Democracy, Global Health, and the Group of Seven

ABSTRACT

COVID-19 produced a health crisis and exacerbated a democracy crisis. Members of the Group of 7 and other democracies were unprepared for the pandemic, and many responded poorly to it. Nearly twenty years of G7 global health leadership did not prevent G7 members from contributing to multilateralism’s failure during COVID-19. The pandemic also made the global decline in democracy worse. COVID-19 has raised questions about the relationship between democracy and health with which the G7 has not grappled. The G7 must do so now because democracy’s credibility on global health is badly damaged. The way forward includes fulfilling existing COVID-19 commitments made by G7 members, critically evaluating the COVID-19 responses of G7 nations, creating G7 ministerial and engagement groups on democracy, and identifying how to use development assistance for health to defend and advance democracy.

CHALLENGE 

For the Group of 7, COVID-19 produced a health crisis and exacerbated a democracy crisis. Inadequate pandemic preparedness and poor COVID-19 responses by many G7 countries and other democracies mean the pandemic has not been “an advertisement for the health effects of democracy.”¹ Nearly twenty years of G7 global health engagement did not prevent G7 members from contributing to multilateralism’s failure during COVID-19. The pandemic made the global decline in democracy worse.² COVID-19 has raised difficult questions about the relationship between democracy and health. The G7 has never grappled with such questions. It must do so now when democracy’s credibility on global health is damaged.  

Democracy and global health before the COVID-19 pandemic 

Democracies in the G7 and beyond helped transform global health after the Cold War by, among other things, supporting the Global Fund. G7 members did not engage in global health to promote democracy, but their development assistance for health (DAH) highlighted the importance of democratic governance and sought to increase civil society participation in programs consistent with democratic norms.  

In the immediate post-Cold War period, democracy spread. Research on adult health data from 170 countries between 1980 to 2016 found that, after controlling for HIV/AIDS, average life expectancy at age 15 increased by three percent after ten years in countries that transitioned to democracy.³ This research also found that democratic experience explained lower mortality rates from cardiovascular diseases and transport injuries. However, it did not explain variation in mortality from leading communicable diseases (e.g., HIV/AIDS and malaria) or from diabetes, mental health, and musculoskeletal disorders. These findings led the researchers to conclude that “democratic experience matters for global health.” 

In 2006, a global decline in democracy and a rise in authoritarianism began and continued during a period of increased DAH.⁴ This decline appeared across regions (e.g., Eastern Europe and Latin America) and in many nations, including low- and middle-income countries (LMICs) that received DAH. However, high-income democracies generally did not allocate DAH based on whether recipients were democracies or were democratizing. Democratic engagement with global health was saving millions of lives, but it had no effect in stemming democracy’s decline and authoritarianism’s rise.  

Democracy and global health during the COVID-19 pandemic 

Although democracies and authoritarian countries struggled with COVID-19, the poor performance of many democracies during the pandemic was unexpected. Before COVID-19, democracies warned about pandemics and the need for better pandemic preparedness and response (PPR) capabilities. Assessments of country readiness to handle outbreaks ranked G7 members and other democracies highly.⁵ In addition, the pre-COVID global health engagement of democratic states contributed little to the respective abilities of donor democracies and recipient LMICs to respond effectively to a pandemic. 

The suboptimal domestic and foreign policy responses of many democratic countries reflected changes associated with the global decline of democracy, such as nationalism, populism, and forms of illiberal democracy. These phenomena created problems among democracies (e.g., within the G7 in 2020) and between LMICs and democratic states over vaccine nationalism. During the pandemic, democracies were targets and sources of disinformation that harmed public health, undermined trust, and polarized domestic politics. The pandemic helped accelerate the global decline in democracy and the rise of authoritarianism.  

G7 members also appeared more interested in countering Chinese and Russian vaccine diplomacy than reducing global vaccine inequity in low-income countries.⁶ This prioritization of geopolitical interests over global health needs further tarnished perceptions about how democracies value health.  

In addition, research on COVID-19 infections and infection-related fatalities (IFR) across 177 countries indicated that there is no statistical relationship between regime type and pandemic responses. The research found that no “features of political systems . . . had statistically significant association with cross-country variation in infections or IFR.”⁷ Environmental seasonality, altitude, GDP per capita, corruption, and levels of trust in the government and interpersonal relationships explained variations in infections. For variation in IFR, the significant variables were age, GDP per capita, and body mass index. 

