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A. The Ebola Outbreak as a Wake-up Call
The 2014 Ebola outbreak was a human tragedy that took thousands of lives, caused tremendous suffering, and left deep wounds in communities in Guinea, Sierra Leone and Liberia. And yet, it was preventable. Much more could have been done to halt its spread earlier. The crisis must serve as a wake-up call for increased global action to prevent future health crises.
The multiple failures experienced during the Ebola response demonstrated that the world remains ill-prepared to address the threat posed by epidemics. A lack of basic surveillance capacities in West Africa meant that the virus initially spread undetected for three months. When recognized, the scale of the outbreak was underestimated by experts and minimized by authorities. Despite numerous warnings from groups including Médecins Sans Frontières (MSF), the governments of the three most-affected countries and the World Health Organization (WHO) maintained that the outbreak would soon be under control. It was not until 1,600 people had been infected and the epidemic was spiralling out of control that the WHO declared the Ebola outbreak to be a Public Health Emergency of International Concern (PHEIC), thereby attracting the world’s attention.
When the epidemic was recognized as a global threat, the world mobilized unprecedented resources and capacities, which included the deployment of foreign military assets and the decision by the Secretary-General to establish the first-ever UN health emergency mission. Nevertheless, the response was hampered by a lack of trained and experienced personnel willing to deploy to the affected countries, inadequate financial resources, a limited understanding of effective response methods, ineffective community engagement and poor coordination. As a result of these delays and failures, thousands of lives were lost.
More than two years after the first death from the epidemic, 11,316 people have been killed by the disease, and 28,638 infections have been reported.1 The epidemic also caused an estimated US$2.2 billion in economic losses in the most affected-countries, reversing hardwon progress towards the Millennium Development Goals (MDGs).
B. The global burden of communicable diseases
For centuries, the world has been subjected to epidemics and outbreaks with often devastating consequences. In 1918, a pandemic of H1N1 influenza killed an estimated 50 million people. Today, a number of other communicable diseases continue to claim millions of lives. Recent outbreaks of influenza (H1N1 and H5N1), Severe Acute Respiratory Syndrome (SARS) and Middle-East Respiratory Syndrome (MERS) have shown that even sophisticated health systems in developed countries can be challenged by the appearance of new or emergent pathogens.
Notwithstanding its devastating impact in West Africa, the Ebola virus is not the most virulent pathogen known to humanity. Mathematical modelling by the Bill and Melinda Gates Foundation has shown that a virulent strain of an airborne influenza virus could spread to all major global capitals within 60 days and kill more than 33 million people within 250 days.
Despite the significant threat, global efforts to prepare for epidemics have been woefully insufficient. The global legal instrument negotiated to ensure early warning and pandemic response, the International Health Regulations (2005) (IHR), has only been fully implemented by one-third of its 196 States Parties. Similarly, only a small fraction of global investment in Research and Development (R&D) for vaccines, therapeutics and diagnostics is devoted to the emerging communicable diseases that primarily affect the developing world.
C. A call for action
Future pandemic threats will emerge and have potentially devastating consequences.
We can either take immediate action to ensure that future threats are contained and humanity is protected, or we will remain vulnerable to losing millions of lives and suffering devastating social, political and economic consequences.
The Panel has made twenty-seven recommendations for action at the national, regional and international levels, including many measures that cut across governance levels and require engagement with all sectors of society. While complex, there are a few concrete actions that can be taken immediately that will involve partners from governments, international institutions, civil society, and the private sector all working together with a newfound urgency. These priority actions will begin to build the global capacity required to manage future health crises and accelerate the implementation of the Panel’s recommendations.
First, the WHO must build a new Centre for Emergency Preparedness and Response and ensure that the world has a standing capacity to immediately identify and respond to emerging communicable disease threats. The Centre must have real command and control capability, access to specialized human and operational resources to execute a health response, and the ability to visualize and share validated surveillance data in real-time. The Centre should benefit from the best technology available to ensure the global community can identify, track and respond effectively to any emerging threat.
Second, all countries must meet the full obligations of the IHR. Where capacities are lacking, support should be provided to urgently implement a core set of measures. These measures should be under the direct authority of the heads of government and should include the establishment of pandemic preparedness and response mechanisms, with clear command and control; hiring and training health professionals and community health workers; and building a comprehensive surveillance system with a national laboratory.
Third, appropriate financing is required. Assistance should be provided to countries requiring additional support for IHR compliance, while WHO and the new Centre for Emergency Preparedness and Response must be resourced to meet global needs. In addition, a fund should be established to support R&D for vaccines, therapeutics and diagnostics for neglected communicable diseases.
To ensure that key measures are taken, a central recommendation of the Panel’s work is to establish a High-level Council on Global Public Health Crises within the General Assembly to provide political leadership on global preparedness, monitor the implementation of reforms, and help prepare for a Summit on Global Public Health Crises in 2018.
The Ebola outbreak was a wake-up call. Global leaders must act now to implement the following recommendations.
i. National level (see recommendations 1 to 4)
The local community is on the front-line of any outbreak, and the state is the primary actor responsible and accountable for issuing appropriate alerts and responding to a crisis. The local and national levels of the global health architecture require the development of foundational capabilities for effective preparedness and response.
