In 2004, before anti-HIV drugs were widely available in India, an AIDS ward in Chennai was filled with patients.

In 2004, before anti-HIV drugs were widely available in India, an AIDS ward in Chennai was filled with patients.

Malcolm Linton

Health panel: Pump new billions into disease outbreaks—or else

A new report written by a high-profile commission urges the world to learn from the many mistakes made during the Ebola epidemic and revamp how it collectively responds to infectious disease crises.

The report by the Commission on Creating a Global Health Risk Framework for the Future (GHRF) recommends that the world spend about $4.5 billion more each year to bolster the ability of countries to respond to pandemics. “The reality is we have neglected this dimension of human security,” says commission chairman Peter Sands, who spoke at a well-attended launch of the report held this morning in New York City at the Rockefeller Foundation, one of eight sponsors.

Sands, the former CEO of the United Kingdom’s Standard Charter Bank who is now at Harvard University, notes that the report spells out the cost of not making substantial changes to the “framework” of global health preparedness and response: The world could spend up to $60 billion per year addressing pandemics. “The scale of our risk is huge,” Sands says.

In addition to Rockefeller, the GHRF commission was sponsored by six other philanthropies, including the Bill & Melinda Gates Foundation and Ford, and the U.S. government. The release of the report comes 1 day before the World Health Organization (WHO) is expected to announce that the Ebola epidemic has formally ended.

The 26 recommendations in the report, The Neglected Dimension of Global Security, overlap a great deal with the conclusions of other recent reports, including one published by what’s known as the Harvard-LSHTM panel in The Lancet 28 November 2015 and another issued in July 2015 by an independent group of experts convened by WHO. “Of all the reports dealing with Ebola and its consequences, this is clearly the most comprehensive, linking governance changes to financial commitments,” says Barry Bloom of Harvard, who formerly headed that university’s school of public health and did not co-author any of the reports. The new report was written by 17 commissioners from 12 countries aided by input from more than 250 experts who spoke at four public meetings organized by the U.S. National Academy of Medicine over the past year.

All three reports call for bolstering national health systems and public health infrastructure. Each group also heavily criticized WHO’s Ebola response—the GHRF report called it “sluggish, ill-coordinated, and clumsy”—and proposed substantial changes in its structure and policies, including forming a new Center for Health Emergency Preparedness and creating a $100 million contingency fund to help member states rapidly mount emergency responses. And the reports all called for strengthening and accelerating research and development of new drugs, vaccines, and diagnostics, as well as improved personal protective equipment for health care workers.

The new GHRF report is the only one that attaches dollar figures and funding sources to its recommendations. “There’s no one entity that is going to be writing a check for $4.5 billion a year,” Sands noted.

An estimated $3.4 billion of the called-for $4.5 billion would go toward upgrading public health capacities in every country, which includes adequately training a work force that can quickly detect and respond to outbreaks. Although many international projects have aimed to do just that, the report laments, they have “largely failed.” For instance, the commission noted that only 33% of WHO’s member states so far have complied with the International Health Regulations (IHR) they endorsed in 2005. “The report places the right emphasis on countries, with national engagement as the first step to strengthening public health and health security of individuals, and the collective society,” says David Heymann, a co-author of the Harvard-LSHTM report who heads the Centre on Global Health Security at Chatham House in London (which also has issued a recent report on WHO reform).

The $3.4 billion would mainly come from the countries themselves. For poorer countries, the report says the World Bank should organize additional funding with a diverse array of donors, and it suggests the United Nations secretary-general should coordinate assistance to failed and fragile states.

The report recommends that WHO’s new Center for Emergency Health Preparedness have an independent board and oversee an external assessment whether member states are meeting the IHR requirements. “The World Bank, bilateral, and other multilateral donors should declare that funding related to health system strengthening will be condi­tional upon a country’s participation in the external assessment process,” one recommendation states. By mid-2017, all countries should publish plans that show how they plan to address shortcomings within 3 years.

R&D needs a boost of $1 billion per year, the report says, which Sands described as “a challenging ask.” Potential public and private sources include existing budgets for related national defense and university-led research efforts, as well as new money from businesses not typically associated with global health investments, such as the insurance industry.

WHO and the World Bank would receive the balance of the $4.5 billion, a mere $155 million a year at most. The report recommends that WHO put out a daily “watch list” of high-priority outbreaks instead of the current system of waiting for infectious diseases to spiral out of control and then declaring a “public health emergency of international concern”—which took 8 months with the Ebola epidemic. WHO also would create a Pandemic Product Development Committee, monitored by an independent board, to define priorities, streamline clinical trial designs, and help create stockpiles of vaccines.

At the launch, Bruce Aylward, the interim executive director of WHO’s new program on outbreaks and emergencies, called the report “outstanding.” He noted that the recommendations align with the thinking of WHO’s Director-General Margaret Chan. “It’s a vision she’ll lay out at the end of this month to the [WHO] executive board,” he said. Aylward contended that what really failed in WHO’s response to Ebola was that the institution was set up for one purpose and was asked to do another job. “You push a penguin off a cliff we know it doesn’t fly,” Aylward says. He also argued that it needs far more new money to address these issues than recommended in the report.

Commission chairman Sands acknowledged that it will be difficult to find $4.5 billion in new money. “But it is not out of reach,” he says. “And the alternative is frankly much more expensive.”

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A 3D plot from a model of the Ebola risk faced at different West African regions over time.
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