How an outbreakbecame a pandemic
The defining moments of the COVID-19 pandemic

Disclaimer:
The designations employed and the presentation of the material in this publication do not imply
the expression of any opinion whatsoever on the part of the Independent Panel for Pandemic
Preparedness and Response concerning the legal status of any country, territory, city of area orof its authorities, or concerning the delimitation of its frontiers or boundaries.
Report Design: Michelle Hopgood, Toronto, Canada
Maps: Taylor Blake
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Contents

Abbreviations4
What happened, what choices were made, and what can we learn?

6

1.

Despite warnings, the world was not prepared8

2. The detection of a novel coronavirus: SARS-CoV-2

12

3. The reality hits home

17

4.

23

The frontline under stress and requiring protection

5. The scramble for supplies

27

6.

Navigating the digital environment and the trust deficit

32

7.

The unprecedented pace of R&D acceleration

37

8.

Geopolitical tensions challenging multilateralism

43

9.

Economies take major hits

46

10. The pandemic affects everyone, but not everyone is affected equally 51

11. Vaccine nationalism

55

12. Building forward better — realizing the sustainability vision

59

13. A future with mutant SARS-CoV-2?

64

About the Panel

67

References68Abbreviations

ACT-A
Africa CDC
CEPI
COVAX
COVID-19
C-TAP
ECDC
EU
GDP
ICU
IHR (2005)
KEI
MERS
PCR
PHEIC
PPE
R&D
SARS-CoV-2
UK
UNAIDS
UNICEFUSUS CDCUS$US FDAWEF

Access to COVID-19 Tools Accelerator
Africa Centres for Disease Control
Coalition for Epidemic Preparedness Innovations
COVID-19 Vaccines Global Accesscoronavirus disease
COVID-19 Technology Access Pool
European Centre for Disease Prevention and Control
European Union
gross domestic productintensive care unit
International Health Regulations (2005)
Knowledge Ecology International
Middle East respiratory syndrome
polymerase chain reaction
public health emergency of international concern
personal protective equipment
research and development
severe acute respiratory syndrome coronavirus 2
United Kingdom of Great Britain and Northern Ireland
Joint United Nations Programme on HIV/AIDS
United Nations Children’s Fund
United States of America
United States Centers for Disease Control and Prevention
United States dollars
United States Food and Drug Administration
World Economic ForumThis report is a companion to themain report, COVID-19: Make it theLast Pandemic, of the Independent Panelfor Pandemic Preparedness and Response.
It is an evidence-based narrative, providing
in-depth analysis of 13 defining momentsof the evolution and impact of the
COVID-19 pandemic.

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5 of 74What happened, what choices were made,and what can we learn?
In physics, a “moment” is defined as the change indirection produced when a force acts to move a system
around a pivot point. The moments we describe here
are the critical junctures which changed the direction or
nature of the force of severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) and the pandemic it caused.
Some are discrete moments in time; others are more
extensive. Together, they account for where we aretoday, and why.
The Panel has ranged widely in its investigations, consulting experts within
and beyond the health sector, hearing from those on the frontline, frommidwives and nurses to city mayors, obtaining the perspectives of womenand youth, the private sector and people living with chronic diseases. Its
analysis synthesizes the evidence from hundreds of studies of responses
to the pandemic and its impact. That volume of information is daunting
but, as the Panel compiled it all, key themes emerged clearly and were
held in common across the world, despite the very different lived realitiesof the COVID-19 pandemic in different countries.
The evidence the Panel gathered showed that decisions mattered andhad consequences. It also showed that prior conditions mattered — there
was much more freedom to act and more choices available in thoseplaces where a robust and resilient health system existed, where socialand economic protections were solid, and where governments, scientists
and citizens trusted one another to do their best.
It is a basic human trait to make sense of new information on the basisof past experience. We could not function any other way. But when we
encounter something genuinely new, that trait can lead us astray. We
alternate between the paralyzing anxiety of indecision, when facedwith something truly unpredictable, and the temptation to impose ourold models on the new events, whether they fit well or not. This pandemic
has seen plenty of evidence of both reactions.
As the Panel submits its report, nearly one-and-a-half years into thispandemic, it is tempting to assert that it is “obvious” what should havebeen done at each stage in the past, based on the knowledge we havegained now. But that temptation fails to respect the difficulty of decisionmaking when a new disease is emerging and the radical uncertainty
about how it will unfold.

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Our account of 13 defining moments on which the response to thispandemic has turned is based on a meticulous examination of
the evidence and the evolving knowledge. We look at the state of
preparedness prior to this pandemic, the identification of the virus(SARS-CoV-2) and the disease it caused (COVID-19) and responses
globally, regionally and nationally, particularly in the pandemic’s earlymonths, and the wide-ranging impact and social and economic crisis
it has precipitated up to today.
The pandemic is not yet over. It is continuing to surprise us. The moments
described below will therefore have a sequel. The “defining moment”
of the end of the pandemic is the most important one of all, but that is
yet to come. How we approach that moment will depend on how willingthe world is to take stock honestly, but without blame or rancour, anddetermine what could have been done better, and how to ensure thatis the path that is taken in the future.

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Credit: Watsamon Tri-yasakda

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1. Despite warnings, the world was not preparedIn under four months from the moment when SARS-CoV-2
was first identified as the cause of clusters of unusual
pneumonia cases in Wuhan, China, COVID-19 became a
global pandemic threatening every country in the world. (1)Although public health officials, infectious disease experts
and previous international commissions had warned ofpotential pandemics and urged robust preparations since
the first outbreak of severe acute respiratory syndrome(SARS), COVID-19 still took large parts of the world
by surprise.
This should not have been the case. The number of infectious disease
outbreaks has been accelerating. Major outbreaks this century inaddition to SARS have included influenza, Ebola virus disease and Zika
virus disease. At the end of the last century, the HIV pandemic took
hold, and remains with us — there is still no HIV vaccine, millions rely on
antiretroviral treatment to remain alive and new infections still occur at
an unacceptable rate.
Population growth and accompanying environmental stresses are
driving an increase in emerging novel pathogens. Air travel has increased
fourfold since 1990, which means a virus can reach any place in the world
in a matter of hours (2).
Figure 1: Global emergence of selected pathogens over the past 50 years(naturally emerge/re-emerge/deliberately released)
Source: United States National Institutes of Health, National Institute for Allergies and Infectious Diseases.

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Concerted efforts have been made in recent years to boost pandemic
preparedness, but too many national governments still lack solid
preparedness plans and core public health capacities, as well asorganized multisectoral coordination (3). Country self-reported assessmentof preparedness capacities, required by WHO under the International
Health Regulations (IHR) (2005), gave a global average score of 64 out of
100 (4). Only two thirds of countries reported having full enabling legislationand financing to support needed health emergency prevention, detection
and response capabilities (5). Country preparedness was also assessed
under the voluntary joint external evaluation process, undertaken to dateby 98 countries. An independent academic exercise, the Global Health
Security Index, also sought to score country pandemic preparedness.

Figure 2: Death rates in this figure shows the cumulative, reported, age-standardized to COVID-19 deaths per
hundred thousand people in the 50 days following the date of the first death in that country
Source and adapted from: Sawyer Crosby et al, IHME, Think Global Health

Death Rate

Joint External Evaluation Scores vs. COVID-19 Death Rates
32.2

BEL

16.1

STP

8

KWT
DJI

4
2
1
0.5

GAB

LBR

COG

TGO

CIV

0.1

GHA

LTU
ZAF
MAR

BEN

ZWE LBY

BHR

KGZ

IDN

30

SGP

NZL

JOR

AUS

BGD
PHL

BDI

ARM

LVA

TUN

SDN
GEO

FIN

BGD

0
0

LBN

IRQ KEN

GMB
MWI

ALB
MUS

SEN

SVN

SAU

OMN

SRB

PAK

COD

0.1

MDA
QAT

AFG

0.3

CAN

SLE

CMR

TCD

ARE

MKD

MDV
GNB

CHE

USA

THA

LKA

JPN

ETH

40

50

60

70

80

90

Joint External Evaluation Score
Central/Eastern Europe & Central Asia

North Africa & Middle East

Southeast/East Asia & Oceania

Latin America & Caribbean

South Asia

Sub-Saharan Africa

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The thing that all these measures had in common was that their rankingof countries bore no relation to the countries’ success in containing
COVID-19 (6, 7, 8). They missed the importance of political leadership, trustin government institutions and speed of response (9). For example, while
the US ranked highest in its aggregate score on the Global Health Security
Index, it scored less well on universal health care access, and in relation to
public confidence in government, and received a score of zero indicating
a confidence level of less than 25%. (10)The need to prepare for and prevent the growing risk of zoonotic
outbreaks of new diseases with pandemic potential has been recognized.
One Health approaches seek to better understand the interdependence
between animals, humans, and the environment (11). Predicting andcontrolling zoonotic outbreaks requires close coordination across a
range of experts and disciplines. Under the tripartite collaboration
between WHO, the Food and Agriculture Organization of the United
Nations and the World Organisation for Animal Health, guidance wasdeveloped in 2019 on the prevention, preparedness, detection andresponse to zoonotic threats with examples of best practices (12).

“What all these assessment measures had in common wasthat their ranking of countries bore no relation to how wellcountries have contained COVID-19.”
However, implementation has not taken place at the scale needed. The
World Bank’s COVID-19 response framework committed US$220 million for
One Health activities in 13 countries in 2020, far short of their estimate ofan annual US$3.4 billion needed to build and operate systems for effective
zoonotic disease prevention and control in low- and middle-income
countries through One Health systems (13).
It seems that preparedness systems need to be put to the test frequently
if they are to remain supple. Many of the countries that have successfully
contained COVID-19 drew on their experiences of both success andfailure in their relatively recent responses to SARS, Middle East
respiratory syndrome (MERS) and Ebola virus disease.
The 2003 SARS epidemic galvanized WHO Member States into rapidly
concluding their decade-long comprehensive redraft of the International
Health Regulations, which was agreed in 2005 and entered into force
in 2007. The SARS epidemic also set in train a pattern of post-pandemic
reviews, repeated after the pandemics of Ebola virus disease and H1N1
influenza of the past two decades.
Eleven high-level panels and commissions have laid out specificrecommendations for global pandemic preparedness in 16 reports
since 2011. Despite their consistent messages, few of these suggestions
have been implemented.
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In Summary
Zoonotic disease outbreaks are increasing and will continue to do so.
The risk of a new respiratory pathogen is high.
Countries were not prepared and investment in disease outbreakpreparedness systems and capacities has been insufficient; in too few
cases were national response capacities subjected to rigorous stress tests.
Preparedness metrics failed to predict weaknesses — COVID-19 haslaid bare the deficiencies.
In spite of the warnings of pandemic risk and clear recommendations
on what needed to be improved, the world had not taken theseissues seriously.

