Dr. Joanne Liu is a professor at the School of Population and Global Health at McGill University and a practicing physician at the University of Montreal. She is the former international president of Medicines Sans Frontiers/Doctors Without Borders and for the purposes of this conversation she served on the Independent Panel for Pandemic Preparedness and Response.
This panel was co-chaired former New Zealand Prime Minister Helen Clark and Former President of Liberia Ellen Johnson Sirleaf. It was formed by the World Health Organization in 2020 to provide an audit of how both the WHO and its member states were responding to COVID-19 and what steps need to be taken to prepare or prevent the next pandemic.
As Dr. Joanne Liu explains, world leaders need to be approaching pandemic preparedness and response as if it were a potentially existential threat to humanity, on par with a nuclear catastrophe. This requires far greater levels of political attention than it currently receives. We discuss at length why global cooperation around pandemic preparedness is lagging and what steps need to be taken in the near term to change course.
What is the Independent Panel for Pandemic Preparedness?
Dr. Joanne Liu [00:03:48] So what we call the IPPPR, which is the Independent Panel for Pandemic Preparedness and Response, was basically launched after basically the bit of the crisis that happened at the World Health Assembly in 2020 when all of a sudden, the US said we would not continue to support at the level that we’re supporting the WHO. What was put forward was that maybe the WHO wasn’t performing at the level of expectation that some member states thought, and this basically started a process of saying, well, maybe we need to look at how the WHO responded to the COVID-19, but as well, its member states. And so, the general director, Dr. Tedros, decided to appoint two co-chairs, which was Helen Clark, the former prime minister of New Zealand and Ellen Sirleaf, the former president of Liberia, to put together an independent panel that would evaluate the performance of the preparedness and response of WHO, but as well the member state to COVID-19. And they basically recruited 12 people around the world, and this is done on a voluntary basis for the people who are participating on the panel. And the idea was to present the next year a report to just give an idea of how the performance in response and preparedness was.
Mark L. Goldberg [00:05:16] And what did you find?
Dr. Joanne Liu [00:05:20] So I think that one of the things that we wanted to hammer was the fact that it wasn’t the first time that the world has been having a warning or a taste of what would be the challenge to respond to a pandemic through SARS, but then with MERS or through Ebola. And so there have been numerous commission and independent evaluation, about more than a dozen of them. And what we discover is less than 10% of the recommendation that were offered and recommended were implemented. And so, the basic thing is the world knew that it wasn’t prepared; there were some clues and recommendations on how to get better prepared, but this wasn’t implemented. And then after that we went through a big plan to try to figure out what is the chronograph, the timeline of how the COVID-19 unfolded. And what was very clear is at the outset, there was some missteps in terms of calling the shot when it was needed. There was some sort of delay in terms of the alert. But as well, calling the public health emergency of international concern, which wasn’t a big thing, there was maybe a delay of a few weeks, but when you compare it to Ebola in 2014, 2016, we went from a delay of six months to a delay of six weeks.
What mistakes were made in the beginning of the COVID-19 pandemic?
Mark L. Goldberg [00:06:54] The public health emergency of international concern is like the World Health Organization’s version of a five-alarm fire. It’s the emergency button that is pushed upon the recommendation of an independent panel. The director general can declare this public health emergency, and this is supposed to be what captures international attention, that a situation is indeed grave and serious and deserves everyone’s utmost attention. And you’re saying that back in the West Africa Ebola crisis, it took a very long time for that emergency button to be hit, whereas back in COVID, it took a shortened period of time. But still, as you’re saying, a little too long.
Dr. Joanne Liu [00:07:32] Yeah, a little too long. And then the other thing was one of the things that the report highlighted was the fact that the principle of precaution wasn’t applied, meaning that as soon as we had, I would say, suspicion that human to human transmission was happening, it should have been shared. And what is quite interesting is when you look at some of the country response, especially in Asia, many of them closed their border and then started to make, I would say, a response that was basically assuming there were human to human transmission, whereas the rest of the world was a bit still in denial until on January 20 that clearly we said, yes, there is human to human transmission. So that was another, I would say, big thing. But despite all that and the fact that people have been trying to find a scapegoat in in in what happened initially with COVID-19, the reality is once the highest alert of concern on the public health emergency was done, which was on January 30th, 2020. Well, basically, most of the world sat on their hands for a month. The month of February was the last month and basically, people look at what was going on in Wuhan and said it’s so far, this will not happen. I remember because I was in Canada and it was just like oh, it will never get here. And instead of gearing up and preparing basically the European countries and very much so the North American countries did nothing except watching instead of gearing up. And so, when we talk about the failure, the initial failure of the response to COVID-19, it’s really the failure of being able to grasp the scale of the emergency back then.
