4. What happened, what we've learned, and what needs to change
The Panel has carefully reviewed each phase of the present crisis in order to establish facts and draw lessons for the future.
4.1 Before the pandemic – the failure to take preparation seriously
In under three months from when SARS-CoV-2 was first identified as the cause of clusters of unusual pneumonia cases in Wuhan, China, COVID-19 had become a global pandemic threatening every country in the world. Although public health officials, infectious disease experts, and previous international commissions and reviews had warned of potential pandemics and urged robust preparations since the first outbreak of SARS, COVID-19 still took large parts of the world by surprise. It should not have done. The number of infectious disease outbreaks has been accelerating, many of which have pandemic potential.
It is clear to the Panel that the world was not prepared and had ignored warnings which resulted in a massive failure: an outbreak of SARS-COV-2 became a devastating pandemic.
The fast-moving SARS epidemic had shaken the world in 2003. While the epidemic only lasted some six months and was responsible for 8096 cases and 774 deaths , it was judged by the WHO Regional Director for the Western Pacific to have “caused more fear and social disruption than any other outbreak of our time.” SARS was a novel coronavirus causing respiratory disease. It travelled rapidly to 29 countries, territories and areas, and debilitated health systems, with many health workers being infected. Even so, expert observers knew that, with SARS, the world had dodged a bullet – screening and isolation could readily contain its spread, because people with SARS did not transmit the virus until several days after showing symptoms and were most infectious when symptoms were most severe. It was understood that if a new fast-moving pathogen were transmissible in the absence of symptoms, it would pose a much deadlier challenge.
The SARS epidemic was followed by the 2009 H1N1 influenza pandemic, the 2014–2016 Ebola outbreak in west Africa, Zika and other disease outbreaks, including another new coronavirus, Middle East respiratory syndrome (MERS). These outbreaks were the impetus for a series of initiatives to strengthen health security, animated by the conviction that disease outbreaks and other health threats constituted a major global risk and required a web of actions across all countries.
SARS propelled the decade-long negotiations to revise and broaden the International Health Regulations (IHR) to a rapid conclusion. The current regulations were adopted in 2005, setting out legally binding duties for both States and WHO in notification and information-sharing, prohibitions on unnecessary interference with international travel and trade, and cooperation for the containment of disease spread. The new IHR (2005) came into force in 2007 and imposed new requirements that must be met before the WHO Director-General could act on emergencies, rather than enabling WHO to act immediately and independently.
Groups of States also took initiatives to boost health security. The Global Health Security Initiative was established in 2001 by eight States and the European Commission, with WHO as an observer. The Global Health Security Action Group was its implementation and information-sharing body. The Global Health Security Agenda was launched by the United States in partnership with two dozen other countries in 2014 and has now grown to include seventy countries and a number of international organizations. It has sought to complement efforts to strengthen IHR (2005) implementation, including through support for voluntary Joint External Evaluations. The fact, however, that not all States participate in the Agenda and its related processes has limited its effectiveness and reach.
Despite the consistent messages that significant change was needed to ensure global protection against pandemic threats, the majority of recommendations were never implemented.
Since the 2009 H1N1 influenza pandemic, at least 11 high-level panels and commissions have made specific recommendations in 16 reports to improve global pandemic preparedness. Many concluded that the World Health Organization needed to strengthen its role as the leading and coordinating organization in the field of health, focus on its normative work, and receive more secure funding. Reviews also suggested improvements in the implementation of the IHR (2005). Some of the reviews resulted in specific action, including the establishment of the new WHO Health Emergencies Programme in 2016.
Yet, despite the consistent messages that significant change was needed to ensure global protection against pandemic threats, the majority of recommendations were never implemented. At best, there has been piecemeal implementation. A coalition of interests with sufficient power and momentum to achieve a package of essential reforms has never been assembled. As a result, pandemic and other health threats have not been elevated to the same level of concern as threats of war, terrorism, nuclear disaster or global economic instability. When steps have been explicitly recommended, they have been met with indifference by Member States, resulting in weakened implementation that has severely blunted the original intentions. It is clear to the Panel that pandemics pose potential existential threats to humanity and must be elevated to the highest level.
The United Nations High-level Panel on the Global Response to Health Crises, chaired by President Kikwete of the United Republic of Tanzania, was established in response to the 2014–2016 epidemic of Ebola. It recommended that the United Nations General Assembly should immediately create a high-level council on global public health crises. On receiving its report, the United Nations Secretary-General Ban Ki-moon established a task force to oversee implementation of its recommendations. The task force’s report in June 2017 recommended that the Secretary-General implement a time-limited independent mechanism for reporting on the world’s preparedness, rather than the high-level independent council which had been recommended by the Kikwete-led panel. The outcome was the establishment of the Global Preparedness Monitoring Board in May 2018, with its members appointed by the heads of WHO and the World Bank.
