Never Again – Until Next Time? Push to Pandemic-Proof the World as Political Will Wanes
WHO staff Dr Simon Ssentamu verifies the oxygen cylinder supply at a health facility in Cox’s Bazar, Bangladesh during the COVID-19 pandemic.

GENEVA – The global will to ensure that COVID-19 is a “never-again” pandemic is dissipating fast, according to many delegates attending the World Health Assembly (WHA) and its plethora of side events – threatening initiatives such as local manufacturing of vaccines.

Jeremy Farrar, the newly appointed Chief Scientist at the World Health Organization (WHO), reminded a forum on mRNA vaccines that, in previous outbreaks, the global health community had “made a promise of ‘never again’, but interest waned over time and it will pass again”.

“If we don’t invest in the whole global R&D ecosystem in the next year, there won’t be local vaccine production by the next pandemic,” Farrar warned delegates gathered in a white marquee on the lawns of the French Mission attending a event organised by the Medicines Patent Pool (MPP).

But it’s not just vaccine production. It is also diagnostic tests and treatments – and ensuring that countries’ health systems are able to offer services to all citizens, regardless of their ability to pay.

Timely testing

On Friday, the WHA passed a resolution to strengthen countries’ diagnostic testing capacity, stressing support for the local production of diagnostic tools and tests in low- and middle-income countries (LMICs).

COVID-19 tests were scarce in many parts of Africa, leading to a misconception that the continent had not suffered that much from the virus. Meanwhile, Tanzania struggled to identify a deadly Marburg outbreak recently because of a lack of access to laboratories and testing.

“Timely access to the right testing tools is one of the most critical parts of any medical intervention to curb an outbreak and save lives, so it’s encouraging to see access to testing being discussed at a global level,” said Dr Salha Issoufou, Director of Operations for Médecins sans Frontieres (West and Central Africa) in response to the resolution.

“We urge all governments to make sure everyone has access to lifesaving tests by swiftly adopting WHO guidelines in national policies, developing national essential diagnostics lists (EDL), and ensuring nationwide access to essential tests for all diseases relevant to the local context, including neglected diseases, and beyond pandemics alone.”

Keeping vaccine factories ‘warm’ outside pandemics

During COVID-19, vaccine delivery to Africa – which imports 99% of its vaccines – was frozen for months after India slapped an export ban on vaccines being made by the Serum Institute of India to deal with its own infection crisis.

The months’ long delay underscored the need for regions to be able to make their own vaccines. But ensuring this is expensive.

 “mRNA is a buzzword at the moment, but how do we keep the factories warm when there isn’t a pandemic?” asked Morena Makhoana, CEO of the South African company, Biovac, which is involved in vaccine production.

His own company faced a crisis recently when the South African government opted to switch its order of the pneumococcal vaccine from Biovac to India’s Cipla, which was producing it far cheaper.

Martin Friede, WHO’s head of vaccine research, recounted at the mRNA event how factories set up to produce influenza vaccine had closed one by one as governments’ support dried up once the threat of H1N1 had passed.

Seth Berkley, CEO of Gavi, the world’s biggest purchaser of vaccines, said that Gavi was committed to giving priority to regional manufacturers, and was currently working with 33 companies.

However, he warned that these vaccines will cost more and would need to be subsidised, not just by donors but by countries where manufacturers are based.

Dr Jean Kaseya, the new head of Africa CDC, told an event at the WHA that his continent has a potential market of 1.3 billion people – and that regional manufacturing of vaccines and medicines is a key pillar of Africa’s New Public Health Order

Africa CDC has set a bold target of purchasing 60% of the vaccines it needs from African producers by 2040 – an almost impossible task without massive investment and political will.

Even the recently formed Pandemic Fund has shied away from regional production in its first call for proposals because of the cost, said Priya Basu, executive lead of the fund’s secretariat.

The World Bank estimates LMICs need to invest $30 billion a year for the next five years to pandemic-proof themselves, said Basu.

Regulatory hiccups and pathogen sharing

A key component of regional production also rests on medicines and vaccines being passed by regulatory authorities – and in Africa’s case, each of the 55 countries has different regulatory authorities. The Africa Medicines Agency (AMA) is being set up to streamline this.

IFPMA’s Thomas Cueni (centre) flanked by Jayashree Iyer, CEO of Access to Medicines Foundation (left)  and WHO’s John Rheeder.

But Thomas Cueni, the plain-speaking Director-General of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), described the AMA as “a bit of a mess at the moment”, particularly as the main countries on the continent have not yet ratified it.

Cueni also said there was a huge gap between “the political rhetoric and reality on the ground” in relation to regional manufacturing, and it was “toxic” to expect that the North would always pay.

The IFPMA also wants the rapid sharing of pathogens without strings attached – such as access benefit-sharing agreements – one of the points of disagreement in the current pandemic accord negotiations.

“The rapid sharing of SARS-COV-2’s sequencing enabled the pharmaceutical industry to start developing vaccines, treatments and diagnostics in record time. The first vaccine was approved 326 days after the virus sequence was known. This sharing of data and information mustn’t be jeopardized in the future, and the principle needs to be kept in any solutions for pandemic preparedness,” said Grega Kumer, the IFPMA’s Deputy Director of Government Relations.

He added there had been cases where access to pathogens was either blocked or delayed because of access benefit-sharing agreements derived from the Nagoya Protocol, which led to delays in vaccine production. For instance, this has been the case for seasonal influenza, Ebola or Zika.