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Credit: Angela Ponce2. The detection of a novel coronavirus:
SARS-CoV-2
In late December 2019, several health facilities in China
reported clusters of a pneumonia of unknown origin. As
patients did not respond to typical pneumonia treatments,
clinicians became concerned that the illness might
be something new and sent samples to laboratories
for evaluation. The pathogen turned out to bea new coronavirus.
The course of the COVID-19 pandemic was shaped by a series of insights,
research findings, actions and reactions that took place amid great
uncertainty. Many of the choices made and decisions taken were highly
time-sensitive — conditions changed from day to day; in some cases,from hour to hour. While it may not be possible to dismiss completely
the wisdom of hindsight, any account of events as they unfolded needs
to recognize, in all humility, the radical uncertainty involved in responding
to a novel disease event.
One of the urgent
notices issued on
30 December 2019 by
the Wuhan Municipal
Health Commission.

On 30 December 2019, the Wuhan Municipal Health Commission
issued two urgent notices to hospital networks in the city about casesof pneumonia of unknown origin. Discovering what was causing the casesand how it might be transmitted was an urgent concern. While a majorityof the people with confirmed exposure had attended the Huanan SeafoodMarket, a substantial minority had not, raising the question of which
common factor was causing their illness, including the possibilityof human-to-human transmission.
While the market was the initial focus of investigation of spread, two later
studies of the early laboratory-confirmed cases (14, 15) linked only 55% to 66%
of cases to exposures there, suggesting the market may have been a site ofamplification of the virus rather than its origin, and that human-to-humantransmission in December 2019 was very likely. The SARS-CoV-2 virus has
zoonotic origins, and current evidence suggests a species of bat is themost likely reservoir host; the intermediate host is still unknown, as is theexact transmission cycle. WHO has convened a technical mission to better
understand the origins of the virus which reported on 30 March 2021. (16).
The WHO China office took note of the public bulletin issued by the Wuhan
Municipal Health Commission on 31 December, and WHO headquarters
was alerted via the news reports which had appeared on 31 December.
The WHO Western Pacific regional office (WPRO) requested further
information from China. Chinese officials initially met with WHO to

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The World Health Organization’s tweet on 4 January 2020.

discuss the outbreak at a technical briefing on
3 January 2020. WHO subsequently published a
Twitter message about the cases on 4 January,
and on 5 January officially alerted all country
governments through the IHR (2005) Event
Information System, as well as issuing its first“Disease Outbreak News” notice. Meanwhile,by 1 January, both Taiwan, China and theHong Kong Special Administrative Region had
announced their intention to screen incoming
travellers. Others soon followed their lead.

The Wuhan Institute of Virology had sequenced almost the entire genomeof the virus on 2 January. The Chinese Center for Disease Control andPrevention developed a diagnostic test that was distributed to facilities in
Wuhan on 11 January, and a draft digitized sequence of the SARS-CoV-2
genome was published, making it available to researchers worldwide.
WHO published the first protocol for a polymerase chain reaction assay
for detection of the novel coronavirus, developed in collaboration withpartner laboratories, on 13 January.
WHO began developing guidance for countries on how to respondto the new disease, including advice for international travel and trade,
although it did not recommend travel restrictions. Meanwhile, the first

Figure 3: Severe acute respiratory syndrome coronavirus 2 isolate Wuhan-Hu-1,
a close-up of part of the genome sequence
Source: GenBank: MN908947.3

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case outside China was confirmed on 13 January; a woman who had
travelled to Thailand from Wuhan on 8 January. Japan reported an infected
person on 15 January. More countries began screening passengers from
Wuhan, looking for fever or other symptoms of respiratory disease. On
23 January, following investigation by Chinese officials and a few days
after human-to-human transmission was publicly confirmed, Wuhan
instituted a drastic population lockdown to try to contain the virus as
581 cases and 17 deaths were reported (17). According to the report ofthe second WHO-China joint mission, which took place from 16 to 24
February 2020, the lockdown and public health measures taken in
China were considered successful in rapidly reducing transmission (18).
At the 22–23 January meeting of the WHO IHR Emergency Committee todiscuss the outbreak, the Committee was divided about whether it should
recommend that the outbreak be declared a public health emergency
of international concern (PHEIC). The IHR Emergency Committee met
again one week later, and the Director-General of WHO declared thatthe outbreak constituted a PHEIC on 30 January. At that time, there were
98 cases in 18 countries outside China (19). Stating that it was alarmed by
the extent of both spread and inaction, WHO went on to characterize
COVID-19 as a global pandemic on 11 March 2020, when there werea reported 118 000 cases in 114 countries (20).
The ability of SARS-CoV-2 to transmit from person to person before
people show symptoms, or from people who may never show symptoms,
complicates its detection. Estimates of the rate of asymptomatic infection(i.e. infection where the person never develops signs of illness) frommeta-reviews put the average rate between 17% and 20% (21). Becauseof widespread travel, the virus moved quickly and stealthily to localities
throughout China and the world. Cases were identified in many places
throughout February and March as new epicentres emerged, including
the region of Lombardy in Italy and New York City in the United States.
By the end of March 2020, the virus had been confirmed in nearly every
country in the world (22).
A meticulous and verified chronology of the events as they unfolded
shows the evolution of the science, the spread of the outbreak, theguidance issued and the decisions that were made (a). Clinicians andlaboratory staff in Wuhan were quick to investigate suspicious clusters
and collect and analyse samples. Once WHO was alerted to theoutbreak, the Organization took immediate steps to activate a response
and request more information. Although the public health measures
introduced in Wuhan caused severe hardship for many, they helped tocontain transmission substantially. Researchers sequenced the genomeof the novel virus rapidly, and a reliable test became available.
However, the evidence collected by the Panel suggests that action should
be taken to ensure an even more rapid and efficient early response in the
future. Viruses move in the space of hours, and every moment gained is ana See the Independent Panel's Authoritative Chronology
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opportunity to curb further outbreaks. Information about cases and theircharacteristics was not available quickly enough. The different IHR articles
require information to be shared, but some of the requirements are toovague. There were few restrictions on the movement of people in Wuhan
before 23 January, and people were travelling extensively within China
and abroad.
While continuing to warn of the possibility of human-to-humantransmission, WHO communication continued to report a lack of definitive
evidence of that, until the WHO Regional Office for the Western Pacific(WPRO) tweeted on 19 January that there was evidence of limited
human-to-human transmission. Following a Chinese national mission
to Wuhan it was confirmed on national television on 20 January that
there were cases involving human-to-human transmission.
Several countries did begin to monitor incoming travellers and initiate
emergency processes, but even when the PHEIC was declared on 30
January, most countries still did not respond adequately. The chronology
suggests that formal identification, verification, notification, and response
systems need to be more rapid and seamless if local outbreaks are to becontained before they can spread out of control.
Retrospective analysis shows there was a significantly greater number ofcases and a greater extent of spread than was recorded at the time, bothwithin and outside China. Estimates of the true extent of infection required
diagnostic tests and estimates of case fatality rates, but even after tests
were developed, early screening criteria focused on travel histories and so

Figure 4: A short segment of the Independent Panel’s authoritative COVID-19 chronology
Source: The Independent Panel for Pandemic Preparedness and Response

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failed to pick up the extent of virus circulation in the community. Symptombased screening missed the true extent of asymptomatic infection.
The International Health Regulations, which are a legally binding
instrument agreed by all WHO Member States, are designed to facilitate
rapid information sharing to enable effective global action in the face ofa widespread health emergency. A fundamental question is how fit forthis purpose the IHR are, and how to guarantee the seamless informationexchange and collective action required for the world to get ahead of afast-moving virus.

In Summary
The conclusion is that the alert system does not operate with sufficient
speed when faced with a fast-moving respiratory pathogen, that thelegally 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 could have been.
The earliest possible recognition of a novel pathogen and open andrapid sharing of emerging information and science regarding its modesof transmission are critical for alerting governments to a potential healthemergency and for containment measures.
The speed and the pace of the formal procedures that WHO is required tofollow, as prescribed in the IHR (2005), do not reflect the rapid availabilityof data and information today through digital tools and social media.
For the future, a precautionary approach should be used from the outset,
acknowledging that a respiratory disease may spread from person toperson unless and until established otherwise.
Capacity for local and rapid access to next-generation genetic
sequencing should be expanded as an invaluable tool to investigate
suspected novel pathogens without delay.

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3. The reality hits home
At the end of January 2020, news footage showed dozens
of excavators furiously digging the foundation for a new
1000-bed hospital in Wuhan (23). It was needed quickly totreat a growing influx of patients with the newly identified
coronavirus disease. For most observers, the outbreak
seemed a distant development. But some governments,
mostly those which had experienced SARS and/or MERS,
had noted the 31 December 2019 press reports of a newpneumonia identified in Wuhan and WHO’s early January
alert. Immediately understanding the threat, they began
to activate response plans.
Thailand activated its Emergency Operations Centre by 4 January 2020,
even before its first case was reported on 13 January (24). In Viet Nam, on
16 January, the Deputy Prime Minister tasked the health ministry withurgently issuing an action plan. The Vietnamese response established aunified chain of command from national to village level, enabling rapid
action (24, 25). Singapore set up a multi-ministry task force to tackle thecoronavirus on 22 January, the day before its first case was confirmed (26).

“There was an anticipationthat something bad wasgoing happen. It was very
weird, and I was scared.”
Ekaterina Faldina,small business owner in St. Petersburg, Russia

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Credit: Katya Rezvaya

All of these early responders established multi-ministry committees at
the highest level to coordinate a whole of government response. But
early responders were a small minority. The highest level of global alert,
a PHEIC, declared by the Director-General of WHO on 30 January, did
not spur a worldwide response as it should have done.
On 4 February 2020, the Director-General briefed the Organization’s
Executive Board about the coronavirus outbreak, reporting that there
had been 20 471 confirmed cases and 425 deaths in China and a totalof 176 cases in 24 other countries (27). The number of countries withconfirmed cases reached 53 by the end of February and 93 by thefollowing week (28, 29). Amid a clamour of calls for urgency, the DirectorGeneral, alarmed by both the spread of the disease and the lack of action,
said on 11 March that “COVID-19 can be characterized as a pandemic” (19).
For many countries, it was not until they had already seen widespread
local transmission and their hospitals were starting to fill with desperately
ill patients that they finally took action.
Hospital admissions were a lagging indicator of spread. Looking back,it is very clear that the extent of local transmission had been vastly
underestimated well before any response was instituted.
The first case in the United States of America was in a person who arrived
on 15 January 2020 and tested positive six days later. By the first week ofMarch, the epidemic in the country was doubling in size every 2.68 days,
suggesting rapid uncontrolled spread (30). On 13 March, the Government
declared the pandemic a national emergency.
The first confirmed case in Africa was in Egypt on 14 February. On 22
February, a meeting of African Union health ministers with the Africa
Centres for Disease Control (Africa CDC) and WHO established a task
force and containment strategy for the continent.
Italy reported its first cases on 31 January 2020 and quickly became
an epicentre for infections, although substantial undetected local
transmission was almost certainly happening much earlier (31). On
10 March, Italy became the first European country to enact strict
public health measures, followed shortly by Spain and France.