National pandemic preparedness has been vastly underfunded, despite the clear evidence that its cost is a fraction of the cost of responses and losses incurred when an epidemic occurs. The total cost of the economic losses due to SARS was estimated at US$ 60 billion . The 2015 MERS outbreak in just one country, the Republic of Korea, with 185 cases and 38 deaths, cost US$ 2.6 billion in lost tourism revenue and US$ 1 billion in response costs. The 2016 Commission on a Global Health Risk Framework for the Future argued that its proposed preparedness spending boost of US$ 4.5 billion annually was a small investment compared with a scenario of the potential global cost of pandemics over the whole of the 21st century, which they assessed as being “in excess of $6 trillion”.
While there have been concerted efforts in recent years to boost pandemic preparedness, they have fallen far short of what is required. Too many national governments lacked solid preparedness plans, core public health capacities and organized multisectoral coordination with clear commitment from the highest national leadership. The self-reported assessment of core capacities for preparedness that countries are required to submit to the WHO under IHR (2005) gave a global average score of 64 out of 100. Only two-thirds of countries reported having full enabling legislation and financing to support needed health emergency prevention, detection, and response capabilities. Country preparedness was also assessed under the voluntary Joint External Evaluation process, undertaken to date by 98 countries. An independent academic exercise, the Global Health Security Index, also sought to score country pandemic preparedness.
What all these measures have in common was that their ranking of countries did not predict the relative performance of countries in the COVID-19 response. The measures failed to account sufficiently for the impact on responses of political leadership, trust in government institutions and country ability to mount fast and adaptable responses. For example, while the United States ranked first in the world in its aggregate score on the Global Health Security Index, it scored less well on health care access and in relation to public confidence in government received a score of zero indicating a confidence level of less than 25%. The failure of these metrics to be predictive demonstrates the need for a fundamental reassessment which better aligns preparedness measurement with operational capacities in real-world stress situations, including the points at which coordination structures and decision-making may fail. The current pandemic will generate a wealth of data to guide that reassessment.
Underscoring the consequences of a failure to invest sufficiently in preparedness capacity is the increasing background level of risk. Population growth and accompanying environmental stresses are driving an increase in emerging novel pathogens. Air travel, which has increased fourfold since 1990, enables a virus to reach any place in the world in a matter of hours. A new pathogen could emerge and spread at any time.
Most of the new pathogens are zoonotic in origin. Driving their increasing emergence are land use and food production practices and population pressure. Global surveillance systems need to monitor burgeoning infrastructure, environmental loss and the status of animal health. One Health interagency and multisectoral collaboration need to be an integral part of pandemic preparedness planning. Accelerating tropical deforestation and incursion destroys wildlife health and habitat and speeds interchange between humans, wildlife and domestic animals. The threats to human, animal and environmental health are inextricably linked, and instruments to address them need to include climate change agreements and “30x30” global biodiversity targets.
Pandemic preparedness planning is a core function of governments and of the international system and must be overseen at the highest level. It is not a responsibility of the health sector alone.
SARS-CoV-2 is just such a virus of zoonotic origin whose emergence was highly likely. Current evidence suggests that a species of bat is the most likely reservoir host. The intermediate host is still unknown, as is the exact transmission cycle. WHO convened a technical mission to better understand the origins of the virus. While the mission has now reported, investigations of the origins of the virus will continue. The experience of other pandemics, such as HIV, suggest that it will be some time, possibly years, before there is an accepted consensus about how and when the virus first infected humans and when and where the first human-to-human transmission clusters occurred. There is some evidence, based both on reconstructions looking backwards in time at the likely epidemiology and through the analysis of samples collected and stored, that the virus may already have been in circulation outside China in the last months of 2019. This evidence, however, still requires further examination, and confounding explanations, such as the contamination of samples, are still to be ruled out.
COVID-19 exposed a yawning gap between limited, disjointed efforts at pandemic preparedness and the needs and performance of a system when actually confronted by a fast-moving and exponentially growing pandemic.
The Panel’s conclusion is that closing the preparedness gap not only requires sustained investment, it requires a new approach to measuring and testing preparedness. Drills and simulation exercises resulting in immediate rectification of identified weaknesses must become routine, and preparedness assessment must place more focus on the way the system functions in actual conditions of pandemic stress.
Zoonotic outbreaks are becoming more frequent, increasing the urgency for better detection and more robust preparedness. Given the increasing stakes, monitoring pandemic threat needs to be on the agenda of decision-makers at the highest levels of governmental, intergovernmental, corporate and community organizations.
Pandemic preparedness planning is a core function of governments and of the international system and must be overseen at the highest level. It is not a responsibility of the health sector alone.
4.2 A virus moving faster than the surveillance and alert system
The earliest possible recognition of a novel pathogen is critical to containing it. The emergence of COVID-19 was characterized by a mix of some early and rapid action, but also by delay, hesitation, and denial, with the net result that an outbreak became an epidemic and an epidemic spread to pandemic proportions.
The Independent Panel has consulted widely in order to develop a meticulous and verified chronology of events as they took place from the end of 2019 when cases were first detected in China through to the end of March 2020, by when the outbreak had spread extensively worldwide and had been characterized as a pandemic. Inputs to this chronology have included a systematic review of all the relevant published studies – both those that were available at the time and retrospective studies; submissions from WHO Member States, interviews with key actors in China and other countries, with WHO and other organizations; and a review of internal documents and correspondence from WHO.
