“I’m not a medical scientist or public health specialist,” proclaims Dr. Wilmot James. But with a Ph.D. in Sociology and African History, Dr. James says convening experts across disciplines and national borders to focus on compelling issues is at the heart of his work.
“In order to deal with pandemics it is particularly important to build bridges across divides – intellectual, geographical, cultural and political – and engender global cooperation,” he says. That is what led him to be the co-convener of the Columbia University Irving Medical Center’s very first COVID-19 Vaccine Development, Strategy, and Implementation virtual symposium, February 22-26, 2021, featuring an extraordinary list of distinguished speakers from across the globe. As a former Member of Parliament and opposition spokesman on health in South Africa, Dr. James specializes in global health security policy formulation and practice. He has lectured for Columbia University’s Bioethics M.S. program for many years, serves as a Senior Research Scholar at the Institute for Social and Economic Research and Policy (ISERP), and has authored and edited 17 books, including Nelson Mandela’s presidential speeches titled In His Own Words (Little Brown and Co, 2003). He recently spoke about the greatest challenges that lie ahead in the global effort to curtail the current and future pandemics.
What’s the role of social scientists in putting ethics at the center of policies for the next generations?
There are three areas of work that need to be tackled with renewed urgency looking ahead: incentivizing sustainable financing for disaster prevention, mitigation and response; building greater resilience in health systems with greater emphasis on mental health aspects; and addressing the educational, legal, and social/behavioral aspects of the pandemic.
Governments require an enabling framework to invest in prevention and preparedness. Historically, countries go through ‘panic and neglect’ cycles when confronting epidemics and pandemics. Currently, we’re in the middle of a pandemic so everyone’s thinking, “We’ve got to do things differently.” But once the pandemic burns out, people will let their guard down – that’s what tends to happen. Governments tend to respond to the immediate needs of communities when a crisis hits; they’re working to provide food, medicine, and so on. This, of course, is very important. It is a visible act to which everyone bears witness, brings public recognition and applause, and politicians are thanked for it at the ballot box. Conversely, if you invest in prevention, a crisis is averted, communities are saved from a disaster, and nobody knows by its very nature that the government’s proactive actions prevented a catastrophe; no one is thanked for it. It doesn’t enter the news cycle and there’s no political reward. It’s a little perverse, but that’s how it works. We, therefore, need to develop an incentive architecture for the prevention of disasters. Economists are challenged to work on these issues, which involves figuring out a sustainable way of financing preparedness.
The second challenge is to consider how we can accelerate the building of greater resilience in health systems and give special attention to the mental health needs of individuals. The COVID-19 pandemic has tested our resilience over a long period of time. Our ability to bounce back after the economic devastation and prolonged periods of social isolation and family fragmentation will not be easy or straightforward. The disciplines involved in mental health need to figure out how to better provide real-time support to people, especially as society adjusts to a “new normal” of limited face-to-face interactions in the short to medium term.
If you invest in prevention, a crisis is averted... and nobody knows by its very nature that the government’s proactive actions prevented a catastrophe; no one is thanked for it... We, therefore, need to develop an incentive architecture for the prevention of disasters."
Third, social scientists have to look at the educational, legal, and social/behavioral aspects of pandemics. Everyone can see how greater trust in governmental public health interventions makes a difference in the reach and success of pandemic response, but trust is more than a public relations exercise. It is earned through better individual experiences with local health systems and staff. It is earned through better education in the public health, clinical, and socioeconomic facts of pandemic management. It requires the marginalization of conspiracy theories that inevitably circulate but are tempered with even more robust fact-checking curation on social media, pushing all the loony stuff to the sidelines of popular epistemologies.
The International Health Regulations have the status of international law, but it is unenforceable; if you break the law, there is no punishment and there are no fines. The WHO is a body of governments, but we really need to think hard about how to get many of the governments to adhere to their own international laws. The legal fraternity should look into what credible sanctions can be established. And really, it is disgraceful that many governments do not pay their WHO dues or do so late. It is chronically under-funded. Some people say that under-funding the WHO is a cynical ploy to keep it dependent and weak. Perhaps, but it does not have to stay that way.
Finally, there are pretty robust ethical frameworks and guidelines in existence for conducting research during a pandemic, including how to handle medical rationing and how to deal with quarantines. The question is, are governments adhering to the guidelines? We also need more training opportunities for the police and the military in many parts of the world, so that the security services understand what precisely their role and place should be during a public health emergency. I recently led a study of pandemic response in Ethiopia, Kenya, Egypt, Nigeria, and South Africa and we found so many unnecessary rights transgressions and security over-reaches that were counterproductive to governments’ broader efforts to get the pandemic under control.
Vaccine rationing will acutely test the resilience of countries in the developing world because the politics are more fragile and resources thin. But do not underestimate the political consequences of poor vaccine rationing strategies in the developed world either. The world of politics will be profoundly affected by the COVID-19 in ways that we cannot even imagine today."
With vaccines coming on to market, 2021 is expected to be a big year. How can leaders set and enforce policies that uphold sound standards in the development and distribution of the vaccines?
