Letter From Munich
People in poorer countries are still waiting for vaccines, but the leaders of global health organizations have a new priority: preparing for the next pandemic.
People walk past the Bayerischer Hof hotel in Munich, Germany, Friday, Feb. 18, 2022, on the first day of the Munich Security Conference. | Michael Probst/AP Photo
By Erin Banco
Erin is a health care reporter for POLITICO.
MUNICH — One night last month, a select group of the world’s most prominent health leaders — investors and directors of the largest nonprofits — sat around white linen-lined dinner tables. Around them, long yellow drapes fell from the ceiling and French chinoiserie panels bordered the walls, in the 18th-century style of Louis XV. The room — a formal salon — sits on the first floor of the Bayerischer Hof, one of the oldest and most expensive hotels in the city. It is also the site of the Munich Security Conference, an all-star international political event held each year.
Thomas Bollyky, the director of the global health program at the Council on Foreign Relations, and Ilona Kickbusch, one of the most renowned German global health policy leaders, hosted the dinner on the first night of the conference. Bollyky had just published a year-long study, funded by the Bill & Melinda Gates Foundation, on ways to improve health responses in the next pandemic. Bill Gates, the co-chair of the foundation, was in attendance as were some of the biggest names in global health.
In a scene reminiscent of the HBO show Succession, the hosts of the event went around the room, asking attendees to muse about the future of global health security and where the world should focus its efforts in the coming months and years.
As guests spoke, it became clear that the majority had concluded what so few were willing to say publicly in fear of retribution and because so many across the world have yet to receive the vaccine: It is time to move on from the emergency phase of the pandemic. Focus should go to shoring up billions of dollars in funding so that governments and global-health organizations can engage in massive efforts to prepare for the next pandemic, they said.
“We need to fund global surveillance, to see the next pathogen early. We need to fund [research and development] for better diagnostics, therapeutics,” Gates said in an interview in Munich.
The discussion at the dinner was emblematic of a broader shift taking place inside the global health world — one that is pulling the messaging away from ending the Covid-19 pandemic to ramping up funding for the multi-year process of scaling up manufacturing capacity, upgrading surveillance systems and strengthening health for the next worldwide outbreak.
But not everyone has been on board with that approach. Over the last several weeks, leaders of the top global health organizations — those pushing to begin preparing for the next pandemic — and advocates for the people most vulnerable to new Covid variants have debated the direction of global health strategy. Advocates working to ramp up vaccinations worldwide have argued that although Covid-19 is now somewhat manageable for wealthy Western countries, populations in low- and middle-income countries are still struggling, and the more people hear about preparing for the next pandemic, the more likely it is they will forget the world is still dealing with the current one.
It’s a messaging problem many who were interviewed for this story likened to the debate around booster shots last fall. While COVAX and other organizations were trying to ramp up primary vaccinations in low- and middle-income countries, wealthy nations were beginning to move on and announce broad-scale booster campaigns — a signal to the world that protecting healthy populations in places like the U.S. was more important than giving first shots to those in developing countries. U.S. and European officials shot back at those allegations, saying they had ample vaccine supply to give booster shots and continue to distribute internationally.
“We’re still in danger because there are masses of people in the world not vaccinated,” Ngozi Okonjo-Iweala, director general of the World Trade Organization, said in an interview in Geneva. “There is now this feeling that it’s over after Omicron, that we’ve seen the back of it, let’s just let everything go. And I think that that may be a little bit too complacent. We really need to be careful.”
In recent weeks, as some have tried to broadcast the shift toward pandemic preparedness, others have pushed back, denouncing the effort as dangerous — delusional, even — as Covid-19 is still infecting millions of people and killing thousands each day. The mere insinuation that the world could begin to think more broadly about preparing for the future has ruffled feathers among representatives of organizations whose main mission is to ensure the billions of doses coming online make their way into arms in low- and middle-income countries. The World Health Organization, for example, is still trying to push the world to reach its goal of vaccinating 70 percent of the population by mid-2022.
But as countries across the world begin to ease public health mandates, global health leaders are seeing an opening to refocus their priorities — to shift the narrative to preparing for the next pandemic.
Over the course of the last six weeks and dozens of interviews with the world’s top minds on global health security, almost everyone indicated that pandemic preparedness is the new global health priority — and rightly so, they argued. The world’s response to Covid-19 was woefully inadequate. Too slow. Too under-resourced. And now is the time to plug the gaps. Gates has a book about this coming out in May. Even some of the global health advocates who six weeks ago balked at the idea of the push to begin focusing more heavily on pandemic preparedness are engaging in the conversation.
