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1Global Health Governance Programme, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK. 2Harvard Kennedy School, Cambridge, MA,
USA. 3Division of Infectious Diseases, Department of Medicine, Okinawa Chubu Hospital, Okinawa, Japan. ✉e-mail: devi.sridhar@ed.ac.uk
It has now been just over one year since the first two cases of coro-
navirus disease 2019 (COVID-19) were confirmed in two Chinese
nationals staying at a hotel in York, England, on 31 January 2020
(ref. 1). On 26 January 2021, the death toll from COVID-19 in the
United Kingdom had surpassed 100,000 and there were reportedly
over 30,000 daily cases of the disease, with an estimated 1 in 10
people going on to experience the enduring effects of ‘long COVID’
(Official UK Coronavirus Dashboard, https://coronavirus.data.gov.
uk/details/deaths). The global death toll has just reached 2.1 million
(World Health Organization (WHO) COVID-19 Dashboard,
https://covid19.who.int). The global death toll had reached almost
2.5 million by 23 February 2021.
However, around the world, a varied picture has emerged (https://
covid19.who.int and refs. 2,3). Countries such as China, Taiwan,
New Zealand and Australia have managed to eliminate or get close
to elimination of their epidemics caused by severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2) relatively well2,3. Others
such as Hong Kong, South Korea, Singapore, Finland and Norway
have managed to control it at low levels. Sadly, both the United
States and the United Kingdom are still battling high numbers of
daily cases, tens of thousands of deaths, and an exhausted health
workforce and overstretched health services4,5.
As the virus proliferated across the globe, it also revealed criti-
cal vulnerabilities in our global and national health governance
systems that have resulted in inadequate outbreak responses6,7. In
this Perspective, we explore what is now known about the virus and
identify key lessons learned about the WHO and national gover-
nance and the impact on pandemic preparedness and response.
What do we know scientifically?
Since January 2020, a massive surge of research into COVID-19 has
enabled the scientific and medical communities to better under-
stand how to manage and ultimately eliminate the virus through
pharmaceutical and public health interventions8. Among the key
findings a year on is that transmission occurs through droplets and
aerosols spread through breathing, coughing, speaking and sneez-
ing9. Stopping the spread of COVID-19 requires people to avoid
mixing through restrictions on social and economic life, as well as a
robust test–trace–isolate system and travel restrictions10,11.
We have learned that COVID-19 causes more severe symptoms
and death in those who are older12 and who have underlying health
issues (such as cardiovascular disease or obesity) or are immuno-
compromised (as in those with malignancies or diabetes mellitus)13.
We have learned that certain genetic markers can identify individu-
als more susceptible to respiratory failure14.
We have also been learning about the long-term effects of
COVID-19, the so-called long COVID, and the morbidity attached
to having this virus15. Even after recovery from acute illness caused
by COVID-19, some patients continue to experience symptoms
such as dyspnea and fatigue for weeks or months15. Also, the emer-
gence of hyperinflammatory symptoms in children (multisystem
inflammatory syndrome, or MIS-C) was reported to coincide with
regional COVID-19 epidemics16.
We have learned that immunity lasts at least eight months17. We
also have three licensed vaccines in the United Kingdom, which are
already being rolled out and are effective at reducing the incidence
of severe COVID-19, although we do not know how long immunity
will last or whether the vaccines stop people from being infectious18.
We have learned that the virus can mutate into various strains that
can be more transmissible, can be more severe in their health out-
comes and can possibly evade natural or vaccine-induced immunity
to the original SARS-CoV-2 virus, requiring governments to plan
for a cat-and-mouse game between vaccines and variants19.
The role of the WHO
This pandemic has highlighted the interdependence of countries
like never before and, most importantly, the need for a globally coor-
dinated governance response20. As countries attempted to respond
to COVID-19 outbreaks, the WHO was thrust into the spotlight as
many countries looked to it for leadership and guidance21. In the
process, it has faced inevitable criticism from various stakeholders.
This criticism has unveiled—not for the first time—some misinter-
pretation of the WHO’s mandate, its authority, or the lack thereof,
over its member states and a number of organizational and legal
instrument constraints that have impacted pandemic prepared-
ness and response6,22–24. The WHO has three key roles in addressing
health emergencies: coordination, normative guidance and techni-
cal steering25.