Vaccine nationalism is the extreme end of a normal impulse for countries to first take care of their own citizens. What we need is a better balance between the national and the global and to work on pivoting the world towards a global solution to a global problem. The WHO’s mantra is correct: a pandemic by its nature is global, and no one is safe until everyone is safe, from a public health strategy point of view. With demand outstripping supply, the immediate challenge for developing countries is to get accelerated access to safe and efficacious vaccines. Emergency supplies are required now especially in the aftermath of surging second waves. The developing world cannot afford to have a third wave resulting from late and slow vaccination. The longer it takes, the less the chance there is for them to stay on top of the situation and to establish levels of vaccination required to achieve herd immunity. What that means is that the global entity called COVAX that has been set up to finance vaccines for countries that cannot easily afford them should be properly resourced at scale. In the developed world, the major challenge is to manage initial rounds of vaccine rationing with sufficient public understanding, support, and buy-in, which will require targeted and coordinated campaigns. Vaccine rationing will acutely test the resilience of countries in the developing world because the politics are more fragile and resources thin. But do not underestimate the political consequences of poor vaccine rationing strategies in the developed world either. The world of politics will be profoundly affected by the COVID-19 in ways that we cannot even imagine today.
The ISERP recently released a report Epidemic/Pandemic Response in Africa, of which you were the principal investigator. What can world leaders learn from the countries you studied?
Lesson #1: A multilateral approach works. Out of necessity, 55 countries in Africa embraced a multilateral approach to fighting the pandemic and the results are visible. They had the good fortune of having the Africa Centre for Disease Control to coordinate and provide technical support in the key strategic areas of pandemic management as well. Response to the first wave was successful, but with the second wave Africa is in a weaker position and we all need to double down on multilateral solutions to deal with the next round of challenges.
Lesson #2: In countries where trust in government is low, leaders must be savvy and wise enough to identify and work with citizens who enjoy popular community appeal to communicate the risks and advise on what personal measures – like mask-wearing -- to take. In Africa, the most trusted individuals in the health sector are nurses and community health workers. Countries must therefore support these influencers by paying their salaries, supporting their families, and give them the tools to spread accurate information.
The issue is not so much about whether citizens trust in science (though that does help); it’s about whether they trust their government’s public health interventions when they impose policies that directly impact their personal lives."
Lesson #3: It is of the greatest importance always to have the first citizen (President or Prime Minister) lead the response, backed-up by the best science, and to constantly communicate with citizens about which intrusive measures will be taken and why. The issue is not so much about whether citizens trust in science (though that does help); it’s about whether they trust their government’s public health interventions when they impose policies that directly impact their personal lives.
Lesson #4: A whole-of-society approach is necessary, requiring a whole-of-government effort led by the first citizen. The public, private, and civil sectors must all be involved and included. A cross-sectoral one-health approach – human-animal-plant – should be the new normal.
There are also lessons not to be learnt: about police and military overreach and citizen abuse. Africa is not alone in that respect.
Which professions can get involved in creating or scaling up solutions to the layered challenges that have come out of the pandemic?
Beating a pandemic requires transparency, sharing of information, and collaboration across borders and disciplines. This is all about health diplomacy and global public affairs because these things are negotiated. It is about creating collaborations, getting people to work together across a wide variety of disciplines – clinical medicine, public health, political science, economics, climate science, journalism, and more – and collaborate to find the best interventions, monitor their effects and consequences, and adjust policies, regulatory regimes, and budget allocations. The world of medical science and biotechnology has delivered vaccines in breathtakingly short times, but innovations in therapies have been slower because they have not been de-risked. Epidemiologists need to continue to break down walls between their respective countries so that world leaders can have access to better and faster disease reporting. Risk communication is about good journalism. Developing systems requires the world of engineering. Dealing with IP issues the world of law. Innovations come out of the business world.
How did the Irving Medical Center’s COVID-19 Vaccine Development, Strategy and Implementation Symposium come about?
The Symposium is the first large public event of the Program in Vaccine Education (PVE) at the Vagelos College of Physicians and Surgeons. It is a partnership effort with the Center for Pandemic Research at the Institute for Social and Economic Research and Policy (ISERP) of which I am the interim executive committee chairman situated on Columbia University’s main campus. It is an outcome of a team effort involving Drs Lawrence R. Stanberry, Philip Larussa and Marc Grodman, and myself. The Symposium’s collaborators are ICAP Mailman and the Columbia Global Centers. My own interest in convenings meetings such as this goes back to 2016 when I organized with the support of the Ford Foundation a review of the West African Ebola Outbreak at the Carnegie Council for Ethics in International Affairs in New York City. Dr. Michael Osterholm and former Assistant Secretary of Defense Andy Weber served as guest speakers. That is where I first met Dr. Marc Grodman. The event brought together leaders in the health sciences, industry, government, and diplomacy. Similarly, in April 2017, Drs. Stephen Nicholas, Marc Grodman, Lawrence Stanberry, and I convened a symposium in response to the Zika epidemic and had experts in medicine, public health, government, the corporate sector, and journalism – including Ian Lipkin, Roy Vagelos and Jennifer Nuzzo – participating. The forthcoming COVID-19 vaccine symposium is built therefore on a cumulative effort that started in 2016. We had to overcome many barriers and obstacles to get it right, but with assistance and support of many across Columbia University and an unrestricted educational gift from Pfizer, we finally succeeded.