The Honourable Mark Dybul MD speaks to us about the findings of the Independent Panel for Pandemic Preparedness and Response.
The Independent Panel for Pandemic Preparedness and Response (IPPPR) was established by the World Health Organization (WHO) in July 2020, in response to a resolution of the 73rd World Health Assembly calling for an ‘impartial, independent and comprehensive evaluation’ of the international response to the COVID-19 pandemic, as co-ordinated by the WHO, and establish lessons learned for potential future health crises. In May 2021, the Panel published its findings in a comprehensive report titled ‘COVID-19: make it the last pandemic’.
With more than 150 million people infected and more than three million killed by COVID-19 in less than 18 months, the Panel’s findings were grim, identifying structural and institutional failings at all stages of the pandemic. The report states: ‘[O]ur careful scrutiny of the evidence has revealed failures and gaps in international and national responses that must be corrected. Current institutions, public and private, failed to protect people from a devastating pandemic. Without change, they will not prevent a future one…We must work together to end this pandemic, and we must act urgently to avert the next. Let history show that the leaders of today had the courage to act.’
The Panel is co-chaired by former Prime Minister of New Zealand the Rt Hon Helen Clark and former President of Liberia Her Excellency Ellen Johnson Sirleaf; and has 13 members, including international policymakers, economists, healthcare stakeholders and academics. Panel member the Honourable Mark Dybul MD, a professor at Georgetown University and former Head of the Global Fund, speaks to Health Europa Quarterly (HEQ) about the Panel’s findings and the actions needed to prevent potential future pandemics.
What were the key factors which contributed to the failure to contain COVID-19 in the first few months of the pandemic?
There were multiple factors: one was the lack of a rapid response in China, but then by mid-January 2020, the WHO had acted and issued a Public Health Emergency of International Concern (PHEIC) determination – that could have been done earlier, but only around a week earlier.
Then it was fundamentally the failure of governments to respond. Between mid-January and the end of February, very few governments did much of anything – we call it the lost month of February; it was really a failure of action by governments around the world. Some governments did respond extremely effectively, and we learned a lot of lessons from them about what could be done to prevent the next pandemic – because this pandemic did not need to happen. We could have stopped it. We do now know what it would take to stop the next one; and that is the basis of our recommendations.
Could the slow response to the initial outbreak of COVID-19 have been in part due to complacency following successful responses to earlier outbreaks, such as H1N1 and SARS-CoV-1?
It is possible that there was some complacency, but most of the political leaders who were in place during COVID-19 were not around during H1N1 in 2009. Systems that had been put in place for H1N1 were dismantled by some governments and were simply not carried out by others, particularly in North America, in Mexico and the United States. Throughout the world, there was not initially a response to COVID-19. What we do know is that the countries that did respond well had experienced the threat of pandemics or outbreaks in the past – this was particularly the case in Southeast Asia; the countries in that region which responded well to COVID-19 had experienced the threat of severe acute respiratory syndrome (SARS) or Middle East respiratory syndrome (MERS) and put systems in place, but importantly, they then maintained those systems for the 10 or 15 years since their last pandemic. In fact, it is perhaps less an issue of complacency and more that having not experienced a major outbreak played a role in countries’ responses. In a number of countries the necessary systems did exist, but the political leadership just was not there to implement them.
Is there a correlation between institutional mistrust or a lack of faith in government and higher rates of infection?
We were not able to do overall surveys on this: there have been reports from some countries on a lack of trust in government, but we cannot draw that direct link between institutional trust and infection rates. We do talk about lack of trust in the report; however, that is something that political leadership is intended to overcome – even in situations where there might not be as much confidence or belief in government as elsewhere, that can be overcome with strong leadership.
What was missing was the political leadership, both nationally and globally, to respond to COVID-19. In the report we point out the fact that the United Nations Security Council did not have a resolution on COVID-19 until July 2020, but we also saw the same issues in individual countries. It was a failure of political leadership; and that is why we are calling for a Global Health Threats Council at the head of state level, with the private sector and communities deeply engaged – which is what happened in the countries that did well – to ensure that we support countries and regions to build the systems for pandemic prevention, preparedness and response. Regions are very important: in the report we spend some time focusing on the regions; Africa is a key example of a region that responded in a pan-continental way, with President of South Africa Cyril Ramaphosa as chair of the African Union leading that effort, along with other heads of state and the Africa Centres for Disease Control and Prevention (CDC). Unfortunately, they just did not receive the support that they needed to carry through with the plans and the actions that they wanted to put in place. It is important to emphasise that we did have the examples of what can be done. It just was not done.