The intention of the Panel in examining in detail the steps taken to respond to COVID-19 is not to assign blame, but rather to understand what took place and what, if anything, could be done differently if similar circumstances arise again, as they almost certainly will. We are conscious that our judgements benefit from the wisdom of hindsight and acknowledge that the decisions made at the time were made in conditions of great uncertainty.
4.2.1 The first reported cases
In December 2019, a number of patients with pneumonia of unknown origin were admitted to hospitals in Wuhan, China. Later tests on a cohort of patients admitted between 16 December and 2 January found 41 with COVID-19. On 24 December, doctors concerned about a pneumonia patient not responding to the usual treatments sent a sample to a private laboratory for testing. Clinicians noticed that a number of patients – although not all – had attended the Huanan Seafood Market in Wuhan. For example, in a family group, a woman who was treated on 26 December had attended the seafood market, while her husband and son, whose chest scans were conducted shortly thereafter and showed similar patterns, had not. While the market was the initial focus of investigation, two later studies of the early laboratory-confirmed cases linked only 55–66% of cases to exposures there, suggesting that the market may have been a site of amplification of the virus rather than its origin. Definitive evidence of human-to-human transmission of a new pathogen in December 2019 was not available at the time, but by the end of the month there were signs that pointed to it being likely.
On 30 December 2019, the Wuhan Municipal Health Commission issued two urgent notices to hospital networks in the city about cases of pneumonia of unknown origin linked to the Huanan Seafood Market. The market was closed and cleaned between 31 December and 1 January. On the morning of 31 December, Chinese business publication Finance Sina reported on one of the notices issued by the Wuhan Municipal Health Commission. This report was picked up by several disease surveillance systems, including the Centers for Disease Control, Taiwan, China, which in turn contacted WHO via email through the IHR (2005) reporting system, requesting further information. A machine translation of the Finance Sina report was published on the website of the Program for Monitoring Emerging Diseases (ProMED). This report was picked up by the Epidemic Intelligence from Open Sources (EIOS) system and alerted WHO Headquarters to the outbreak. Later in the afternoon of 31 December, the Wuhan Municipal Health Commission issued a public bulletin describing 27 cases of pneumonia of unknown origin. The WHO Country Office in China took note of the bulletin shortly after it was posted and immediately informed the IHR focal point in the WHO Western Pacific Regional Office (WPRO).
The Wuhan Institute of Virology sequenced almost the entire genome of the virus on 2 January 2020. On 5 January 2020, the complete genetic sequence was submitted to the open-access websites GenBANK and GISAID from a sample sequenced by the Shanghai Public Health Centre and this was published on 10 January, with further sequences uploaded by the China CDC on 11 January. The China CDC successfully isolated the virus by 7 January 2020. Chinese scientists developed a PCR testing reagent for the virus by 10 January 2020.
These events, as they unfolded in Wuhan in the last two weeks of December 2019 and into January 2020, demonstrate the diligence of clinicians who noticed clusters of unusual pneumonia, sent samples for screening where commercially available next-generation sequencing detected signs indicative of a new SARS-like coronavirus, and escalated their concerns about this cluster of unexplained disease to local health authorities. The local health authorities closed and cleaned the market that was suspected as a potential source of the virus.
Within a day of the local alert being issued to hospitals, it was noted in the media. The signal was picked up by other health authorities and by the global epidemic surveillance networks that constantly scour open sources around the world. There were thus three routes through which WHO became aware of the outbreak on 31 December 2019 – the Centers for Disease Control, Taiwan, China contacting WHO through the IHR (2005) reporting system after noting media references to the outbreak; the alert published on the ProMED website and picked up by the epidemic surveillance system; and the WHO Country Office in China noting the public bulletin from the Wuhan Municipal Health Commission.
These events, as they unfolded in Wuhan in the last two weeks of December 2019 and into January 2020, demonstrate the diligence of clinicians who noticed clusters of unusual pneumonia
On 1 January 2020, WPRO formally requested further information and verification under the IHR (2005) procedures. The Chinese National Health Commission and the Country Office met for a technical briefing on 3 January and provided initial information about the first set of 44 reported cases during the briefing and by email. The WHO subsequently published a Twitter thread about the cases on 4 January, and on 5 January officially alerted all country governments through the IHR Event Information System, as well as issuing its first Disease Outbreak News notice on the cluster.
The Chinese authorities and WHO held a subsequent briefing on 11 January. The Country Office reached an agreement with Chinese authorities on 15 January to visit Wuhan. On 16 January, a further briefing was held, and a more complete list of case information was shared. The first WHO mission to Wuhan took place on 20–21 January.
In an announcement on national television on 20 January 2020 Chinese health experts confirmed publicly that human to human transmission was occurring and that health workers were among those who had become infected. Wuhan instituted a drastic population lockdown on 23 January to try to contain the virus, as 830 cases and 25 deaths were reported. According to the report of the second joint WHO-China mission, which took place from 16 to 24 February, the lockdown and public health measures taken in China were considered successful in rapidly reducing transmission.
