Unprepared: How the Global Health Infrastructure Failed to Contain the COVID-19 Pandemic
Nils Gilman (NG) is the VP of Programs for the Berggruen Institute. Andrew Lakoff (AL) is a professor of sociology at USC Dornsife College of Letters, Arts and Sciences, and author of Unprepared: Global Health in a Time of Emergency (University of California Press, 2017).
This interview took place by phone, on April 7, 2020. Edited for length and clarity.
NG: One of the first controversies in the handling of the COVID-19 pandemic concerned the World Health Organization’s process for declaring it a pandemic. The WHO didn’t declare a pandemic until March 12th, by which time there were already over 100,000 identified cases worldwide and almost 5000 deaths. Can you describe the process the WHO uses in determining when to declare a disease outbreak a pandemic?
AL: There’s an important distinction to be made between two kinds of declarations the WHO can make when there’s a disease outbreak, each of which are important but which have different legal and symbolic ramifications. The first one is a “Public Health Emergency of International Concern” (PHEIC), which is a bureaucratic classification of an outbreak. This is the most urgent clarion-call the WHO can make to its member states. It calls on countries to put their pandemic preparedness plans into motion and to devote resources to dealing with an unfolding disease emergency. Getting to a PHEIC declaration is a process that involves an emergency committee that gathers all the information it can, makes a risk assessment, and then proposes to the Director General that this declaration be made. From the perspective of the WHO as a bureaucracy, a PHEIC is a more important category than the category of pandemic. The declaration of the PHEIC took place on January 30th, which was significantly earlier than the pandemic declaration, and from a technical and bureaucratic perspective, that’s the declaration that really mattered.
By contrast, “pandemic” is more of a descriptive, qualitative term. It doesn’t by itself have any technical or bureaucratic implications in terms of the kinds of actions member states are supposed to perform. I think the WHO is hesitant about using the term pandemic, in part because such a classification doesn’t say anything about the virulence of a disease; it just says where it’s located.
But the term pandemic does, of course, have an important symbolic connotation: it connotes urgency and means that a disease has spread all around the world and cannot be contained in one location anymore. So you’re right that by the time the WHO officially named COVID-19 a pandemic, it felt belated, in that epidemiologists already knew it was all over the world.
Perhaps they should have made that declaration earlier. But I think they also feel wary of using the term pandemic because they think that may set into motion intense and maybe counterproductive reactions. If you look at the announcement by the Director General of the WHO when they assessed COVID-19 as a pandemic, he spends a lot of time saying, ‘But this isn’t really what matters. What matters is that you put in place your containment techniques and your method of isolating and tracking cases.’
NG: The real point of a PHEIC or pandemic declaration is to galvanize political action. But there’s a problem of both overreaction and underreaction with respect to pandemic threat that creates a kind of a political paradox, a dilemma for politicians. The Harvard Business Review recently noted that, “The most effective time to take strong action is extremely early when the threat appears to be small or even before there are any cases. But if the intervention actually works, it will appear in retrospect as if the strong actions were an overreaction. And this is a game many politicians don’t want to play.” Arguably part of the point of creating a global public health technocracy is to relieve politicians of having to play this politically unpleasant game, and instead enabling bureaucrats to make this designation. In that context, what’s the role of the WHO in dealing with a pandemic? And what are the relative responsibilities of nation-states?
AL: You’re right that the declaration of an emergency is a kind of technocratic designation meant if not to force then certainly to strongly encourage countries to put into motion plans, irrespective of what the local political implications of doing that are. As part of the International Health Regulations, member states have signed on to an agreement that in the event of a potential health emergency, they will provide information to the WHO. Investigators will be allowed to come in. The declaration of a PHEIC also leads to strong recommendations on how national governments should respond to the disease. So you’re right that it’s supposed to have a galvanizing quality. The earlier it’s done, the less likely it is to turn into an irremediable catastrophe.
NG: In the swine flu pandemic in 2009-10, which ended up infecting some 600,000 people and killing “only” about 18,000 people, the WHO was accused of having been too quick out of the gate in naming it an emergency, thus diverting resources to deal with an allegedly exaggerated threat. Some medical experts even claimed that the WHO had “cried wolf.” While the WHO vigorously defended its swine flu emergency declaration, do you think that that critique inhibited them at all from declaring an emergency earlier in January or a pandemic in March?