For many countries, it was not until they had already seen
widespread local transmission and their hospitals werestarting to fill with desperately ill patients that they finally
took action.

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New Zealand reported its first case on 28 February and acted to isolate
new cases rapidly. However, during the first three weeks of March,
the virus spread rapidly, mainly via superspreading social gatherings.
At 23:59 on 25 March 2020, the country was placed in a strict national
lockdown which lasted seven weeks (32).
The first confirmed case in Latin America was in Sao Paulo, Brazil
on 26 February. It prompted closures of schools and businesses, andrestrictions on international flights beginning around 12 March. Countries
around Latin America instituted stringent control measures relatively
early. Even so, many countries in the region were unable or unwillingto sustain them and, as a result, cases began to rise relentlessly.
Globally, 750 890 confirmed cases of COVID-19 were reported as of
31 March 2020 — a substantial underestimate of the actual number.
The Panel’s review of country responses (b) emphasizes that countries thatrecognized the threat of SARS-CoV-2 early and reacted comprehensively
fared much better than those adopting a “wait and see” approach andwhose responses were more fragmented.
Countries with more successful outcomes, measured by deaths per
capita, introduced precautionary action earlier to prevent community
transmission, buying time to collect more information and develop andoperationalize a cohesive approach. Response models developed inrelation to earlier outbreaks were rapidly adapted to the novel virus and its
pathways of transmission. Timely triage and referral of suspected cases toensure swift case identification and contact-tracing were key elements, as
was providing designated isolation facilities. Social and economic support
was instituted to promote widespread uptake of public health measures.
Resilient and successful country responses heeded the evolving science;
they quickly mobilized, trained and reallocated their health workforce.
System capacity increased in some cases with the rapid constructionof makeshift hospitals, but also by extending telemedicine services,
postponing elective procedures and supporting primary care. Local
research and development in many countries were used to bolster
supplies and begin the development of response tools, ranging frompersonal protective equipment (PPE) to test kits and vaccines. National
efforts were both catalysed and amplified by good regional responses,
where these existed. For example, the Africa Centres for Disease Control
and Prevention were able to coordinate a continent-wide approach by
virtue of their location within the African Union, for instance through the
Africa Medical Supplies Platform. (33)Countries with less successful outcomes to date had adopted
uncoordinated approaches that devalued science, denied the potential
impact of the pandemic, delayed comprehensive action and allowedb The Panel has conducted a review of policy responses in 28 countries selected torepresent different regions and the best, worst and median outcomes measured by deaths
per 100 000 population.
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Credit: Tuane Fernandes Silva“One important lesson is that we needed
more information and knowledge. Dealing
with the market on specific products is a highly
specialized area. I did not have someone who
could help me to assess products and negotiate
price. I wish we had a specialized agency in theregion to support us.”ex-Health Minister, Latin America“As soon as the World Health Organization
declared a pandemic, we understood what it
was and that it would arrive here, and it would
arrive with power.”
Father Julio Lancellotti, a priest in Sao Paolo, Brazil, cares for people in his community,
including by delivering breakfast every morning to people who need a meal.
Credit: Angela Poncedistrust to undermine efforts. Many had health systems beset bylong-standing fragmentation, undervaluing of health workers andunderfunding. They lacked capacity to mobilize quickly and coordinate
between national and subnational responses. Many poorly performing
countries prioritized just one public health intervention at the populationlevel, such as mandatory face masks or school and business closures,
rather than a comprehensive approach alongside public outreachand social and economic support.
Evidence and guidance were important in shaping country action. The
first package of guidance documents for countries was issued by WHO
in the second week of January 2020, and a strategic preparedness andresponse plan was first issued on 4 February, being subsequently updated
in April and June. Between January and November 2020, WHO issued over
250 guidelines and policy and scientific briefs on clinical and public healthmanagement of COVID-19. Comprehensive guidelines published on
27 May 2020 were downloaded an average of 34,000 times per monthfrom June until November.
As the pandemic developed, countries sought advice more tailored totheir specific context, relying both on documents developed by the WHO

Mobilization of community
health workers was one
success factor for countries.

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Credit: Miriam Watsemba

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regional offices and evidence generated by their own expert scientificgroups. Countries did not always follow WHO guidance when they foundit lacking or disagreed with it, notably in the case of mask-wearing andaerosol transmission of SARS-CoV-2.

In Summary
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 dramaticallyat home that governments took serious action to prevent transmission.
February was a lost month of opportunity to contain the outbreak, evenas the evidence of infections spreading globally was apparent.
Timing mattered — early recognition of the COVID-19 threat and quick
responses kept the epidemic small. But even countries that acted later
have been able to maintain success with adaptable responses that arecoordinated, multisectoral and science-based.
Countries that devalued science, failed to build trust in their response
and pursued inconsistent strategies found themselves continually lagging
behind the epidemic and have seen the consequences in high rates ofinfection and death.

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4. The frontline under stressand requiring protection
As the COVID-19 pandemic progressed, graphic news
footage was broadcast of thousands of distressed
patients overwhelming health facilities across the world,many of which were woefully unprepared for the surge.
Ambulances waited in line, emergency rooms overflowed,
and hospital beds were dangerously oversubscribed. In
Spain, to give just one example, many intensive care units(ICUs) operated at 200% to 300% of capacity, and othercountries were under similar strain (34).
Holding it all together were health professionals and other essential
workers on the frontline — medical technicians, doctors and nurses,
border and quarantine staff, midwives and community workers, foodsuppliers and cleaners — working hour after hour, often lacking adequate
PPE and patient supplies, watching helplessly while patients died without
loved ones by their side, and worrying about their own health and theirfamilies. Response measures added to their stresses — as schools andday-care centres closed down, parents who were essential workers
found themselves having to juggle impossible demands on their time.

“In the beginning of the pandemic, there was a lot ofconfusion. It was total chaos. Nobody knew. There were
no guidelines. There was nothing.”
Health worker participating in an Independent Panel focus group

The COVID-19 pandemic has taken an enormous physical and emotional
toll on the world’s health workers. While there is a lack of globally
representative data, Amnesty International, Public Services Internationaland UNI Global Union drew on a wide range of sources recently toestimate that at least 17 000 health workers died from COVID-19 in thefirst year of the pandemic’ (35). In addition to the unacceptable deathtoll, health workers have suffered extreme and sometimes debilitatingstress. A recent analysis of 65 studies enrolling nearly 100 000 healthworkers in 21 countries found a high prevalence of moderate depression,anxiety and post-traumatic stress disorder (36). Research shows increases
in substance abuse and even suicides (37, 38). Experts predict the strain on
caregivers during COVID-19 could result in high levels of burnout andexacerbate human resource shortages.
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Preparing for
the worst“One importantlessonis that we needed
Dr Alia Dharamsi remembers the exact moment she heard a person had been
more informationand knowledge. Dealing
admitted with the novel coronavirus in a Toronto hospital. “I texted my friend and‘I don’t wanton
to diespecificfrom this’.” Alia,products
six months out of residency
and one ofwith thesaid
marketis a highly
the youngest doctors on her team, made a decision to learn all she could. She
specialized
area. I did not have someone who
set up in-situ simulation exercises with her colleagues, which partly involved a
medicalmannequinto “cough” outphosphorescentand
dust. Usinga glow light, thecould helpmeto assessproducts
negotiateteam could then see where the dust was landing including “on our necks, on theprice. I wish
had aducts”.
specialized
agencyincolleagues
thewalls andwein the ventilator
Through these exercises,
she and her
determined how to organize resuscitation teams, what safety/PPE precautions
region tosupport us.”were needed, and how to prepare. “We built protocols from the ground up”,
she says. She shared everything the team learnedon an open
blog Latinsite that
ex-Health
Minister,
Americaencourages peer-reviewed cases, and the case has been viewed thousands oftimes by doctors from around the world. “This was very purposeful. It was a way
for all of us to prepare, at a time we weren’t sure if we would even need to use
the skills.” By mid-March, with cases spreading around the world, Alia knew thesimulations had been essential. “We walked into a fire everyone was trying toescape from. We walked towards our patients, as prepared as we could be.”Credit: Christine
Angela Ponce
McNabCountries adopted a range of measures to provide health worker
surge capacity. In Europe, 75% of countries allowed early recruitment ofhealth professionals who were finishing their formal training, 71% asked
professionals to work additional hours, and nearly half have allowed
retired personnel to re-enter the workforce. Community health workers
were engaged in some countries to help with prevention and ensure
continuity of services other than COVID-19 care.

“Nurses do so much of the work in patient care, yet we areundervalued and not heard. My submission is to encourage
those of us in areas of evidence-based research to influence
the policies and change the old narrative.”
Comment from Uzoma, a nurse in Nigeria, during an Independent Panel exchange with nurses

Countries adopted a variety of strategies in an effort to reduce the extent
to which COVID-19 disrupted services. In Kenya, for example, highly
targeted COVID-19 restrictions were coupled with efforts to mitigate
negative impacts on the health system, including home-based malaria
visits with community health workers, vaccine catch-up campaigns, andthe use of telemedicine and phone-based consultations (39). Redesign ofdelivery can reduce the strain, for example introducing triage systems inprimary health care that can direct patients either to routine services orto dedicated pandemic management facilities (40).
Telemedicine, multi-month medicine dispensing and expanded home
visits can reduce pandemic impacts on essential health services. In a
sample of 46 countries, UNAIDS found that accelerated use of multi-monthdispensing of antiretroviral medicines for people with well managed HIV
had reduced clinic visits by half by mid-2020 (41). In addition to healthsystem reconfigurations, essential service disruptions can be minimised bytargeting lockdown policies in a way that ensures access to needed care.
In addition to health workers, the pandemic has also affected otheressential workers, including those working in food shops or delivery
and transportation, cleaning staff and others. 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, noiselevels requiring workers to shout, crowded working conditions and,often, limited access by employees to sick leave.
The nature of the frontline and the degree of risk to workers reflects
an income gradient, both between and within countries. While those who
could (and could afford to) worked from home during the crisis, others
kept food supplies, transportation and deliveries functioning. Theselargely lower-income workers themselves were at risk of infection.