As the only organization in the United Nations (UN) focused
on health, the WHO has a mandate to be “the directing and coor-
dinating authority on international health work” (ref. 25). During
the COVID-19 outbreak, it convened the seventy-third World
Health Assembly, in which a resolution was adopted to bring the
world together to fight the pandemic. The WHO has called for
equitable access to all essential health products, such as vaccines,
tests and treatments, through the Access to COVID-19 Tools (ACT)
Hindsight is 2020? Lessons in global health
governance one year into the pandemic
Ines Hassan1, Mitsuru Mukaigawara2,3, Lois King1, Genevie Fernandes1 and Devi Sridhar 1 ✉
Fourteen months into the SARS-CoV-2 pandemic, we identify key lessons in the global and national responses to the pandemic.
The World Health Organization has played a pivotal technical, normative and coordinating role, but has been constrained by its
lack of authority over sovereign member states. Many governments also mistakenly attempted to manage COVID-19 like influ-
enza, resulting in repeated lockdowns, high excess morbidity and mortality, and poor economic recovery. Despite the incredible
speed of the development and approval of effective and safe vaccines, the emergence of new SARS-CoV-2 variants means that
all countries will have to rely on a globally coordinated public health effort for several years to defeat this pandemic.
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Accelerator (https://www.who.int/initiatives/act-accelerator). The
WHO has also assembled the COVAX Facility as the vaccine pil-
lar of the ACT Accelerator with other global actors, a mechanism
designed to ensure timely access to a diverse set of vaccines for at
least 20% of countries’ populations, and the COVID-19 Technology
Access Pool (C-TAP), a platform to share patent-protected trial
data on emerging treatments26. There has been some success: to
date, two billion doses of approved and pipeline vaccines have been
pledged by wealthy nations, the European Union Commission
and the Bill and Melinda Gates Foundation, among others27.
However, as of January 2021, while vaccine rollout is fully under-
way in many wealthy nations such as the United Kingdom and
the United States, no COVID-19 vaccines have been administered
on the continent of Africa and in other low- and middle-income
countries28. This highlights the limited accountability of COVAX
participants and perhaps inefficient incentives for wealthy nations,
which have secured in some cases more doses than required to
protect their populations (refs. 29,30 and Our World in Data, https://
ourworldindata.org/covid-vaccinations). Furthermore, by January
2021, C-TAP had attracted zero contributions, nine months after
its launch30.
Through the International Health Regulations (IHR; last revised
in 2005), the WHO also has a “central and historic responsibility”
to manage the “global regime for the control of the international
spread of disease” (ref. 31). In its normative role, it has the “power
to shape or influence global rules and norms and to monitor com-
pliance” (ref. 32). It has arguably fulfilled a large part of this role by
providing state-endorsed guidance and by setting norms and stan-
dards on outbreak preparedness and response, which include mak-
ing use of measures such as border controls, identification of cases,
prioritization of testing, contact tracing and isolation of carriers of
the virus and their contacts, among other interventions31. Critically,
this guidance ensured that China reported the presence of a novel
pathogen on 30 December 2019 and enabled the WHO to declare a
Public Health Emergency of International Concern (PHEIC)—the
highest level of alert—one month later on 30 January 2020, notably
111 days before the UN Security Council adopted a resolution stat-
ing that the COVID-19 pandemic threatened international peace
and security26,33. Four days after adoption of this resolution, the
WHO published a global strategy to tackle the pandemic, much of
which remains valid today26.
Moreover, within its technical capacity, it was able to send an
international team on mission to China in February 2020 to col-
lect key data on how the virus was spreading and the emerging
disease profile as well as lessons learned from policy responses in
China up to that point34, invaluable knowledge that was shared with
the rest of the world in the same month. Furthermore, through
its technical role, the WHO has provided daily press briefings on
a variety of scientific and policy topics, including up-to-date epi-
demiology data, the nature of SARS-CoV-2 transmission and
appropriate non-pharmaceutical intervention guidance, since it
declared a PHEIC (https://www.who.int/emergencies/diseases/
novel-coronavirus-2019/media-resources/press-briefings).