AL: If we’re thinking about what kind of criticism the WHO should now be subject to, we should probably look at the period in mid-to-late January. I don’t know whether they were hesitant to declare an emergency at that stage because of earlier criticisms concerning their alleged overreaction in the swine flu pandemic of 2009-10. I do think they are now coming under scrutiny because they seemed to think in January that it was still possible to contain the disease. That may also help to explain why they waited a long time to declare it a pandemic.
Another factor is that because it was a coronavirus, and because the outbreak was in China, it seems like the WHO used the 2003 SARS episode as the paradigm for how to respond. In the case of SARS, there was a pretty successful containment effort: after the initial outbreak in China, global public health interventions were fairly successful in isolating cases, tracing contacts, and preventing its spread. In the case of COVID-19, if you look at the WHO recommendations throughout January and even into February, they were making the case for a strategy of containment.
Of course, we now know that the containment strategy failed, that it turned out not to be a containable disease – perhaps because it’s more transmissible than SARS, or perhaps efforts to contain it came too late. By March it became clear that the WHO’s containment recommendations weren’t working. And at that point, each country began to come up with its own strategy to address the threat.
NG: You say that the novel coronavirus was ‘uncontainable.’ Is this uncontainability an artefact of some biological qualities of the disease, or is it because we’re in a more tightly interconnected world than at the time of SARS? For example, China had ten times as many international travelers going in and out of the country in 2019 as it did 2003 when the SARS epidemic happened. Did the WHO end up thinking that the strategies that were used to successfully fight the last war, against SARS, would be again successful this time, despite the very different circumstances?
AL: It’s a good hypothesis. We need to figure out why the WHO and other health experts weren’t as urgently concerned about a catastrophic pandemic as now it looks like they should have been back in January. In retrospect, if you look at the lack of really intense, strong alarms – which we can now see as having been necessary back in mid-January – there’s a sense that perhaps officials were overly complacent.
The United States specifically has had a very fragmented and belated response. Somehow as of late January we didn’t think this was something that was headed to our cities in the West or that we had to intensely prepare for along the lines of, for example, setting up temporary hospitals, making sure that there were enough ventilators, ensuring that there was enough protective gear for health workers, and so on. But we’re not the only wealthy country that has had a disorganized response to the virus.
NG: In your book Unprepared (2017), you provide an overview of the evolution of international health regulations (IHR). International contracts about how to collaborate internationally in the face of pandemic risk date back to the mid-19th century. The purpose of these regulations was, first, “to minimize the global spread of infectious disease,” while at the same time “discouraging countries from imposing unnecessary trade and travel restrictions in response to outbreaks.” Of course, major restrictions in trade are exactly what has happened as a result of the pandemic, including domestic business. Now, as you know, one of the major points of the debate in the United States right now, as over 10 million people have been unemployed as a result of the lockdown, is whether “the cure is worse than the disease.” What do you think the appropriate mechanism is for determining what is or isn’t a “necessary trade and travel restriction” in response to a disease outbreak like COVID-19, especially in a world that’s characterized by the complex economic interdependence that we have here today?
AL: It’s worth distinguishing between the 19th century vision of what were then called the International Sanitary Regulations and are now called the IHR. These regulations have historically been about trying to ensure that countries didn’t take actions like blocking trade and travel from another country, given an outbreak. Before the adoption of the new regulations, admitting to outbreak of a new disease would have very bad economic ramifications for the country, because they would quickly end up with their trade blocked. This in turn made countries very reticent to report outbreaks of disease. The purpose of the IHRs is to strike a balance, to discourage countries from putting up barriers when they hear about an outbreak somewhere else, because such moves will inhibit the flow of critical information.
NG: It does appear as if the Chinese weren’t very forthcoming about the initial coronavirus outbreak in Wuhan – and they still may not have come clean about the origins and initial spread of the virus. Whereas Chinese health officials notified the WHO of the appearance of a novel coronavirus on December 31, 2019, it now appears as if the virus may have been circulating in Wuhan since at least mid-November, and possibly even earlier. On the one hand, governments don’t want to be embarrassed by things like disease outbreaks, and so they have an incentive to hoard information. On the other hand, if the Chinese had been transparent as soon as they knew about the COVID-19 outbreak, even a few weeks earlier, maybe the disease could have been contained in China. What’s politically feasible in order to change those incentives?
