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There was warning after warning after warning, and yet the world failed to do what was needed to prepare for a pandemic, the first comprehensive review of the global response to COVID-19 finds. This lack of preparation left countries short of essential supplies, burdened by underresourced health systems, and scrambling to coordinate a response, while large vulnerable populations had few options to protect themselves.
“The combination of poor strategic choices, unwillingness to tackle inequalities, and an uncoordinated system created a toxic cocktail which allowed the pandemic to turn into a catastrophic human crisis,” the Independent Panel for Pandemic Preparedness and Response (IPPPR) writes in its report, which was presented today.
To do better next time, the group proposes a top-to-bottom overhaul of the pandemic preparedness system, including the creation of a new global health council akin to the United Nations Security Council and more money and power for the World Health Organization (WHO). “Pandemics pose potential existential threats to humanity and must be elevated to the highest level,” the authors write.
“It’s a frank assessment of literally systematic failure in the COVID response at every level, from WHO down to country level,” says Lawrence Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University. But Gostin says the panel is vague on how to bring about the massive changes it seeks and has missed an opportunity to call out countries’ bad behavior, including China’s early handling of the outbreak. “The independent panel had the opportunity to give WHO political cover to name names, to identify fault honestly where it occurs. And they didn’t do that,” he says.
IPPPR was created last year at the behest of WHO’s member states. The 13-member panel, led by former Liberian President Ellen Johnson Sirleaf and former New Zealand Prime Minister Helen Clark, interviewed dozens of people on all aspects of the pandemic and sifted through hundreds of publications.
Their report, COVID-19: Make it the Last Pandemic, concludes that the world has failed to take pandemic threats seriously and build structures that can respond to fast-spreading pathogens. Countries relied on WHO to keep it safe but didn’t equip it with the resources to do so. “For many years, [WHO] has been given new tasks without sufficient authority or resources to undertake them fully,” the authors write. “In this pandemic, the efforts of its leadership and staff have been unstinting but structural problems have been exposed.”
The International Health Regulations (IHRs), which govern how WHO and its member states should respond to infectious disease threats, slowed down the response to the new virus, the panel argues—despite the fact that they were overhauled in 2005 in response to the worldwide outbreak of severe acute respiratory syndrome. Information about the cluster of pneumonia cases in Wuhan, China, was rapidly picked up and shared globally, and the virus sequence was published soon after. But global action was hampered by “the slow and deliberate pace with which information is treated under the IHR.”
The report proposes giving WHO more clout, independence, and resources. Member states’ fees should be increased to make up two-thirds of the agency’s core budget. (Currently, fees represent 20% of WHO’s overall budget; the remainder comes from donations, most of them earmarked for specific projects.) The organization’s director-general should be elected for 7 years instead of 5 years, but should be limited to one term, IPPPR says, eliminating the politics involved in running for reelection. That is a sensible proposition, says Jeremy Farrar, head of the Wellcome Trust. The fact that WHO’s current leader, Tedros Adhanom Ghebreyesus, will reportedly seek a second term next year does not seem to affect his policies, Farrar says, but it “must be on the mind of people at WHO.”
The report proposes giving WHO the power “to investigate pathogens with pandemic potential in all countries with short-notice access to relevant sites, provision of samples, and standing multientry visas for international epidemic experts to outbreak locations.” Although that’s a great goal, it could mean breaching countries’ sovereignty, Gostin says. “It’s going to require an international agreement with teeth,” he says. “The report does not tell us how we get there.” But similar provisions exist for the International Atomic Energy Agency, says panel member Mark Dybul, a physician at Georgetown. “We think the world should be recognizing that a pandemic threat is as big a threat as a nuclear threat,” he says.
The report also takes aim at some of WHO’s own decisions. For example, a Public Health Emergency of International Concern (PHEIC) should probably have been declared by the first meeting of WHO’s Emergency Committee, on 22 January 2020, the authors write, instead of 1 week later, after a second meeting. And WHO could also have done more to warn of possible human-to-human transmission early on, even when that hadn’t been proved to occur, they argue.
Virologist Angela Rasmussen of the University of Saskatchewan agrees about the PHEIC: “WHO is not above criticism,” she says—but adds there’s little reason to think it would have altered the course of the pandemic. “The issues are really structural.”
We think the world should be recognizing that a pandemic threat is as big a threat as a nuclear threat.
Even after the PHEIC was declared it did not spur most countries into action. “It is glaringly obvious to the Panel that February 2020 was a lost month,” the authors write. “In the absence of certainty about how serious the consequences of this new pathogen would be, ‘wait and see’ seemed a less costly and less consequential choice than concerted public health action.”
Wholesale changes are needed to prevent a repeat of these failures, the authors write. The report proposes establishing a Global Health Threats Council, consisting of country leaders from different regions and representatives from the private sector and civil society, to ensure long-term attention for the prevention of pandemics. Gostin likes that suggestion. WHO’s executive board and its highest decision-making body, the World Health Assembly, are led by health ministers, he notes. “Getting it up to the heads of state is a great idea.”
The report also calls for creating an International Pandemic Financing Facility that would receive $5 billion to $10 billion annually, most of it from richer countries. It would provide money to countries to prepare for pandemics, for instance by stocking up on personal protective equipment for health care workers and building up diagnostic infrastructure. “Some people’s eyes might pop out,” at those sums, Dybul says. “But this is not out of proportion to many things we do already.” The facility should be able disburse up to $100 billion at short notice to help countries once a pandemic is declared, Dybul says; that gives them an incentive to notify others early on of a pandemic threat instead of hiding it.
Separately, the world should build a platform similar to WHO’s Access to COVID-19 Tools Accelerator, to develop and distribute diagnostics, therapeutics, and vaccines in a pandemic. That should not be left to the market, with manufacturing capacity and trials concentrated in a few countries, the panel says.
All countries should update their pandemic plans, appoint national pandemic coordinators reporting to the highest level of government, conduct simulation exercises every year, and invest in building resilient health care systems and risk communication capacities.
The panel’s recommendations are a package that needs to be fully implemented, Sirleaf said at the report’s presentation today. Only that “will put the world on course to ensure that this is the last pandemic causing devastation on the scale we are experiencing now.” But Gostin, who welcomes many of the ideas, says he’s disappointed the report doesn’t explain how to make them reality: “It’s an empty vessel because it doesn’t tackle the really hard problems about how you actually implement these plans.”
After all, many of the suggestions in the report are not new, Farrar notes. In 2015, a panel led by Barbara Stocking made similar points in a harsh report about WHO’s handling of the West African Ebola epidemic. “You could have taken the Stocking report and crossed out Ebola and put it in COVID, and it would have said many of the same things,” Farrar says. “Unless there is political will and real financial support, then all of these reports are just going to be reports.”
Editor’s note: The author of this story was interviewed by an IPPPR member and staff on 23 February about the communication aspects of the pandemic.