However, there was some criticism that the PHEIC should have
been called earlier and that the WHO’s diplomatic, but perhaps
opaque, approach in working with China to investigate the source
of the outbreak and rapidly share information demonstrated a lack
of authority over member states6. This was further publicized as a
result of the Trump administration’s threat to withdraw from the
WHO35. However, the IHR only afford the WHO normative power,
a ‘soft’ power that relies on the cooperation of member states and
cannot be legally enforced32. Throughout the pandemic, the WHO
has struggled with country cooperation, namely because it does not
have an official operational role in outbreak response36. This has
also been demonstrated in the failure of notable countries such as
the United Kingdom and the United States to implement some of
the WHO’s key public health guidance, such as ‘testing, testing, test-
ing’, the provision of personal protective equipment and the ramp-
ing up of hospital capacity37.
Furthermore, although the WHO’s technical capabilities dur-
ing the pandemic are mostly to be lauded, it was slow to offer
some key recommendations, namely, on the potential risk of air-
borne transmission of SARS-CoV-2 under special circumstances
(enclosed spaces, prolonged exposure and inadequate ventilation38),
the important role that masks39 have in preventing transmission
and the use of border controls. History has shown us that the risk
of doing nothing while waiting for perfect data outweighs the risk
of acting quickly with imperfect data. As Mike Ryan, the execu-
tive director of the WHO’s Health Emergencies Programme, said
in a press conference on 13 March 2020, “Be fast—have no regrets
[...] perfection is the enemy of the good when it comes to emer-
gency management. Speed trumps perfection” (https://twitter.com/
SkyNews/status/1238504143104421888). Another technical area
where it fell short was that its preparedness metrics (WHO Joint
External Evaluation (JEE) mission reports, http://www.who.int/
ihr/procedures/mission-reports/en/) seemingly did not account
for variations in country leadership and political will, which have
clearly had a big impact on the way countries have responded to
the pandemic. Also, it did not sufficiently focus on policies to mini-
mize the increase in social, racial and health inequalities resulting
from outbreaks31. One major factor that has an impact on all of these
coordination, normative and technical shortcomings is the limited
funding available to the WHO to operate optimally40. Critically,
it has been suggested that the health and economic fallout of this
unprecedented pandemic may spur new opportunities for more
stable funding that might result in transformational change41.
National governance: best practice
By the end of March 2020, almost all countries around the world had
introduced nationwide public health measures aimed at containing the
spread of SARS-CoV-2 (Coronavirus Government Response Tracker,
https://www.bsg.ox.ac.uk/research/research-projects/coronavirus-
government-response-tracker). However, the measures used and,
subsequently, the health and economic outcomes of the response
varied drastically42. This variation in response seems to reflect past
Credit: Designer/DigitalVision Vectors/Getty
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experience in managing infectious disease outbreaks, societal val-
ues, long-term investment in healthcare and, critically, the political
will of the government in power.
Overall strategic differences. In Europe and the United States, a
combination of mitigation and suppression strategies has largely
been used at various points in time. This is despite the WHO advis-
ing countries to follow the model of elimination from February
2020 (ref. 43). The United Kingdom’s initial strategy was based
largely on the response to pandemic flu, and government commu-
nications made several mentions of mild flu and cold-like symp-
toms as a result of COVID-19 for the majority of the population44.
Elimination of the virus was touted as impossible, with the best
course of action being to shield the vulnerable as the virus made its
way through the population, to avoid overwhelming health services
in an attempt to achieve so-called ‘herd immunity’ (ref. 45). While the
successful use of measures such as social distancing and home isola-
tion in China was noted by government advisors, these measures
were perceived as postponing the inevitable46. The overreliance on
the flu model painted an inaccurate picture of how COVID-19 is
transmitted: as COVID-19 is more contagious than the influenza
virus, it leads to super-spreader events in crowded places. This ini-
tial stance evolved into a suppression strategy where targeted health
interventions have been used to reduce COVID-19 cases to ‘accept-
able’ levels, for example, by implementing mass testing, lockdowns
and the use of masks in indoor public spaces47. In contrast, in New
Zealand, Taiwan, Vietnam, South Korea, Australia and China, effort
was taken to try to rapidly exclude community transmission of the
virus using an elimination strategy. As Jacinda Ardern, the prime
minister of New Zealand, recently said, even if elimination is not
achieved, the approach “will result in a reduction of lives lost in
the process” (https://www.facebook.com/deutschewellenews/vid-
eos/236469201156575/). As the world has witnessed a return to
almost normalcy—at least within national borders—in countries
that chose an elimination approach, there appears to be greater
enthusiasm to pursue this approach among academics and politi-
cians2. In contrast, those who did not follow this approach have
succumbed to repeated national lockdowns throughout the year,
high mortality rates, long-term health consequences in survivors
(including in up to 10% of survivors in the United Kingdom), indi-
rect health impacts, long-term economic loss and an increase in
social and health inequalities48.