AL: This is precisely what the WHO was grappling with when they put together a major report in 2007 on “global public health security” that included the new international health regulations. They were trying to figure out what would incentivize national governments to be open and transparent with global health authorities. One piece of it was that participation meant that there would be resources coming. The idea was that the wealthy countries would provide a lot of help in preparing for and responding to emerging disease, and that would be a good incentive to governments to participate actively with global health authorities. While this is perhaps less relevant to China today, it’s an important part of the appeal of participation in places like sub-Saharan Africa.
Another thing that global infectious disease experts were excited about in the early 2000s was the idea that you would no longer have to rely on national health authorities to report outbreaks. Internet-based systems had been developed that could find anomalies in symptom reports or look at local journalistic reports. The idea was that since these internet-based systems would make outbreak information publicly available anyway, national government would have an incentive to be frank up front, since they wouldn’t want the embarrassment of having tried to hide the disease. This actually happened in the case of the SARS outbreak in China, which was one reason why the WHO was able to mount a pretty quick response to SARS.
Now, it seems in this case the WHO relied on the Chinese health ministry. And, at least from their early public pronouncements, the WHO seemed to feel that China cooperated well and was quite transparent. It’s possible that we’ll find that there were internal Chinese tensions such that the health authority reported things late or just that there was a lack of communication within China. We will also want to learn about why the WHO was convinced that they were getting all the information that they needed from China up through late January – at least, again, in terms of their public reports.
But it’s worth underlining what’s implicit in your question, which is that WHO doesn’t have a lot of power to force national governments to do things like letting outside investigators come into a country to find out the details of an outbreak. It relies on maintaining good relations. It’s a diplomatic relationship, not one that supersedes the sovereignty of nation-states.
NG: In the same way that we have to balance public health and trade concerns at the global level, what’s the right way to think about the trade-off between pandemic preparedness and the second order effects that our mitigation efforts are having on the economy?
AL: Given that the only effective public health mechanism we have right now to deal with a widespread COVID-19 outbreak is social distancing, that means shutting down the economy. But we need to start figuring out how we can re-open social and economic life while assuring ourselves that we’re not worsening the outbreak. I don’t mean we should do this immediately, but we need to figure out which countries are doing this in a smart way.
Widespread serological testing will likely be a necessary part of this, so that we can make sure that people who are vulnerable stay isolated in their homes, but that people who have already been exposed or who clearly aren’t carrying the disease may be able to return to work or to school with milder social distancing measures in place. The hope is that there won’t be an inherent conflict between the norm of protecting public health versus the goal of staving off a massive economic crisis. Ideally, social and biomedical technologies will be developed in the next several weeks and months to figure that out.
NG: You bring up the norm of protecting public health and the norm of keeping the economy functioning. But there’s actually a third norm that we need to bring into the mix: medical privacy. In fact, it seems that we are facing a kind of trilemma, whereby society only really respects two of those three in the face of the pandemic.
What’s happening in China now is instructive. The Chinese have already begun to roll out a solution that is allowing them to restart their economy while protecting public health. But it’s come at the cost of a really fundamental loss of privacy. The way they’re doing it begins with very widespread testing and tracing of contacts. Everybody then gets one of three designated ratings. Either they’re green, which means that they have had no known exposure to the virus or they’ve gotten healthy after having had it. Or they’re red, which means that they have a fever or are presenting other COVID-19 symptoms. Or they’re yellow, which means that in the previous two weeks they’ve had contact with somebody who was red. Only people with a green designation are allowed outside.
Everybody now has an app on their phone that carries their designation that they are required to show before they go into any kind of a public space, like a mall or subway. And the Chinese police can, of course, check on anyone’s status at any time to make sure that the Red and Yellow designees are not on the street. The scale of this is breathtaking: they’ve developed and rolled this app out to nearly a billion people, which is what is allowing them to reopen their economy despite the fact that there is still risk of the disease re-igniting, if only because the pandemic continues to rage worldwide.
Is that kind of an intrusive sacrifice of privacy something that we can countenance in the West?
AL: We need tools that aren’t as invasive as that one, because I think you’re right that that Americans and more generally citizens in liberal democracies are probably not going to stand for that that kind of intrusiveness. An interesting question is whether a tool that is more aligned with liberal norms, that would give individuals the right and, let’s say, the social obligation to attend to what’s expected of them, could work. If you could, for example, give people their antibody information without making it public, would they then act in accordance with public health recommendations? I don’t know whether that would be effective. It’s important to look at what places like South Korea, Singapore, and Taiwan are doing. These places obviously have had more coordinated and successful responses to COVID-19 than we have in the U.S.