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A United States study found that between 56.7 and 74.3 million adults who
lived with people who were, or who were themselves, at increased risk
for severe COVID-19 outcomes had positions that did not accommodate
working from home (42).
Early in the pandemic in New York City, 120 employees of the Metropolitan
Transportation Authority died from COVID-19, and nearly 4000 tested
positive. In London, 28 bus drivers died (43). Especially early on, thoseforced to go to work and associate with possibly infected co-workers
and members of the public lacked proper protective equipment andgovernment guidance. Those who quit to protect themselves and theirfamilies faced long-term unemployment in depressed economies.

In Summary
Health systems were not prepared, and health workers have not only
been put under enormous stress, but also at personal risk.
Health systems will be prepared to meet the needs of a crisis only if they
have preplanned across multiple dimensions, including for supply anduse of proper protective equipment, adequate staffing, childcare support,
mental health support, and income support for those for whom continuing
to work is too risky. Those capacities need to be in place well in advanceof the point when a crisis hits.

A US study found thatbetween 56.7 and 74.3
million adults who lived
with people who were, or
who were themselves, atincreased risk for severe
COVID-19 outcomes had
positions that did notaccommodate working
from home.

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5. The scramble for supplies
Within days of COVID-19 being declared a PHEIC, it
became clear that getting basic PPE and medical supplies
into the hands of affected people, health professionals
and other frontline workers would be a massive andpersistent problem.
In February 2020, the Director-General of WHO warned that severe
global shortages of face masks and protective suits could delay supplies
by four to six months (19). As the pandemic spread in March 2020, WHOestimated that 89 million masks, 76 million gloves and 1.6 million pairs ofgoggles would be needed every month, 40% more than manufacturers
could produce.

Mechanisms intended
to route supplies towhere they were mostneeded broke down.

The demand for essential protective and medical supplies extended to
PPE, respirators, gloves, gowns, oxygen bottles, sanitizing products andintensive-care beds. Many factors were at the root of the shortages: poor
stockpiling, hoarding, panic-buying, protectionism, cargo restrictions,trade barriers, overdependence on a few supplier countries and thelack of immediate procurement funding, especially for low- and middleincome countries.
Stockpiles created in the wake of the 2009 H1N1 influenza outbreak had
been depleted — in France and the United States, for instance, they werein a parlous state by around 2013 (44, 45). Hoarding and fraud occurredin many countries — the European Anti-Fraud Office identified over 340
companies brokering or trading counterfeit or substandard face masks,
medical devices, disinfectants, sanitizers and test kits (46).
The smooth flow of goods was impeded by trade and border restrictions.
Beginning with China, lockdowns and port-of-entry restrictions, designed
to curb the spread of the virus quickly, proliferated around the world.
Border restrictions also affected trade and the movement of goods,
whether by land, sea or air.
Movement restrictions within countries compounded the problem.
Mechanisms intended to route supplies to where they were most needed
broke down. As well as the logistical challenges, by April 2020, 75 countries
had enacted controls on exports of medical supplies and medicines (47).
However, on the other side of the ledger, a number of countries removed
import taxes on medical supplies to facilitate access and reduce costs.

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Credit: Christine McNabAs Italy became the first European epicentre of thepandemic, it sought supplies of face masks throughthe European Union civil protection mechanism.
A week after its request of 28 February, it had still
received no response. Meanwhile France andGermany imposed export limits on protective medical
equipment. It was only on 18 March that Germany
cleared export licences for protective equipment,
opening the way for 400 000 protective masks to besent to Italy, along with 300 ventilators, and it was
not until the end of April that the European Union civil
protection mechanism bore fruit, enabling the supplyof some 3360 litres of hand disinfection liquid fromneighbouring Austria (48).

Oxygen supplies are critical in many health contexts, and especiallyduring a respiratory pandemic, but there is no clear leading agency
devoted to the delivery of oxygen. This is not a new problem. One quarterof hospitals surveyed in resource-limited countries lack sufficient oxygen
supply (49) and another survey of Ethiopia, Kenya, India, Nigeria andUganda found that fewer than half of health facilities had reliableoxygen supplies (50).
A global pandemic demonstrates the fragility of global supply chains tied
to a few manufacturers or concentrated in a few supplier countries. With
China the major global producer of PPE and also the first country to be
hit by the coronavirus, there were spillover impacts in many countries (51).
Similarly, nitrile glove manufacturing was largely concentrated in
Malaysia; when Malaysia locked down, global supplies were affected.

“The first few months were terrifying. Presidents were callingme asking for diagnostics. We were waiting for the task force
in Geneva. It took forever.”Leader in the response, Africa

Prices shot up: by early March 2020, surgical masks were six times more
expensive than before the pandemic, prices of N95 respirators tripled,and surgical gown prices doubled. Procurement came with higher
financial risk, with 50% upfront payments, excessive mark-ups andlimited access to known, quality-assured suppliers. Low- and middleincome countries were excluded from this market for essentials, with direconsequences — for example, in March 2020, some countries reported
health workers reusing masks for multiple days to conserve stocks.
Globally, one estimate suggested that less than 20% of global demandfor protective equipment and test kits had been fulfilled by June 2020.
Delivery delays permeated the system.

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…in March 2020 somecountries reported
health workers reusingmasks for multiple days
to conserve stocks.

National and international efforts sought to increase the flow of essential
supplies. Countries which were able to establish purchasing partnerships
nationally and with neighbours fared best. At international level, theUnited Nations and WHO launched the United Nations COVID-19 Supply
Chain System — a procurement consortium. It eventually provided halfof the essential supplies reaching lower- and middle-income countries,
but the results were mixed: the new system created confusion amonginternational actors, and big gaps remained, some of which persist to thisday. Surge manufacturing capacities were rapidly developed in somecountries — India established 100 PPE manufacturers from zero in a few
months. A new pan-African online market set up direct procurement
channels with China, creating an alternative regional channel to getaround the delivery delays that beset international platforms.
In the pandemic context, sluggish capital flow and financing gaps quickly
restrict efforts to obtain supplies, especially for middle- and low-income
countries in competition with high-income countries. Opaque market data
make it even more difficult. Financial and data networks are needed toease supply bottlenecks, especially fast-moving risk capital that is not tiedto specific products or channels. Information on what will arrive, when,and from whom is essential for the coordination of operational support.
Pre-procurement quality assurance will be useful for vetting the small,new or “grey” manufacturers of medical supplies that are repurposing
production lines or entering the market during times of stress. Thesesources can help fill gaps, but procurement also needs to screen out
potential bad actors. Market-making is needed for all essential supplies,
but particularly oxygen, diagnostic tests and PPE.

Credit: Angela Ponce

Figure 5: Personal Protective Equipment Prices (as of 15 July 2020)
Source: UNICEF Global COVID-19 Special Interim Report, August 2020.

Personal Protective Equipment Prices (as of 15 July 2020)$70

Pre-COVID Price
Average UNICEF price during COVID response
Maximum market prices during COVID response

60
50
40
30
20
10
0
Face mask(Pack 50)

Mask N95(Pack 10)

Nitrile gloves(Pack 100)

Coveralls

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In Summary
The world faced major shortcomings in terms of obtaining basic
protection and medical supplies. Neither national nor international
systems managed to meet the initial and urgent demands.
There was a lack of rapid and dedicated financing at the right scaleand decentralized manufacturing and procurement capacities.
The international system fell short in terms of agreed playbooks, clear
leadership and defined roles for multilateral organizations in supportof procurement of basic supplies.

“There was a shortage of PPE.
When nurses have to see apatient, well, how do you go
into that room if you don’t
have complete PPE? That isreally scary. ”
Jimvelle Cac, nurse in training

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“One important lesson is that we needed
more information and knowledge. Dealing
with the market on specific products is a highly
specialized area. I did not have someone who
could help me to assess products and negotiate
price. I wish we had a specialized agency in theregion to support us.”ex-Health Minister, Latin America

Credit: Angela Ponce6. Navigating the digital environment
and the trust deficit
The communication landscape in which the COVID-19
pandemic unfolded is marked by vast social networks, arelentless appetite for instant information, a digital divide
and, in many places, a deep distrust of government
and institutions. Breaking news of the coronavirus itself
emerged through social media channels, from within
Chinese networks where people were alarmed by rumoursof a possible SARS outbreak, and then through WHO’s first“official” information about the new pathogen via Twitter.
In a fast-moving crisis with many unknowns, the stakes are high: clear
technical guidance and effective risk communication from a high-level
information source like WHO can make the difference between virus
containment and rampant spread, illness and death. Even when filteredthrough people with good intentions — national and local governments,
academics and influencers, health practitioners, translators andlocal leaders — accurate information can arrive fragmented. Whendisruptors — wilful political manipulators, armchair experts, denialists,
profiteers and bots — meddle with information, the results are even worse.
In this environment, a global “infodemic” of information, misinformationand disinformation spread almost as fast as the virus (52).
Public distrust goes hand in hand with social division and inequality.
According to the annual survey across 28 countries by a global
communications firm, trust in government briefly rose in May 2020
as people looked to governments to lead the fight against COVID-19
and restore economic health but, by the beginning of 2021, they had
squandered that trust bubble. Their assessment of people’s trust in
government, business, nongovernmental institutions and the media
declares “information bankruptcy” for all realms (53, 54). They also findthe divide between the highly informed and the mass of the population
at an all-time high.
Advice emerging from the evolving science around COVID-19 has tocontend with this complex and divided information environment. To takeone example: cultural norms in many Asian countries are to wear masks
when sick and the reflex action in many communities was to adopt maskwearing at the earliest sign of the outbreak. The European Centre for
Disease Prevention and Control and the United States Centers for Disease

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Credit: Rosem Morton“We've got to educate people. We've got tohelp them understand that it's real. It's sadthat it's been a year and some people still
don't understand or they just don't care.”
Mali Johnson, Nurse, Baltimore, USA

Credit: Angela Ponce

“We’re trying to make sure that timely, accurate, andauthentic information is communicated clearly and simply
to our people.”
Alvin Tan, a Minister of State in Singapore

Control and Prevention recommended more widespread use of masks
in April 2020, while WHO updated its community masking guidance on
5 June. In some places, mask-wearing became a divisive issue, pittingsocial responsibility against individual liberty.
The unprecedentedly fast pace of vaccine development caused both
elation and suspicion, and the internet was a prime space for the spreadof vaccine rumours. As concerns grew that vaccination strategies were
under threat, major social media companies cracked down more firmly
on vaccine misinformation in early 2021.
The digital divide shaped strategies — where access is good, “mythbusting” has extended to ever-growing social media channels (55),but where access is limited countries had to invest in reaching out tocommunities directly in local languages and in accordance with local
norms. (56) Messaging services were also a challenge, with misinformation
spread widely through friends and family but with no source to factcheck. Fact-checking itself in the contemporary information environment
can confuse as much as clarify when done with a point of view, or as avehicle for partisan content (57). As the pandemic has demonstrated, social
media channels are a double-edged sword — they are an effective andvital way to convey evidence-based information quickly, but are alsoa space where rumours, anxieties and fears can be amplified instantly.