One factor that has impacted the strategies used by governments
is the relatively low case fatality rate (CFR) for COVID-19 of 2%
(ref. 49). The CFRs of severe acute respiratory syndrome (SARS) and
Middle East respiratory syndrome (MERS) are much higher than
that of COVID-19 at 9–10% and 36%, respectively49. On the basis of
past experience, most countries would have adopted an elimination
strategy if the CFR for COVID-19 were higher, because it would
have been impossible to let SARS-CoV-2 spread within communi-
ties43. However, CFR is a deceptive metric on its own because the
underlying SARS-CoV-2 virus spreads more easily among people
than other viruses with higher CFRs, leading to more cases and
therefore more deaths at the population level. Hospitalization rates
are a better measure of COVID-19 prevalence because they not only
reveal the level of community spread but also provide insight into
hospital capacity50.
Public health measures. We also now know that effective use of
test, trace and isolate (TTI) programs, where infected people and
their contacts are rapidly identified and provided financial sup-
port to isolate during the incubation period of the virus, along with
border controls and efficient and equitable rollout of emerging vac-
cines, is key to controlling this virus.
In East Asian and Pacific countries, TTI programs, strict border
measures and good voluntary public health guidance were central
to elimination strategies, allowing these countries to rapidly manage
local flare-ups. These measures also resulted in relatively few lock-
downs42. In Hong Kong, uptake of testing was encouraged by pay-
ing people to be tested. Germany also had a relatively lower CFR in
comparison to its European counterparts like Italy and the United
Kingdom, in part because of its early and broad testing strategy3.
The development of vaccines has provided governments with
an additional tool to protect their populations. Governments in
high-income countries in particular have embarked on mass efforts
to roll out vaccine, starting with their most vulnerable groups.
By mid-January 2021, Israel had administered the first dose of a
two-part vaccine to over 25% of its population, including to 75% of
those over the age of 60 years. There are early indications that this
is having a positive impact, with a reduction from 30% to 7% in the
occurrence of critical illness in patients in the older age bracket two
weeks after vaccination51. However, questions remain on the protec-
tion provided until the second dose is administered. Additionally,
inequitable access, both globally and nationally, is an issue; in Israel,
cities of lower socioeconomic status had administered fewer vac-
cinations than their wealthier counterparts (COVID-19 Maps,
https://vaccinations.covid19maps.org/). What is clear is that a fast
rollout is essential to stopping hospitalizations and deaths, as well
as—eventually—community transmission, ultimately reducing the
likelihood that new variants of the SARS-CoV-2 virus will emerge.
Social inequalities. The disproportionate impact that this pandemic
has had on vulnerable populations and minority ethnic groups
around the world must also not be overlooked52. This is typically a
result of riskier work and living conditions, limited access to protec-
tive wear—and in some countries treatments—and limited availabil-
ity of financial protection to ensure that key public health measures
such as isolation and distancing can be implemented52. Governments
have learned, often as a result of a public outcry, that identifying
these vulnerable groups quickly and implementing tailored inter-
ventions to reduce the risk of infection in these groups is critical. For
example, in Hong Kong, people were paid to encourage testing, while
in the United Kingdom mass testing was eventually introduced in
care homes as a way to rapidly identify and isolate cases53,54.
Other key lessons are that elimination is achievable if swift politi-
cal commitment is made early on in an outbreak and that, by accept-
ing short-term stringent public health measures, viral community
transmission is reduced, fewer COVID-19 cases are detected and
economic loss is minimized2. At the global level, however, we should
also recognize that not every country is able to implement the same
public health measures. Countries such as Japan could not legally
enforce strict containment measures because of their infringement
on human rights55. Furthermore, in Nigeria, political disorder and
aggressive use of force by the police to limit protests intensified
when strict public health interventions were enforced56.