NG: In Unprepared, you make a distinction between two different approaches to thinking about future threats, including but not exclusively biomedical threats. One is what you refer to as risk management, and the other one is vigilance. And these two “rationalities,” as you call them, in turn point to two different approaches for remediating threats, what you termed the “precautionary model,” which seeks to prevent a recurrence or the occurrence of a catastrophe, and the “preparedness model,” which implies that the threat cannot be evaded and the government officials must act as if the worst case is going to take place and they be ready to deal with that. Tell me about the difference between the sorts of mechanisms implied by each of these rationalities.
AL: Let me start with precaution. Precaution as a modality of decision became very well known in the world of environmental activism as an argument against cost-benefit models of regulation. From the perspective of cost-benefit analysis, you make a decision about whether to regulate a pollutant by calculating the economic benefits versus the losses of such a regulatory action. In the United States, cost-benefit analysis is the dominant regulatory mode in areas like drug and environmental regulation. By contrast, advocates of precaution argue that there are certain cases in which the danger is so great, it is actually catastrophic, with literally incalculable costs. Incalculability makes it difficult to demonstrate that the benefits of regulation outweigh its costs. The argument is therefore that we should bypass cost-benefit calculation on the grounds that if something does go awry, it will be catastrophic.
A good example would be opposition to genetically modified organisms in Europe. Opponents say, “We don’t have the data about how risky GMOs are, but that’s because it’s going to take a while for that information to come in. And by that time, if we’ve allowed GMOs into the wild, the catastrophe may already be underway. So we need to prevent the introduction of the technology.”
Now, in the case of COVID-19, you start with cost-benefit analysis and ask, how much is it going to cost, in terms of health consequences, to reopen the economy? And how does that compare to the costs of shutting down the economy? By contrast, a precautionary rationality would say, if we allow this disease to spread rapidly, it may turn out to be a massive calamity – therefore we just have to take the social distancing measures, without taking into account a risk/benefit calculus. So that’s a first distinction: precaution versus risk assessment.
The preparedness framework actually comes in at an earlier stage. Like precaution, its goal is to stave off catastrophe. But it applies to a situation in which the event may not be preventable. It doesn’t ask about costs and benefits. It doesn’t try to prevent the occurrence of the event. Preparedness says, even if we want to be precautionary about this danger, we may not be able to stop it from happening. If there is no precautionary option, the action we need to take is to anticipate its occurrence and put in place measures so that we will be ready for it. Preparedness techniques include things like scenario planning that generate and enact a possible catastrophic future event in order to learn about our vulnerabilities, so that we can try to mitigate those vulnerabilities in advance of the catastrophe’s occurrence.
NG: Speaking of foresight, one of the things that’s really striking about the Coronavirus pandemic is that it was not only foreseeable – it was widely foreseen. The kinds of scenario planning techniques you mention have been used for years, and pandemic risk scenarios are some of the most common scenarios that get simulated. Just six months ago, for example, the Johns Hopkins Center for Health Security partnered with the World Economic Forum and the Gates Foundation to host a pandemic tabletop exercise that was meant to illustrate the areas where public-private partnerships will be necessary in response to a severe pandemic. Over the last two decades there have been literally dozens of similar kinds of exercises.
And yet when the real event arrived in 2020, we turned out, at least in many places, to be unprepared. Is there something about how the foresight community stages these kinds of events that is insufficiently compelling to galvanize action on the part of public health bureaucracies and political leaders? In other words, is there a technical problem with the method? Or, alternatively, is the fundamental failing at the political level – that the kinds of leaders we have just aren’t responsive?
I should note that this isn’t a uniquely American failing. While a lot of people are inclined to want to blame the Trump administration for the bungled U.S. response (and I would certainly not want to defend every one of their moves), it isn’t just the Trump administration that’s catastrophically failed in the face of the pandemic. It’s also the Italian government, the Spanish government, the British government, the Swedish government, and so forth. Some of these are social democratic governments and some of them are conservative governments, so it doesn’t seem like an ideological issue per se, but rather an across-the-board governance failure in many democratic countries. What do you think caused these failures? And what can the foresight community do better in engaging political echelons?