Some places began screening incoming visitors almost immediately, as news of the Wuhan outbreak became public. Meanwhile in Thailand, a case was confirmed on 13 January of a woman who had travelled there from Wuhan on 8 January, the first case to be confirmed outside China. Japan reported an infected person on 16 January.
4.2.2 The declaration of a public health emergency of international concern
A Public Health Emergency of International Concern (PHEIC) is the loudest alarm that can be sounded by the WHO Director-General. The IHR (2005) mandate that in determining whether an event constitutes a PHEIC, the WHO Director-General consider the advice of an Emergency Committee convened for the purpose and drawn from a roster of experts maintained by WHO. The affected State is invited to present its views to the Emergency Committee. If a PHEIC is recommended, the WHO Director-General has the final authority to make a declaration, taking all information into account. The meeting of the WHO IHR Emergency Committee called to discuss the outbreak on 22–23 January was split on whether to recommend that the outbreak be declared a PHEIC. The Committee met again the following week when the Director-General returned from a mission to China. Following the Committee’s recommendation, the WHO Director-General declared that the outbreak constituted a PHEIC on 30 January. At that time there were 98 cases in 18 countries outside China. In the statement from the Emergency Committee reported by the Director-General, it was specified that no travel restrictions were recommended, based on the information available.
Reference to the PHEIC outbreak was included in the 3 February 2020 report by the WHO Director-General to the WHO Executive Board. On 4 February in an oral briefing to Member States he reported that there had been 20 471 confirmed cases and 425 deaths reported in China, and a total of 176 cases in 24 other countries.
The IHR (2005) do not use or define the term “pandemic”. The most extensive use of the term by WHO is in relation to the detailed framework and guidelines for pandemic influenza, although even there the distinction between seasonal and pandemic influenza is not clear-cut. As COVID-19 spread during February 2020, and there was an apparent lack of understanding that declaring a PHEIC was to sound the loudest possible alarm, there was an increasing clamour for WHO to describe the situation as a pandemic. Eventually, stating that it was alarmed by the extent of both the spread of the disease and the level of inaction in response, WHO went on to characterize COVID-19 as a global pandemic on 11 March 2020, when there were a reported 118 000 cases in 114 countries.
The Panel has considered this sequence of events between December 2019 and the declaration of a PHEIC on 30 January 2020 in detail in order to assess what could potentially have been done differently and whether changes are needed in the international system of alert.
There is a case for applying the precautionary principle in any outbreak caused by a new pathogen resulting in respiratory infections, and thereby for assuming that human-to-human transmission will occur unless the evidence specifically indicates otherwise
The IHR (2005) are designed to ensure that countries have the capacity to detect and notify health events. They require that, when disease or deaths above expected levels are detected, essential information is reported immediately to subnational or national levels. If urgent events, defined as having “serious public health impact and/or unusual or unexpected nature with high potential for spread” are detected, they must be reported immediately to the national level and assessed within 48 hours. Events assessed to warrant a potential PHEIC must be reported to WHO within 24 hours of assessment, via the IHR national focal point. Events with PHEIC potential must meet at least two of four conditions, namely: (1) have serious public health impact; (2) be an unusual or unexpected event; (3) have significant risk of international spread; and (4) carry significant risk of travel or trade restrictions. The Panel’s view is that the outbreak in Wuhan is likely to have met the criteria to be declared a PHEIC by the time of the first meeting of the Emergency Committee on 22 January 2020.
While WHO was rapid and assiduous in its early dissemination of the outbreak alert to countries around the world, its approach in presenting the nature and level of risk was based on its established principles guided by the International Health Regulations of issuing advice on the balance of existing evidence. While WHO advised of the possibility of human-to-human transmission in the period until it was confirmed, and recommended measures that health workers should take to prevent infection, the Panel’s view is that it could also have told countries that they should take the precaution of assuming that human-to-human transmission was occurring. Given what is known about respiratory infections, there is a case for applying the precautionary principle and assuming that in any outbreak caused by a new pathogen of this type, sustained human-to-human transmission will occur unless the evidence specifically indicates otherwise.
The Panel’s conclusion is that the alert system does not operate with sufficient speed when faced with a fast-moving respiratory pathogen, that the legally binding IHR (2005) are a conservative instrument as currently constructed and serve to constrain rather than facilitate rapid action and that the precautionary principle was not applied to the early alert evidence when it should have been.
The Panel’s view is that the definition of a new suspected outbreak with pandemic potential needs to be refined, as different classes of pathogen have very different implications for the speed with which they are likely to spread and their implications for the type of response needed.
4.2.3 Two worlds at different speeds
The chronology of the early events in raising the alarm about COVID-19 show two worlds operating at very different speeds. One is the world of fast-paced information and data-sharing. Open digital platforms for epidemic surveillance, in which WHO plays a leading role, constantly update and share outbreak information. Digital tools are now core elements in disease surveillance and alert, sifting through vast quantities of instantly available information. Epidemic surveillance operates symbiotically with information exchange – the constant pace of news, gossip and rumour that characterize social media and can be mined for epidemic-relevant signals. Open data on the information and collaboration platforms central to scientific exchange also, by their nature, enable near-instant global availability of information.