Figure 6: A digital divide, and a gender gap
Source: The Mobile Gender Gap Report, GSMA, 2020.

3.7 billion people
are not online.

300 million fewer women than men
in low- and middle-income countries
access the internet on a mobile.

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While millions of people follow WHO as well as their own government
public health messaging on social media, most do not (c). Central torisk communication is listening to and working with communities —with the knowledge that people trust their neighbours more than they
trust faraway officials(58). Among the many examples across the world,
Thailand, before the pandemic, had in place a dedicated budget fornational and provincial coordinated all-hazards risk communication.
It made use of an extensive network of health volunteers in dialogue
with village communities when the pandemic came. Another example
of extending the reach of messaging is India’s use of public service
announcements on its mobile phone services in regional languages (d).
Digital tools are now core elements of disease surveillance and alerts,
sifting through vast quantities of instantly available information — countries
and news media picked up digital postings from Wuhan about a new
disease moments after they were published. Surveillance, contact-tracing,data-sharing and early warning systems have digital management
technologies at their core. But these tools can also be accompanied byoverhyped promises about what can be done with big data and artificial
intelligence, and not enough thought about how algorithms may work inpractice, including the risk they will amplify social biases (59).
Data collection needs to be accompanied by privacy and otherprotections (60). Under pressure to track the status of the pandemic,
there was a push to create digital tools and national up-to-the-minute

Figure 7: Change in public trust in government during the first year of the pandemic
Source and adapted from: Edelman Trust Barometer, 2021.

Trust bubble bursts
61
-5

+6

56

55

Jan 2020

May 2020

Distrust(1–49)

Neutral(50–59)Trust(60–100)

Jan 2021

Change, wave to wave

c WHO’s Twitter following, for example, has grown from just over five million followers in early
January 2020 to more than nine million as of 30 March 2021.
d The Independent Panel National Responses paper
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35 of 74dashboards. But fancy portals could mask inconsistent data fed from local
health units. Experts warn against an instinct to add more digital solutions
without taking stock of what is already there, and also ensuring highquality field data collection. At the other end of the information cycle,
digital solutions must not forget the people they are addressing:a prompt to self-isolate will not work if a person has no home inwhich to isolate, or no food in the fridge (61).

In Summary
Digital tools and solutions provide major opportunities for informationsharing, data analysis and improved management and international
cooperation.
The present digital and social media environment has also provenperilous, with disinformation, misinformation and inconsistency —of words and actions — eroding trust in institutions and governments.
Rapid and clear communication has been a matter of life and death
during this pandemic and will continue to be with the intensificationof vaccination and public health control measures. The fast-evolving
science of SARS-CoV2 and COVID-19 disease makes risk communicationeven more important, despite the challenges.
Digital communication does not reach everyone. The billions ofpeople and their communities who are offline must not be forgotten
in communication outreach — and the needs involved in responding
to the pandemic can also provide the opportunity to help bridge thedigital divide.

Digitalcommunication
does not reacheveryone. The
billions of people
who are offline
must not be
forgotten.
Students in thisregion trek up themountain to sit
by a transmission
tower so they cancomplete theirassignments.
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Credit: Saiyna Bashir

7. The unprecedented pace of R&D acceleration
The emergence of SARS-CoV-2 was met by the largest
and fastest accumulation of scientific research in humanhistory, much of it coming through more open channels
than ever before. Scientific journals opened to greater
sharing, preprint servers distributed findings quickly,
databases such as the European Bioinformatics Institutecollated information. Researchers have been able to
make broad use of tools such as SAGE, a technologicalinfrastructure that makes sharing relevant data suchas genome sequencing easier. (62) There are now
approximately 650,000 genome sequences available,
although half are from just five countries, with the mostcoming from the UK, and there are major gaps fromthe African and Middle East regions.
Laboratory researchers and large public health institutions immediatelybegan working on vaccines, therapeutics, and test assays from the day thenovel virus was sequenced — it was made publicly accessible on GenBankon 11 January 2020. As of April 2021, 23 vaccine candidates were in Phase III
or IV clinical trials and 13 vaccines are in use — a feat accomplished within 12
months, versus a conventional vaccine development timeline of 8–10 years.

Figure 8: Number of COVID-19 vaccine candidates by development stage
Source: UNICEF COVID-19 Vaccine Market
Dashboard.
Datacandidates
as of 21 April 2021.
Numberof vaccine
by development stage

4 (1.1%)

Inactive

38 (10.3%)

Discovery

223 (60.4%)

Preclinical39 (10.6%)

Phase 126 (7.0%)

Phase 1/2

12 (3.3%)

Phase 2Phase 2/3

6 (1.6%)

Phase 37 (1.9%)Regulatory review

2 (0.5%)
13 (3.5%)

Approved for use
0

25

50

75

100

125

150

175

200

225

Number of vaccine candidates
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The unprecedented pace of research and development was backed
by a massive infusion of public funds. Expertise and technology fromdecades of work — especially on HIV, Ebola, cancer vaccine research,and immunology — was available and ready to apply toward the newvirus. Regulators also raced to find ways to speed clinical testing while
doing the utmost to maintain safety. Several regulatory agencies,
including in Europe, India, the US Food and Drug Administration, andHealth Canada approved emergency procedures to expedite clinicaltesting and approval. (e)“When we started, we
did not have at-risk
ignition funding for
R&D. So, we borrowed$100 million in ourbank account to pay
manufacturing lot for aphase 1 clinical trial to
get things started. Also,
CEPI does not normallypay for manufacturing.
However, there was nofinancing for that. So,
we stepped up and put
in US$600-$700 million.
We had to borrow fromour core funding to fillthis critical gap.”
CEPI leadership

COVID-19 reaped the reward of years of effort to expand capacities
for R&D to address potential pandemics. The WHO’s R&D Blueprint was
launched in 2015 and the following year in the throes of the West Africa
Ebola outbreak it was used to create a new model for R&D responseto emerging pathogens. (63) It identified bottlenecks in international
collaboration, encouraged agreement on basic data-sharing, and sought
more efficient ways to conduct clinical trials in times of distress. (64) The
Coalition for Epidemic Preparedness Innovations (CEPI) was launchedin 2017 as a non-profit organization funding basic research and earlyclinical trials against a list of epidemic-prone infectious diseases.
This infrastructure deployed almost as soon as the COVID-19 alert wassounded. CEPI sought out and sponsored some of the first vaccine
candidates (Moderna and Oxford University) when there were fewer than
600 cases around the world. 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 randomised evidence
using simple large trials. Alongside the global efforts were national
measures to support COVID-19 R&D, the largest of which was the US
federal Biomedical Advanced Research and Development Authority
whose cumulative investment was US$14 billion by November 2020. (65)
However, the existing R&D infrastructure was not adequate to thescale of the emerging pandemic. In April 2020, WHO and partners
established ACT-A, the Access to COVID-19 Tools Accelerator, to pushahead the development, procurement, and allocation of vaccines, tests,
and treatments. (66) ACT-A brought together partners to define andaccelerate vaccine development from the basic science to clinical trial
stage, although the constraints of finances and dose availability limited
its power to resolve access and equity matters. Major vaccines currently
produced in the world are not necessarily fit for global access. They havenot fully followed Target Product Profiles established under the WHO R&D
Blueprint for COVID vaccines since they require, for example, ultra-coldchain and specific technical know-how for various platform technologies.

e The Panel has conducted a review on efforts to develop and delivery COVID-19 vaccines,
diagnostics, and therapeutics.
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“I’m not so sure if we will ever even get thevaccine. And those who will get it I think are
the ones who will have the money.”
Mildred Nakahima, a small café owner owner in Kampala, Uganda

Credit: Esther Ruth Mbabazi

The collaboration among key institutions under ACT-A is unprecedented.
It is, nevertheless, seen by some countries and civil society interest groups
as supply-driven, exclusive, and biased toward western interests. The
involvement of Russia, China, and India in ACT-A was weak especially atthe outset, although these three countries are key vaccine producers andnow supplying vaccines to many countries around the world. The delayedparticipation of the US government also limited the scope of ACT-A as a
global mechanism. ‘Operation Warp Speed,’ the US public sector effort
to accelerate vaccine development, had its own notable success; so did
purely private sector efforts such as that of Pfizer/BioNTec.
ACT-A also supported diagnostics development with a degree ofsuccess, and to a lesser extent therapeutics, although not many effective
therapies have been found. From 2020 to early 2021 more than 600
potential therapies for COVID-19 were brought to preclinical or clinicaldevelopment. (67) Efforts to develop therapeutics cover several categories,
including immunomodulators, neutralizing antibody therapies, celltherapies, and gene therapies.
While the virologic and immunological complexities of SARS-CoV-2 madethe development of therapeutics a challenge, it has also been hampered
by a lack of funding, a fragmented research landscape, and the absenceof a strong aggregator to help drive efforts forward. Trial coordinationneeds an over-arching framework, fed by head-to-head comparison
studies of products within each product/tool category. Many therapeutic
trials were poorly designed for decision making, and trialling in low- andmiddle-income countries and in diverse populations is crucial.

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In some countries diagnostic development and rollout was a challenge
due to slow bureaucracies, cautious rollout, and a spike of unfamiliar
entrants into the test manufacturing market. But there have also been
rapid and effective diagnostics programmes such as that from the Korea
Centers for Disease Control and Prevention. By early March 2020 tests
had been ramped up to 20,000 a day with five local manufacturers
producing kits for domestic use and export. (68)Globally, there is a mismatch between commercial developments andinternational approval. As of March 2021, only 26 out of hundreds ofcommercialized tests and diagnostic kits had gained the WHO emergency
use listing required for global distribution through ACT-A.
Modelling efforts were part of the COVID-19 response from the
beginning. (69) These had immediate effects in official efforts to modulate
public behaviour and enforce distancing, quarantine, trade, travel, border,and social restrictions. The role of nonpharmaceutical interventions werepart of the research agenda for COVID-19 under the R&D Blueprint. (70)
While the success of nonpharmaceutical interventions in COVID-19
containment has been manifest, there is less clarity about which levers
produce best results, partly as they are highly context-dependent, andalso because of their inherent complexities. (71, 72, 73)
Increasingly, the paradigm of knowledge to be shared will be digital. The
Nagoya Protocol provides the legal basis for the fair sharing of genetic
resources, and voluntary science networks such as GISAID, which madewidely available the first whole genome sequence of SARS-CoV-2, shows
the critical role of open science and data platforms to pandemic response.