AL: It’s been widely pointed out that we’ve run a whole series of pandemic scenarios, some of which have an eerie similarity to what’s actually unfolding now. So it poses this question you ask: Why, despite all these efforts, were we nonetheless so unprepared?
There are at least two different answers to this question. The first, as you suggest, is that scenarios – the vulnerabilities that are identified and the recommendations that come out of them – by themselves don’t do much. They might make some of the actors more aware, the ones who themselves actually participate in the scenario exercises or simulations. But unless the recommendations that emerge are turned into real policies that are sustained over time, the vulnerabilities will still be there.
Consider the example of stockpiling. You might have a scenario of a pandemic that demonstrates we’re likely to need tens of thousands of ventilators across the country to deal with respiratory failures. But to make that useful, we need to have not only a system for stockpiling ventilators, but a system for maintaining them, for distributing them, for prioritizing them to hotspots, and so on. And indeed, we can find those recommendations in the ‘lessons learned’ from these scenario exercises. But just because you’ve got the recommendation doesn’t mean that in fact Congress is going to allocate the resources, or that the people who run the departments that are supposed to build those stocks are going to actually do it. Or perhaps, as is what actually happened in the United States, orders were placed for ventilators, but then because one medical device company bought another medical device company the contract wasn’t fulfilled. In short, as you suggest, just because you do a scenario to give voice to concerns about a given threat doesn’t mean that effective and sustained bureaucratic action will result.
The second issue is that how useful a scenario is depends on the particularities of the scenario. As you may know, in 2019, the U.S. was ranked as the best-prepared country in the world for a pandemic, in part because of how many scenarios it had run. The United States is the place where pandemic preparedness planning started, back in the late 1990s and early 2000s, and there’s a whole industry that has been arguing for the need to prepare for a pandemic.
But if you look at the details of these scenarios, a lot of the recommendations that emerged centered on biomedical interventions, things like rapid vaccine development or stockpiling antivirals. The pandemic scenarios focused, initially at least, on the possibility of a bird flu pandemic. Now, avian flu bears some resemblance to COVID-19, but in many ways it’s quite different. For example, in preparing for avian flu the National Strategic Stockpile accumulated lots and lots of antiviral medication. Unfortunately, however, this antiviral medication hasn’t been proven effective for coronavirus. So, one way to put it is that we simply were prepared for the wrong event.
An even more striking example is the various exercises that have been conducted in relation to bioterrorism threats, and the policies that those led to. There’s the famous “Dark Winter” simulation that was conducted in June 2001, just before the 9/11 attacks, which simulated a smallpox attack on the U.S. Various well-known public figures participated, with Sam Nunn playing the role of the President of the United States, James Woolsey as the CIA Director, and so on. By all reports, it was terrifying: the participants were scared by the outcome of the exercise; the congressmen that heard the briefings afterwards were scared by it; Vice President Dick Cheney’s office was worried about it as well. The result was that we wound up stocking up on smallpox vaccine. So, the good news is: we still have millions and millions of doses of smallpox vaccine. Alas, it turns out that’s not going to help us with COVID-19.
In sum, a lot hinges on what exactly is built into your scenario exercise.
NG: One of the places that’s so far had relative success in mitigating the epidemic is Taiwan. And in that case, what really galvanized them was their experience of SARS in 2003. And for the last 10 or 11 years, they’ve invested a lot of time, energy, and money into readying the entire medical system of Taiwan to deal with a potential respiratory infection pandemic event. For example, hospitals practice how to convert overnight from patient-centered care to community-centered care, how to allocate scarce resources fairly, how to trace patients effectively, etc. They rank every hospital in the country based on how well they do. In other words, Taiwan committed a lot of resources into getting generally ready, even though they were specifically concerned with the possibility of another bird flu pandemic. The former PM Jiang Yi-huah recently told me that this practice has been critical to Taiwan’s success in stemming the COVID-19 pandemic on the island.
So, while it’s true that things like vaccines aren’t portable from one disease to another, it turns out that some of the organizational and operational things you need to do to get ready for bird flu are relevant for addressing, in this case, a novel coronavirus. What’s more, I do think operational competence also emerges not just from having plans that you put on a shelf to deal with a specific thing, but also from actually going through exercises. There’s a reason why theatrical companies do rehearsals and militaries run war games.
