Introduction

The COVID-19 pandemic has forced us to acknowledge the distressing dynamics affecting health that exist on multiple levels. On the international stage, the pandemic has highlighted the importance of collaborative global health institutions and global health cooperation for information and resource sharing. Closer to home, as the bulk of the pandemic has been borne by those in long-term care (both patients and carers) and essential service workers – who are predominantly low-income and racialized – the well-known phenomenon of the vulnerable, disadvantaged and disempowered among us almost always suffering the most has once again borne true. The health penalty, associated particularly with being Black or Indigenous and poor, is present for well-established chronic and infectious diseases, and, as it turns out, it is also true for a disease that is brand new. Unfortunately, the patterns of health inequities assert and reassert themselves because we have failed to do much about them. The May 2020 deaths of George Floyd in Minneapolis, Minnesota, and Regis Korchinski-Paquet in Toronto, Ontario, were horrific and perhaps even more tragic as they were avoidable. But they were just the latest in a long string of documented “encounters” between police and Black, Indigenous and Brown people that have involved everything from harassment to death. Moreover, there is evidence that healthcare institutions may also provide differential levels and quality of care to citizens belonging to racialized communities.

As the incoming editors of Healthcare Papers, we will take on these and other pressing issues that have clear implications for health and healthcare policy and are also clearly timely. It is our hope that by focusing on the main societal challenges we are facing, we will be able to engage a broad range of stakeholders and create more fruitful dialogues among them. We plan to focus on issues that are (or should be) top of mind in Canada, and also draw on those that force us to reflect on how our own context relates to the international context and to issues of international policy.

The Current Issue: Canadian Perspectives on Global Health Institutions

In the current issue, we focus on the institutional context for global health. If the COVID-19 pandemic has emphasized one thing, it is that our health is very much a function of a set of societal institutions. We can do what we can to protect ourselves, but the scale of what we can do for ourselves is completely dwarfed by our dependence on systems of institutions. In the COVID-19 era, these institutional systems have been critical for processing data in real time and making decisions about the distribution, determinants and treatment for COVID-19. These systems have been responsible for regulating our exposures to risk for ill health by mandating and enforcing social distancing, the wearing of masks, lockdowns and other public health measures. They have also been crucial for strategizing how to get the masses vaccinated quickly and safely.

Certainly, the public health system(s) and other institutional systems in Canada are central to the health of Canadians and, as such, deserve extensive scrutiny in terms of whether their actions have kept us healthy.and to what extent health gains have been equally shared across the population. However, in a global pandemic, we are not our own entity. We are highly connected with the rest of the world, which requires that we think about the COVID-19 pandemic in terms much broader than the dynamics within our own country. We must understand how global institutional systems have been operating and what their effect has been on a global disease phenomenon.

From a global perspective, the most obviously significant institution for any global pandemic is, inarguably, the World Health Organization (WHO), whose mandate it is to lead the global health responses of UN member states. According to its mandate then, the WHO should lead in mounting a coordinated, global response to the COVID-19 pandemic. However, the WHO’s success relies heavily on the institutional systems it inhabits. These systems include member state governments, other international agencies, and the network of universities and pharmaceutical companies, among others, on whose work the WHO relies to inform and support its work.

In this issue, we tackle a dilemma that has been spotlighted by the COVID-19 pandemic. Specifically, we address the increasingly vocal critique that the WHO and the institutional systems in which it is enmeshed are not working as they ideally should. We rely on Kohler (2021a), professor of Pharmacy at the University of Toronto and the director of a WHO collaborating centre on governance in the pharmaceutical sector, to set the stage by describing what she sees as the fundamental issues that are preventing the WHO and its institutional systems from working well.

Kohler (2021a) suggests that the central impediment is a lack of global cooperation among the member states of the WHO, which itself is related to a lack of leadership in fostering this cooperation. Moreover, Kohler sees Canada as a strong candidate for this leadership role, despite its middle-power status in the world.

The Commentators’ Responses

The commentaries written in response to Kohler’s (2021a) paper provide a range of diverse perspectives and insights that further expand the discussion.

Di Ruggiero (2021), at the University of Toronto’s Centre for Global Health, posits that equity must be at the heart of global cooperation in public health. She calls for removal of barriers that lead to racial, social and health inequities. She further suggests that Canada can take a leadership role in the move to improve equity by leveraging existing initiatives such as the 2030 Global Agenda for Sustainable Development (UN 2015), which already has support from nearly 200 countries.

In his thoughtful consideration of where global efforts failed during the pandemic, Wong (2021), at the Monk School for Global Affairs at the University of Toronto, calls out the tendency of WHO member countries to prioritize their individual national interests over collective global needs. He argues that the health of all individuals must be prioritized over the health of nation states.

Describing the potential role of the private sector, Singh and Greenberg (2021), at US-based Kinsa, suggest that partnerships between governments, NGOs and the private sector may be positioned to better align global health priorities than individual countries or institutions. They emphasize “coalition management” over “consensus building” and explain that this is possible when there is mutual agreement on goals and roles, credible negotiating intermediaries are identified and technological innovation is welcomed.

The advantage of regional integration over single global leadership is the theme taken up by Latin American health policy experts Durán et al. (2021). They suggest that in a world dominated by nationalistic superpowers, regional integration rather than one overarching global organization is the best way to ensure that local public health concerns are recognized and addressed.

Human rights scholar Forman (2021), at the University of Toronto, disagrees with the call for a new organization to replace the WHO and argues that given its history, legal traditions and authority, it would be impossible to replace the WHO. Instead, she suggests that the COVID-19 pandemic provides an opportunity to strengthen the WHO’s legal and institutional framework and thus give it the credibility to assume a leadership role on issues of global health concern.

The Author’s Response

In her final response, Kohler (2021b) cites the recent deployment of COVID-19 vaccines, along with the sharp rise in nationalistic interests of wealthy countries, particularly those with vaccine manufacturing capability, at the expense of developing nations, as a prime example of why global cooperation in public health is a critical issue. She concludes that while it may be possible to reframe the WHO to take on a uniting leadership role, without “an authentic commitment to global health equity and global health coordination in public health to advance that, we remain very much apart” (Kohler 2021b: 51).

Readers’ Perspectives

As editors, we welcome your comments and insights into the debate initiated in this issue. Should Canada take a leadership role in creating global health partnerships? How can true equity and transparency be achieved? What does accountability look like on the global stage, and how can it be enforced? The authors in this issue of Healthcare Papers have shared their vision of the changes that can strengthen global collaboration. We encourage readers to continue this discussion. 

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