To Gates and many of those who attended the dinner in Munich, there are ways to continue fighting Covid-19 while simultaneously preparing for the next large-scale outbreak. And in finding ways to scale mRNA vaccines and expand manufacturing and distribution of therapeutics, you’re also helping in the fight against Covid-19.
In other words, they said, you can do both at the same time.
Bill Gates speaks at the Munich Security Conference last month. | Sven Hoppe/DPA via AP
“I don’t think it’s one thing or the other,” said Harley Feldbaum, head of strategy and policy at the Global Fund to fight AIDS, Tuberculosis, and Malaria. “I’m sure you could come up with pieces of the global health community that are more or less focused on, you know, getting back on track to the original sustainable development goal targets versus fighting Covid versus thinking about future pandemics. But when you bring it down to people and health systems, there’s overlapping capacities, and they’re not antithetical to each other.”
The push toward strategizing around pandemic preparedness is rooted in part on signals governments across the world are sending, global health representatives said. For example, as cases wind down in the U.S., hospitals are beginning to deactivate the formal Covid units that have operated over the last two years. The Centers for Disease Control and Prevention recalculated the current risks posed by Covid-19 in the country, allowing more state and local officials to wind down public health mandates such as masking in schools.
As a way of transitioning out of the emergency phase of Covid-19, governments and multilateral organizations are beginning to release massive budget requests for pandemic preparedness.
In just the last few weeks, the Biden administration has laid out a new plan for preparedness. Lawmakers on Capitol Hill have launched a new bill outlining funding priorities for domestic and international preparation. And the G20 is calling for $75 billion in international public funding to address gaps in pandemic prevention and preparedness.
Health advocates and officials leading the race to vaccinate the world have long feared the money they secured would disappear as soon as wealthy countries vaccinated the majority of their populations. Now, they see those dollars potentially flowing to preparedness rather than efforts to end the Covid-19 pandemic.
That might be true, a senior European official told me.
“There’s not an unlimited amount of money out there,” the senior European official told me. “There has to be some priority setting. We can try to do both at the same time. But the money has to come from somewhere.”
That rhetoric is making representatives of the global health community anxious — anxious that not only the funding for Covid-19 will fall off but that general interest in global health will begin to wane. On that February night at the dinner in Munich, attendees noted, even if indirectly, that the intensity with which governments and multilateral organizations had attacked the Covid-19 issue in 2020 and 2021 was beginning to fade.
“The concern that many who are concerned about lower-income countries have is that in the West, as the pandemic is perceived to have subsided or become manageable … that [countries] are going to turn to other pressing issues and crises,” said Richard Hatchett, the CEO of the Coalition for Epidemic Preparedness Innovations, who attended the dinner. “I mean, here we are talking about this at a conference that is dominated by Ukraine.”
Just two years ago, the same global health leaders who attended the Munich dinner in 2022 buzzed in a hotel coffee bar about the increasing SARS-Co-V-2 case numbers and gamed out how to prevent the worst-case scenario where governments would fail to contain the virus, allowing it to spread across the world, killing millions. Representatives from regions in Europe, Southeast Asia and Africa all scrambled to meet with these top global health institutions to learn and prepare for what was to come. Officials knew these global health representatives were going to be the ones that would lead the way in finding ways to prevent Covid-19 from wreaking havoc on the world. Their organizations collectively gobbled up billions of dollars in funding.
But by the time attendees of the conference reached the Bayerischer Hof in 2022, Covid-19 appeared to be an afterthought. The conference had turned into a real-time crisis-planning session on Russia’s likely invasion of Ukraine. Officials met to solidify plans for NATO, sanctions and arms transfers to Kyiv. There were a few panels on global health and the pandemic, but for the most part conference badge holders rushed around the hotel to find out if and when Ukrainian President Volodymyr Zelenskyy would arrive.
Okonjo-Iweala said there’s been a similar dwindling of interest in coming up with pandemic preparedness money.
“We’ve spent $26 trillion in fighting the pandemic … but we are not ready to spend $75 billion for starting prevention now? That is wrong,” she said, referring to a recommendation a panel of experts made to the G20 earlier this year. “I’m a former finance minister, I know budgets are stretched, and it’s very difficult. But the leaders have to come together. Where is the political will?”
