Political courage needed to prevent the next pandemic

In May, 2021, The Independent Panel for Pandemic Preparedness and Response, in which most of us were involved, recommended a package of transformational but practicable recommendations that, if implemented, could make COVID-19 the last pandemic of such devastation.1 But 3 years later, only limited progress has been made. Political leaders need to unite now in the mutual interest of making the world safe from evolving pandemic threats.

We are closely watching the evolution of the latest outbreak of highly pathogenic avian influenza (HPAI) A(H5N1) in cattle in the USA. In 2024 (as of May 30), there have been ten reported cases of human infection with HPAI A(H5N1) globally, with three of these in the USA following exposure to infected dairy cows.2 Discovered almost three decades ago, since 2003 health authorities have reported 891 human cases of infection with HPAI A(H5N1), with half of the infected individuals dying.3 Although the risk of transmission to the general public remains low,4 alarms are now raised due to a surge in infections in multiple mammal species that has increased the risk of virus mutation and a leap to sustained transmission between people.5 HPAI A(H5N1) could potentially kill millions of individuals worldwide. The world is not ready to protect people and prevent a pandemic as too many gaps in the system remain.

The new report of the former Co-Chairs of The Independent Panel for Pandemic Preparedness and Response, No Time to Gamble: Leaders Must Unite to Prevent Pandemics, details the gaps and what must be done now to fill them,6 including a proposed roadmap to strengthen pandemic preparedness and response in the next year (panel).

In considering the threat of avian influenza A(H5N1) people turn immediately to the question of vaccine availability.7 Pandemic influenza vaccine manufacturing has increased in the past two decades,8 but still falls short of what will be needed in a pandemic. A best case scenario estimates that up to 8 billion doses could be manufactured in 1 year, with a more realistic scenario of just over half that many.9 Each person needs two doses, cutting the effective coverage of 1 year’s production to a quarter of the world’s population.9

Panel: A roadmap to strengthen pandemic preparedness and response in the next year

June, 2024

• A pandemic agreement: after not finalising negotiations at the 2024 World Health Assembly, the Intergovernmental Negotiating Body process resumes with new ways of working, and the inclusion of independent experts including civil society, and will conclude by December, 2024, with an effective agreement that has equity at its heart.

September, 2024

• A Champions Group to Prevent Pandemics is formed and declares their commitment to continued advocacy, including to a successful pandemic agreement, to finance and equitable access to countermeasures; and to rally a strong response in times of health crises.

October, 2024

• The Global Preparedness Monitoring Board is made fully independent and delinked from WHO; or a new independent pandemic preparedness and response monitoring panel similar to the Intergovernmental Panel on Climate Change is established.

November, 2024

• A successful pledging for The Pandemic Fund of nonoverseas development assistance.
• South Africa G20 Presidency prioritises converting The Pandemic Fund into a preparedness and surge mechanism with a global public investment model in 2025.
• Brazil, South Africa, and other middle-income countries use opportunities such as the G20 to negotiate to a move away from a charity model for medical countermeasures access and towards one of regional innovation centred on resilience, knowledge, and technology sharing.
• WHO member states meet the milestones for WHO’s investment round and repledge to meet targets for unearmarked funding.

January, 2025

• WHO member states initiate a one-term approach for the WHO Director-General and Regional Directors, and WHO to actively work with member states to depoliticise senior appointments.

June, 2025

• The amended International Health Regulations are fully implemented, including with new multisectoral national authorities with engagement of civil society organisations.

Who would get access to vaccine doses first? Despite efforts to expand manufacturing sites,8 today most influenza vaccine manufacturing still occurs in a small number of high-income counties.9 We have learned from the COVID-19 pandemic that national governments will work first to protect their own populations and that governments with the money can advance purchase the most vaccines. This approach is not fair, equitable, or rational on public health grounds, but it is the reality. Initiatives such as the Pandemic Influenza Preparedness, or PIP framework, are likely insufficient to rebalance this equation.10

Beyond vaccines, access to diagnostics, treatments,11 and personal protective equipment will also be crucial to stop outbreaks and for pandemic response. Having clarity on where these countermeasures reside, who has stockpiles, and who does not is essential, yet today this information is not transparently available.

Therefore, there is still much work to do—starting today—to ensure every region is on a path towards self-sufficiency with its own research, development, and manufacturing capacities for vaccines, diagnostics, and treatments. Technology and knowledge transfer remain an imperative, with freedom to operate in crises. Monoclonal antibodies are particularly appealing as potential therapeutics for emergency use for viral infections generally.12 Ensuring this self-sufficiency will take time, but if investments are not expanded and accelerated now, lower-income countries will continue to rely on charity, which will continue to fail to deliver fully and equitably.

Next, finance must be approached differently. Pandemic preparedness and response is a global public good, and pandemic countermeasures should be managed as part of the global commons. There is not yet nearly enough rapidly accessible finance in place to offer the billions in day-zero surge funding to countries that need to shore up their economies, offer social protections, and purchase emergency supplies during a crisis. G7 finance ministers, several development financial institutions, and others have also called for this,13 but it must be done now.

Meanwhile, preparedness financing continues to fall woefully short of the additional US$10–15 billion plus a year required.14 Yet sufficient funds can be raised and fair governance achieved—with a global public investment model, whereby every country contributes to the fund according to an ability-to-pay formula and every country withdraws according to its needs for preparedness and response. The G20 must transition The Pandemic Fund into such a mechanism.

