An expert's point of view on a current event.
May 30, 2021, 6:00 a.m.
This week the World Health Assembly (WHA), the governing body of the World Health Organization, is grappling with the question of how best to prepare for future pandemics and ideally prevent them. The WHA is based on recommendations from the independent Pandemic Preparation and Response Panel, which published its findings earlier this month. The report is more toothy and specific than previous comparable commissions, but it has also sparked a debate about whether and how a global governing body for pandemic action can be created.
There are important lessons to be learned here from the global fight against HIV. Twenty years ago, the impossible became the inevitable as a fund similar to the one currently being debated was created. Conventional technocrats said AIDS drugs were too complex and costly, and health systems too weak for the drugs to be widely available in low-income countries. At that time, we both started our careers and joined a transnational movement of people living with and affected by the deadly virus.
Before this dire calculation, the movement sought and won billions of dollars in annual investments. These came through the US President's Emergency Plan Program for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), a multilateral fund for community-based efforts to fight the three diseases. These resources were a moral imperative and the only sensible answer to a public health crisis that gripped the globe. Although it is difficult to pinpoint PEPFAR and GFATM precisely, GFATM has saved an estimated 38 million lives over the past two decades, while PEPFAR has saved an additional 20 million lives.
Today the world is grappling with the question of preventing the next pandemic – and every time the question is raised we think of the Global Fund. In March, the US House of Representatives Committee on Foreign Affairs took the first steps and passed a committee bill establishing a new pandemic-focused fund similar to GFATM. President Joe Biden's original budget proposal, which included $ 800 million for global health security, included a portion aimed at a catalytic health security funding mechanism. Since then, 120 members of the House of Representatives have approved the new fund, including a majority of House Democrats, and they have written a letter to Biden asking him to add at least $ 2 billion in seed capital to his budget.
However, the proposed $ 2 billion seed funding is a bare minimum and is mainly focused on helping countries meet the cost of meeting International Health Regulations (IHR). IHRs were designed and adopted as a global to-do list for disease outbreak containment, and expanding compliance is a key priority. McKinsey & Company estimated initial investments over the next two years at $ 85 billion to $ 130 billion, followed by annual investments of $ 20 billion to $ 50 billion required worldwide to put in place surveillance and response systems and the risk of future pandemics drastically decrease. The size of the investment seems to be the most salient feature – and it actually requires a massive, bold expense. But money alone will not prevent or contain future pandemics. The structure, mandate and home of the new fund are immensely important.
To be truly successful, GFATM must learn two important lessons. Firstly, prevention must be expanded to include combating the root cause of many pathogens: environmental destruction. Second, GFATM's successful governance model, which includes the most affected communities, should be incorporated into the management of future funds.
The GFATM shows that a close focus on biomedical solutions – diagnostics and drugs – does not stop or prevent pandemics. A pathogen spreads from one person to another; A pandemic is spreading through a broken system. Outbreaks arise from the severe wounds in the planetary ecosystem. Despite attempts at a holistic approach, prevention struggled to contain the HIV pandemic. There were 1.7 million infections in 2019 compared to 2.1 million infections in 2015, an important but insufficient improvement.
Every new fund must define and finance a comprehensive approach to prevention. A narrow focus on interventions that solely focus on the surveillance of human health and disease should be avoided, and it should be ensured that pandemic prevention also requires direct action to reverse the types of environmental degradation that affect the vast majority of the world have triggered new outbreaks of disease.
The disease that causes COVID-19 is the result of a zoonotic overflow from animals to humans. There were six times more zoonotic spillover events in 2010 than in 1980. And zoonotic diseases account for 60 percent of emerging infectious diseases, most of which are due to wildlife. Notably, there is a question posed by preventing spillovers from investing in human health. Such a binary view cannot be successful. The new fund needs to focus on the environmental and climate action needed to prevent new outbreaks from occurring while building resilient health systems to address them when they do.
In addition, GFATM offers lessons on how to run a successful fund and how donor-funded interventions are rooted and owned by communities and developing countries. Today there is consensus on funding country plans to comply with the IHR, but less attention is paid to who is planning, monitoring, and doing this vital work. When GFATM was launched almost 20 years ago with the mantra “Nothing About Us Without Us”, people living with HIV from around the world and others hardest hit by AIDS, tuberculosis and malaria took their place at the decision-making table in countries and countries have a boardroom – and never leave.
To be effective, the new fund must have “long-term COVID-19” people, key employee representatives, infectious disease-affected communities and health workers on its board of directors to act as technical experts while helping with country plans. No response to outbreaks can be successful without community collaboration and the heroic commitment of healthcare workers. Outbreaks start and end in communities, and involving these groups from the start leads to buy-ins and provides frontline knowledge.
Health in Harmony offers a successful model for improving human health while healing the planet. The organization works with indigenous people in Indonesia, Brazil and Madagascar to build skills and transform local contexts. Crucially, this work begins by listening radically to these communities who generally do not want to cut the forest, but do so because of the lack of other options. Their model is backed by data: In Borneo, working with the community in moving from deforestation to health care and organic farming has improved health outcomes, saved millions of dollars in carbon, and not only stopped but reversed deforestation.
Such a fund is not impossible, provided a mobilized, angry and grieving civil society calls for action. The new prevention and health fund must be fully funded at the upper levels of the estimated needs. It must fund country compliance with the IHR and have a governance structure that reflects the expertise and priorities of those hardest hit by pandemics. And it must include a comprehensive definition of pandemic prevention, including environmental and health interventions, in its mission and mandate. If these criteria are not met, it is entirely possible that no amount of money will ward off the next global crisis. If so, the goal of making sure nothing like COVID-19 happens again could be within reach.