Analysis: A landmark report from Helen Clark has traversed in detail how the world failed to prevent the Covid-19 pandemic and what can be done to avoid the next global health emergency, Marc Daalder reports
More than 160 million people have been sickened by Covid-19 and more than 3.3 million have been killed since the pandemic burst onto the scene in December 2019.
All of this was avoidable, according to a landmark independent review of the global pandemic response released by Helen Clark and former Liberian President Ellen Johnson Sirleaf on Wednesday evening.
The report was commissioned by the World Health Organisation (WHO) in May 2020 and tasked with investigating how Covid-19 became a global pandemic, the quality of national and international responses and what lessons can be learned to head off future health threats. Clark and Sirleaf chaired the Independent Panel for Pandemic Preparedness and Response, which was composed of academics, politicians, health experts and civil society representatives.
Alongside long-term recommendations for reforming the international health system and guaranteeing more robust national responses to future health threats, the panel called on countries still experiencing spread of Covid-19 to engage in effective public health measures now and agitated for a more equitable distribution of vaccines to those countries with the most need and the least means.
'How an outbreak became a pandemic'
The report's proposals are rooted in an in-depth examination of the failures that allowed the coronavirus to so profoundly threaten our lives, health and wellbeing.
A 74-page accompanying report traces the path from an outbreak of a novel respiratory disease to 3 million people killed (and counting) in the worst global pandemic in a century. To begin with, the world knew this threat was real and was still not prepared for it by the time SARS-CoV-2 emerged in late December.
"Although public health officials, infectious disease experts and previous international commissions had warned of potential pandemics and urged robust preparations since the first outbreak of severe acute respiratory syndrome (SARS), Covid-19 still took large parts of the world by surprise," the authors write.
"This should not have been the case. The number of infectious disease outbreaks has been accelerating. Major outbreaks this century in addition to SARS have included influenza, ebola virus disease and zika virus disease. At the end of the last century, the HIV pandemic took hold, and remains with us - there is still no HIV vaccine, millions rely on antiretroviral treatment to remain alive and new infections still occur at an unacceptable rate."
If anything, our risk exposure to new pathogens has only grown in recent years. Air travel has quadrupled since 1990 alone and humans are increasingly encroaching on the natural world, where zoonotic illnesses like coronaviruses, ebolaviruses and HIV are known to have emerged from.
Although the WHO was first notified of the novel illness on December 31, and although Wuhan had entered a drastic lockdown on January 23, the organisation declined to label the coronavirus a Public Health Emergency of International Concern at a meeting on January 22 and 23. By a week later, when the number of cases outside China was verging on the triple digits in 18 different countries, the WHO at last acted.
Part of the delay was the result of an unwillingness to say the virus was able to spread from human-to-human until evidence of such transmission had crossed a high enough threshold.
"For the future, a precautionary approach should be used from the outset, acknowledging that a respiratory disease may spread from person to person unless and until established otherwise," the panel recommended.
While the review found the WHO should have declared a public health emergency a week earlier than it did, the real issue was the response from the international community: complacence.
"When the WHO puts out the Public Health Emergency of International Concern declaration, when it was ebola, everyone went nuts. But this alert didn't provoke that kind of thing," Clark told Newsroom.
"February was pretty quiet. I was in Europe for almost the first three weeks of February, I was going to meetings, and no one was talking about it. At all. Except to say, 'Have you seen what's happening in Wuhan?' as if it was outer space. When I came home, I didn't get the impression that people were talking about it as anything that would affect New Zealand.
"A key message that comes out of this is that when WHO says 'jump, this is an alert,' you jump. That's when you definitely need to have your readiness plans to the fore, and they've got to be flexible. Obviously New Zealand had one for a flu pandemic, not for this, and the smartest thing in the end was when in March the flu plan was ditched and they had a bespoke one."
In the report, February 2020 is described as "a lost month, when steps could and should have been taken to curtail the epidemic and forestall the pandemic". The failure of most governments to act in February to shut down international travel, bolster testing and contact tracing capabilities and prepare health systems for the burden of the pandemic had locked in much of the death and destruction that was to come.
"People sat and watched when it was the time to drag everything out of that bottom [pandemic preparedness] drawer and really throw everything at it," Clark said.
"For many countries, it was not until they had already seen widespread local transmission and their hospitals were starting to fill with desperately ill patients that they finally took action," the report found.
"Hospital admissions were a lagging indicator of spread. Looking back, it is very clear that the extent of local transmission had been vastly underestimated well before any response was instituted."
'Deeply concerned and alarmed'
While these observations have the benefit of hindsight, countries today are continuing to make the same mistakes as in February and March of 2020, the independent panel found.
"The panel is deeply concerned and alarmed about the current persistent high levels of transmission of SARS-CoV-2, which are driving illness and deaths, and about the development of virus variants all of which continue to impose an intolerable burden on societies and economies."
Many of the panel's final recommendations deal not with the long-term lessons that can be learned from the pandemic, but the immediate actions that must be taken to bring an end to it.
"Given what is known already, all countries should apply public health measures consistently and at the scale the epidemiological situation requires. Vaccination alone will not end this pandemic. It must be combined with testing, contact-tracing, isolation, quarantine, masking, physical distancing, hand hygiene, and effective communication with the public," the panel found.
"The uneven access to vaccination is one of today’s pre-eminent global challenges. High-income countries have over 200 percent population coverage of vaccine doses, obtained mainly through bilateral deals with manufacturers to secure existing and future stocks. In many cases low- and middle-income countries have been shut out of these arrangements."