Pandemic-proofing humans and health systems

People also need to be pandemic-proofed. COVID-19 also showed that humanity is extremely unhealthy – with NCDs in particular whittling away resistance to infection. Those with co-morbidities, particularly obesity and diabetes, were far more likely to die from the virus.

Thus the WHO’s updated guidelines on tackling NCDs that were adopted by the assembly are extremely timely.

Member states at the WHA also expressed alarm that over a billion people cannot access health services because there is no universal health coverage (UHC) where they live, and they cannot afford to pay for healthcare. 

“In a transformative policy shift, member states across high-, middle- and low-income countries expressed a strong commitment to reorient their health systems based on primary health care (PHC) as a foundation for achieving health for all and reaching the furthest left behind first,” said the WHO after the adoption of a resolution to this effect.

“About 90% of UHC interventions can be delivered using a PHC approach; from health promotion to prevention, treatment, rehabilitation and palliative care, potentially saving 60 million lives by 2030.

UHC will also be discussed at a United Nations High-Level Meeting in September, where a political declaration is expected to commit all countries to UHC.

Are politicians out of the loop?

Joy Phumaphi (left) former Minister of Health of Botswana and co-chair of the Global Preparedness Monitoring Board, Terrence Deyalsingh, Health Minister of Trinidad and Tobago, and Precious Matsoso, co-chair of the pandemic accord negotiations.

Two processes are currently underway at the WHO to sharpen up the governance of future pandemics: negotiations for a pandemic accord to provide guidelines for how countries should behave during pandemics, and the amendment of the International Health Regulations, the only binding global rules for health emergencies.

But at an event on pandemic leadership, the Health Minister of Trinidad and Tobago, Terrence Deyalsingh, warned that politicians had to deal with a host of post-pandemic issues – particularly economic woes – and preparing for the next pandemic was no longer a priority.

A similar point was made by eSwatini’s Health Minister, Lizzie Nkosi, who questioned whether politicians were aware of pandemic accord negotiations – let alone preparing for new pandemics: “Are Ministers of Health in countries able to follow the processes in the negotiations and take the issues to their teams?”

Global health leaders are pinning their hopes on the United Nations High-Level Meeting on Pandemic Prevention, Preparedness and Response in September to reignite the political will seen at the height of the COVID-19 pandemic.

Michael Kazatchkine, a member of the Independent Panel for Pandemic Preparedness, is part of a lobby for the establishment of a high-level Global Health Threats Council to keep the issue alive. 

“This is very much a debated issue here in Geneva everywhere. Clearly, we need more work on this to make sure that we’re all on the same page, but what is certain is that saying ‘never again’ with regard to pandemics will remain just words unless we ensure that sustained high-level political engagement,” said Kazatchkine.

Meanwhile, a new pandemic lurks

A researcher explores evidence around the wildlife trade, possibility the source of the next pandemic.

Yet scientists warn that another pandemic is lurking, and is even more likely to erupt as humans encroach more on animals’ territory and the world gets heats up. 

The Intergovernmental Panel on Climate Change (IPCC) warned in its report last March that, without swift climate action, we will see an escalation of infectious diseases such the vector-borne dengue, Zika and malaria, and water-borne typhoid and cholera.

Chadia Wannous, One Health co-ordinator for the World Organization of Animal Health (WOAH), stressed at a number of panels during the past week that primary prevention of pandemics has to focus on “zoonotic spillover” – the messy interface between humans and animals as shown at the Huanan Market in Wuhan, the likely ground zero for the COVID-19 pandemic, where all kinds of wild animals were caged in poor conditions. 

At the opening of the WHA, WHO Director-General Dr Tedros Adhanom Ghebreyesus warned that an even worse pathogen than SARS-COV-2 might be ahead, while Maria van Kerkhove, WHO’s lead on COVID-19, also warned that while the emergency may be over, COVID-19 is not yet done killing humans.

Total R&D ecosystem overhaul?

Meanwhile, Wellcome Trust, one of the biggest private donors of infectious disease response, kicked off a global conversation about what needs to be done in a discussion paper released a few days back that declares: “The R&D infrastructure ecosystem for infectious disease is unfit for purpose and requires ambitions overhaul.”

At the heart of the discussion paper is this wish: “We want to see progress towards an infectious disease R&D ecosystem that efficiently and sustainably develops and brings to the market the range of vaccines, diagnostics and treatments required to address the growing threat posed by infections. At its heart, this ecosystem should be structured to provide appropriate products to the people that need them, wherever they live in the world, at an affordable price and in a timely way.”

Wellcome’s four-point vision for transforming infectious diseases R&D.

Wellcome points out that “resources are not allocated to research activities efficiently or equitably with whole fields suffering long-term neglect”. Key problems include “empty pipelines” for major infectious disease threats, especially affecting low-resource settings, barriers to registration, and lack of access.

“Individuals’ ability to access lifesaving products often depends more on economics and geography than on need,” the Trust points out.

Between now and the end of the year, Wellcome will engage key stakeholders on how to change four key areas around establishing health priorities, streamlined clinical trials and regulatory approaches, the strategic scale-up of geographically diverse and sustainable manufacturing capacity and how to both “centre access and affordability while incentivising innovation”.

Factor in three UN high-level meetings – on UHC, pandemic preparedness and tuberculosis – in September. Plus the two pandemic negotiations – on the pandemic accord and how to amend the International Health Regulations (IHR) to make them fit for the next pandemic – that are due to be concluded by the next WHA in May 2024.

It’s going to be a busy  12 months.

Image Credits: WHO/Fabeha Monir , Wildlife Conservation Society.

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