The COVID-19 pandemic produced official vows around the world to strengthen the global public health infrastructure. Yet three years after the peak in worldwide COVID-19 deaths, preparedness for the next pandemic remains “fragile,” in the words of the Global Preparedness Monitoring Board (GPMB) of the World Health Organization (WHO) and World Bank. Distracted by geopolitical frictions and lulled by the easing of COVID-19 death rates, political leaders are neglecting the pandemic’s grim lessons. However, new public health threats, possibly even more dangerous than the SARS-CoV-2 virus, already loom and will inevitably emerge if current complacency persists.
Progress and lost momentum
The need to plan for the next pandemic was made clear in 2021 with reports by the Independent Panel for Pandemic Preparedness and Response and the G20 High Level Independent Panel on Financing the Global Commons for Pandemic Preparedness and Response (HLIP). Both groups proposed extensive upgrades in the global public health infrastructure and its financing. The Group of Twenty (G20) leaders established a Joint Finance-Health Task Force (JFHTF) in October 2021 to better prepare for the next outbreak. At the time, COVID-19 had killed 5 million worldwide already—surely an undercount of the true number of COVID-related deaths—and governments were reporting roughly 200,000 more deaths each week.
Following these steps, a World Bank financial intermediary fund for pandemic prevention, preparedness, and response (PPR) was established in 2022 under the Indonesian G20 presidency. The Pandemic Fund aimed to channel and leverage contributions to support PPR initiatives in lower- and middle-income countries. In a little over a year, the Fund attracted commitments of more than $2 billion from a range of sovereign donors—not just wealthy countries but also emerging markets such as China, Indonesia, and South Africa—as well as from foundations. The fund has leveraged its initial $338 million in grant awards by a factor of six through project co-financing arrangements, which are required of applicants. Applications for a second round of awards, potentially totaling $500 million, open in February.
This progress is impressive, but the momentum on other improvements to the global public health architecture has slowed amid fears of inflation and fissures in the G20 over the Ukraine war. World leaders have not done much to advance most recommendations of the Independent Panel and the HLIP, or related recommendations by Bill Gates in his 2022 book. Reducing the sense of urgency, in 2023 the monthly rate of confirmed COVID-19 deaths worldwide fell from around 54,000 in January to around 2,200 in December. (The figure below shows cumulative confirmed COVID-19 deaths across the world.) Even though the Pandemic Fund could be on track to mobilize the $10 billion per year for five years that the HLIP identified as the minimal necessary financing for PPR, it is not there yet, despite outpacing many earlier efforts to finance global public goods. A WHO document of June 2023 referred to the “catastrophic failure of the international community in showing solidarity and equity in response to the coronavirus disease (COVID-19) pandemic,” and not nearly enough has happened to rule out a repeat.
Our luck could soon run out
Despite the sharp decline in COVID-19 deaths, long COVID remains a challenge for many countries and communities, especially among the elderly and immunocompromised populations and those with certain preexisting conditions. These groups remain at risk even after vaccination. The creation and deployment of effective vaccines in record time, alongside the development of antivirals for SARS-CoV-2 like Paxlovid, reflected the confluence of intensive government support for vaccine development and new vaccine technologies waiting in the wings, notably those based on genetic information coded by messenger RNA molecules. It was fortunate that the COVID-19 pathogen was relatively easy to target because of its structure and replication process. We may not be so lucky next time. A more easily transmissible pathogen that is both lethal and (like HIV) harder to target would be far more devastating even than SARS-CoV-2. It could arise naturally or originate in a lab accident or intentional bioterror.
Potential threats abound. In late 2023, for example, a serious outbreak of atypical pneumonia in China sparked concern. While the Chinese announced that no unusual pathogens were involved, and the WHO largely concurred after formally requesting more detailed information from Chinese health authorities, suspicions over the Chinese failure to be transparent about the 2019 Wuhan outbreak were revived. The strain of the Mycoplasma pneumoniae bacterium apparently driving many of the infections in China is known to have affected a large number of children, filling up hospitals and threatening to spill over into other countries. Health experts suspect that this strain is resistant to azithromycin, the mainstay of treatment for M. pneumoniae. Azithromycin has been widely prescribed in China and other countries to address secondary bacterial infections associated with COVID-19, possibly increasing bacterial resistance to it. The broader issue of antimicrobial resistance (AMR)—that is, the increasing resistance of microorganisms to antibiotics, antifungals, and other medications—is of mounting concern at the Centers for Disease Control and Prevention (CDC) and the WHO.