While there are hundreds of trials for possible
COVID-19 drugs taking place globally, there arevery few in Africa. One of the few good examples is
the ANTICOV Trial, a collaborative effort launchedby an international network of research institutions
and 13 African countries, that aims to find cheap,
readily available drugs that can keep those
suffering from COVID-19 out of hospital, so that
already-weak health systems are not overwhelmed.
More specifically, the trial seeks to find a drugthat reduces by half the likelihood that mild
COVID-19 cases progress to severe illness. ANTICOV
leveraged the African Vaccine Regulatory Forum, aplatform established by WHO that brings together
National Regulatory Authorities and national Ethics
Committees on the African continent with theobjective of strengthening clinical trial regulation in
Africa. More strategic and coordinated investment
in clinical trial capacities across the world will
be a critical part of preparedness for the
future pandemics.

Credit: Xavier Vahed-DNDi

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Knowledge generation and technology transfer is far from even in theworld. The pandemic exposes the cost of not investing in these capacities
in low- and middle-income countries. That many of the most effective
health responses to COVID-19 have come from these countries should bea signal to redress the balance in the way knowledge is generated andvalued — to the benefit of the world as a whole.

In Summary
The speed of the scientific and R&D response to COVID-19, especiallywith vaccines, is unprecedented. The pace of has shown the value ofpre-existing platforms, secured funding to reduce investor risk, and agile
stakeholders prepared to cooperate.
R&D needs to be guided by explicit strategies to deliver widely accessible
tools that can be used fairly, and participation from low- and middleincome countries needs to be built in from the outset.
Technical leadership works best with distinct research, development, andmanufacturing streams, but with a common strategic focus and end-toend coordination to reduce the time from pathogen characterization to
emergency use authorization.
Upfront public sector funding is necessary for research acceleration but
needs to be matched with equitable access. Critical areas of market
failure need to be addressed — such as underinvestment in diagnostics,
especially given the vital role of testing.

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8. Geopolitical tensions challenging multilateralism
The line between geopolitical conflict and health protection
has always been a fine one. Florence Nightingale invented
modern health informatics with her polar charts producedin the Crimean war demonstrating that sanitary conditions
were causing more deaths than war wounds. Even as the
League of Nations was failing to prevent the outbreak of
the Second World War, combating countries continued tocontribute information to its Health Organization’s technicalepidemiology bulletins until 1941.
Competition between the world’s two largest economies has shaped
the global landscape of response to COVID-19. Former United States
President Donald Trump announced a withdrawal from WHO because hefelt it lacked impartiality and was biased towards China. This challenge,
however, appeared to result in rallying support for the organization. Six
Heads of State or Government spoke at the May 2020 opening of theWorld Health Assembly — from Barbados, China, France, Germany, theRepublic of Korea, and South Africa. This was a larger number of national
heads than has ever before been present at a World Health Assembly.

The General Assembly helda Special Session in Responseto the COVID-19 Pandemic in
December 2020.

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Credit: Eskinder Debebe / United Nations PhotoTortuous negotiations behind a UN Security Council resolution on the
pandemic are a case in point. Estonia first proposed that the Security
Council issue a statement on the growing pandemic on 18 March 2020.
Discussions among the five Permanent Members of the Security Council
on a resolution began around the same time, but soon stalled. Attempts
by the elected members of the Council to break the deadlock also
foundered. It was not until 1 July that a resolution was passed expressing“grave concern about the devastating impact of the COVID-19 pandemic
across the world, especially in countries ravaged by armed conflicts, orin post-conflict situations, or affected by humanitarian crises.” It lacked
concrete proposals, however, and made no reference to WHO. (74)While the tension between US and China over COVID-19 made theheadlines in international news, the tendency for nationalism andprotectionism rather than cooperation and multilateralism has been muchwider. In many countries, domestic priorities drove the closure of borders,sometimes on a selective basis more reflective of alliances than driven
by public health evidence. The major non-compliance with the IHR in the
COVID-19 pandemic has been in the selective imposition of travel andtrade restrictions. (75) In our highly interconnected age the science aroundtravel restrictions need to be updated urgently to inform the applicationof the IHR in respect to travel and the containment of pandemics.
In the contest between national needs and global solidarity, nationalism
has often won out with the imposition of bans on the export of essential

Figure 9: International travel controls during the COVID-19 pandemic as of 31 March 2020
Source: Hale, Angrist, Goldszmidt, Kira, Petherick, Phillips, Webster, Cameron-Blake, Hallas, Majumdar, and Tatlow (2021).“A global
panel database of pandemic policies (Oxford COVID-19 Government Response Tracker).” Nature Human Behaviour. — Last updated
20 April, 16:00 (London time) OurWorldInData.org/coronavirus

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products, including in a range of measures designed to erect protective
barriers around supplies of COVID vaccines. The rhetoric of global
solidarity vanished into hot air when governments were faced withdomestic political pressures.
This pandemic might suggest dismal prospects for multilateralism asa tool for progress, but a look over history suggests that while the roadto securing agreement is never smooth, lasting resolve with real impact
is possible.
The global response to HIV beginning in the 1980s failed to keep up withthe scale of that pandemic and was unable to draw on the strengths not
only of all the United Nations system organizations, but also of a global
movement of activism and science. UNAIDS was created in 1996 as a
new type of coalition, more able to bring UN organizations together
in common purpose and including a formal place for civil society in its
governing body. When effective antiretroviral therapy was developedin the mid-1990s, the lack of access in the most affected countries wascast as an intolerable global moral failing. From the turn of the century,
access began to be ramped up for all in need in one of the largest-scale
extensions of medicines access the world has ever seen.
Similarly, the Paris Climate Agreement and the 2030 Agenda for
Sustainable Development suggest that multilateral corporation candeliver agreed targets despite differences between countries bothon the nature of the problem and what solutions will work best.

In Summary
The multilateral system as whole failed to take collective responsibility.
There is no alternative to multilateral cooperation. No nation acting alone
can bend the negative climate curve, nor stop the spread of a deadly virus
which does not respect national borders.
A crisis of the scale of COVID-19 demonstrates the indispensability of
governments acting together in their mutual self-interest. But it has also
made graphic the frustrations attendant on a multilateral system held
hostage to international rivalries and bogged down in endless negotiation
on minor matters.
This mega-crisis makes a compelling case for strengthening a true andeffective multilateral system which ensures that disease outbreaks do
not become pandemics and pandemics are not allowed to escalate into
world-wide social, economic, and health crises. This opportunity must
be seized.
Understanding the political economy of incentives and barriers tointernational agreement is a vital task that needs to draw on researchdisciplines much wider than done today.
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9. Economies take major hits
The economic toll of the COVID-19 pandemic will takeyears to emerge, but already the impact is stark. The
global economy shrank by 3.5% in 2020, and US$10 trillionof output is expected to be lost by the end of 2021, growing
to about US$22 trillion in the period 2020-2025. For the
first time in decades, global poverty is likely to significantly
increase.(76, 77, 78) COVID-19 has pushed some 115-125 million
people into extreme poverty.
These costs are spread around the world, albeit not equally: East Asiaand the Pacific are projected to grow a very weak 0.5%, South Asia tocontract by 2.7%, sub-Saharan Africa by 2.8%, the Middle East and North
Africa by 4.2%, Europe and Central Asia by 4.7%, and Latin America
by 7.2%. (79) More than nine out of ten national economies experienced
contraction in per-capita gross domestic product, which is the highest
share of countries simultaneously contracting since the Great Depressionof 1930-32. (80) The world has seen in its worst period of economic
contraction since the Second World War.
The economic impact of COVID-19 has depended on the interplay ofpre-existing structural conditions in economies, the amount of fiscal andgovernance space made available for mitigation, and the nature andtiming of decisions made in response to the pandemic.
Figure 10: Forecast global GDP growth in mid-2020
Source: Extrapolated from World Bank Data.(f)0

Em. Asia
ex. CHN

LAC

SSA

Global GDP growth 2020

MECA

EMDE

World

Em. Eur.

AE

China

UnitedStates

-1
-2
-3
-4
-5
-6
-7
-8
-9
f

The World Bank: The Global Economic Outlook During the COVID-19 Pandemic: A Changed World, June 8 2020.

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The economic impact of COVID-19 on the workforce is massive but
distributed unevenly—a banker, lawyer, or software engineer may be able
to carry on with work remotely using information and communications
technologies, while a restaurant employee, hotel clerk, or market stall
operator could not. Around the world some 600 million people workin hard-hit sectors like hospitality or retail. (81) The decline in travel andtourism in 2020 is expected to result in global losses of around US$2.1
trillion for that sector alone. (82) Shifts in workforce patterns may be longlasting. For example, commerce in goods began to rebound after the
initial pandemic shock, but services, such as transportation and contactheavy activities, continued to decline.
Those able to lean on technology in order to support their jobs found it
easier to do in some parts of the world than others. Between 25 and 50%of the population in Latin America has no internet access at home; thatfigure is more than 75% in much of sub-Saharan Africa and India. Informal
workers, of which there are 1.6 billion in the world, did not have the optionof working remotely. Either the work disappeared, or it was done at risk of
exposure. (83, 84)“We wouldn't have survived
another two months ofthe lockdown. The wholebusiness would have fallen
apart. At the time, it wasa nightmare. ”
Alex Vardanyan is a café-bar ownerin St. Petersburg, Russia

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The extent of the economic impact of the pandemic on individuals isdirectly related to the extent of social protection. If economic downturns
result in job losses and if health insurance is tied to employment, then the
results can be catastrophic. If precarious employment conditions leave
workers without access to sick leave, then transmission will increase. The
risk is the creation of a feedback loop. (85)Where there were high levels of informal employment, mobility,
restrictions did not reduce the number of cases, according an analysis
of more than 80 countries. Stay-at-home orders can only be successfulwhen households can make ends meet through the lockdown period,
when workers are able to work remotely, and when there is a level oftrust in government sufficient for orders to be complied with. (86)Responses to COVID-19 have often been framed as a ‘trade-off’
between economic costs and public health costs, or between saving
lives and saving livelihoods. However, health and economics are
inseparably intertwined.
The timing of public health and social measures and when to relax themhas been critical. Countries that have been unable or unwilling to sustain
measures even when the epidemic is trending upwards have often foundthemselves experiencing both the economic pain of lockdown and thehealth consequences of rampant spread. Short and sharp measures areless problematic than lengthy restrictive orders that fail to take accountof structural vulnerability. For example, stringent lockdowns in India
disproportionately impacted internal migrants employed in the informal
sector. The lengthy stay-at-home orders in Argentina saw its economy
contract by 26.4% in April 2020 alone.
There are countries that have managed to reap the benefits of swift
containment in terms of economic growth — or at any rate less contraction
than might have been expected. Viet Nam emphasized transparency andreal-time information sharing and was one of the few nations to record
positive economic growth in 2020. (87) The 2015 MERS outbreak cost theRepublic of Korea US$2.6 billion in lost tourism revenue and US$1 billion
in response. Not wanting to repeat that experience, its swift response
to COVID-19 was grounded in testing, tracing, isolation, and treatment
rather than closing businesses and issuing stay-at-home orders. For many
leaders it was important to argue explicitly that there was not a trade-off
between the economy and health.
Recovery from COVID-19 will be protracted. Even optimistic forecasts
suggest major advanced economies will have depressed output levels
until at least 2024. (88) Emerging and low-income economies may findrecovery takes even longer.