Mark L. Goldberg [00:09:36] You have recently released a new report looking back at the work of the independent panel and whether or not it has been implemented. Can you just kind of walk me through this latest report that was released just a few days ago, and we’re speaking on Monday, May 23rd.
Dr. Joanne Liu [00:09:54] So basically what we did is when we released our first report, we came up with a set of recommendations that was to basically be followed right away, which was basically, I would say, in terms of access to essential tools to fight COVID-19 and a set of recommendations that was saying if you apply this set of recommendation, COVID-19 may be the last pandemic. And so, what we decided to do is six months after and then one year after, which is now, we decided to do a follow up report to see what happened since our recommendation and our recommendation were pretty, I would say, straightforward to a certain extent. What was important for me was the recognition that pandemic is raised at the level of what I call the existential threat, at a level like a nuclear accident, where we think it’s so grave, it’s so important that country would accept to have verification of what’s going on and would accept to share in full transparency the number of cases and then as well the proof of what’s going on. And so, we wanted to basically do something based on what happened after the Chernobyl event in 1986, when we just said there needs to be a specific type of alert and a specific, I would say, sequence of events that need to happen when such an alarm is raised. And for me, that was one of the big things, was to elevate the threat of pandemic at the level of an existential threat like a nuclear accident in order for heads of states to really take leadership and to call the shots instead of treating a pandemic at a level of a technical public health issue where actually it would never get the traction and the finance that is necessary to respond to it. Because for me it’s the key that would basically get the rest of the necessary traction to prevent an epidemic to become a pandemic.
Mark L. Goldberg [00:12:11] If that was the initial goal, and if you’re treating a pandemic like COVID-19 or a future pandemic as a potential existential threat to humanity, and you have demand highest levels of political attention, how do you get that political attention? How do you convince leaders that indeed this is an existential threat?
Could a political declaration of importance on pandemics help prevent the next pandemic?
Dr. Joanne Liu [00:12:34] Well, the idea was we had been doing briefing at the UNGA over the last summer, and we were hoping for a political declaration at the United Nations General Assembly in September 2021 and unfortunately, it didn’t happen, but we thought it was necessary, I would say, body language in terms of securing the future. And basically, a lot of people relied on rather the fact that there was this initiative of having a pandemic treaty at the level of the World Health Assembly, and people thought it was good enough. There was this extraordinary World Health Assembly in November last year, and they decided on this sort of a timeline where they would come back with a proposal by 2024, which my personal take on that is we went from what I call the coalition of fairly low action or inaction to a coalition of hesitation and negotiation. And it’s rare that you win in those kinds of moments, you often dilute things. The more you think about things, the more you hesitate and dilute the motivation and the drive to do something significant.
Mark L. Goldberg [00:13:52] Yeah, one of the key recommendations is to have a key meeting at the United Nations General Assembly attended by heads of state in which they somehow declare and affirm that preventing the next pandemic is a top political priority. But instead, as you just mentioned, the political momentum now has coalesced around a more perhaps modest international mechanism organized and debated at the World Health Assembly and the World Health Organization around like a pandemic preparedness treaty. But you’re saying that sort of like a dilution of that top level political attention that’s required to really drive progress?
Dr. Joanne Liu [00:14:32] Yes, I think that we have decided to rely on a lengthy process to find out the best recipe to prepare ourselves better for the next pandemic. And I personally think that by doing so, instead of putting people in front of politics, we’re probably going to put politics in front of people. And I’m very concerned, to say the least.
What is the Access to COVID-19 Tools Accelerator Act?
Mark L. Goldberg [00:15:02] One other suite of recommendations in your most recent report is around providing more equitable access to COVID-19 and other pandemic tools in order to prevent, treat, diagnose future pandemics and the current pandemic as well. The initial model of this was created in April 2020 through a coalition that convened around the World Health Organization called the Access to COVID-19 Tools Accelerator or ACTA. Can you just remind us of what that was? And we’ll then talk about what we can do to make this system stronger.
