A Framework to Counter
COMMISSION ON A GLOBAL HEALTH RISK
FRAMEWORK FOR THE FUTURE
NOTICE: Statements, recommendations, and opinions expressed are those of the Commission on a Global Health Risk Framework for the Future (GHRF Commission). The National Academy of Medicine served as Secretariat for the GHRF Commission, with support from the following National Academies of Sciences, Engineering, and Medicine staff:
Carmen C. Mundaca-Shah, Project Director
V. Ayano Ogawa, Research Associate
Priyanka Kanal, Intern (until July 2015)
David Garrison, Senior Program Assistant (from December 2015)
Mariah Geiger, Senior Program Assistant (until December 2015)
Faye Hillman, Financial Officer
Patrick W. Kelley, Director, Board on Global Health
Anas El Turabi, Doctoral Candidate in Health Policy (Evaluative Science & Statistics), Graduate School of Arts and Sciences, Harvard University
Philip Saynisch, Doctoral Candidate in Health Policy, Harvard Business School and Graduate School of Arts and Sciences, Harvard University
The Commission was supported by the Paul G. Allen Family Foundation, the Ford Foundation, The Bill & Melinda Gates Foundation, Mr. Ming Wai Lau, the Gordon and Betty Moore Foundation, The Rockefeller Foundation, the U.S. Agency for International Development, and the Wellcome Trust.
International Standard Book Number-13: 978-0-309-39093-4
International Standard Book Number-10: 0-309-39093-1
Digital Object Identifier: 10.17226/21891
Copyright 2016 by the Commission on a Global Health Risk Framework for the Future.
Suggested citation: GHRF Commission (Commission on a Global Health Risk Framework for the Future). 2016. The neglected dimension of global security: A framework to counter infectious disease crises. http://nam.edu/GHRFreport. doi: 10.17226/21891.
COMMISSION ON A GLOBAL HEALTH RISK FRAMEWORK FOR THE FUTURE
Peter Sands (Chair), Former Group Chief Executive Officer, Standard Chartered PLC and Senior Fellow, Mossavar-Rahmani Center for Business and Government, Harvard Kennedy School
Oyewale Tomori (Vice Chair), President, Nigerian Academy of Science
Ximena Aguilera, Director, Center of Epidemiology and Public Health Policies, Universidad del Desarrollo, Chile
Irene Akua Agyepong, Greater Accra Regional Health Directorate, Ghana Health Service
Yvette Chesson-Wureh, Establishment Coordinator, Angie Brooks International Centre for Women’s Empowerment, Leadership Development, International Peace & Security, C/O The University of Liberia
Paul Farmer, Kolokotrones University Professor and Chair of the Department of Global Health and Social Medicine, Harvard Medical School and Cofounder of Partners In Health
Maria Freire, President, Foundation for the National Institutes of Health
Julio Frenk, President, University of Miami
Lawrence Gostin, University Professor of Global Health Law, Georgetown University and Faculty Director, O’Neill Institute on National and Global Law
Gabriel Leung, Dean, Li Ka Shing Faculty of Medicine, The University of Hong Kong
Francis Omaswa, Executive Director, African Center for Global Health and Social Transformation
Melissa Parker, Reader in Medical Anthropology, Department of Global Health and Development, London School of Hygiene & Tropical Medicine
Sujatha Rao, Former Secretary, Ministry of Health and Family Welfare of India
Daniel Ryan, Head of R&D–Life & Health and Big Data, Swiss Re
Jeanette Vega, Director, Chilean National Health Fund
Suwit Wibulpolprasert, Vice Chair, International Health Policy Program Foundation, Health Intervention and Technology Assessment, Ministry of Public Health, Thailand
Tadataka Yamada, Venture Partner, Frazier Life Sciences
INTERNATIONAL OVERSIGHT GROUP
Victor J. Dzau (Chair), President, National Academy of Medicine
Judith Rodin (Vice Chair), President, The Rockefeller Foundation
Fazle Hasan Abed, Founder of BRAC and Chairman of BRAC Bank Limited
Arnaud Bernaert, Senior Director, Head of Global Health and Healthcare Industries, World Economic Forum
Chris Elias, President of the Global Development Program, The Bill & Melinda Gates Foundation
Jeremy Farrar, Director, Wellcome Trust
Shigeru Omi, President, Japan Community Health Care Organization
Paul Polman, CEO, Unilever
Mirta Roses, Former Director, Pan American Health Organization
Shen Xiaoming, Professor of Pediatrics, Xin Hua Hospital and Shanghai Children’s Medical Center, Shanghai Jiao Tong University School of Medicine
Tan Chorh Chuan, President, National University of Singapore
Miriam Were, Chancellor, Moi University
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the Commission in making its published report as sound as possible and to ensure that the report meets International Oversight Group standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