Just because vaccines are being rolled out does not mean we should take our foot off the gas, Clark and Sirleaf say. Instead, we should redouble our efforts, using proven public health measures to reduce transmission.
"Variants may still emerge that our vaccines cannot manage. The more quickly we vaccinate now, the less likelihood there is of ever more variants emerging," the report found.
"One action which can be taken now is an equitable redistribution of available vaccine doses. Scaling up the development and supply of therapeutics and of diagnostic tests is also very urgent to save lives."
One of the key recommendations in this area is to build new vaccine manufacturing capacity in Africa and Latin America.
"It's clear that a number of countries, including our own, have ordered far more [vaccines] than they can use. So the critical thing is to release those orders back into the COVAX pool and get them allocated," Clark said.
"There's two things. One, get the surplus back out there, but secondly, the manufacturing scale-up. The companies need to get voluntary licensing agreements with a range of manufacturers around the regions of the world scaled up. We're not just looking at trying to vaccinate the bulk of the world population only once. Chances are, we're going to need ongoing capacity for boosters and re-vaccination and so on.
"Where the TRIPS waiver comes in is one step. You can have the TRIPS waiver, but unless you have the technology and knowledge transfer, you can't do a lot with the waiver. What we're really trying to do is add to that pressure and say, for heaven's sake, license more production."
Clark is optimistic that the tide is starting to turn in the direction of vaccine equity.
"When the Biden administration moves on this and says it's extraordinary times, well, you need extraordinary measures. We have to get the IP out there and the manufacturing scale-up. It's a bit of push and pull and shove in those recommendations."
In this vein, the panel recommended that high-income countries with enough vaccines to cover their population already secured should provide a billion vaccine doses to 92 low- and middle-income countries by September and another two billion by mid-2022, the report says.
The panel also called on the international community - and particularly the wealthiest countries - to fund the full budget of the Access to Covid-19 Tools Accelerator (ACT-A), a WHO initiative set up in April 2020 to research, develop and distribute Covid-19 vaccines, tests and treatments. The COVAX facility is the vaccine arm of ACT-A, but the entire programme is expected to need US$19 billion for its operations in 2021. The panel said 60 percent of this should come from the G7 countries and the remainder from the G20 and other wealthy countries.
'Make it the last pandemic'
The bulk of the panel's recommendations, however, deal with the long-term future of international pandemic preparedness. The main report is itself titled 'Make it the last pandemic'.
"The shelves of storage rooms in the United Nations and Member State capitals are full of the reports of previous reviews and evaluations that could have mitigated the global social and economic crisis in which we find ourselves. They have sat ignored for too long. This time, it must be different," the report stated, in the lead-in to its ambitious recommendations for reshaping the global health emergency system.
A Global Health Threats Council established by the United Nations would be the central focus of future worldwide preparedness efforts. It would monitor international and national readiness, agitate for greater action and maintain political commitment to the cause.
This council would be backed by new international law: a Pandemic Framework Convention.
The WHO itself would also need to be strengthened and more adequately resourced. This would include the creation of a new Standing Committee for Emergencies and bolstering the ability of the WHO to make rapid decisions to declare an event a Public Health Emergency of International Concern while operating on the precautionary principle. No more waiting for unanimous agreement or infallible evidence which, by the time it comes, may be too late.
"I think at the national level, the lessons were taken, that you have to be onto this fast. The question's going to be whether the member states of WHO and the UN take the next lesson, which is we have to support our global institutions to be able to perform," Clark said.
"We have to fund the WHO properly, we have to strengthen it, we have to give it more authority. We do need a global oversight mechanism. We do need to close gaps in the legal framework. All these things need to be done."
This beefed-up WHO would set targets and benchmarks for pandemic preparedness, which individual countries would then align their own pandemic plans with. It would also work to transform ACT-A into "a truly global end-to-end platform for vaccines, diagnostics, therapeutics, and essential supplies, shifting from a model where innovation is left to the market to a model aimed at delivering global public goods".
"There is a lack of shared vision among all stakeholders, including both countries and manufacturers, that the therapeutics, vaccines and diagnostics needed to counter pandemics are global health commons. Without that shared vision, the 'business-as-usual' approach prevails dominated by the development and sale by global corporations of proprietary products designed for wealthy countries, leaving the rest of the world dependent on the goodwill of donors, development assistance and charity to gain access - eventually - to life-saving health technologies."
The panel also makes recommendations for national-level preparedness, including for New Zealand.
In the short-term, this involves the appointment of national pandemic coordinators to see out the remainder of the pandemic.
"This takes more than the Ministry of Health," Clark said.
"We found that out in the end, didn't we? When different structures needed to be put in place to manage quarantine and all sorts of things. This absolutely needs head of government's attention, finance minister's attention. If you're going to address pandemic preparedness on an ongoing basis, that's a dedicated, high-level function that needs to report directly to the leader and to senior ministers. This all needs a revamp."
In the longer-term, governments are instructed to conduct yearly pandemic exercises to ensure they are ready for whatever comes their way. More money needs to be invested in health systems "grounded in high-quality primary and community health services, universal health coverage, and a strong and well supported health workforce, including community health workers".
"Covid-19 is the 21st century’s Chernobyl moment - not because a disease outbreak is like a nuclear accident, but because it has shown so clearly the gravity of the threat to our health and wellbeing. It has caused a crisis so deep and wide that presidents, prime ministers and heads of international and regional bodies must now urgently accept their responsibility to transform the way in which the world prepares for and responds to global health threats. If not now, then when?" the panel concludes.
"Our message for change is clear: no more pandemics. If we fail to take this goal seriously, we will condemn the world to successive catastrophes."