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Credit: Katumba Badru Sultan

Government officials and the
Red Cross distributing foodto vulnerable populationsin Kampala during the early
lockdown in April, 2020.

As the ripple effects of income and job losses persist, the consequences
emerge of putting off health care and of mental health stresses.
Development of human capital is set back. Stabilization of national
economies in the face of the COVID-19 shock is just the first task —a concerted focus is needed on long term protection, stability,
and resilience.
WHO estimates that additional spending of US$72 billion is needed on
pandemic preparedness annually (US$19.1 billion for low- and middleincome countries and US$47.5 billion for high income countries). (89)This pandemic has shown that the returns on investment in pandemic
preparedness will be vast and will flow to all. Pandemic preparedness isa paradigmatic global public good. It has to overcome both the free-rider
problem, where beneficiaries do not feel they have to shoulder the costs,
and the weakest link problem, where a single act of non-compliance canjeopardize the benefits. (90) The sheer scale of this pandemic shows theneed to overcome these problems and secure the necessary investment.

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In Summary
The US$22 trillion impact of the COVID-19 pandemic is the biggest shockto the world’s economy in three-quarters of a century.
The return on investment in pandemic preparedness is vast. The US$72
billion estimated cost for preparedness corresponds to less than 1% of thetotal cost as we know it right now.
The capacity of countries to respond has been shaped by the policy
choices but also by pre-existing structural conditions and the availabilityof fiscal space.
Responses were less effective when social measures were not applied,or as structural weaknesses and lack of social protections in economies
prevented them from working.

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10. The pandemic affects everyone,
but not everyone is affected equally
The impact of COVID-19 has landed unevenly. It has
deepened the entrenched structural inequalities of income,health, and education. The best line of defence to preventthe epidemic from becoming a pandemic would havebeen to recognize that the virus would exploit these fault
lines and accelerate measures to overcome them. Instead,heedless ‘beggar thy neighbour’ responses and theinconsistency of one rule for the rich and another for thepoor accelerated the pandemic and made inequity worse.

11 million of the poorest
girls in the world may
never go back to theclassroom.

Credit: Katumba Badru Sultan

Disparities in digital access and entrenched education inequalities
means that the 90% of students whose education was disrupted by the
pandemic will not all return at the same rate or be able to make up lost
ground. (91) Children with disabilities, ethnic minorities, refugees, anddisplaced populations are less likely to both be able to access remotelearning materials and to return to school post-crisis. The impact on girls
is acute — perhaps 11 million of the poorest girls in the world may nevergo back to the classroom, and an additional 10 million girls are at riskof early marriage. (92, 93)
At one point in 2020, about 90% of schoolchildren around the world wereunable to go to the classroom. (94, 95) By the end of 2020, 320 million of
the world’s 1.6 billion student population were still locked out of schools.
Seventy-two million primary school-aged children risk being unable toread or understand a simple text by age 10. (77, 96) The impact of gaps ineducation may be felt long term, with the World Bank estimating up to
US$10 trillion in lifetime earnings lost. Early reports suggest that pupils
from lower income households are taking longer to catch up due to lost
schooling. Schools also provide social support and, in many places, a hot
meal every day. One estimate counts 39 billion lost school meals since
shutdowns began. (97)
The pandemic is driving a shortfall in human capital — the knowledge,
skills, and health that people accumulate over their lives. The WorldBank’s Human Capital Index is designed to capture the human capitala child born today can expect to attain by age 18 as a marker of future
well-being. COVID-19’s economic impacts threaten all inputs, with drops
projected in all country income bands, but they will be worse for lowand lower-middle-income countries. (98) COVID-19 kept children at home,and survey data from the UK and Italy has shown increases in anxiety
levels, depression, and adjustment problems among children, parents,
and caregivers. (99, 100)

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Mayors on the frontline
The pandemic has also highlighted struggles for cities trying
to provide for marginalized people including those without
documentation. From Accra to Geneva, lack of an identification
card or proof of residency translated to lack of access togovernment social protection. Mayors from several cities told
the Panel they were shocked by the hardships revealed during
the pandemic, as they tried to meet the needs of people who
were not officially resident in their cities but without a place
to live, suddenly exposed during lockdowns. Mayors stressedthat the pandemic underscored why they need a bigger role
to inform decisions and policy in pandemic preparedness andresponse, as national responses can fail to address the realities
of everyday life. As Mayor Yvonne Aki-Sawyerr of Freetown
explained: “You are first in the response, but often last in thequeue for policy formation.”
Mayor Yvonne Aki-Sawyerr of Freetown, Sierra Leone
helped the Panel to invite mayors together to share
their pandemic experiences.

“If COVID doesn’tkill me, hunger
will kill me.”
Olinda Silvano Inuma isa leader of the ShipiboKonibo Amazonian
migrant community
in Lima, Peru.

The pandemic is causing a sharp rise in the newly poor, many frommiddle-income countries. The International Labour Organization
projects that the proportion of the newly poor who are paid employees
will rise sharply, which is a measure of thinning resources—wages will
be reduced or will simply not be high enough to keep pace withexpenses. Large numbers of poorer families in developing countries
rely on remittances, which are estimated to decline globally by 14
percent in 2021. (101) Meanwhile, migrant workers are often shut out ofhealth care and vaccination programmes, either by eligibility rules or
because of fears of reporting or deportation due to migration status.
For that reason, multilateral organizations have issued clear guidance
not only that vaccination is a right for migrants, but also that firewalls
should be established between immigration enforcement and COVID-19
vaccination access. (102)The pandemic has increased inequality within countries. In a surveyof developed countries reporting overall unemployment increases in
2020, women were the most affected. (103) Economic and race-based
disparities have been observed from the wealthiest to the most resourceconstrained settings. Los Angeles is reckoned to be the third-wealthiest
city in the world. Despite its periodic lockdowns, it became an epicentreof COVID-19’s spread in October and November 2020, with caseloads
falling disproportionately among poorer populations and ethnic
minorities. Patterns of inequality are not restricted to high-income
countries — in Nigeria, also, incidences of COVID-19 seem to be higher
among particular ethnic groups. (104, 105)
In low-and low-middle income countries, the largest part of the labour
force is in informal work, and the majority of these informal workers are
women. Most have limited earnings, few labour law protections, limited

Credit: Angela Ponce

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“Inequality makes you fundamentally ill-unprepared fora pandemic.”
Community NGO lead, Cape Townsocial benefits coverage such as pension, health insurance, or paid sickleave, and little savings. Informal labour is often undertaken in unsafe
conditions. Caregiving for children, parents, or relatives, which is timeconsuming and often unpaid, has markedly increased with the pandemic,
and also needs to be seen through a gender lens — the largest share ofthis burden falls on women. (106, 107)
The social impact of the pandemic has included untreated mental
health, including depression and social anxieties. The pandemic has also
contributed to the rise of gender-based violence. This is not surprising,
given that home is the primary location where gender-based violenceoccurs and exposure to abusers has increased with measures requiring
people to stay at home. UN Women has documented the increasing
incidence of gender-based violence in many countries. (108) To take justone example: in France, reports of domestic violence increased by 30%
in the 10 days following the announcement of the lockdown.
According to a McKinsey survey, women make up 39% of global
employment, but account for 54% of overall job losses — jobs in sectors
where women are more prevalent are more at risk. (109) Current global
statistics show more men than women are dying of COVID-19; whereas
women may suffer more than men from the health, social, and economic
consequences in the long term. (110) Increased gender inequality is a major
impact of COVID-19.
Previous pandemics suggest COVID-19’s impact will linger as equity gaps
increase. A study of five pandemics between 2003 and 2016 found that
income inequality increased in affected countries over the five years
following each event, and this pandemic is on a larger scale. (111) But
well-functioning safety nets mitigate impact. Among the innovations
that have paid off in this pandemic are unique-code-based payments toensure cash transfers and social insurance reach vulnerable populations
in Guatemala and Peru or the use of financial inclusion agents in India.
These are measures that can have lasting benefit beyond the pandemic.

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In Summary
Inequality has been the determining factor explaining why the
COVID-19 pandemic has had such differential impacts on peoples’
lives and livelihoods.
If national governments had better social protection systems alreadyin place, they would have been more resilient, and people would havesuffered less, and if there were fewer people in precarious or informal
employment, there would have been fewer people exposed to risk.
Preparedness and response systems need to be gender responsivefrom design through to implementation.

Women make up 39%
of global employment,
but account for 54% of
overall job losses dueto the pandemic.

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Credit: Christine McNab

54 of 7411. Vaccine nationalism
Vaccine access and distribution takes place now in ahighly charged and political environment. Governments
are struggling to meet demands to take care of their own
people, even as they address the greater good. In thissense vaccine nationalism is not just a selfishness to becondemned, but a force to be feared and a problem
to be reckoned with.
As of now, high-income countries such as Canada, the UK, Australia,
New Zealand, and the United States and across the EU have been able
to secure vaccine doses that would be enough to cover 200% and moreof their populations. (112)
It took a powerful effort to get to the point of making a COVID-19 vaccine.
Back in April 2020, public health experts said the optimistic expectation
was that a vaccine was at least 12-18 months away. (113)
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 expressedin September 2020 was to purchase two billion COVID-19 vaccine dosesby the end of 2021 and deliver them to people in 190 countries. By midMarch 2021, COVAX had shipped 30 million doses to at least 54 countries,
a number that was rapidly increasing. (114, 115) At that time, COVAX expected
approximately 1.8 billion doses to be available to 92 low- and middleincome countries before the end of 2021, covering 27 per cent of
their populations.
But these expectations must contend with uncertainties of manufacturing
capacity, regulation, funding availability, final contract terms, and thereadiness of countries to begin their national COVID-19 vaccination
programmes. The lack of enough early and readily available funding for
COVAX contributed to the failure to secure enough immediate supply
to meet its aims. (116) Further, twenty-seven per cent is well short of thecoverage required for herd immunity and many people beyond thiscoverage level may have to wait until 2023 or 2024 for vaccination. (113)
However, the main immediate issue is how to reach a political agreement
for sharing and redistributing available doses of vaccine and committed
doses based on what is best from a global public health perspective withequity at the centre. There is an agreement that covering only your own
population will not end the pandemic but moving from that rhetoric toan actual effective flow and allocation of vaccine doses as they become
available is critical to the fight against COVID-19.
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Figure 11: Total COVID-19 vaccine doses per 100 people as of 21 April 2021
Source: World Health Organization Coronavirus (COVID-19) Dashboard. Data as of 21 April 2021.