Leadership and communication. Clear and evidence-based com-
munication during an outbreak is critical to build trust with the
public and to ensure adherence to public health measures and suc-
cessful containment. Most importantly, a government’s concept of
a successful outcome and the strategy used to achieve it need to be
well defined57. Some leaders seem to have managed clear communi-
cation, for example, in New Zealand, South Korea, Scotland, Taiwan
and Senegal, while others have struggled, for example, in the United
States and the United Kingdom. As the pandemic has unfolded,
knowledge about the virus, how to manage it and the interven-
tions available to us has rapidly evolved. Some governments have
been good at communicating uncertainty and necessary changes
in strategy when better options have become clear. For instance,
in New Zealand, after the PHEIC was declared by the WHO, the
government communicated that an elimination strategy was
being adopted58.
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In the United States and the United Kingdom, it has at times
been unclear what success would look like, how this would be mea-
sured and what approach was being adopted: exclusion, elimina-
tion, suppression or containment of the virus2. In the United States,
the Trump administration regularly ignored scientific evidence and
the federal government “largely abandoned disease control to the
states” (ref. 59), resulting in a massive failure in handling COVID-
19. In the United Kingdom, questions about changes were often
met with protestations of having ‘world-beating’ approaches, a
symptom of the UK exceptionalism that underestimated the virus
in the first place60. Moreover, some government ministers in the
United Kingdom recently announced that National Health Service
(NHS) hospitals were full because the public was not adhering to
public health measures61. Shifting responsibility to individuals alone
through such disparaging messaging can lead to a lack of compli-
ance with government rules.
Economy versus health. Throughout the pandemic, a false dichot-
omy pitting public health against economic success has emerged62.
In fact, one common argument against stringent public health mea-
sures like lockdowns is the potential damage such measures could
inflict on the national economy. It is incorrect that loss of eco-
nomic growth and job losses are a primary consequence of social
distancing measures rather than the virus itself62. Not taking strict
public health measures to prevent harm to the national economy
during the pandemic is a short-sighted policy; in the long run, a
brief closure and temporary subsidization have proven to be more
cost-beneficial than keeping the economy open. Although New
Zealand experienced an annual contraction in real gross domestic
product (GDP) of 6.1%, this is much lower than the decrease seen
in other comparable countries, and in Taiwan the net GDP was 0%
(ref. 63). Furthermore, economists argue that the estimated economic
cost of the pandemic in the United States has been US$16 trillion64.
Effective public health measures, if implemented, can reduce these
financial costs significantly. Contrary to the false—yet commonly
cited—dichotomy, protecting the health of the people is equivalent
to protecting the wealth of the people. Similar analyses have shown
that this was also the case in the 1918 influenza pandemic65.
Conclusion
Looking ahead to year two of the pandemic, our collective prog-
ress will be dependent on a coordinated global effort to leave no
one behind. Although the mass vaccination rollout will dominate
COVID-19 policy this year, the emergence of new SARS-CoV-2
variants that may escape the body’s neutralizing antibody response
and continued inequitable access to vaccines indicate that the
COVID-19 pandemic will continue. This may well turn out to be
the year of variants and vaccines. However, now we are armed with
knowing what works, what does not and the range of interven-
tions needed to keep case numbers low. Let us fix our fragmented
global health system and follow the elimination playbook together
because, if we have learned anything this past year, it is that, glob-
ally, we are only as strong as our weakest link.
Received: 28 January 2021; Accepted: 28 January 2021;
Published: xx xx xxxx
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Author contributions
D.S. and I.H. conceptualized the piece. D.S., I.H. and M.M. drafted the first version of the
manuscript. L.K. and G.F. commented on and edited the draft. All authors reviewed and
agreed with the final version.
Competing interests
D.S. advises the UK and Scottish Governments and receives research funding for her
team from the Wellcome Trust. The other authors declare no competing interests.
Additional information
Correspondence should be addressed to D.S.
Peer review information Marianne Guenot was the primary editor on this article
and managed its editorial process and peer review in collaboration with the rest of the
editorial team.
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