Democracy and global health after the COVID-19 pandemic  

As seen in the G7 summit in 2021 and Germany’s priorities for its G7 presidency in 2022, G7 members want to protect democracy and prepare for future pandemics. President Biden’s democracy agenda includes demonstrating that democracies can handle transnational threats, such as pandemics. In other contexts, democracy and health agendas are not linked. The Summit for Democracy in 2021 hosted by the United States and attended by over 100 countries did not include a focus on health. Germany’s priorities for the G7 in 2022 concerning global health and democracy are not expressly connected. 

In addition, G7 members have forged no consensus on what global health governance reforms to prioritize. This situation contrasts with the G7 solidarity demonstrated on HIV/AIDS, the Global Fund, and the revision of the International Health Regulations in the first decade of this century. At present, the European Union’s decision to build a “European health union” constitutes the most prominent governance reform in the democratic world arising from COVID-19.⁸ 

The post-pandemic period will also reveal how democratic elections address COVID-19 and PPR. The infrequency of pandemics means that little experience exists about how such events affect elections. For example, U.S. elections in 2020 produced mixed signals. The Republican Party narrowly lost the White House and the Senate but gained seats in the House of Representatives. Republicans did well at the state level, and several Republican-controlled state governments have weakened public health authorities and capabilities. Republicans might regain control of Congress in the mid-term elections in 2022 without renouncing the assaults on democracy and public health that occurred during, and have continued after, the Trump administration. Such an outcome would further damage the credibility of the G7’s most powerful member—and the G7 itself—on democracy and health.  

COVID-19 leaves the G7 facing a predicament on the relationship between democracy and health. The G7’s impotence concerning the global decline in democracy, its geopolitical fears about the spread of authoritarianism, the behavior of its members during the pandemic, and doubts about U.S. reliability have undermined the G7’s democratic and health bona fides. The predicament gets worse when the inadequacy of the G7’s responses to the global health threats posed by climate change are also considered.⁹ 

The Russian invasion of Ukraine has created a new crisis for democracies and global health.¹⁰ This war forces G7 nations and other democracies to confront a grave threat to national and regional security, the global balance of power, and democratic principles. Responses must prioritize economic and military power in ways that will marginalize global health in the foreign policies of G7 members. Containing Russian aggression and managing its aftershocks are unlikely to produce positive externalities for efforts to repair global health after the COVID-19 pandemic and to address the health threats climate change is creating.  

PROPOSALS 

1. In 2022, G7 members should fulfill, and, where possible, increase their commitments to donating and delivering vaccines to LMICs and help make antiviral drugs for COVID-19 accessible globally.  

2. At the 2022 summit, G7 members should discuss strengthening the Global Fund’s role in global health considering the COVID-19 pandemic to inform the fund’s seventh replenishment later in 2022. 

3. At the 2022 summit, G7 members should commit to review their domestic and foreign policy actions against COVID-19 for discussion at the 2023 summit. The reviews should identify steps G7 members can take to improve how they and other countries prepare for and respond to pandemics, including investments to build trust in government, counter disinformation, and expand access to health care. 

4. At the 2022 summit, G7 members should create a ministerial working group on democracy tasked with developing a G7 strategy for defending and advancing democracy. To provide input to this working group, G7 members should establish an engagement group on democracy (Democracy 7). 

5. For the 2023 summit, G7 ministerial working groups should identify how to use (1) health assistance to defend and advance democracy (e.g., by directing some DAH to countries that demonstrate commitment to democratic institutions and processes); and (2) non-health development assistance to support health objectives, including PPR and climate change mitigation and adaptation strategies. 

IMPLEMENTATION  

The G7 is one of the most prominent collective-action mechanisms within the community of democracies. The group has integrated global health into its work for two decades, and its members include countries that are leading providers of development assistance for health. In recent years, it has begun to address the threats that democracy confronts globally. The G7 is well-positioned to collaborate with other efforts by democracies, such as in the European Union, to strengthen how democracies approach global health problems. Thus, the G7 is an important forum for addressing the contributions that democracies can make to global health for the remainder of the COVID-19 pandemic and beyond, particularly considering the immediate dangers and longer-term consequences that the war in Ukraine creates.  