Sharon Abramowitz, University of Florida
George Alleyne, Pan American Health Organization (Emeritus) and University of the West Indies
Ramesh Bhat, Indian Institute of Management
Emmanuel d’Harcourt, International Rescue Committee
Mark Feinberg, International AIDS Vaccine Initiative
Mohamed Jalloh, FOCUS 1000
Dean Jamison, University of California, San Francisco
Margaret Kruk, Harvard T.H. Chan School of Public Health
Peter Lamptey, FHI 360
Diop Ndack, University Cheikh Anta Diop
Srinath Reddy, Public Health Foundation of India
Kenji Shibuya, University of Tokyo
Samba Sow, Center for Vaccine Development–Mali
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by David Challoner, University of Florida. He was responsible for making certain that an independent examination of this report was carried out in accordance with International Oversight Group procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the Commission.
“Messieurs, c’est les microbes qui auront le dernier mot.”
(Gentlemen, it is the microbes who will have the last word.)
While Louis Pasteur, the famed 19th-century microbiologist, may have literally spoken the truth, individuals, communities, and nations expect governments to use all the available tools of science and public policy to combat the threat of infectious disease. And where such tools are lacking, or poorly used, responsible leaders are expected to take action, plugging the gaps and enhancing execution.
Much has been done since the days of Pasteur to mitigate the threat of infectious diseases to individuals and humanity as a whole. Hygiene, water purification, vaccines, and antimicrobials have all contributed to great improvements in well-being and life expectancy. However, despite these advances, we have in the last few decades seen several large-scale outbreaks of infectious diseases, not only old foes—such as cholera and yellow fever—but new threats such as Ebola, severe acute respiratory syndrome (SARS), hantavirus, human immunodeficiency virus (HIV), and novel strains of influenza. A range of factors, including increasing population, economic globalization, environmental degradation, and ever-increasing human interaction across the globe, are changing the dynamics of infectious diseases. As a consequence, we should anticipate a growing frequency of infectious disease threats to global security.
We have not done nearly enough to prevent or prepare for such potential pandemics. While there are certainly gaps in our scientific defenses, the bigger problem is that leaders at all levels have not been giving these threats anything close to the priority they demand. Ebola and other outbreaks revealed gaping holes in preparedness, serious weaknesses in response, and a range of failures of global and local leadership. This is the neglected dimension of global security.
Part of the problem is the way this threat is perceived. Framed as a health problem, building better defenses against the threat of potential pandemics often gets crowded out by more visible and immediate priorities. As a result, many countries have underinvested in their public health infrastructure and capabilities. And global agencies, such as the World Health Organization (WHO) and the rest of the United Nations system, have lacked the focus and capacity to provide the required international support and coordination.
Yet, framed as an issue of human security, the current level of investment in countering this threat to human lives looks even more inadequate. There are very few threats that can compare with infectious diseases in terms of their potential to result in catastrophic loss of life. Yet nations devote only a fraction of the resources spent on national security to prevent and to prepare for pandemics.
Framed as a threat to economic growth and stability, the contrast is equally stark. Both the dynamics of infectious disease and the actions taken to counteract it can cause immense damage to societies and economies. And in a globalized, media-connected world, national borders are no barriers to real or perceived threats. Fears, whether rational or unwarranted, spread even more quickly than infections. And such fears drive changes in behavior and public policy, often leading governments to implement non-scientifically-based actions that exacerbate economic
impact, such as travel bans, quarantines, and blockades on the importation of food, mail, and other items. Yet both at the level of individual countries and at the global level, there has been remarkably little analysis and preparation for potential pandemics as a source of economic risk.