The other world is that of the slow and deliberate pace with which information is treated under the IHR (2005), with their step-by-step confidentiality and verification requirements and threshold criteria for the declaration of a PHEIC, with greater emphasis on action that should not be taken, rather than on action that should.
The critical issue for this two-speed world is that viruses, especially highly transmissible respiratory pathogens, operate at the faster pace, not the slower one.
The Panel’s conclusion is that surveillance and alert systems at national, regional and global levels must be redesigned, bringing together their detection functions – picking up signals of potential outbreaks – and their relay functions – ensuring that signals are verified and acted upon. Both must be able to function at near-instantaneous speed.
This will require the consistent application of digital tools, including the incorporation of machine learning, together with fast-paced verification and audit functions. It will also require a commitment to open data principles as the foundation of a system that can adapt and correct itself.
4.3 Early responses lacked urgency and effectiveness
The declaration of a PHEIC by the WHO Director-General on 30 January 2020 was not followed by forceful and immediate emergency responses in most countries, despite the mounting evidence that a highly contagious new pathogen was spreading around the world. For a strikingly large number of countries, it was not until March 2020, after COVID-19 was characterized as a “pandemic”, and when they had already seen widespread cases locally and/or reports of growing transmission elsewhere in the world, and/or their hospitals were beginning to fill with desperately ill patients, that concerted government action was finally taken.
In recommending the declaration of a PHEIC on 30 January, the WHO COVID-19 IHR Emergency Committee stated its view that it was “still possible to interrupt virus spread, provided that countries put in place strong measures to detect disease early, isolate and treat cases, trace contacts and promote social distancing measures commensurate with the risk”. Most countries did not seem to get that message, despite the fact that, at the time, cases had been reported in 19 countries and human-to-human transmission was reported in at least four countries in addition to China. The majority of reported cases outside China had a history of travel in China, but that was partly because testing was initially directed only at those who both had symptoms and had recently travelled from Wuhan.
On 30 January 2020, it should have been clear to all countries from the declaration of the PHEIC that COVID-19 represented a serious threat. China had reported upwards of 20 000 confirmed or suspected cases and 170 deaths. The number of countries to which the virus had spread and where local transmission was occurring was growing by the day. Even so, only a minority of countries set in motion comprehensive and coordinated COVID-19 protection and response measures – a handful even before seeing a confirmed case, and the remainder once cases had arrived.
The question we must ask ourselves is why the PHEIC declaration did not spur more action, when the impending threat should have been clearly evident? After a stuttering start to the global response in January 2020 by the end of that month it was clear that a full-scale response would be needed. It is glaringly obvious to the Panel that February 2020 was a lost month, when steps could and should have been taken to curtail the epidemic and forestall the pandemic.
The Panel’s analysis suggests that the failure of most countries to respond during February was a combination of two things. One was that they did not sufficiently appreciate the threat and know how to respond. The second was that, in the absence of certainty about how serious the consequences of this new pathogen would be, “wait and see” seemed a less costly and less consequential choice than concerted public health action.
4.3.1 Successful countries were proactive, unsuccessful ones denied and delayed
The Panel’s review of a range of country responses up until March 2021 demonstrates that countries that recognized the threat of SARS-CoV-2 early, and were able to react comprehensively, fared much better than those that waited to see how the pandemic would develop. The early-responding countries acted in a precautionary way to buy time, while getting information from other countries, particularly from Wuhan in China where the impact of the lockdown showed that stringent measures could effectively stop the outbreak.
Response models developed in relation to earlier outbreaks, including SARS and MERS, were rapidly adapted to the specific characteristics of this novel virus and its pathways of transmission. The 2003 SARS epidemic had left a permanent mark, especially in the most affected east Asian and south-east Asian countries. SARS resulted in governments instituting whole-of-government approaches with clearly defined, tiered command structures to prepare for and respond to future outbreaks, with clear involvement of communities and transmission of information. Health protection functions were consolidated under new centralized agencies.
Effective and high-level coordinating bodies were critical to a country’s ability to adapt to changing information
Even though Ebola virus disease is a very different type of disease to COVID-19, countries with that experience drew on it to rapidly establish coordination structures, mobilize surge workforces and engage with communities.
National responses were most effective where decision-making authority was clear, there was capacity to coordinate efforts across actors, including community leaders, and levels of government, and formal advisory structures were able to provide timely scientific advice that was heeded. Effective and high-level coordinating bodies were critical to a country’s ability to adapt to changing information; in the context of a pandemic caused by a novel pathogen, adaptability has been vital.
The strategies chosen by countries to respond to COVID-19 played out in very different ways. In analysing national responses, the Panel has identified three distinct strategic approaches: aggressive containment, suppression or mitigation. In addition, there are some countries without any discernible or consistently applied strategy.
The aggressive containment strategy has been dominant in Asian and Pacific countries. Of the 28 country responses analysed in depth by the Panel, those adopting aggressive containment include China, New Zealand, Republic of Korea, Singapore and Thailand and Viet Nam. Most of the countries that adopted this strategy operationalized their national COVID-19 response through a coordinated and centralized governance structure.