The next gap is in trust. If an influenza outbreak or pandemic occurred, physical distancing and the use of masks and other non-pharmaceutical measures would likely be required to protect lives until medical countermeasures were adequate and equitably distributed.15 Which citizens would comply, and how many would fight such measures? How many would reject vaccination? Governments must invest today to bring societies closer together and build trust, including investments in policies16 and community driven strategies to counter the misinformation and disinformation created by well-funded groups who thrive on societal division.

At the global level, there is still no sure way to bring governments together to take responsibility to prevent and respond to pandemic crises. As with the COVID-19 pandemic, another pandemic would affect every sector and segment of society. The UN Secretary-General’s proposed Emergency Platform for complex global shocks17 could have this role by enabling a multilateral, multisectoral coordinated response to crises such as pandemics. The UN Summit for the Future in September, 2024 is an opportunity for countries to agree this and provide the platform with a mandate to not only respond to, but also prepare for and ideally prevent, crises from occurring.

The amended International Health Regulations (IHR) adopted at the 77th World Health Assembly in 202418 offer promising new directions for faster information sharing, including from countries that do not wish to collaborate. These regulations will not come into force for a year, but pandemic threats will not wait for the formal procedures of WHO and governments worldwide. To make us all safer, countries must take the decision to abide by the amended IHR today.

Despite the amendments to the IHR, gaps remain in the rules for widespread collaboration to prevent pandemics. Countries must come together to conclude negotiation of a pandemic agreement, with equity at its heart, before the end of 2024. This work must include a pact that guarantees equitable distribution of pandemic countermeasures for public health needs during crises. The premise of some vocal people and politicians— that the proposal to contribute to a WHO medical countermeasures stockpile would rob people of their rightful share of diagnostics, vaccines, or treatments— deserves re-evaluation.19 Pathogen access and benefitsharing should result in a WHO-coordinated stockpile that ensures medical countermeasures are directed towards people most at risk in real-time in a public health emergency, no matter which country they live in. The proposed stockpile is not a set aside from people in one country for people in another, it is a way to reduce risk for all people in all countries.

Global and regional organisations and governments must also continue to strengthen our understanding of country preparedness, including why preparedness metrics failed to predict country responses to COVID-19 and why—despite many data and many dashboards— it is so hard to determine if countries are prepared. Evidence and agreement are needed on a robust set of indicators that extend beyond health.20 The establishment of an independent monitoring body is another crucial step to understand the true state of preparedness.21

What does it take to prepare for and prevent a pandemic? It takes political leadership. Yet the leadership witnessed during COVID-19, from the Presidents and Prime Ministers who led science-informed national responses,22 to the global convenings and summits, have all but receded from view. Where is that leadership today?

Estimates suggest a 40–53% probability the world might face another pandemic of the magnitude of COVID-19 in the next 25 years.23 H5N1—or a new emergent pathogen— could cause widespread devastation next month, or next year. The insufficient action from political leaders is a gamble with all of our futures. Why gamble, when there are readily available solutions? In a world beset by complex problems, averting another pandemic is one challenge that can be solved. Why would leaders make any other choice?

HC and EJS are former Co-Chairs, and MC, MD, MK, JL, DM, and TAO are former members of the Independent Panel for Pandemic Preparedness and Response; AN is former head of the Panel secretariat; RM, CM, RP, ER, and GW are advisers and former advisers to the Panel Co-Chairs and members; and HEM is a consultant for the former Panel. The continued work of the former Independent Panel is supported by a grant from the Bill & Melinda Gates Foundation administered by Panorama Global and AN, HEM, CM, RM, and GW report consulting fees from the project. MD reports grants from the Hilton Foundation to support Africa Pandemic Champions Commission on PPR and travel support to attend a meeting from the Swedish Government. MK is a member of the data safety monitoring board for the MTBVAC TB vaccine trial and is an independent board member of ExeVir. HEM is Director of HEM Consultancy that provides consulting services within the global health and international development sectors and reports consulting fees from Panorma Global, Barcelona Institute for Global Health, the European Association for the Study of the Liver, GBCHealth, and the United Nations University-IIGH. RP is President of Raj Panjabi, LLC, which provides consulting services to medical and bio-technology companies; he is on the boards of Last Mile Health, the WHO Foundation, Biotia, Biophy, Skoll Foundation, the Bipartisan Commission on Biodefense, and owns stocks in Biotia and Biophy. HC, MC, JL, DM, TAO, ER, and EJS declare no competing interests.

*Helen Clark, Mauricio Cárdenas, Mark Dybul, Michel Kazatchkine, Joanne Liu, Henry E Mark, Rosemary McCarney, Christine McNab, David Miliband, Anders Nordström, Thoraya Ahmed Obaid, Raj Panjabi, Elizabeth Radin, George Werner, Ellen Johnson Sirleaf

The Helen Clark Foundation, Auckland 1010, New Zealand (HC); Centre on Global Energy Policy at Columbia University, New York, NY, USA (MC); Georgetown University, Washington, DC, USA (MD); Global Health Center, Graduate Institute of International and Development Studies, Geneva, Switzerland (MK); McGill University, Montreal, QC, Canada (JL); Independent Consultant, Nottingham, UK (HEM); University of Toronto, Toronto, ON, Canada (RM); Independent Consultant, Toronto, ON, Canada (CM); International Rescue Committee, New York, USA (DM, ER); Department of Global Public Health, Karolinska Institute, Solna, Sweden (AN); Independent Consultant, Riyadh, Saudi Arabia (TAO); Harvard Medical School and Brigham & Women’s Hospital, Boston, USA (RP); Independent Consultant, Monrovia, Liberia (GW); Ellen Johnson Sirleaf, Presidential Center for Women and Development, Monrovia, Liberia (EJS)

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