ENDNOTES 

1. Bollyky, T. J., & Kickbusch, I. (2020). Preparing democracies for pandemics. The BMJ, 371:m4088. doi: https://doi.org/10.1136/bmj.m4088 

2. Slipowitz, A. (2021, September 27). The devastating impact of COVID-19 on democracy. Think Global Health. https://www.thinkglobalhealth.org/article/devastating-impact-covid-19-democracy 

3. Bollyky, T. J., et al. (2019). The relationships between democratic experience, adult health, and cause-specific mortality in 170 countries between 1980 and 2016: An observational analysis. The Lancet, 393, 1628-40. 

4. On the global decline in democracy, see: Freedom House’s annual Freedom in the World reports at https://freedomhouse.org/report/freedom-world. On DAH levels, see: Institute for Health Metrics and Evaluation’s Financing Global Health database at https://vizhub.healthdata.org/fgh/ 

5. Cameron, E. E., Nuzzo, J. B., & Bell, J. A. (2019). Global health security index: Building collective action and accountability. Nuclear Threat Initiative. 

6. Kiernan, S., Tohme, S., & Song, G. (2021, December 2). Billions committed, millions delivered: The mixed record of vaccine donations and diplomacy. Think Global Health. https://www.thinkglobalhealth.org/article/billions-committed-millions-delivered 

7. COVID-19 National Preparedness Collaborators. (2022). Pandemic preparedness and COVID-19: An exploratory analysis of infection and fatality rates, and contextual factors associated with preparedness in 177 countries, from Jan 1, 2020, to Sept 30, 2021. The Lancet. https://doi.org/10.1016/50140-6736(22)00172-6 

8. European Commission (2022). European health union. https://ec.europa.eu/info/strategy/priorities-2019-2024/promoting-our-european-way-life/european-health-union_en 

9. For the latest research on the challenge of climate change adaptation, see: Intergovernmental Panel on Climate Change (2022). Climate change 2022: Impacts, adaptation, and vulnerability. Intergovernmental Panel on Climate Change. 

10. Fidler, D. P. (2022, February 24). Guns, germs, and gases: The invasion of Ukraine darkens the future for global health. Think Global Health. https://www.thinkglobalhealth.org/article/guns-germs-and-gases   

REFERENCES 

Bollyky, T. J., & Kickbusch, I. (2020). Preparing democracies for pandemics. The BMJ, 371:m4088. doi: https://doi.org/10.1136/bmj.m4088 

Bollyky, T. J., et al. (2019). The relationships between democratic experience, adult health, and cause-specific mortality in 170 countries between 1980 and 2016: An observational analysis. The Lancet, 393, 1628-40. 

Cameron, E. E., Nuzzo, J. B., & Bell, J. A. (2019). Global health security index: Building collective action and accountability. Washington, D.C.: Nuclear Threat Initiative. 

COVID-19 National Preparedness Collaborators. (2022). Pandemic preparedness and COVID-19: An exploratory analysis of infection and fatality rates, and contextual factors associated with preparedness in 177 countries, from Jan 1, 2020, to Sept 30, 2021. The Lancet. https://doi.org/10.1016/50140-6736(22)00172-6 

European Commission (2022). European health union. https://ec.europa.eu/info/strategy/priorities-2019-2024/promoting-our-european-way-life/european-health-union_en 

Fidler, D. P. (2022, February 24). Guns, germs, and gases: The invasion of Ukraine darkens the future for global health. Think Global Health. https://www.thinkglobalhealth.org/article/guns-germs-and-gases   

Intergovernmental Panel on Climate Change (2022). Climate change 2022: Impacts, adaptation, and vulnerability. New York: Intergovernmental Panel on Climate Change. 

Kiernan, S., Tohme, S., & Song, G. (2021, December 2). Billions committed, millions delivered: The mixed record of vaccine donations and diplomacy. Think Global Health. https://www.thinkglobalhealth.org/article/billions-committed-millions-delivered 

Slipowitz, A. (2021, September 27). The devastating impact of COVID-19 on democracy. Think Global Health. https://www.thinkglobalhealth.org/article/devastating-impact-covid-19-democracy