Across all countries with successful responses, timely triage and referral of suspected cases to ensure swift case identification and contact-tracing, and providing designated isolation facilities, either for all or for those unable to self-isolate, were key actions. Social and economic support was instituted to promote widespread uptake of public health measures. High-performing countries developed partnerships on multiple levels across sectors and extra-governmentally, communicated consistently and transparently, and engaged with community health workers and community leaders as well as the private sector.
Successful containment of COVID-19 has required comprehensive approaches which align multiple health actions with public outreach and social and economic support. Prioritizing just one public health intervention at the population level, such as mandatory face masks or school and business closures, has not been effective.
Many countries fell in the middle ground. Their strategies aimed for containment to the greatest extent possible but were often inconsistent over time. Some countries put in place lockdowns when incidence exceeded certain thresholds, or when hospital capacity was about to be saturated. Changes in lockdown policies were difficult to time and often lagged behind fast-changing epidemic dynamics. Border closure policies differed between countries. Contact tracing programmes proved highly successful where they were implemented stringently, early on, with coherent delivery However, catching up on contact tracing that had been introduced late and in settings of high community transmission often failed and was abandoned.
In contrast, countries with the poorest results in addressing COVID-19 had uncoordinated approaches that devalued science, denied the potential impact of the pandemic, delayed comprehensive action, and allowed distrust to undermine efforts. Many had health systems beset by long-standing problems of fragmentation, undervaluing of health workers and underfunding. They lacked the capacity to mobilize quickly and coordinate between national and subnational responses.
The denial of scientific evidence was compounded by a failure of leadership to take responsibility or develop coherent strategies aimed at preventing community transmission. Leaders who appeared sceptical or dismissive of emerging scientific evidence eroded public trust, cooperation and compliance with public health interventions.
In many cases, national efforts were both catalysed and amplified by regional responses. For example, the Africa Centres for Disease Control, as an organ of the African Union, was able to coordinate a continent-wide approach to the pandemic backed by requisite political support from Heads of State and Government and ministers.
4.3.2 The crisis in supplies
Part of the story of the slide of COVID-19 from an outbreak into a pandemic relates to issues of leadership, coordination and decision-making at national level. But another part of the story is the difficulties in which countries found themselves as they scrambled to get hold of the equipment, supplies, diagnostic tests, advice, funds and workforce they needed to respond to the exponentially growing COVID-19 caseload. There was no international system that had created accessible stockpiles sufficient for the scale of country needs, or that could trigger the flow of resources and step in to regulate orderly access.
In early February 2020, the Director-General of WHO warned of delays of 4–6 months in the supply of face masks and protective suits. By March, the shortfall between needs and manufacturing capacity was estimated at 40%. Stockpiles created in the wake of the 2009 H1N1 influenza outbreak had been depleted; hoarding, price-gouging and fraud appeared in many countries; border restrictions hampered the flow of supplies; and by April 2020 controls on the export of medical supplies and medicines had been imposed by 75 countries. Furthermore, supply chains were overly dependent on a few manufacturers or concentrated in a few supplier countries.
National and international efforts sought to overcome this supply crisis, with mixed success. Countries which were able to establish purchasing partnerships nationally and with neighbours fared best. In conjunction with the African Union and Africa CDC, a partnership platform to increase purchasing power was established to achieve greater leverage in the supplies market in a bid to avoid being frozen out by richer countries. At international level, the United Nations and WHO launched the United Nations COVID-19 Supply Chain System, which eventually channelled half of the essential supplies reaching low- and middle-income countries. Local research, development and manufacturing were used to bolster supplies, ranging from personal protective equipment (PPE) to test kits and developmental work on vaccines.
An early and continuing critical gap is in oxygen supplies, vital in a respiratory pandemic, and there is no clear lead agency devoted to its delivery. This is not a new problem – up to half of all health facilities in resource-limited settings have persistently been found to lack reliable oxygen supplies.
The shortage of essential supplies had a major impact on health workers in the early stages of the response, contributing to the high death toll. Health workers have reported that their fears at the outset of the pandemic were heightened by initial systems failures, including a lack of evidence-based guidelines, shortages of PPE, sudden lockdowns that disrupted normal operations, and an overwhelming sense that facilities were unprepared.
The agility with which countries were able to manage surge health workforce demands has been a key difference between successful and struggling responses. The health systems that managed the COVID-19 response better quickly mobilized, trained and reallocated their health workforce with a combination of hiring new staff, using volunteers and medical trainees and mobilizing retirees. They took proactive steps to increase system capacity – in some cases with the rapid construction of makeshift hospitals in places where COVID-19 was out of control, but also by extending telemedicine, postponing elective medical procedures and supporting primary care.
Rapid research and development: while much of the early response to COVID-19 involves missed opportunities and failure to act, there are some areas in which early action was taken to good effect, most notably in research and development (R&D) and, in particular, vaccine product development.
