It’s been barely three years since the COVID-19 pandemic ended, yet many world leaders appear to have little appetite for pandemic-proofing. Ahead of the UN High-Level Meeting on Pandemics, a major 20-country research project offers a blueprint for the future that could save millions more lives.

The United Nations hosts a High-Level Meeting on Pandemics on Friday, but the political declaration draft, currently thin on practical implementation plans, may be rendered even skinnier as the United States is almost certain to throw its spanner in the multilateral wheel.

At the end of the eighth round of talks to negotiate the last outstanding piece of the World Health Organization’s (WHO) Pandemic Agreement last Friday, WHO Director-General Dr Tedros Adhanom Ghebreyesus, its most ardent cheerleader, admitted that progress is “slow”.

Barely three years ago, in May 2023, the global trauma of the COVID-19 pandemic was declared to be at an end – after seven million official deaths, 28 million “excess deaths” and at least 70 million more people being thrust into poverty. 

Yet other global crises appear to have blunted world leaders’ appetite to pandemic-proof their countries.

However, a global team of experts, coordinated by the National University of Singapore (NUS) and The Lancet, has been hard at work since September 2023, working out what went wrong during COVID-19, and offering a blueprint to enable the world to perform better next time.

The overarching conclusion of the PRIME Commission report is that many countries failed to protect those who needed it most, relying on technical plans that left millions exposed to infection. 

“Protection failed in contexts where housing was overcrowded, work was insecure, administrative systems excluded people, distrust disrupted communication, or health and social systems shifted risk onto households and communities,” the commission notes.

Twenty-country case studies

The research rests on 20 country case studies, ranging from the United States, the worst affected developed country, to low-income countries such as Mozambique. 

“What the PRIME Commission found is that people themselves aren’t ‘vulnerable’, but rather that systems create vulnerability,” said Professor Helena Legido-Quigley, co-chair of PRIME Commission. 

“A person living in a crowded apartment cannot socially isolate, a person with no identity papers cannot access a government payment, and a person who doesn’t speak the dominant language cannot understand health advice.”

In Ethiopia, Indonesia, Mozambique, Tanzania, and Lebanon, lockdown regulations that restricted movement meant that the subsistence income of millions collapsed, with households “falling into hunger within days”. 

“We would survive the night after eating a piece of bread in the morning,” an internally displaced person in Ethiopia told researchers. 

In Indonesia, people without a national ID number could not get vaccines. In Peru, domestic workers were not covered by emergency cash transfers. Older Japanese residents did not know how to use digital information systems.

“USA represents the deepest form of systemic exclusion, where immigration status, historical labour exclusions, and powerful industry lobbies combine to block access to services. Fear generated by federal immigration policy prevented workers from seeking basic care,” the report notes.

In contrast, countries with universal health coverage, social protection, and there was trust in institutions, fared better – such as New Zealand, South Korea, Finland, and Bhutan. 

Groups commonly overlooked by national systems included older people, migrant workers, people with disabilities, indigenous peoples, informal workers, and people living in remote and underserved communities.

“Across the 20 countries, common patterns emerged. People could be put at greater risk because they could not afford to stop working, did not have housing that allowed them to isolate, could not access government support, did not trust the information they received, or depended on health and other essential services that struggled under pressure,” the research found.

More equity, more lives saved

The Commission modelled future pandemic scenarios, comparing a response driven by power and national interest with a response favouring international cooperation and public health. 

In a hypothetical future influenza A pandemic, if vaccines were developed rapidly, this could reduce deaths by 59% (from 58.5 million to 23.9 million), even when vaccines were distributed first to countries with the greatest ability to pay. 

But if vaccine allocation was based on population size rather than purchasing power, global mortality would be reduced by 64%, to 21·2 million deaths. Measures to improve vaccine confidence would reduce deaths by another 1.9 million lives. 

“The influenza pandemic modelling findings unequivocally show that while the status quo will protect many lives, a more equitable approach to vaccine distribution will save millions more,” said Legido-Quigley. “There is every moral justification to create a system where vaccines reach those who need them in order to live, and not only those who can afford them.”

What must change?

The Commission has developed a blueprint for the future based on six blocks, starting with protecting people and communities.

It argues that the missing element in pandemic readiness is a “practical and profound whole-of-society approach that connects communities, health systems, social protection, finance, law, education, labour, food systems, environmental governance, and regional and global cooperation”.

Pandemic “readiness” must be geared to ensuring that people and systems can withstand a pandemic, it argues, offering a practical test for any plan.

To be effective, any measure needs to reduce avoidable harm, strengthen the capabilities and wellbeing of people and communities, reach those most underserved and remove structural barriers to protection and care.

Communities should be involved in the design of the intervention, which must also be able to respond to misinformation.

“Governments have heard for years that they should take a ‘whole-of-society’ approach to pandemic planning,” said Helen Clark, co-chair of the Independent Panel for Pandemic Preparedness and Response. 

“It is a government’s responsibility to protect all of their citizens and residents. We know that a new pandemic threat could arise at any time. The NUS-Lancet PRIME Commission offers a blueprint that must not be ignored.” 

Image Credits: Photo by Joshua Fernandez on Unsplash, WHO / Ploy Phutpheng, UNICEF , Luisvilla, WHO.