How could the adoption of newer digital technologies accelerate the detection of new diseases and streamline international alert and response systems?
The IPPPR report does mention the need for a more robust surveillance system – not just for humans but for animals, because that is where pandemic threats occur: when a virus jumps from an animal to human, as happened in this case, as well as in the case of HIV and other past pandemic threats. You have to do the surveillance in both humans and animals, you have to link the two; and then you also have to act on those data in what is called One Health, which links animal and human health together. This entails doing prevention and preparedness work in the animal community: observing husbandry practices; the proximity of humans to animals; how animals are shipped around the world; or how they are used in markets. Digital surveillance would help track those movements and model the spread of infection; for example, by picking up the drift of genetic codes for diseases which occur in animals, we may be able to predict a spread to humans, or to predict where the virus will go based on weather and seasonal patterns. That type of surveillance system would help us to prepare and respond and even help to prevent the spread of disease.
The surveillance was not the principal issue in this case – there were reports coming out of China in the middle of December 2019, including private physicians sequencing the virus. Capitals around the world were aware of this; and meetings were recorded at the head of state level in countries around the world in December. It was not principally a surveillance issue; it was principally a response issue and a preparedness issue. We knew by mid- to late December that there was a significant issue; by the middle of January, the WHO had already announced that it was a PHEIC.
Surveillance is essential to be able to respond faster and to prepare for that response, but even when we knew about it, people did not respond. Surveillance is important – we make a clear recommendation on that – but then, if you do not do anything with that surveillance, the surveillance has not done anything other than let you know that you’re going to have a big problem.
What are the risks posed by unequal vaccine distribution? What must higher-income nations do to address vaccine inequity?
The key risk, as long as the virus is circulating around the world rather freely, is that we will see increased variation: new variants of concern are popping up all over the world in India, South Africa, Brazil – places that do not have high vaccine coverage – and of course, we also have a variant coming out of the United Kingdom. We have no idea whether or not those variants started in those countries; these are simply where they are first detected. In a similar way, the Spanish Flu started in the United States, not in Spain. The risk is that variants will continue to appear and that those variants might eventually develop resistance to existing vaccines. We also cannot control a virus in a global world if we just have pockets of vaccination; we need global vaccination.
We make very clear recommendations in our report that what can be done immediately in order to address the inequitable distribution of vaccines is redistribution of excess capacity. High-income countries have ordered more than twice as many doses as they need to vaccinate their entire population, and no-one is actually vaccinating their entire population: we are only vaccinating people aged 12 or older; and many people – in some countries, up to 30% of the population – are saying that they will not take the vaccine. There is substantially more capacity out there, although that does not mean that those doses are in hand: they have been ordered and there is a sequence to when those vaccines will arrive, which is why we call for a billion doses to be delivered from high-income countries to the 92 low- and middle-income countries covered by the COVID-19 Vaccines Global Access (COVAX) facility by 1 September 2021 and two billion by early next year. That would allow for more than a billion people to be vaccinated, because some of those doses are the Johnson and Johnson vaccine, which is delivered as a single dose.
We are calling for the G7 to step up and provide 60% of the financing that is necessary, not just for vaccines, but also for oxygen, personal protective equipment (PPE) and diagnostics, which are essential if we are to understand where the virus is and how it is spreading. We then call for the G20 to make up the rest of the difference: high-income countries should fully fund the needs that have clearly been put forward so that we can not only vaccinate, but also provide treatment and diagnostics so that we can track this epidemic and get it under control. If we do not do that, we cannot get this epidemic under control; we will continue to have variants, some of which might well escape the current vaccines that we have available; and then we are back to square one.
We need to maintain the public health measures we have in place as well. Vaccines alone will not end this pandemic: public health measures need to be maintained and to be put in place where people have grown lax with them and the virus is spreading significantly. The solutions are not just medical; we know from every epidemic and every outbreak that we need that behavioural aspect as well. We know that from the countries that have done well: they had no access to vaccines, they had no access to treatment at the beginning, and yet they completely controlled the virus through public health intervention. We need to combine the medical and behavioural factors and we need to not lose sight of that.
Looking to the future, we need new institutions to ensure that we have the type of response that we need and the preparedness that we need. This includes establishing a Global Health Threats Council at the head of state level globally, so that we have co-ordination across the systems; and for something similar to be repeated at the regional and national levels for a network global response. In order to fund these networks, we will also need a new financing mechanism that can provide resources to countries so that they can build the systems that are necessary throughout the world and help build surge capacity, so that when outbreaks do occur we can respond rapidly in containing them. If we do these things, we can not only control the current pandemic through those mechanisms, but we can also ensure that this is the last pandemic.