Moreover, while economic or financial problems in fragile or failed states pose very little direct risk to the rest of the world, infectious disease outbreaks in such states represent a direct threat. The lack of health care and public health capacity in these countries is both a disaster for their own populations and an acute vulnerability for the world as a whole. The recent Ebola outbreak showed how fragile post-civil-war nations can serve as incubators for infections of global pandemic potential. Guinea, Liberia, and Sierra Leone are far from being major engines of the African economy, let alone the global economy, but the sparks that came out of their remote jungles ignited an enormously expensive global reaction. Moreover, it could have been much worse. If Ebola had spread to much bigger, more globally integrated cities, such as Lagos, Nairobi, or Kinshasa-Brazzaville, it would have been a very different story. Indeed, we saw the impact of an infectious disease spreading rapidly through urban centers around the world in 2003 when SARS emerged from China.
It was against the backdrop of the Ebola outbreak that the Commission on a Global Health Risk Framework for the Future was conceived. While Ebola was the catalyst, the aim of this exercise was to look to the future, taking a broad view of the potential threats from infectious diseases, without putting particular emphasis on a single outbreak or agent. Indeed, our objective was to set out a framework of institutions, policy, and finance that would be resilient to a wide range of such potential threats, whether known—such as influenzas, coronaviruses, and haemorrhagic fevers—or as yet unknown.
The Commission was established in response to an urgent need. Eight philanthropic and government sponsors recognized the crisis of Ebola, the underlying neglect of health systems around the globe, and the associated peril for economies and security. Because of its extensive history of managing complex advisory studies, these sponsors asked the U.S. National Academy of Medicine (NAM, formerly the Institute of Medicine) to provide staff to support the Commission in carrying out its task in a comprehensive, rigorous, and objective manner. While the NAM provided staff expertise, the Commission’s report should be regarded as independent of the NAM and all other organizations. The Commission’s task was to provide peer-reviewed consensus recommendations based on evidence and expert opinion. The 17 members of the Commission include citizens of a dozen countries, and its peer reviewers are similarly balanced. Rather than following the well-established procedures of the NAM, the process and policies of the Commission were informed by them and customized to reflect the international nature of this effort and the constrained timeframe. An Independent Oversight Group, composed of 12 eminent and diverse leaders from Africa, the Americas, Asia, and Europe, provided oversight. To ensure that the Commission drew on insights and expertise across the globe, it was informed through a total of 11 days of public meetings held in Accra, Ghana; Hong Kong; London; and Washington, DC. More than 250 invited presenters offered their perspectives at these events.
The Commission’s recommendations encompass three broad areas: first, reinforcing national public health capabilities and infrastructure as the foundation of a country’s health system and the first line of defense against potential pandemics; second, reinforcing international leadership and coordination for preparedness and response; and third, accelerating research and development in the infectious disease arena. Together, these recommendations amount to a comprehensive, costed, and coherent framework to make the world much safer against the threat of infectious disease.
Inevitably, there will be discussion as to which of the Commission’s recommendations are most important and which are the hardest to implement. Four observations are perhaps worth making in this context. First, a policy framework is most effective when the various elements combine to complement each other. Partial implementation makes even those elements that are put in place less efficacious. Second, we should heed the oft-learned lesson that, in this arena as in others, investment in prevention and preparation is worth much more than spending on response, and that the best response is a well-prepared response. Third, ultimately the fight against infectious disease outbreaks will be fought on the ground within specific communities, and the battle will only be won if these communities are engaged with and part of the response. Finally, science is our most powerful weapon in combating infectious diseases,
but the development of tools such as vaccines and diagnostics must be begun before the crisis occurs. Otherwise, the time it takes to deploy scientific tools effectively could be immensely costly in terms of lives and livelihoods.
So, while we should reinforce international mechanisms to lead, coordinate, and resource the response to infectious disease crises, including strengthening WHO’s capabilities and creating contingency financing mechanisms through WHO and the World Bank, we should avoid the temptation to see such initiatives as being in any respect a complete answer. These may be the most visible actions, and perhaps the least difficult to achieve, but that does not mean they are the most important.
To make a truly significant impact in reducing the risks to humanity and to human prosperity, we must catalyze the building of stronger public health capabilities and infrastructure at a national level, even in failed and fragile states, and do so in a way that establishes effective community engagement. We do not underestimate the difficulties in achieving this, because it requires leadership at multiple levels and sustained financing. Yet this must be the top priority.