Many pathogens, from bacteria to fungi to parasites and protozoa, are now classified as “superbugs,” infectious agents that are no longer affected by compounds targeted to kill them or block their ability to multiply. The antimicrobials in use today are all compounds derived from natural substances found in nature: Microorganisms develop defenses against their own pathogens and, in the process, produce antimicrobial molecules—such is the case with penicillin. Therefore, the gold standard in drug discovery and development has remained the search for new substances that can target microorganisms without damaging human cells. Some researchers have developed platforms to identify new substances and deploy them in preclinical trials.
Still, these efforts are costly and will require big government-supported investments. Furthermore, the destruction of some natural environments (for example, the Amazon rainforest) compromises scientists’ ability to derive future antimicrobials from the most promising natural sources.
The problem of insufficient investment in drug development and discovery to address AMR has numerous causes but may also reflect a perception that these problems are more relevant for poor countries that are plagued by resistant pathogens but lack adequate health infrastructures and the financial capacity to invest in fighting AMR themselves. In reality, despite a very high disease burden from tropical pathogens in the Global South, populations in some of these countries have developed a degree of resistance to infections. For example, HIV and Plasmodium falciparum, the protozoan agent that causes malaria, do not cause significant infections among some populations in Africa, just as SARS-CoV-2 also failed to have the anticipated devastating effects in many of the continent’s countries.
As climate change progresses, however, we can expect the impact of tropical pathogens to become higher over time in the Global North, where populations are immunologically naïve to these agents. Global warming has led to pathogens and diseases traditionally seen in warmer climates migrating north. This fact should not be lost on complacent advanced countries and underscores the urgency of making coordinated investments to encourage private markets to develop new drugs and delivery systems while discouraging the excessive use of antimicrobial drugs that promotes AMR.
What the world can and should do now
An effective response to all the public health challenges would entail:
- Strengthening WHO capacities to detect outbreaks, speed up responses, share information, survey national health systems, and support research and development on both vaccines and drug discovery.
- Coordinating international support for the development of new vaccines, drugs, and delivery systems, while monitoring existing pathogens for drug resistance and/or zoonotic jumps.
- Globally coordinating genomic analysis of pathogen evolution, including pathogens found in animals that have potential to jump to humans.
- Strengthening national health systems, especially in poorer countries.
- Securing global agreement on drug/vaccine approval protocols to speed up production and delivery.
- Ensuring broader vaccine and treatment access and strengthening global vaccine and treatment supply chains to help less prosperous countries.
- Providing more funding resources from wealthier countries for the global public health infrastructure, including its central institution, the WHO. We could accomplish much more with a small fraction of what we need for climate transition.
An intergovernmental negotiating body of the WHO is currently drafting a convention on pandemic prevention, preparedness, and response to be considered at the World Health Assembly meeting in May 2024. Any agreement should address the issues above.
It is sobering that the Global Preparedness Monitoring Board of the WHO and the World Bank, in its first report entitled “A World at Risk,” warned in September 2019, a few months before the COVID-19 pandemic, “The world is not prepared for a fast-moving, virulent respiratory pathogen pandemic.” World leaders are still nowhere near being prepared. Everyone will suffer if they remain asleep at the wheel.
1. These numbers represent “confirmed COVID deaths” which are much smaller than the more comprehensive measure of “excess deaths.”
2. The HLIP recommended that an overall increase in global public health funding of $15 billion per year over five years, followed by sustained investments thereafter, is “the absolute minimum in new international investments required in the global public goods that are at the core of effective pandemic prevention and preparedness.” The level of development assistance for health did rise by $15 billion in 2020, $14 billion of which was directly related to COVID-19, bringing the total to about $55 billion (see Gates, p. 214). A further increase of $15 billion per year would therefore represent 27.3 percent of the 2020 level. Broadly consistent with the HLIP recommendation, the WHO and World Bank concluded in a March 2022 paper for the JFHTF: “Considering current and expected domestic and international financing for [pandemic preparedness and response], it is estimated that at least an additional US$10.5 billion per year in international financing will be needed to fund a fit-for-purpose PPR architecture.”
3. Other promising areas of research addressing AMR involve the use of chains of macromolecules known as polymers that could target specific fungi or bacteria—artificial intelligence and machine learning algorithms have been useful in finding potential candidates. Still, it remains unclear whether such drugs would have minimal off-target effects, that is, whether they would not cause damage to human cells.
This publication does not include a replication package.