A panel at the World Health Summit reflects on pandemic preparedness in the 21st Century
Every month thousands of public health threats are detected in countries around the world, each signaling the possible start of a disease outbreak which, if not addressed rapidly, could potentially spiral into an epidemic or pandemic with vast social and economic costs. In the past two decades, outbreaks of SARS, H1N1, MERS, Ebola and Zika have forced the global community to grapple with what it takes to identify and contain deadly outbreaks in an age of unprecedented interconnectedness. Since the 2014-15 Ebola outbreak in West Africa, which led to more than 11,000 deaths and billions in economic losses in the three affected countries, great progress has been made in improving pandemic preparedness, not least in the area of financing. But does this mean that the world is ready for the next ‘big one’?
On October 15, experts from academia, international and regional health organisations, the private sector and development cooperation came together at the World Health Summit in Berlin to take stock of pandemic preparedness in the 21st century. The panel discussion, which was moderated by Peter Piot, the director of the London School of Hygiene and Tropical Medicine, was co-organised by Germany’s Federal Ministry of Economic Cooperation and Development (BMZ) and the Kreditanstalt für Wiederaufbau (KfW) development bank.
New systems and products are causes for optimism
The panel kicked off with an input from Peter Salama, the Deputy Director General for Emergency Preparedness and Response at the World Health Organisation (WHO), who described in concrete terms what a rapid global response now looks like. If a formal risk assessment of an emerging threat deems that follow-on action is needed, WHO activates an incident management system. Within 48 hours, people, cash and supplies are on the ground in the country in question, and the United Nations and the humanitarian system are on standby that a broader response may be needed. By the end of the first week, regional and international partnerships, such as the Global Outbreak Alert and Response Network (GORN), are activated; there is a costed action plan for tackling initial priorities; preparedness has been assessed in neighbouring states; more human resources and supplies are available in country; and an investigation into vaccines and therapeutics has begun.
Salama went on to note that the current Ebola outbreak in North Kivu in the Democratic Republic of Congo is the ‘single biggest test of all those we’ve faced in recent years.’ Despite incredible complexities – a high-threat pathogen spread over a large territory, armed conflict, a highly mobile population, the presence of international borders and an upcoming election – there is also cause for optimism, according to Salama. ‘In addition to traditional response measures, we’re using products, systems and innovations we’ve never been able to use before,’ he explained. New investigative products, including four therapeutics and the Ebola vaccine developed by Merck, are being used at scale for the first time.
Pandemic insurance offers fast financing for inevitable risks
Another area where notable progress has been made is in the financing architecture for pandemic response. Although disease outbreaks are an inevitable risk, there was previously never a reliable way to ensure that funding for pandemic response was available quickly in times of need. This is now changing. Tim Evans, the Senior Director for Health, Nutrition and Population at the World Bank, described the features of the World Bank’s new Pandemic Emergency Financing Facility (PEF), which was developed by the World Bank together with the WHO and private sector partners. Germany, through BMZ, contributes to the PEF.
The ‘insurance window’ of the PEF, which launched in July 2017, makes funding available for six specific diseases which are likely to cause major epidemics. Payments are made within days of an outbreak reaching a pre-defined level of severity. A complementary ‘cash window,’ which was launched this year, allows resources to be made available in a flexible manner for outbreaks which do not meet the criteria for the insurance window. In May 2018 the PEF closed a $12 million gap in funding for the ninth Ebola outbreak in DRC; the funds were disbursed to WHO and UNICEF within 24 hours. ‘There is a lot more maturation ahead of us,’ said Evans, ‘but the broader financial architecture is now such that the likelihood of outbreaks spiraling into pandemics is decreasing.’
The African Union is also developing an insurance product which aims to support its member states to respond quickly to disease outbreaks by making catalytic funding available. Robert Agyarko, the Lead Advisor with African Risk Capacity (ARC), an agency of the AU specialising in disaster risk with support from KfW and other partners, described how ARC is working with countries which lie in the risk zone for Marburg, Ebola, Lassa and meningitis. ARC helps them better understand the outbreak risk that is going to be insured, to assess their plans and capacities, and to model what it would cost to respond to various outbreak scenarios. The product which ARC is developing, which should be ready by 2020, will complement instruments like PEF. ‘There are some big players on this market already,’ said Agyarko, ‘but just because there is a fire station next door doesn’t mean we shouldn’t have a fire extinguisher in the house.’ ARC’s added value is its commitment to promoting regional and country ownership of epidemic response.
Collaboration is critical for strengthening health systems…
The importance of regional collaboration was also highlighted by Stanley Okolo, the Director General of the West African Health Organization (WAHO). WAHO works to strengthen networks and technical collaboration between West African states on the assumption that responses to disease outbreaks will be quicker and more effective when countries support one another. Strengthening the surveillance infrastructure across the region, including laboratory networks, is a major area of focus at present. With support from Germany through KfW, WAHO is improving the capacities of regional and national reference laboratories and encouraging them to work together outside the context of disease outbreaks. ‘We have the laboratories collaborating now on anti-microbial resistance,’ explained Okolo. ‘This gets them talking to each other and makes them more functional at a time when there is no epidemic underway.’
Marjeta Jager, the Deputy Director General at the European Commission’s Directorate-General for International Cooperation and Development, also touched upon the need for collaboration among different types of actors to strengthen pandemic preparedness. ‘The key to preparedness is having strong national health systems in place when crises hit,’ Jager said. ‘This means we have to strengthen all aspects of health systems from qualified health care workers and affordable medicines to adequate financing of the sector as a whole.’ National governments, private sector companies, international organisations, multilateral and bilateral development partners all have roles to play here. ‘The main word is collaboration,’ said Jager. Sustainable and resilient health systems will only come to pass if we work together on the regulatory, financing and implementation side.
… and for developing new vaccines against deadly infectious diseases
Paul Stoffels, the Chief Scientific Officer of Johnson & Johnson, described how intensifying collaboration between public, private and philanthropic organisations is leading to incredible progress in the development of vaccines to stop diseases with the potential to become epidemics. ‘If you want to control a pandemic, you have to start thinking a long time in advance,’ he explained. ‘Efforts to develop the Ebola vaccine we have now didn’t start after the West Africa outbreak in 2014, but 10 years before that,’ when the United States government designated the Ebola virus as a potential security threat. This catalysed critical early funding, research and collaboration and laid the groundwork for pharmaceutical companies to develop and run vaccine trials which resulted in the Merck vaccine. The existence of validated vaccine platforms makes it realistic to develop high-quality, globally approved products and get them to market within as little as 12 to 18 months. ‘All of us are an essential part of combatting these pandemics,’ Stoffels said. ‘Ebola is a good test case. Let’s be prepared for the next one.’
All this progress comes to nothing if communities lack trust
While very positive progress has been made in recent years, all the financing, epidemiological capacity and vaccines in the world will not stop disease outbreaks from becoming epidemics if members of affected communities do not trust in and engage in outbreak responses. Tim Evans of the World Bank linked the rejection of response measures in some communities to a ‘fundamental underinvestment’ in people and their opportunities for health, education and livelihoods. ‘When going to the health center means emptying your pockets, or dying rather than getting better, you are sowing the seeds of chronic distrust,’ he said. In this respect pandemic preparedness represents a critical opportunity not just to strengthen preparedness and response, but health systems more broadly.
Peter Piot concluded the session by noting that ‘we will never be able to prevent outbreaks, but we can prevent them from becoming big epidemics.’ Building robust systems is key, but ensuring the trust of communities is just as important.