The COVID-19 pandemic did not need to become a pandemic: it could have been an outbreak. It became a pandemic because of failures in national, regional and global systems and a lack of financing; and if we put those in place, we can ensure that that this is the last pandemic.
How has the pandemic and countries’ response to it deepened inequalities? Should recovery measures take into account the need to mitigate inequality?
The inequality arising from the pandemic has been remarkable, both in terms of who suffers – in many countries, access to healthcare is limited or divided by race or by gender, so the inequality faced by those who become infected, nationally and globally, is just extraordinary – and in access to vaccination, oxygen, PPE, diagnostics, and treatment, which is all very much divided by national income right now. And that inequality makes no sense, even just from a self-interest perspective of the high-income countries; as long as the virus is spreading all over the world those variants will pop up and there is no way any country or any person is going to be safe until all people in all countries are safe. That is the nature of a global pandemic; and that’s why we need that equitable solution: we need it for humanitarian reasons, but we also need it to provide basic health and safety measures for everyone in the world.
As we look forward, that equality needs to be built into the system. That is one of the reasons why the IPPPR is calling for a Global Health Threats Council, which would be made up of equally of people from all regions in the world, with equitable distribution by race and gender; but which would also include representation from communities and the private sector, not just governments. Inequity occurs when communities are not involved in the process; and we know that in the countries that did well, communities were deeply involved from the beginning. We also call for a pre-negotiated way to ensure equitable distribution of commodities for future pandemics, as well as for this one – but that needs to be decided in advance, we cannot keep redoing it every time a new pandemic comes out. In order to do that we need resource pools now, so that we can support countries to build those systems for preparedness, prevention, preparedness and response, but also so that there are resources available to build platforms. We call for local production capacity in countries around the world, not just in high-income countries; and we need to invest in building those platforms now, so that they can be triggered immediately should there be another pandemic threat.
Equity has to be at the heart of ending this pandemic, but it also needs to be at the heart of preparing for the next one. We call for that very clearly in our recommendations: equity really is at the core, both from a humanitarian perspective and from a public health perspective. The virus does not care what your income level is; it does not care what colour your skin is or what country you live in; the virus will spread and mutate and outrun our ability to keep up with it. It will stay ahead all of our measures until we have equitable distribution and an equitable response.
Is there a need to adopt a TRIPS waiver for the COVID-19 vaccine and associated equipment and resources?
TRIPS waivers do not necessarily lead to more vaccines, because there is still a need for technology transfer, physical capacity, and investment. We call for the companies which hold the intellectual property for vaccines to issue voluntary licences and technology transfer in an appropriate way so that the capacity exists throughout the world, not just for high income countries, but for all countries. This has been done before, with HIV, so we have a precedent for this and we know how to do it, which is why we can set up that pre-negotiated system.
If that does not occur – if the companies do not engage, not only in providing a voluntary licence, but also delivering the technology transfer – and if we do not see movement within three months, then we strongly suggest that a TRIPS waiver be considered; but I think we need to be clear that this will not necessarily lead to new products in the absence of technology transfer. The technologies involved are very complicated: vaccines are much more complicated than antiretroviral therapy for HIV, for example; so it will take time, and it should not be done everywhere, but it can be done in a way that ensures equitable global access.
Are there any other key aspects of the IPPPR’s report that our readers should be particularly aware of?
I would like to emphasise that the WHO needs to be strengthened and elevated; it needs to be part of that Global Health Threats Council; and it needs to be focused as the principal surveillance and co-ordinating mechanism for pandemics. The WHO did quite a good job this time – the difference between its responses to the COVID-19 pandemic and the Ebola pandemic in 2014 is like night and day – but there are limitations, because it operates at the ministry of health level and there are always political forces at play. Public health cannot be influenced by political forces: one of the principal reasons that this outbreak became a pandemic is that politics got involved.
We call for a couple of key things related to this: firstly, that WHO be elevated and be engaged deeply in the Global Health Threats Council, which would be at the head of state level across sectors and ministries. We also call to strengthen its financing, which is essential. Then, to eliminate the politics of the process, we recommend that the Director General and the regional directors of WHO no longer be re-electable positions and that those roles last for a single seven-year term – this would remove the issue of introducing politics into the decisions that they need to make, because they are worried about re-election.
Let’s get this pandemic ended, and then make sure we don’t have another.
The Honourable Mark Dybul MD
Independent Panel for Pandemic Preparedness and Response