Dr. Joanne Liu [00:15:42] The Access to COVID-19 Tools Accelerator was, in essence, a coalition of different entities: the Gates Foundation, the Wellcome Trust Philanthropy, but in addition to that, like GAVI, UNITAID, the World Bank, etc. So, these are all organizations that are involved in research and development and discovery and in addition to that, were the WHO and the World Bank. And basically, what happened in 2020 — but I was not part of that so I’m describing that from what I read and from what I heard — but basically it was a coalition of the willing of people to just say, this is pretty big. What is happening? Let’s get together. We know each other and sit around a table and just try to shape a mechanism that would allow us to foster for discovery and foster force for redistribution of discovery once they’re done. And we’ll do that at the level of vaccine, of diagnostic test, and treatment in addition to health care system that they had afterwards. And so, when they did that, I think that the intentions were good, but I think that it was shaped and created in a sort of non-inclusive way, meaning by that that it’s kind of odd as some key government representing the low- and middle-income country were not represented. It is odd, as well to find out that there was no civil society representation per say and that created some sort of blind spot to what was necessary for the world to respond to a pandemic with the right tools.
Why was the Access to COVID-19 Tools Accelerator unequitable?
Mark L. Goldberg [00:17:41] How did those blind spots become manifested over the years as ACTA’s various investments began being created and distributed?
Dr. Joanne Liu [00:17:55] What is interesting when you talk about those people who started this initiative, initially it was supposed to be for all the countries. They just said, we’re going to pull everything together and then after that, we’re going to redistribute. And then very early on, people realized that that the high-income countries were making their bilateral deal outside of this agreement or agreed platform and so it ended up being more the platform of distribution of new discovery to fight COVID-19 for the low- and middle-income country. And then finally at the end, it’s almost like a ricochet, but it ended up being more like a clearing house of the surplus of vaccine. I’m talking mainly about vaccine because I think that’s the pillar of the most performing and the most finance at the end of the day. But this is what happened. And I think in terms of blind spots there is the fact that I think if you had low- and middle-income countries represented that they would have thought of having an access policy for them. If there would have been low- or middle-income countries, they would at least raise the issue that you have an ultra-cold chain vaccine. This might be a very, very big challenge for them and they might not be able to distribute this kind of vaccine. And so, you don’t have the same means and the same concerns when you are a low- or middle-income country versus when you are a high-income country because of a question of budget and question of priorities for the health of your people.
How could the Access to COVID-19 Tools Accelerator become more equitable?
Mark L. Goldberg [00:19:49] And in the report you note, or the report notes that ACTA should be reconfigured as an end-to-end platform that puts equity and public health at its heart. What do you mean by an end-to-end platform that puts equity at its heart?
Dr. Joanne Liu [00:20:06] I think end to end, is really that it’s foreseeing all the possible issues that may happen that would prevent an access to the discovery instead of stepping in the middle of the process, thinking that goodwill will happen. It will not happen so it means that we need to have a pre-negotiated deal that will basically overshoot any problem of access and making sure that it’s affordable and available for the high-income country as well as the low- and middle-income country.
Mark L. Goldberg [00:20:47] Can you give me an example of what that might look like in practice?
Dr. Joanne Liu [00:20:54] If it’s a manufacturer: where would it be manufactured? Will the manufacturing take place close to the low- and middle-income country and if so, who will be in charge? And if it were end to end, that is probably the low- or middle-income countries would be in charge, like the hub that is being developed right now in South Africa. Instead of having still some strings attached with the intellectual property and the flexibility of this intellectual property.
How would a TRIPS waiver improve global access to pandemic prevention and treatment resources?
Mark L. Goldberg [00:21:29] I’m glad you brought up the intellectual property issue because the report also recommends a waiver to the WTO agreement on trade-related aspects of intellectual property rights TRIPS for tools related to pandemic prevention. How important is that? I mean, we’ve seen some progress on TRIPS waivers around vaccines, though it hasn’t been enacted yet. But, you know, notably the head of the WTO and also the Biden administration, somewhat surprisingly, is supporting this TRIPS waiver on vaccines. How significant important is enacting TRIPS waivers on pandemic prevention tools? How important is that to the broader cause?