The COVID-19 response benefited from years of effort to expand capacities for R&D to address potential pandemics. Expertise and technology from decades of work – especially on HIV, Ebola and cancer vaccine research and immunology – were available and ready to apply to the new virus.
In the wake of the Ebola epidemic in 2016, a new model for R&D response to emerging pathogens likely to cause severe outbreaks in the future was developed under WHO’s R&D Blueprint. It identified bottlenecks in international collaboration, encouraged agreement on basic data-sharing principles, and sought more efficient ways to conduct clinical trials in times of distress. The Coalition for Epidemic Preparedness Innovations (CEPI) was launched in 2017 as a non-profit organization funding basic research and early clinical trials for a list of epidemic-prone infectious diseases.
This infrastructure was deployed almost as soon as the COVID-19 alert was sounded. CEPI sought out and sponsored some of the first vaccine candidates (Moderna and Oxford University) as early as 20 January 2020, when there were fewer than 600 cases around the world. A number of adaptive clinical trials were launched which provided evidence quickly, for example the UK’s Recovery trial by June 2020 had shown the effectiveness of dexamethasone, and the lack of clinical benefit of the use of hydroxychloroquine in COVID-19 disease. The R&D Blueprint encouraged adaptive clinical trials and launched the Solidarity trial in mid-April 2020, which exemplified an efficient and robust way to generate randomized evidence using simple large trials.
Accompanying the global efforts were national measures to support COVID-19 R&D, the largest of which was the United States federal Biomedical Advanced Research and Development Authority, whose cumulative investment in research, development, manufacturing and procurement of COVID-related vaccines, therapeutics and diagnostics was US$ 14 billion by November 2020. Regulators also raced to find ways to speed up clinical testing while maintaining safety. Several national regulatory agencies, including the European Medicines Agency, in India, the Food and Drug Administration in the United States, and Health Canada approved emergency procedures to expedite clinical testing and approval.
In April 2020, public health experts said the optimistic expectation was that a COVID-19 vaccine was at least 12–18 months away. However, by July, numerous vaccine candidates were already in advanced clinical trials.
4.3.3 Lessons to be learnt from the early response
The Panel has analysed closely the early response to the COVID-19 outbreak, to examine whether responses to the outbreak by countries and the international system could have been different, and prevented it from escalating into the devastating pandemic it became.
The Panel’s conclusion is that the declaration of a PHEIC, the highest level of global concern specified in the international, legally binding, health regulations did not lead to an urgent, coordinated, worldwide response. It was not until the number of COVID-19 cases increased dramatically and COVID-19 had spread internationally that governments took serious action to prevent transmission.
February was a lost month of opportunity to contain the outbreak, even as the evidence of infections spreading globally was apparent.
For the Panel it is also clear that timing mattered – for a few countries, early recognition of the COVID-19 threat and quick responses kept the epidemic small. But even countries that acted later have been able to gain and maintain success with adaptable responses that are coordinated, multisectoral and science-based.
Countries that devalued science failed to build trust in their response and pursued inconsistent strategies that left them lagging behind the epidemic and with high infection and death rates.
4.4 The failure to sustain the response in the face of the crisis
4.4.1 National health systems under enormous stress
Health systems and health workers were not prepared for a prolonged crisis. The COVID-19 pandemic has taken an enormous physical and emotional toll on the world’s health workers. The health systems which had been under-resourced and fragmented over a long period prior to the pandemic were the least resilient. Delivery of essential health services, including those for sexual and reproductive health, noncommunicable and communicable diseases, immunization, and other health programmes were interrupted, with wider impacts in low- and middle-income countries. People with underlying conditions were neglected. People in aged care were especially vulnerable to COVID-19 and for many high-income countries, the huge wave of deaths in these facilities showed profound flaws in protections against a new health threat and in the way care for the elderly and vulnerable is provided.
As the COVID-19 pandemic progressed, graphic news footage was broadcast of thousands of distressed patients overwhelming health facilities around the world, many of which were woefully unprepared for the surge. Ambulances queued, emergency rooms overflowed, and hospital beds were dangerously oversubscribed. In Spain, as an example, many intensive-care units operated at 200–300% of capacity, and other countries felt similar strain.
Holding it all together were health professionals and other essential workers on the front line —medical technicians, doctors and nurses, border and quarantine staff, midwives and community workers, food suppliers and cleaners – working hour after hour, often lacking adequate protective equipment and patient supplies, watching helplessly while patients died without loved ones by their sides, and worrying about their own health and families. Response measures added to their stresses – as schools and day-care centres closed down, parents who were essential workers found themselves having to juggle impossible demands on their time.
4.4.2 Jobs at risk
In addition to health workers, the pandemic has also affected other essential workers, including those self-employed, small and medium sized entrepreneurs, those working in food shops, delivery and transportation and cleaning, and at national and subnational borders. Those involved in meat processing were at particular risk of infection. Meat-packing plants provide favourable conditions for viral transmission, given their low temperature, metallic surfaces, dense production of aerosols, noise levels requiring workers to shout, crowded working conditions and, often, limited access by employees to sick leave.