Neither do we underestimate the challenges of mobilizing additional funds for research and development in the infectious disease arena, or of achieving greater harmonization and efficiency in development and approval processes. Yet ultimately, we depend on science to enable us to counter potential pandemics. So we need to find the money and make our processes less complex and cumbersome.
Infectious disease pandemics represent one of the potent threats to humankind, both in terms of potential lives lost and in terms of potential economic disruption. The Commission’s recommendations represent a framework for making the world much safer. Now the challenge is to make them happen.
Peter Sands, Chair
Commission on a Global Health Risk
Framework for the Future
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The Commission wishes to thank colleagues, organizations, and agencies that shared their expertise throughout the course of the study. Their contributions informed the Commission and enhanced the quality of the report.
First, we would like to thank the study sponsors whose support made this initiative a reality: the Paul G. Allen Family Foundation, the Ford Foundation, The Bill & Melinda Gates Foundation, Mr. Ming Wai Lau, the Gordon and Betty Moore Foundation, The Rockefeller Foundation, the U.S. Agency for International Development, and the Wellcome Trust. We especially thank The Rockefeller Foundation for hosting the report launch event at their headquarters in New York City.
We are grateful for the participation of more than 250 experts who volunteered their time and shared a wealth of information with the Commission at the four international Institute of Medicine (IOM) Global Health Risk Framework workshops on finance, governance, health systems, and research and development (R&D), as well as in two R&D consultations. Their rich discussions and contributions were critically considered by the Commission in their deliberations. Details on the workshops are provided in Chapter 1 of this report and will be published as IOM workshop summaries this year. We would like to express our gratitude to the stakeholders who participated in the R&D consultations: Manica Balasegaram, Beth Bell, Seth Berkley, Luciana Borio, Robert Califf, Edward Cox, Anthony Fauci, Peter Horby, Philip Krause, Cliff Lane, Nicole Lurie, Rohit Malpani, Gary Nabel, Judit Rius, Susan Sherman, Moncef Slaoui, Patrick Vallance, Charlie Weller, and David Wood. We would also like to thank Margaret Chan, Tom Frieden, and Jim Kim, who shared their expertise with the Commission and Secretariat through individual consultations. Olga Jonas from the World Bank also provided invaluable insight into the costings for country-level pandemic prevention and response activities. We also appreciate input from Marc Lipsitch from the Harvard T.H. Chan School of Public Health.
Collaboration with other relevant efforts was critical to the Commission’s work. We are especially grateful to Ramesh Rajasingham with the Secretariat at the United Nations (UN) High-Level Panel on Global Response to Health Crises, and Elil Renganathan with the Secretariat at the WHO Ebola Interim Assessment Panel.
We are appreciative of the support and advice on the dissemination strategy that we received from the Brunswick group, with particular gratitude to Jennifer Banks, Charis Gresser, and David Seldin. We are also very grateful to Casey Weeks for his creative work with the cover design. In addition, we want to thank Attaya Limwattanayingyong for her technical support to the Commission during the second Commission meeting.
The Commission also thanks Anas El Turabi and Philip Saynisch for their technical expertise in pandemic financing and for modeling the business case for investing in preparedness for global health events. Their contributions were critical to the Commission’s deliberations.
We would like to thank the staff in various offices of the National Academies of Sciences, Engineering, and Medicine who were crucial for the success of this project. We thank the staff who organized and conducted the IOM workshops: Allison Berger, Gillian Buckley, Eileen Choffnes, Anne Claiborne, Jack Herrmann, Kathryn Howell, Benjamin Kahn, Michelle Mancher, Rachel Pittluck, Megan Reeve, Joanna Roberts, and Annalyn Welp. We are very grateful to Katharine Bothner and Morgan Kanarek, who coordinated the critical role that the International Oversight Group played along the course of the study. We thank Laura DeStefano for successfully organizing the launch
event of the report, as well as Jennifer Walsh, for coordinating the release of the report to the public. We also thank Megan Slavish for leading the administrative process that supported the peer review of the report. The project also received valuable assistance from Faye Hillman (Office of Financial Administration) and Rebecca Morgan (National Academies Research Center).
