Don't say nobody warned us

By Roberto Bissio^*

The message could not have been clearer: "There is a very real threat of a rapidly moving, highly lethal pandemic of a respiratory pathogen killing 50 to 80 million people and wiping out nearly 5% of the world’s economy. A global pandemic on that scale would be catastrophic, creating widespread havoc, instability and insecurity.”

This prediction was published in September 2019, several months before the identification of the first Covid-19 patient, by Gro Harlem Bruntland, former Prime Minister of Norway and former Director-General of the World Health Organization (WHO), and by Elhadj As Sy, Secretary General of the International Red Cross and Red Crescent, as co-chairs of the the Global Preparedness Monitoring Board. The Board's report entitled A World at Risk was conclusive: "The world is not prepared."^**

The Board defines itself as an “independent monitoring and advocacy body” and is made up of thirteen other prominent people, including the highest officials in charge of controlling epidemics in China and the United States, George Gao and Anthony Fauci. The Board was co-convened by WHO and the World Bank in 2018 "to prepare for and mitigate the effects of global health emergencies" based on the experience of the Ebola epidemic of 2014-16.

The need to prepare for an impending catastrophic pandemic did not arise from a crystal ball, but from the analysis of "a combination of global trends", including "insecurity and weather" derived from climate change. Among the "amplifiers", "population growth and resulting strains on the environment, climate change, dense urbanization, exponential increases in international travel and migration, both forced and voluntary, increase the risk for everyone.”

The Board concludes that "the world needs (...) to detect and control potential disease outbreaks." But an analysis of the previous high-level groups and commissions established after the 2009 H1N1 flu pandemic and the Ebola outbreak shows that their “recommendations were poorly implemented, or not implemented at all," leading to a cycle of panic and neglect: "When it comes to pandemics: we ramp up efforts when there is a serious threat, then quickly forget about them when the threat subsides."

Between 2011 and 2018, WHO tracked 1,483 outbreaks in 172 countries. The Board observes that “potentially epidemic diseases such as influenza, severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), Ebola, Zika, plague, Yellow Fever and others,  are harbingers of a new era of high-impact, potentially fast-spreading outbreaks that are more frequently detected and increasingly difficult to manage.” In this context, the forecast was that the poor would suffer more, because those "without basic primary health care, public health services, health infrastructure and effective infection control mechanisms face the greatest losses, including death, displacement and economic devastation.”

This emphasis of the Global Preparedness Report on public health services is particularly striking if it is noted that both the World Bank - co-sponsor of the Board - and the Gates Foundation, represented on the Board by Dr. Chris Elias, president of the World Development Program, have been active advocates of public-private partnerships in health (PPPs) and have undermined universal public services. They favoured instead focused attention on the poorest and on specific diseases, such as malaria or Ebola, but at the cost of the dismantling of generic health systems.

The World Bank actively promotes Private-Public Partnerships in the health sector, a model initiated in Brazil through the construction firm Odebrecht. The global health alliances actively promoted by the Gates Foundation, in turn, are too focused on silo approaches and deviate attention and resources from public health as a system. The Board finds out, for example, that “the Global Polio Eradication Initiative has (…) focused on poliovirus detection and identification, but this capacity is not leveraged sufficiently for broader health monitoring”. Whereas polio assets have supported other outbreak preparedness efforts (as seen with the outbreak of Ebola in Nigeria in 2014-2016), capacities are threatened, as funding will predictably wane once polio eradication is achieved.”

The influence of the Gates Foundation on global health policies is enormous. Gates is the second largest contributor to WHO (after the United States) and the leading funder of health "alliances" such as GAVI, focused on vaccination.

In one of the few available studies on the role of this philanthrocapitalism in health, Nicoletta Dentico, from Health Innovation in Practice and Karolin Seitz. of the Global Policy Forum, concluded that "the productivist and free-market vision that drives the key players in the philanthropic sector has helped shape up a new political culture skewed toward the commodification and medicalization of both health and food.” This approach is characterized by "lack of accountability mechanisms; public-private partnership (PPP) model; continued decline of the public sector and government responsibility for the provision of public goods and services; and lack of transparency.”

With an admirable sense of self-criticism, the Board itself recognized in its 2019 Report on Global Preparedness that “entities providing funding and programmatic support for countries, such as the Global Fund to Fight AIDS, TB and Malaria (Global Fund) and Gavi, do not explicitly include prevention and preparedness to achieve broader health security.”

The Board especially recommends that women be included in decision-making since “the majority of both formal and informal care givers are women" and the engagement of the community, something that "fundamentally lacking” across all aspects of preparedness planning and response.

The World Bank estimated that a global influenza pandemic akin to the scale and virulence of the one in 1918 would cost the modern economy US$ 3 trillion, or up to 4.8% of gross domestic product (GDP); the cost would be 2.2% of GDP for even a moderately virulent influenza pandemic”.

Faced with such an economic threat, it was estimated that most countries would need to spend on average between US$ 1-US$ 2 per person per year to reach an “acceptable level of pandemic preparedness”. According to the Board, “a yearly investment of US$ 1.9–3.4 billion to strengthen animal and human health systems would yield an estimated global public benefit of more than US$ 30 billion annually (47), a return on investment of 10 to 1 or higher.”

How is it possible to prepare for the unexpected? The Board understands that the effective, accessible and efficient local health systems delivering primary health care, and mental health and psychosocial services essential for prevention will also yield multiple benefits beyond preparedness, including infectious disease prevention and control, better health outcomes and increased community trust, as well as surge response capacity.” The Republic of Korea, for example, managed to contain what could have been a second MERS outbreak in 2018, and this experience informed Korea's comparative success against Covid-19.

But South Korea was the exception rather than the rule, and the coronavirus found national and global health systems unprepared. In early February of this year, with the epidemic already declared, the WHO asked for $676 million to be disbursed between March and April to stop the spread of the new virus and support countries with weaker health systems. It only received $15 million from the United Nations Central Emergency Response Fund (CERF). As this is far from enough, WHO, together with the United Nations Foundation, created the Solidarity Response Fund COVID-19 (www.COVID19ResponseFund.org), a crowdfunding website that collects individual donations.

Meanwhile, the World Bank announced a first $12 billion package of measures against COVID-19, aimed primarily at strengthening health systems and supporting the private sector to cope with the economic consequences of the crisis. The International Monetary Fund (IMF), for its part, has announced that it will provide up to $50 billion in emergency funds to low- and middle-income countries.

Such funds are far from impressive, if you remember that a single country, Argentina, received $45 billion last year in a failed attempt to contain the economic collapse. And furthermore, as shown by the United Nations Conference on Trade and Development (UNCTAD) in 2018, the total debt (public and private) of developing countries before the crisis was already double their gross domestic product, a record high.

Lack of foresight in the face of the announced pandemic is forcing governments around the world to resort to extreme and innovative sanitary measures. The looming debt crisis is now also calling for foresight, leadership and innovation. And who will dare argue that there was no warning?

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