Holding it all together were health professionals and other essential workers on the front line —medical technicians, doctors and nurses, border and quarantine staff, midwives and community workers, food suppliers and cleaners
The nature of the front line and the degree of risk to workers reflects an income gradient, both between and within countries. While those who could, and could afford to, have worked from home during the crisis, others, largely lower-income workers, kept food supplies, transportation and deliveries functioning, risking infection themselves.
The economic impact of COVID-19 has depended on the interplay of pre-existing structural conditions in economies, the amount of fiscal and governance space made available for mitigation measures, and the nature and timing of decisions made in response to the pandemic. Prior conditions mattered – there was much more freedom to act and more choices were available in those places where a robust and resilient health system existed, where social and economic protections were solid, and where governments, scientists and citizens trusted each other to do their best.
An analysis of more than 80 countries shows that, where there were high levels of informal employment, mobility restrictions did not reduce the number of cases – leading to the conclusion that stay-at-home orders can only be successful when three conditions are met: households have enough income to make ends meet through the lockdown period; workers have digital access to enable them to work remotely; and there is a level of trust in government sufficient for orders to be complied with.
Many have lost their jobs and, in some cases, also their health insurance, creating a negative spiral of disease spread and severity. Social protection floors – the set of guarantees for all of the population that every country should have in place, with nationally defined levels of income security through the life cycle and access to health care – recognize the intimate relationship between universal health coverage and social protection. The pandemic has underlined the inequities that result when countries fall short of meeting these standards.
Community responses and local engagement have been vital resources in the response. Where community structures, such as cadres of community health workers, have been mobilized, they have made a critical difference in establishing trust in government instructions, extending services, and in relaying scientific information. However, the potential for communities to shape the response at the decision-making table has been severely neglected.
Similarly, women constitute almost 60% of the health workforce and front-line workers, yet they were not included in most of the COVID-19 response structures, thus increasing the equity gap for an effective response.
4.4.3 Vaccine nationalism
Vaccine access and distribution is a highly charged political issue and choice. As of now, a number of high-income countries, including Australia, Canada, New Zealand, the United Kingdom, across the European Union, and the United States, have been able to secure vaccine doses that would be enough to cover 200% of their populations.
A core mechanism to address global vaccine availability is COVAX, launched by WHO and partners in April 2020 as the vaccines pillar of its Access to COVID-19 Tools Accelerator (ACT-A). Its initial aim expressed in September 2020 was to purchase 2 billion COVID-19 vaccine doses by the end of 2021 and deliver them to people in 190 countries. By mid-March 2021, COVAX had shipped 30 million doses to at least 54 countries. At that time COVAX expected approximately 1.8 billion doses to be available to 92 low- and middle-income countries before the end of 2021, covering 27% of their populations.
But these expectations must contend with uncertainties of manufacturing capacity, regulation, funding availability, final contract terms and the readiness of countries to deliver their national COVID-19 vaccination programmes. Had COVAX had sufficient and readily available early funding it would have been better able to secure enough immediate supply to meet its aims.
The immediate issue is how to reach a political agreement for sharing and redistributing available doses of vaccine, and committed doses to come, based on what is best from a global public health perspective with equity at the centre. There is an agreement that covering only one’s own population will not end the pandemic, but the failure to move from that rhetoric to an actual effective flow and allocation of vaccine doses as they become available is a severe threat to the fight against COVID-19.
There is no definitive information source on the state of facilities worldwide now ready and able to produce COVID-19 vaccine and in what quantities, nor of the raw materials required. Manufacturers in 2020 were having difficulty even predicting how much vaccine they could make for clinical trials, much less in bulk by the billions of doses. Raw materials in thin supply include syringes and glass vials.
Aligning technology transfer, intellectual property and manufacturing capacity could boost efforts to speed up vaccine rollout. Manufacturing capacity, an effective regulatory environment and equitable distribution are interdependent problems, all of which can be solved.
Progress in sharing know-how, licensing and intellectual property has been slow. In May 2020, WHO set up the COVID-19 Technology Access Pool (C-TAP) to pool knowledge, intellectual property and data. Supported in principle by 41 high-, middle- and low-income countries, it has received no contributions so far. A recent push by South Africa and India at the World Trade Organization to waive intellectual property rules and allow generic manufacturers to make COVID-19 vaccines continues to run into opposition. India – potentially among the world’s largest vaccine-makers – is itself lagging in vaccine production and delivery, and surges in cases there have constrained its vaccine exports.
For the Panel it is clear that the combination of poor strategic choices, unwillingness to tackle inequalities, and an uncoordinated system created a toxic cocktail which allowed the pandemic to turn into a catastrophic human crisis.
The Panel notes that COVID-19 has been a pandemic of inequalities and inequities. Those with less social protection were more likely to have pre-existing health conditions that made them more vulnerable to COVID-19, and they were often also more exposed to the virus owing to the nature of their work and their living conditions. When exposed to COVID-19, a lack of social protection prevented vulnerable and sick people from staying at home because of the risk of a loss of income.
Inequality has been the determining factor explaining why the COVID-19 pandemic has had such differential impacts on peoples’ lives and livelihoods.