The COVID-19 pandemic is the greatest global health crisis in at least a generation, and international organizations have responded accordingly. By building on measures initially developed to counter the 2014 Ebola outbreak in West Africa, the global community’s response has easily been the most multilateral public health campaign in human history.
By April 2020, for instance, the World Health Organization (WHO) had announced the Access to COVID-19 Tools (ACT) Accelerator, a program designed to help develop and improve access to diagnostics, therapeutics, and vaccines. Other international organizations quickly pioneered new ways to combat the pandemic’s economic impact. The World Bank approved plans to deploy an unprecedented $160 billion in capital, alongside an additional $50 billion in international development funding, and the International Monetary Fund played a vital role in coordinating economic resources for the response. These multilateral efforts are a far cry from the unilateral model used during previous disease outbreaks (the HIV/AIDS epidemic, to take one example). In many ways, COVID-19 marked an important step toward genuine international cooperation.
But even such unprecedented cooperation has been far from adequate to the challenge at hand. The international community has not responded as quickly and completely as necessary—highlighting just how much work remains to be done to set up a truly cooperative multilateral health system. It is now clear that the world needs a permanent institution—developed and maintained during “pandemic peacetime”—built specifically to counter the next outbreak. This global trust fund would have the resources, flexibility, and backing to quickly distribute aid, facilitate cutting-edge research, and accelerate the manufacture of lifesaving interventions. Without such action, the international community will be unprepared for the next, potentially more devastating pandemic.
MISSING THE MARK
International cooperation has fallen short in a number of vital ways. While multilateral efforts focused on vaccine development have been largely successful, the billions of dollars poured into vaccine research have not been matched with similar efforts to develop innovative diagnostic tools, therapeutics, and preventive measures. The international community has pledged $8.5 billion to COVAX—the international initiative designed to accelerate the development, production, and equitable distribution of COVID-19 vaccines—but only a combined $1.3 billion for diagnostics and therapeutics.
And even as the most well-funded part of the ACT-Accelerator, COVAX itself is also still severely underfunded. The UN estimated that as of April 2021, COVAX needed at least $2 billion in additional funding to reach its objective of delivering two billion vaccine doses by the end of the year. Today, COVAX has distributed only about ten percent of that goal. COVAX’s herculean efforts are, by its own admission, insufficient to address the challenge. This means that therapeutics and diagnostics will continue to be critical for the foreseeable future.
Perhaps most important, developing countries have not received adequate support for their health-care systems. In April 2020, The New York Times reported that ten African states had no working ventilators and that others such as Liberia had fewer than one machine per million people. The $300 million raised by donors for states in need, according to the Economist Intelligence Unit’s COVID-19 Health Funding Tracker, is insufficient to address these challenges.
Without action, the international community will be unprepared for the next pandemic.
Some observers consider such shortcomings inevitable in the midst of an unforeseeable “once in a century” pandemic. But that seemingly ubiquitous epithet obscures the fact that the world has dealt with plenty of pandemics more recent than the 1918 influenza outbreak. HIV/AIDS, for example, has existed as a persistent pandemic since the latter half of the twentieth century and continues to claim as many as one million lives per year. (As recently as 2017, the AIDS-related death rate in South Africa was nearly four times as high as the COVID-19 death rate in the hardest-hit U.S. state in July 2021.) HIV/AIDS also offers a powerful reminder that a truly global perspective on global health—one that acknowledges and properly weighs the experience of the global South—yields a very different pandemic narrative. With the advent of over 30 antiretrovirals approved by the Food and Drug Administration for HIV, significantly declining rates of new infections in the United States, improved treatments for comorbidities, and a corresponding improvement in life expectancy for HIV-positive individuals, Americans have come to believe that HIV/AIDS is no longer the raging pandemic that sub-Saharan Africans know it to be. The global South, by contrast, continues to feel the disease’s worst effects.
There have also been other global public health emergencies in the twenty-first century. COVID-19 is not even the first emergency of its kind; it is the world’s second major SARS outbreak in 20 years. Following the first epidemic in 2003, Gro Brundtland, then director general of the WHO, noted that “SARS is a warning. SARS pushed even the most advanced public health systems to the breaking point. Those protections held, but just barely. Next time, we may not be so lucky.”
