Global Health Security–a blueprint for the future, by Lawrence O. Gostin, is a sweeping journey across current and future issues in health security and the urgency of addressing current gaps in governance. Gostin begins with the COVID-19 pandemic, arguably the greatest global catastrophe in over 100 years, and asks the question why the world was so unprepared. He makes a compelling case for the importance of global cooperation and the risk of national interests overriding global interests in pandemic control. He also highlights the importance and fragility of WHO with the case study of the US threat to withdraw from WHO in 2020. Importantly, he reflects on the lack of global preparedness for COVID-19 despite reforms to WHO following the 2014 Ebola epidemic.
The book is in two parts: Part I, outlining the major threats to global health security, and Part II providing pathways to action. In Part I, Gostin draws on universal lessons from the 2014 Ebola epidemic in demonstrating the importance of community driven engagement and sensitivity to local culture and customs by using case studies around the beginning of the epidemic in Guinea.
The chapter “Disease by Decision – human-induced threats to biosafety and biosecurity” starts with the 2001 anthrax attack in the USA, which was the event that led to the Fink Report, and a range of prescient interventions, including the creation of the National Science Advisory Board for Biosecurity, a committee that later considered gain-of-function (GOF) controversies. Despite no final decision on the perpetrator of the anthrax attack, the evidence pointed to a laboratory origin and highlights the insider threat in laboratories. The tension between the need for scientific advances in treatment and vaccines, versus the risk of rapidly advancing and accessible methods for GOF research are outlined. The risk of a lab accident is discussed, but Gostin concludes that an incident with global catastrophic impact has not yet occurred, thus dismissing the hypothesis that SARS-CoV-2 originated from a laboratory leak.
Because of the anthrax attack in 2001, the USA have been the most advanced country in considering biosecurity risks. The excellent overview of the legal and regulatory frameworks for biosecurity at global level shows the gaps that leave the world vulnerable. From here, Gostin moves to discuss biological weapons, with a detailed discussion of the 1972 Biological Weapons Convention, and the lack of power to audit countries for compliance. By contrast with the Chemical Weapons Convention, the Biological Weapons Convention has no meaningful power. Gostin points out WHO's inability to further the agenda on regulating dual use research of concern.
The second part of the book provides a valuable framework for improving global health security. It sets the scene with the history of WHO and International Health Regulations (IHR), and the process for declaring a Public Health Emergency of International Concern. The failures of WHO around the 2014 Ebola epidemic should have been the trigger for improvements in health security. Important reforms included the formation of the WHO Health Emergencies Program, the Global Health Emergency Workforce, and The Contingency Fund for Emergencies. The COVID-19 pandemic, however, laid bare the gaps in global governance, the under-funding and structural weaknesses of WHO, and the conflict between national and global interests.
Gostin finishes with recommendations for fixing fragmented global health governance, central to which is the legitimacy and strength of WHO. The structure of the UN includes different agencies with overlapping remits in health security, which poses both advantages and disadvantages. He argues the World Bank, the International Monetary Fund and the World Trade Organization all influence health security, but may operate at cross purposes. Together with the growing number of other global health agencies, including public-private partnerships and a range of diverse players in global health, health security is hampered by an increasingly fragmented approach. Public-private partnerships and philanthropic foundations bring more resources to global health, but Gostin points out the need for better coordination. There is also a need to develop governance mechanisms to enable such agencies and smaller local organisations to engage with and support WHO.
Universal funding of healthcare is also essential, and the lack thereof may explain failures of pandemic control in high income countries like the USA. A major revision of the IHR, with the last major revisions in 2005, is clearly needed. Gostin provides a very comprehensive plan for health system strengthening, financing, research and development, governance, equitable access to pharmaceuticals, and global cooperation. Gostin highlights that the economic costs of the COVID-19 pandemic are greater than ever predicted by agencies such as the World Bank. He says “COVID-19 should mark the end of the cycle of complacency and panic, launching a new era of deliberate, systematic, and well-resourced preparation, extending from health systems to One Health, and reaching into our political, social, and economic systems”. If the global political will can be harnessed effectively, this book outlines a pathway forward for a more secure future.