Finally, the Commission could not have done its work without the extraordinary efforts of the staff of the National Academy of Medicine (NAM) Secretariat, including Carmen C. Mundaca-Shah, project director; V. Ayano Ogawa, research associate; Mariah Geiger and David Garrison, senior program assistants; and Patrick Kelley, director, Board on Global Health, at the IOM. Their work was invaluable.
Coordination with Other Initiatives
2 The Case for Investing in Pandemic Preparedness
3 Strengthening Public Health as the Foundation of the Health System and First Line of Defense
Despite Some Improvements, Many Countries Have Failed to Build the Necessary Public Health Capacities
Robust Public Health Capacities Are Achievable in the Context of Building and Sustaining Strong Health Systems
National Governments’ Responsibility to Protect Their Own People and Play Their Part in Protecting Humankind by Implementing the International Health Regulations
4 Strengthening the Global and Regional System for Outbreak Preparedness, Alert, and Response
Strengthening WHO’s Capacity for Outbreak Preparedness and Response
Coordinating with Global Actors
Redesigning Processes and Protocols
Mobilizing Global Financial Resources in Response to Potential Pandemics
5 Accelerating Research and Development to Counter the Threat of Infectious Diseases
A Pandemic Product Development Committee to Drive the R&D Strategy
Accelerating R&D by Investing $1 Billion per Year
Ensuring Consistent Standards for Research During Crises
Securing Overarching Global Agreements to Expedite Approval, Manufacture, and Distribution
6 Building a Framework for Global Health Security
The Overall Financing Challenge
Reversing Neglect: The Challenge of Action
C Background Paper: “Modeling the Economic Threat of Pandemics” by Anas El Turabi and Philip Saynisch
D Biographical Sketches of Commission Members, Consultants, and Staff
Acronyms and Abbreviations
U.S. Centers for Disease Control and Prevention
|CERF||United Nations Central Emergency Response Fund|
|CFE||Contingency Fund for Emergencies|
|CHEPR||Center for Health Emergency Preparedness and Response|
|CHW||community health worker|
|CSO||civil society organization|
Director-General (World Health Organization)
|DHIS-2||District Health Information System|
|DOD||U.S. Department of Defense|
|DTF||district task force|
|EIS||event information site|
Food and Agriculture Organization
|FENSA||Framework for Engaging with Non-State Actors|
|FETP||Field Epidemiology Training Program|
gross domestic product
|GHRF||Commission on a Global Health Risk Framework for the Future|
|GHSA||Global Health Security Agenda|
|GOARN||Global Outbreak Alert and Response Network|
human immunodeficiency virus/acquired immune deficiency syndrome
Inter-Agency Standing Committee
|ICMRA||International Coalition of Medical Regulatory Authorities|
|IHR||International Health Regulations|
|IMF||International Monetary Fund|
|IOG||International Oversight Group for the GHRF Commission|
|IOM||U.S. Institute of Medicine|
Middle East respiratory syndrome
|MOH||Ministry of Health|
|NAM||U.S. National Academy of Medicine|
|NATO||North Atlantic Treaty Organization|
|NFP||national focal point|
|NIH||U.S. National Institutes of Health|
|NTF||National Task Force|
United Nations Office for the Coordination of Humanitarian Affairs
|OIE||World Organisation for Animal Health|
Pandemic Emergency Financing Facility
|PEPFAR||U.S. President’s Emergency Plan for AIDS Relief|
|PHEIC||Public Health Emergency of International Concern|
|PHEOC||public health emergency operations center|
|PPDC||Pandemic Product Development Committee|
|PPE||personal protective equipment|
research & development
|RCF||Rapid Credit Facility|
|RCT||randomized controlled trial|
severe acute respiratory syndrome
|SDG||Sustainable Development Goal|
|SMS||short message service|
Technical Governing Board
|TLAC||total loss absorbing capacity|
|UNICEF||United Nations Children’s Fund|
|UNMEER||United Nations Mission for Ebola Emergency Response|
|UNSG||United Nations Secretary-General|
|USAID||U.S. Agency for International Development|
|UVRI||Uganda Virus Research Initiative|
World Economic Forum
|WHA||World Health Assembly|
|WHO||World Health Organization|