At the dinner in Munich, Hatchett said he pitched an alternative approach — one that the U.S. government and others in Europe have fostered in previous years.
“One of the challenges is that a pandemic is often treated as a health crisis and as it relates to low- and middle-income countries, as a development problem,” Hatchett said. “We need to understand pandemics [as] a security threat. If you view it as a security threat then a lot of the trade-offs — do we focus on health system strengthening or pandemic preparedness? — fall away because you are taking pandemic preparedness out of a fixed health budget or development budget.”
The budgeting discussion — how to continue to put up money for Covid efforts while at the same time providing funds for preparedness — is one that has consumed lawmakers on Capitol Hill and Biden administration officials.
In the past week, the administration has requested from Congress a small fraction — less than $5 billion — of what is needed by USAID in 2022 to help put shots into arms in developing countries. In its official request, the administration stressed that it would reassess the funding situation later in the year and would find alternative ways to ramp up its support for the global Covid fight if needed.
Meanwhile, organizations like COVAX and the WHO are reevaluating how they approach Covid-19 vaccination efforts now that case numbers are declining.
Representatives from both acknowledged in interviews that officials and scientists in developing countries across the world are beginning to factor in prior infection rates in calculating immunity levels. In doing so, countries may decide not to order as many doses in 2022, Seth Berkley, the CEO of Gavi, the vaccine alliance and leader of COVAX, said.
“Each country needs to decide what they want,” he said in an interview last month. “We don’t know how homologous or heterologous those [prior infection] coverage rates are. The second thing we don’t know, of course, is the future. My own view is, we should certainly try to cover the high-risk population with vaccination.”
Berkley said COVAX is working with countries to identify specific vaccination needs, including how many doses governments want to order up front, which kind of vaccine they’d rather procure and where they want to distribute it. The tailor-made response will help COVAX assist governments in administering efficiently.
There’s much more work to be done in ensuring lower- and middle-income countries have the doses they need and that they have the resources on the ground to distribute them, said Kate O’Brien, WHO’s immunization director.
“We do need to remember that for the countries that have the lowest coverage, their flexibility on supply has really only been something that’s opened up since November. It really wasn’t before that that they had any predictable supply,” she said in an interview last month. “We’re in the early days. It’s kind of like comparing the contemporary era we’re in right now for low-income countries to what it was like for high income countries in April of 2021.”
Part of the problem in getting shots into arms in developing nations is that not enough resources have been dedicated to helping countries obtain the infrastructure and medical staffing they need to run widespread vaccine campaigns.
“There are lots of people who are interested in getting vaccinated, but you need to make it super easy for them to get vaccinated,” said Orin Levine, director of vaccine delivery at the Bill & Melinda Gates Foundation.
USAID, in coordination with COVAX, is prioritizing helping countries with weaker health systems develop plans to ramp up vaccination rates in 2022. There are still 30 countries that have levels below 10 percent.
As global health organizations are trying to hold on to their Covid-19 funding and continue to help protect vulnerable populations and simultaneously prepare for the next pandemic, they are also trying to revamp their existing programming. The intense focus on Covid-19 over the past two years has reversed progress on HIV, tuberculosis, malaria and immunization campaigns, global health experts say.
The Global Fund announced recently that the world needs $18 billion to get back on track with that programming while at the same time fighting Covid-19 and preparing for the next pandemic.
“It’s like we’re all trying to walk and chew gum at the same time,” one global health advocate working in Washington told me. It’s a catch-phrase that many used in describing the dichotomy between continuing to focus on ramping up Covid-19 vaccinations and also preparing for the next pandemic.
“We use that term because it really is true,” the advocate laughed. “We have to do it all. But in reality, there are issues we care about more than others.”
For the Biden administration, walking and chewing gum is the goal. It has to live up to its commitments internationally on Covid-19 but it also has to find ways to safeguard Americans for the next large-scale outbreak, which top health officials now say could occur in the next several years.
“We have to do both,” Loyce Pace, the assistant secretary for global affairs at the Department of Health and Human Services, said in a recent briefing with reporters in Geneva. “What I think we can do and should be doing is saying, ‘OK, well, how do we improve our Covid response so that it helps Covid and also gets us ready?’ I don’t think it’s a matter of stopping one and starting another because … some of the actions we’re taking now or see them as dual purpose.”
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‘This too shall pass away’ this famous Persian adage seems to be defeating us again and again in the case of COVID-19. Despite every effort