The Ebola response demonstrated that the inadequate implementation of national obligations under the IHR, weak health systems, governance challenges, and poor engagement with communities hampered the ability of national authorities to stem the spread of the virus.
The following key measures are needed at the national level: Implement the IHR Core Capacities, build an effective health workforce, address governance challenges, improve community engagement, and address gender aspects of health crises.
ii. Regional and sub-regional level (see recommendation 5)
While regional and sub-regional organisations supported the Ebola crisis response with innovative and experienced capacities, a lack of preparedness and pre-existing arrangements contributed to response delays and coordination challenges.
Regional organizations should develop or strengthen standing capacities to assist in the prevention of and response to health crises, with particular emphasis on areas where they can add significant value to national responses.
iii. International level (see recommendations 6 to 9)
The Ebola crisis also highlighted critical gaps in the international system for responding to health crises. In particular, the mechanism for monitoring compliance with the IHR’s Core Capacity requirements is weak. The lack of independent assessments affects international efforts to support more vulnerable countries in implementing preparedness, surveillance, detection, and response capacities. In addition, the absence of a strong WHO response capacity and the lack of clarity over the inter-agency leadership and coordination arrangements for health crises delayed an effective response. This delay led the UN SecretaryGeneral to take the unprecedented decision to establish the first United Nations health emergency mission.
Urgent measures are needed to address these gaps and enhance global capacity to rapidly detect and respond to health crises. These include establishing a stronger periodic review of compliance with the IHR’s Core Capacity requirements, strengthening the WHO’s operational capacities, and enhancing the Inter-Agency Standing Committee (IASC) coordination mechanisms to better respond to health crises.
iv. Cross-cutting issues (see recommendations 10 to 25)
a. Development and health
While new and dangerous pathogens can emerge in any country in the world, poor living conditions mean that developing countries are particularly vulnerable to the impact of communicable disease outbreaks. Inadequate sanitation can accelerate disease spread, and weak health systems undermine the capacities to respond.
The Panel urges all Member States to achieve the Sustainable Development Goals (SDGs), particularly in the area of health. It notes that the threat of health crises from communicable diseases has been recognized in Goal 3.3 and urges Member States to ensure that the SDG monitoring and follow-up process takes into account compliance with IHR Core Capacity requirements as a crucial element in preventing outbreaks of communicable diseases. The Panel further recommends that the WHO work closely with development actors to ensure complementarity between development programmes and efforts to build health care systems and public health.
b. Research and development
The availability of effective medical countermeasures, including vaccines, therapeutics and diagnostics, is crucial in preventing and responding to communicable disease outbreaks.
However, investment in medical R&D for diseases that largely affect the poor is deeply inadequate. Of the $214 billion invested in health R&D globally in 2010, less than 2 per cent was allocated to neglected diseases (ND). Even where vaccines or therapeutics exist, they are often inaccessible or unaffordable to vulnerable populations.
Public policy intervention, including more public funding, is required to ensure greater resources are focused on R&D for NDs and other dangerous pathogens, particularly in developing countries. The Panel therefore recommends that the WHO oversee the establishment of a fund to support R&D of vaccines, therapeutics and diagnostics for neglected communicable diseases. R&D efforts should be targeted according to a priority list of pathogens developed by the WHO. In addition, the Panel notes that additional measures should be taken to support access to and affordability of medicines for all.
c. Finance and economic measures
Building a more effective global health architecture that is better prepared to respond to health crises will require additional financial resources. In the view of the Panel, investments will be needed in three key areas. First, there is a need to mobilize domestic and international funding to support the implementation of the IHR’s Core Capacity requirements. Least Developed Countries and other vulnerable countries should receive assistance from partners in this regard. Second, equipping the WHO with an effective operational preparedness and emergency response capacity will require a 10 per cent increase in the organization’s assessed funding, as well as the provision of adequate contingency funds for emergencies. Third, at least $1 billion per annum is needed to support the R&D fund for medical counter-measures for pathogens that pose a high risk of health crises. More strategic coordination of existing resources and new funding to support these priorities can increase effectiveness and result in a safer world.
The Panel further notes that the trade and travel restrictions imposed during outbreaks often result in significant economic losses for the affected countries and the globe. They also act as a disincentive for governments to report in a timely manner, and can hinder the response effort. As a result, the Panel recommends that measures be identified to minimize their use.
v. Follow-up and implementation (see recommendations 26 & 27)
Inadequate political leadership at the country, regional and international levels in preparing for and responding to health crises can undermine effective and timely responses. In the view of the Panel, heads of state and government must initiate early and decisive actions relating to pandemics.
Moreover, previous attempts to reform the global health architecture have stalled or failed because of lack of political support.
The Panel is convinced that a high-level political mechanism is needed to maintain current momentum, ensure the implementation of crucial reforms, and to support the organisation of a Summit on Global Public Health Crises. The Panel therefore proposes the creation of a High-level Council on Global Public Health Crises.
The Panel believes that, if implemented, its recommendations will serve to strengthen the global health architecture under the leadership of the WHO. By building on existing mechanisms, the Panel’s recommendations will strengthen global capacity to monitor risks, detect outbreaks early, and rapidly deploy a fully resourced, effective response. In addition, the Panel’s proposals to dedicate resources to R&D on prioritized pathogens will ensure the greater availability of critical vaccines and treatments when they are most needed.