO – in battling health crises. The obligation to implement preventative measures together with the provision of the necessary funds must be a priority.
- Fully integrating health security into Germany’s Africa strategy in the sub-Saharan African region. Here, it is important to set priorities for implementing the IHR, combating tropical diseases, and establishing health systems.
An action plan should include investments into a well-developed network of health attachés to enable the strategic advancement of the connection between national and multilateral actions. As in other countries, an Ambassador for Global Health should be appointed to serve as the point of contact for the foreign policy dimension of the policy area. Global health must become a central concern of German foreign policy.