It is also possible, if not likely, that pandemics will become increasingly common over the next century. Most travel industry experts expect that international travel and commerce will return to pre-pandemic levels, creating more opportunities for pandemics to spread. Also concerning are the impacts of climate change—particularly those that result in increased interactions between humans and animals that may carry novel pathogens. Groundbreaking studies have shown that deforestation, a major contributing factor to climate change, is intimately tied to many so-called zoonotic diseases. Scientists have shown, for instance, that many Ebola outbreaks originated in recently deforested areas. Like Ebola, COVID-19 is a zoonotic virus, as is SARS. In fact, approximately 75 percent of emerging infectious diseases are zoonotic.
Although the COVID-19 outbreak has been devastating, future pandemics—spurred on by rapid deforestation and climate change—might be even worse. The international community must begin to prepare for the next pandemic now.
A NEW WAY FORWARD
The global response to COVID-19, alongside the inevitability of future crises, demonstrates the need for a permanent institution—developed and maintained during pandemic peacetime— designed to counter the next outbreak. Although states may ordinarily lack the political will to build an organization that will sit in waiting until the next pandemic, the current political climate presents a unique opportunity to act.
The right model for such an organization is a permanent global trust fund—essentially an insurance policy against large disease outbreaks. This body would have the financial resources, dexterity, and programming required to fight future global pandemics, especially those that disproportionately impact low-income countries. Much like those of a fully realized version of the WHO’s ACT-Accelerator program, the trust fund’s mission and structure would comprise a number of different tools: a mechanism to distribute emergency aid to countries hit hardest in the early days of a pandemic; channels to rapidly distribute supplies; and the means to facilitate research into diagnostic equipment, therapeutics, and vaccines, then quickly manufacture and distribute these new tools.
The trust fund’s governance structure would be similar to that of other large global health initiatives, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria and Gavi, the Vaccine Alliance—both created by major governmental and nongovernmental global health donors to combat infectious diseases. Like these two existing organizations, the trust fund would be governed by an independent board with seats reserved for various member states and constituencies. Some seats would be set aside for specific countries or regions, both to ensure that major contributors feel they have sufficient input and to guarantee that developing states have an impact on the trust fund’s direction. Member states, collections of states, and regions with reserved seats would each be free to develop a nomination process of their own choosing. The trust fund’s board would also include reserved seats for the community of nongovernmental organizations (NGOs), the private sector, and international organizations. The WHO would assume a dual role within the fund, with both a reserved board seat and independent oversight capacity. (The latter could take the form of an annual report and hearing delivered at the World Health Assembly on the trust fund’s activities.)
Future pandemics—spurred on by rapid deforestation and climate change—might be even worse than COVID-19.
In most similar organizations, scientists and experts are represented on a specific advisory committee. Although such a committee should exist at the trust fund to provide an ongoing source of independent scientific deliberation, the role of scientists must be greater. The COVID-19 pandemic has highlighted the particular necessity of scientific leadership in both policymaking and public opinion. Scientists should therefore have representation on the fund’s voting board, with two board seats reserved for experts (one for a basic scientist with research and development expertise and another for a life or social scientist with a specialization in population health).
The trust fund would be funded through an insurance pay-in system, with each country contributing in proportion to its capacity. There are multiple models that the trust fund could emulate. One, the ASEAN-UN Joint Strategic Plan of Action on Disaster Management, was founded by the Association of Southeast Asian Nations and the United Nations in response to a series of natural disasters in Asia, beginning with the 2004 Indian Ocean earthquake and tsunami that claimed more than 225,000 lives. Commonly known as JSPADM III, the plan outlines an approach for responding to future disasters and relies on three sources of funding: cost sharing between ASEAN member states, private-sector investment, and partnerships with venture-oriented companies. Such a model could be ideal for the trust fund. Indeed, private-sector investment in pandemic prevention would be a natural extension of existing efforts in the biotechnology sector. Given the devastating impact of COVID-19 on the private sector, moreover, businesses may be eager to get involved during pandemic peacetime.
NATO’s in-kind giving model—where states provide specific resources rather than funding—could be another useful addition to the trust fund’s financial structure. By analogy, the fund could seek indirect contributions such as supplies, data, and personnel from participating states to support its monitoring, surveillance, and contact-tracing capabilities. Such a system would help less developed states make use of the fund’s advanced infrastructure and facilitate coordination between national, international, private-sector, and trust fund resources.