Dr. Joanne Liu [00:22:13] Well, I think there is a division. There are some people who think it’s a red herring and the reality of what needs to be done is basically a transfer of knowledge and knowhow and individualization of the production of a new discovery or a vaccine, for example. But to some other people, which is where I sit, we believe that by not having the intellectual property waived, it will always create a dynamic or an ecosystem of dependance. And then you would not create, I would say, autonomy and self-reliance for low- and middle-income countries. And I think the biggest issue about ACTA is a foundational flaw in the conceptualization of this because it’s based on charity model meaning on the goodwill of people to share. And this is why it is important that the TRIPS waiver happens eventually. Of course, you know, it might not make a huge difference for the current product by the time we agree and by the time that people get themselves to do it. But it certainly would make a huge difference in the next pandemic if we were to accept that in times of pandemic TRIPS waivers should be happening.
How can we prevent the next pandemic?
Mark L. Goldberg [00:23:42] You’ve identified almost political stasis that’s taken hold right now in which pandemic prevention has fallen far from the top priority of international leaders. Your report has identified technical deficiencies with how we’ve dealt with COVID-19 and also suggestions for how we might deal with the future pandemic. What do we need to fill the political gap and fill the technical gap in order to prevent the next pandemic in ways that, as you said, prevent like an existential catastrophe to humanity?
Dr. Joanne Liu [00:24:20] That’s a big question Mark but I still think at the end of the day that it boils down to political will. And this is what it was in 2014, 2016 for Ebola and I think this is what it is today for COVID-19. It’s about the political will of wanting to basically get a pandemic response that is accessible to all countries and not only accessible to the high-income countries. And the fact that we are not recognizing that we are so interdependent, interconnected, and it’s not sustainable to have only the high-income countries basically responding with the best tool and hoping that as well they going to booster themselves out of the pandemic. It’s naive and shortsighted because you may protect yourself, but we saw it, you know, with what happened with Omicron, you’re not safe until, you know, everybody’s safe. Because as long as the virus will be running loose in one part of the world, there’s going to be a mutation. There’s going to be a risk of mutation escaping the protection of the vaccines that we have. And we’ve went through that jig once, and we might go again through it. And so, it’s about political will of coming together and building a governance and a way of responding that everybody gets to the finish line together. And I think we’re far from that, but this is why by elevating a pandemic at the level of an existential threat will, I do believe, will create the political traction and will. But I think for the time being, we’re far from that.
Mark L. Goldberg [00:26:32] Well, looking forward in the next coming, say, year or so, are there any inflection points that you’ll be looking towards that will suggest to you whether or not we are progressing towards mustering that political will that you identified?
Dr. Joanne Liu [00:26:50] Well, I think that we’re going to see how the international health regulation, which is the process to do the public health emergency of international concern, will basically morph itself into. Because if somehow countries are able to accept that when there’s a public health emergency of international concern, it means that the WHO has the right and actually the duty to go and validate what is going on like we do for a nuclear accident, and then can as well without the permission, share the real data in real time. That would be a step forward in a good direction.
What are the International Health Regulations?
Mark L. Goldberg [00:27:38] So you’re referring to the 2005 international health regulations, which are the operating rules under which the World Health Organization investigates outbreaks like this. And the IHR was created after the SARs pandemic back in 2003. So, you’re saying this kind of technical reforms and politically strengthening the international health regulations to give it a more robust ability to respond to pandemics is something you’ll be looking towards in the next year?
How will more surveillance help prevent future epidemics from becoming pandemics?
Dr. Joanne Liu [00:28:11] Well, I think for me, that’s one of the first steps that is necessary, because if we’re not able to get the right information in a timely fashion, because there will be more epidemic, it’s a certainty. Our role now with all the tools that we have is to make sure that an epidemic doesn’t become a pandemic. And so, it means that we need to abort this transformation of an epidemic into a pandemic straight from the beginning. To do so, then it means that you need to get the right surveillance, the right system, and the right information in a timely fashion. If each time we have to negotiate days or weeks, we are always going to give a head start to the virus. And we’re going to be always playing catching up. And that’s not good; we saw how fast it went with COVID-19.
Mark L. Goldberg [00:29:08] Dr. Liu, thank you so much for your time.
Dr. Joanne Liu [00:29:12] Thank you very much.
Mark L. Goldberg [00:29:14] And thank you for being a listener to the show for so long. I appreciate it. Always love having listeners become the experts I interview.
Dr. Joanne Liu [00:29:22] My pleasure.
Mark L. Goldberg [00:29:24] All right. Thank you all for listening. Thank you to Dr. Liu. That was great. As I said at the outset, I always appreciate the perspective that she brings to conversations about health access and health equity. And just a note that you can find the reports that we reference on theindependentpanel.org. Alright, I’ll see you next time. Thanks, bye!