The question is: how can officials and the public sustain that kind of vigilance, as Taiwan has? What socio-technical tools do we need to build in order to be able to create that kind of sustained commitment to dealing with long term risks, which may not unfold in one year, two years, or even ten years, but are certainly going to happen at some point? How can we build that kind of socio-technical competency?
AL: Although there have been some successes in places like Taiwan, the problem of ongoing vigilance for something that might or might not occur is that there are always other resource demands, or attention turns to other threats, and then the vigilance tends to fade.
The best argument I’ve heard about how to build sustained capacity is rooted in the concept of “dual use.” In other words, we need to develop techniques that are useful for preparedness, but that are also useful for other things as well. A good example might be something like basic public health infrastructure. That’s useful for everyday maladies, and also when a pandemic arrives. Unfortunately, we’ve let that strong public health system fall into decline in many places.
Looking at tools that work for multiple kinds of threats, we actually see some that have been successful in the case of COVID-19. If you think about the emergency response systems that link various kinds of first responders from law enforcement to public health officials, to hospital workers, and so on – in California these groups have worked together pretty effectively in the case of COVID-19, and they’re also ready to work together when there’s another major disaster like an earthquake. So it’s useful to think about addressing generic threats in that way rather than specific ones.
NG: A very fragmented public health system and tens of millions of uninsured is a particularly American problem. But it’s striking that even countries with universal national healthcare systems, like Italy or England or Spain, have had really bad outbreaks. I admit that I myself was a bit complacent in January and even into February. When South Korea, Taiwan, Singapore, and even Thailand seemed (at least initially) to be successfully managing the epidemic with contact tracing, containment, and so on, I figured that if close-to-China middle-income Thailand (where the first case appeared outside of China on January 14th) could handle this challenge, then surely Western public health systems would be able to manage that, too. But that’s not how it’s turned out, at least so far: Western countries have fared worse than East Asian ones. What do you think has gone wrong in the West compared to the East?
AL: Some people looked at South Korea’s response or Singapore’s intensive response back in January and February and said, oh, boy, they might be overreacting. In fact, that was being said here in the U.S., which reflected our complacency. We also have an especially anti-technocratic government right now, one that doesn’t believe in the effort and the efficacy of government for dealing with these kinds of issues.
By contrast, the countries in East Asia realized this was an extremely serious situation. They realized it was time to put in place the plans that had been developed and practiced over the prior decade or two. In places like Singapore and Taiwan, the experience of SARS lent intensity and urgency to the initial response, so that their responses were better. In terms of the distinctions we were alluding to earlier, they were ‘precautionary’ right away. In addition, because of the strength of expert rule in those places, of technocratic authority, they really were able to mount quick, proactive preventive responses in a way that the U.S. and Europe haven’t been able to for the most part.
NG: Towards the end of Unprepared, you remark that, “An apparatus of vigilance constructed at global scale now seeks to envision future disease catastrophe and to put tools in place that can avert or at least mitigate its occurrence.” In other words, we built this global scale apparatus – and yet, when the anticipated global catastrophe arrived, the apparatus failed to avert it. What sorts of learnings – for the global public health community, for national health systems, and for the global apparatus – do you think may emerge from the COVID 19 pandemic?
AL: It seems that we’re relearning the same lesson each time there’s one of these outbreaks. If you look back to the post-hoc reports after the Ebola epidemic of 2014, there was a lot of hand-wringing among global health authorities over why what had been seen as a containable disease, and that had never spread to more than a few hundred people, all of a sudden became a region-wide catastrophe.
In that case, there were a lot of calls for reform of the world health system, for investing more resources in it, for interventions to happen earlier, for alarms to be raised more strongly. And yet here we are, looking again at what seems to be a failure. In this case, we don’t yet know exactly where the key failures were at the early stages. In some ways they lie as much or more at the level of the nation-states than at the level of the global health authorities. Perhaps it’s both.
We have mainly talked about wealthy countries in the Global North. But if you compare Germany vs. Italy or South Korea vs. the U.S., the lesson seems to be that we need to figure out ways to make sure that national governments across the globe take these crises more seriously, more consistently. Maybe an internationalist lesson will emerge from the pandemic in similar ways to those that arose after World War Two. We need to figure out mechanisms that bind ourselves into a global alliance, so that each nation doesn’t have its own and often quite weak response to a given event, when the event is actually global.