Above all, COVID-19 has made it clear that a trust fund must serve as a collective security system against a truly global threat. Even though the cost-sharing model might place the organization’s financial burden primarily on wealthy and well-protected states, COVID-19 has demonstrated that all countries’ fates are intertwined during a pandemic. Even with a relatively high vaccination rate in the United States, for instance, low immunization rates in other countries enabled the emergence of new variants, such as the highly transmissible Delta variant—the dominant strain of COVID-19 in the United States today. Other potentially vaccine-resistant strains seem possible. In the aftermath of COVID-19, cost sharing will seem a reasonable price to pay for collective pandemic security.
SOUNDING THE ALARM
Once the trust fund is established, funded, and staffed, the organization will need to determine when to mobilize its resources. That decision should be based on a monitoring system similar to a reformed version of the WHO’s Public Health Emergency of International Concern program. Like the PHEIC, this warning system would accept reports from states and NGOs. A committee of experts would evaluate the data. The trust fund, however, would depart from the PHEIC in several critical ways.
Unlike the WHO’s current system, the trust fund’s monitoring program itself would actively collect data on potential pandemics, rather than relying on data provided by states. Early detection, even if it leads to some false alarms, is crucial to containing new outbreaks and saving lives. Indeed, overinclusion is desirable at this stage. Still, not all states are fully equipped to monitor potential outbreaks. Although low- and middle-income countries have made notable improvements in this regard, more needs to be done. The trust fund could fill this gap through independent surveillance or by mobilizing some of its R & D capacity to develop cost-effective tools for less developed states. The trust fund could, for example, capitalize on innovative efforts to democratize infectious disease surveillance through self- and community-based reporting. Such techniques would be helpful both in low-income countries and when a state intentionally fails to accurately share public health data.
The trust fund would also monitor animal health—another point of departure from the WHO’s current system. Some innovative programs, such as one in Sri Lanka that relies on a mobile phone app used by frontline veterinarians, already track data on infectious diseases within animal populations, but they should be scaled up to track potential pandemics to their origins.
The trust fund would have the financial resources, dexterity, and programming required to fight future pandemics.
Finally, and perhaps most important, the trust fund’s monitoring system would differ from the WHO’s existing binary classification method (either a PHEIC or no warning at all). Instead, the trust fund should utilize a tiered warning system akin to those used to measure the risk of a terrorist attack or a tsunami. This would include pre-pandemic warning levels that account for the immediacy of a threat. The system would also provide tailored warning levels for different geographic regions.
A tiered warning system would serve both as a surveillance tool and as a method for prescription that could help guide the trust fund’s deployment of resources. The lowest tier of the system, marking a very early pre-pandemic warning, would likely trigger increased monitoring and contact tracing, R & D expenditures on therapeutics, and aid to low-income countries that might be most immediately at risk. But as a public health threat rises through the tiers of the system, so too would the scope and scale of the measures. As the danger increases, R & D for therapeutics and vaccines would increase proportionately. Emergency aid to low-income states would begin and expand as quickly as possible. Finally, at the last stage of the warning system, the trust fund would fully deploy all of its tools.
The tiered system would also provide guidance to states on how to best participate in the trust fund’s efforts. The COVID-19 pandemic demonstrated that there were many states that wanted to take action but did not know how to respond most effectively. The tiered system would provide a clear road map for states and other international organizations, from mitigation tactics through vaccine rollouts. Through these blueprints, the trust fund would be able to influence relevant national precautions—including domestic funding, travel restrictions, and isolation measures—even if it didn’t have direct authority over them.
SEIZE THE MOMENT
With the political will to prepare for future pandemics at an all-time high, now is the moment to form the trust fund. A good place to start would be with a founding conference, much like the one that then World Bank President James Wolfensohn called in 1998 that led to the founding of Gavi. That conference brought together states, UN agencies, international organizations, private-sector firms, and charitable foundations.
By following that blueprint, the trust fund would harness support from a variety of constituencies. This path forward requires strong global leadership from superpowers and international organizations alike. Gavi, the Global Fund, and other past initiatives with structures analogous to the trust fund all relied on assistance from the UN secretary-general, support from leaders of other organizations, and the full backing of many G-7 member states. Today, the United States is particularly well situated to lead. The country suffered disproportionately during the COVID-19 pandemic, and Washington is seeking to reset its engagement with the international community.
Brundtland’s warning in the aftermath of the SARS outbreak 20 years ago remains relevant today. The world will not have to wait another century before the next pandemic, and the next one could ravage the developing world even more severely. If COVID-19 has taught the international community anything, it is that reflexive emergency measures such as the ACT-Accelerator and COVAX are commendable but insufficient to meet the challenge. The trust fund for pandemics is the long-term solution we need.