This week, the World Health Assembly (WHA), the governing body of the World Health Organization, is grappling with how best to prepare for and ideally prevent future pandemics. The WHA is taking as its starting point recommendations from the Independent Panel for Pandemic Preparedness and Response, which issued its findings earlier this month. The report is toothier and more specific than prior comparable commissions but has also generated debate over if and how to create a global governing body for pandemic action.
There are important lessons here from the global fight against HIV. Twenty years ago, the impossible became the inevitable due to the creation of a fund similar to what is now under discussion. Conventional technocrats said AIDS drugs were too complex and costly and health systems too weak for the medications to be widely distributed in low-income countries. Both of us began our careers around that time, joining a transnational movement of people living with and impacted by the deadly virus.
Against this dismal calculus, the movement sought—and won—multibillion-dollar annual investments. These came via the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) program and the Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM), a multilateral fund for community-led efforts to fight the three diseases. These funds were a moral necessity and the only sane response to a public health crisis gripping the globe. Although precise attribution to PEPFAR and GFATM is difficult, over the past two decades, it is estimated that GFATM has helped save 38 million lives while PEPFAR has saved an additional 20 million lives.
Today, the world is struggling with the question of preventing the next pandemic—and each time the question is raised, we think of the Global Fund. In March, the U.S. House Foreign Affairs Committee took the first steps, passing a bill out of committee envisioning a new pandemic-orientated fund akin to GFATM. U.S. President Joe Biden’s initial budget request, including $800 million for global health security, included a portion targeted at a catalytic health security financing mechanism. Since then, 120 members of the House of Representatives have endorsed the new fund, including a majority of House Democrats, and they have written a letter to Biden urging him to include at least $2 billion in seed funding in his budget.
The $2 billion in proposed seed funding, however, is a bare minimum and is largely focused on helping countries meet the costs of fulfilling International Health Regulations (IHR). IHRs were designed and adopted as a global to-do list for disease outbreak containment, and expanding adherence is a key priority. McKinsey & Company estimated initial investments of $85 to $130 billion over the next two years, followed by annual investments of $20 to $50 billion, are needed globally to put surveillance and response systems in place to drastically reduce the risk of future pandemics. The size of the investment may seem like the most salient feature—and indeed a massive, audacious expenditure is required. But money alone won’t prevent or contain future pandemics. The structure, mandate, and home of the new fund are immensely important.
But to be truly successful, there are two critical lessons to be learned from GFATM. First, prevention must be expanded to include addressing the root cause of many outbreak pathogens: environmental degradation. Second, GFATM’s successful governance model, which includes communities of those most impacted, should be incorporated into the managing of any future fund.
The GFATM shows that a narrow focus on biomedical solutions—diagnostics and medicines—does not end or prevent pandemics. A pathogen spreads from one person to another; a pandemic spreads through a broken system. Outbreaks emerge from the grievous wounds in the planetary ecosystem. In spite of attempts at a holistic approach, prevention has struggled to make a dent in the HIV pandemic. In 2019, there were 1.7 million infections compared to 2.1 million infections in 2015, an important but insufficient improvement.
Any new fund needs to define and fund a comprehensive approach to prevention. It should eschew a narrow focus on interventions focused solely on human health and disease surveillance, and it should ensure pandemic prevention is understood as also requiring direct action reversing the types of environmental degradation that have driven the overwhelming majority of new disease outbreaks.
The disease that causes COVID-19 is the result of zoonotic spillover from animals into humans. In 2010, there were six times more zoonotic spillover events than in 1980. And zoonotic diseases account for 60 percent of emerging infectious diseases, most of these originating in wildlife. Remarkably, there is a question that pits prevention of spillovers against investments in human health. Such a binary view cannot succeed. The new fund must focus on environmental and climate interventions needed to stop new outbreaks from ever occurring while also building resilient health systems to address them when they do.
In addition, GFATM provides lessons on how to govern a successful fund and how donor-funded interventions can be rooted in and owned by communities and developing countries. Today, there is a consensus on funding country plans to meet IHRs, but there is less attention paid to who plans, monitors, and implements that essential work. When GFATM was launched almost 20 years ago with the mantra “nothing about us without us,” people living with HIV from around the world and others most impacted by AIDS, tuberculosis, and malaria took their places at the decision-making table in countries and boardrooms—and never left.
To be effective, the new fund must have people living with “long COVID-19,” essential worker representatives, communities heavily impacted by infectious diseases, and health workers on the board and serving as technical experts while also helping to devise country plans. Without community cooperation and the heroic dedication of health care workers, no outbreak response can be successful. Outbreaks start and end in communities, and inclusion of these groups from the beginning will create buy-ins and provide front-line knowledge.
Health in Harmony provides a successful model of improving human health while healing the planet. The organization works with Indigenous people in Indonesia, Brazil, and Madagascar to build skills and shift local contexts. Critically, this work starts by radically listening to these communities that universally do not want to be cutting down the forest but do so due to a lack of other options. Their model is proven by data: In Borneo, working with the community to shift from deforestation-based activities to health care and organic farming has improved health outcomes, saved millions of dollars in carbon, and not only stopped deforestation but reversed it.
Such a fund is not impossible provided that a mobilized, enraged, and grieving civil society demands action. The new Prevention and Public Health Fund must be fully funded at the upper levels of estimated need. It must fund country compliance with IHRs and have a governance structure that reflects the expertise and priorities of the people most impacted by pandemics. And it must incorporate a comprehensive definition of pandemic prevention inclusive of ecological and health interventions into its mission and mandate. If these criteria are not met, then it is quite possible no amount of money will stave off the next global crisis. If they are, the goal of ensuring nothing like COVID-19 happens again could be within reach.