Never has there been a nearly overnight need for so many doses against
a novel virus. (117) UNICEF calculates 5.3 billion doses by the end of 2021
would be needed to take care only of all of the world’s essential workers,
people over 65, and people with comorbidities.
There is no definitive information source on the state of facilities
world-wide now ready and able to produce COVID-19 vaccine andin what quantities, nor of the raw materials required. Some vaccine
manufacturers are producing a finished product in-house; others have
manufacturing partners and a distributing supply chain. Knowledge
Ecology International (KEI) shows about 115 current COVID-19-related
vaccine manufacturing facilities in 38 countries with dozens more that
could be turned over toward COVID-19-related tasks. (118)
But a raw count of facilities does not show where there may bebottlenecks in highly specialized equipment. Limits in manufacturing
capacity contribute to inequity and threaten the effectiveness of

As COVID-19 trends towards endemicity, the world’s
population may need multiple vaccinations. The current
manufacturing capacity is well short of the potential demand.

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“… adding output
capacity can takemonths or years…”
CEPI board member
Rajeev Venkayya

vaccination efforts. Current vaccine production capacity for 2021 acrossall vaccine technology platforms sits at an estimated 14 billion doses, (119)assuming that all vaccine candidates will be successful. As COVID-19
trends toward endemicity, the world’s population may need multiple
vaccinations. The current manufacturing capacity is well short of thepotential demand. Insufficient doses and untimely administration of
vaccines creates more opportunity for viral mutations. Moreover, it
focuses in a few regions: Europe, the US, China, the Russian Federation,and India, with very limited capacity in Africa and Latin America. (120, 120)
This makes it difficult for these regions to access new vaccines. This is evenmore serious in the case of producing mRNA vaccines, the platform criticalfor adapting to and controlling variants.
Manufacturers in 2020 were having difficulty even predicting how much
vaccine they could make for clinical trials, much less in bulk by the billionsof doses. Raw materials in thin supply include syringes and glass vials. (121)
Sharing of capacity has been one strategy to increase total availability.
Merck and Johnson & Johnson made a deal to share manufacturing;
this could be one kind of positive step. Other partnerships include
between Sanofi and BioNTech, IDT Biologika and AstraZeneca (fivenew bioreactors, operational by end 2022), and Novartis and BioNTech.
These agreements are however limited in scope — the intellectual
property licensing and technology transfer is exclusively to the agreed
manufacturer and under the control of the original manufacturer.
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. The approachneeds to be more global: institutions like India’s Serum Institute, Sinopharmin China, and Gamaleya Research in Russia may be key in growing thenumber of vaccine-making facilities in the world.
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) as a place to pool knowledge, intellectual property anddata. (122) 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. (123, 124)

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In Summary
Despite a year of efforts to resolve fundamental issues, effective vaccine
allocation and distribution based on public health needs has failed.
Given the emergence of new strands of SARS-CoV-2, slow and uneven
distribution of the currently approved vaccines against the virus is aurgent global problem.
There is an immediate need for political agreement for redistributionof available and soon-to-come vaccine doses.
Free trade and flow of ingredients and material to produce vaccinesmust be established.
Medium term, but starting now, investments in additional manufacturing
capacity and technology transfer is needed.
Endemic COVID-19 will potentially demand 5 billion booster vaccinations
be globally accessible every year for the foreseeable future.
In addition to vaccines there are urgent needs to improve the accessto diagnostics and therapeutics.

“For vaccination, there are ‘VIP vaccination
facilities’ and a black market. This is aconsequence of low access.”

A community advocate’s assessment in his country

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12. Building forward better —realizing the sustainability vision
The COVID-19 pandemic has shaken confidence inthe global agenda for sustainable development andits ability to cope with the stress of a major global crisis.
But the crisis also presents windows of opportunity to
see the challenges clearly and marshal the political will
for change. As governments and societies contemplate
the end of the initial crisis phase of the pandemic, thepolitical conditions to secure a sustainable recovery need
to be nurtured. Stimulus packages and public investment
allow governments to set a new agenda. Co-benefits ofhealth strengthening and action on climate change canbe leveraged to create resilient societies.
The pandemic has thrust health to the centre of global attention,
generating demand for bold action that recognizes the interdependenceof global health security and systems for health which are accessible,
affordable, and resilient, to provide the bedrock for healthier,greener societies.

A safe, healthy and green recovery will place people
and communities at the centre. Emergency responses
can no longer be gender neutral and inequity blind.
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Credit: Mindy Tan

The crisis has also refocused our attention on creating equitable societies,
shown that change is possible, and shown that science is an indispensableguide to progress. Nationalism and autocracy have proved poor weapons
to counter this crisis; on the contrary, countries that have found successhave seen soaring trust in public institutions and an endorsement of theneed for global solidarity.
A safe, healthy, and green recovery will place people and communities
at the centre. Emergency responses can no longer be gender neutral
and inequity blind. The serious shift in mindsets required must be
accomplished through a re-politicisation that explicitly commits to humanrights and equality in policy design and implementation, acknowledging
the intersectional nature of health and well-being. A green and healthy
recovery from this pandemic would be built on three interlocking aims:
a stronger system to prevent, detect, and respond to future outbreaks;
resilient health systems that provide safe and affordable care to allwhen needed; and healthy, green societies promoting health andwell-being for people and planet.
Figure 12: Building blocks for a green and healthy recovery

Towards a green and healthy recovery

Tackle global health threats

Resilient health systems for all

Healthy, green societies

A stronger system to prevent,detect and respond to
future outbreaks.

Resilient health systems
providing safe and affordable
care to all when needed.

Healthy, green societies
promoting health and well-being
for people and planet

A stronger international system

A future-proof, safe global health system should be equipped to address
both the direct and indirect effects of pandemics, thinking beyond
only surveillance and containing the virus to a long-term focus onresilient national systems that secure health for all. The challenges of
inaccessibility, for example in health systems with high out-of-pocket
costs, or of poor quality of care, undermine trust in the system. The impact
of co-morbidities on COVID-19 death rates is a reminder that maximizing
the health baseline is a key element of preparedness to pandemics. The
right to health demands safe, affordable, quality health care — resilient
health systems, able to step up in times of need, while maintaining routine
health services.
But on the positive side of the ledger, people worldwide have seen proof
that action across society is possible when the objective is to save lives.
This momentum must be maintained to enable people not merely tosurvive, but also to make healthy choices and lead healthy lives beyond
the pandemic. While there has been appropriate attention given to
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Credit: Christine McNabthe negative impacts of lockdowns on social life and mental health,there have also been positive side-effects, as air pollution decreased,families were able to spend more time together, and values of solidarity
were rediscovered.
COVID-19 made some health adaptations urgent, but many are of lastingvalue — telemedicine for example. The pandemic may also have achieved
what years of education and policy change have failed to do in reducing
inappropriate antimicrobial use. In Australia, that use decreased by
36% from April 2020 onwards, and similar data from the US has shown
sustained falls in use of antibiotics commonly prescribed for upper
respiratory tract infections. (125, 126)
The pandemic has shown the need for long-term investment in Universal
Health Coverage, encompassing both service coverage and financial risk
protection. Fundamentally, achieving resilient health systems pays off interms of lives, the economy and public trust. The inequities made starker
by the pandemic are neither inevitable nor insuperable, and there is agroundswell of determination to address them. A global recession should
not provide the excuse to put off this momentum for change; it only makes
it all the more urgent.

The COVID-19 pandemic has also made it clear that we canno longer separate human health from ecosystems andanimal health.
Seizing the opportunity to address previously intractable problems andaccelerate positive transitions is occurring across many fields — energy
and food provide just two examples. The World Energy Council has been
tracking the world energy transition with the impact of the pandemic.
Analysing more than 3000 signals of change in the second half of 2020
from 85 countries, nearly two-thirds indicate that countries are taking
this time of crisis as an opportunity to build forward better. (127) In foodsecurity, the COVID-19 shock not only forced policy makers to makeurgent decisions to secure supply chains, it also focused attention onlong term measures to address the “triple challenge” of food security
and nutrition for a growing global population, protecting the livelihoodsof millions of people working along the food chain from farm to fork, andthe environmental sustainability of the sector. (128)
The COVID-19 pandemic has also made it clear that we can no longer
separate human health from ecosystems and animal health. Climatechange and the many consequences that follow create the conditions
for future infectious diseases to emerge and thrive. The stresses resulting
from climate change exacerbate the same inequities that have shaped
the impact of the COVID-19 pandemic. A green recovery from COVID-19
will thus create co-benefits that address both the pandemic andclimate change.
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In Summary
The present global socioeconomic crisis has its root causes in the failure
to pursue sustainability and resilience as our main objectives.
The pandemic has put health at the forefront of attention for all
humanity and proven that decisive action to shape a better future is not
only needed but possible. It has created both the opportunity and theobligation to act now.
A green and healthy recovery can help generate societies where both thelikelihood of future health threats is reduced, and healthier populations
are better prepared to overcome them. It will require investment but also
political will and public engagement.
Prioritizing the health of people and planet is and must be a broad
agenda — it includes investing in sustainable and safe food systems andclean energy.
Many of the practical solutions and action will come from subnational
level — for example cities across the world are already invested in practicalchange to enable cleaner, safer, and more supportive societies.
This is the moment for transformative change. A healthier tomorrowis possible.

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13. A future with mutant SARS-CoV-2?
SARS-CoV-2 variants continue to emerge, with theirimmunology and impact on vaccine effectiveness anurgent issue. As of April 2021, there were at least threesignificant COVID-19 variants in circulation: SARS-CoV-2
VOC 2020 12/01 (also known as B.1.1.7), 501Y.V2 (also known
as B.1.351), and P.1 (also known as 20J/501Y.V3). All weredetected through routine sampling, genomic testing,and surveillance. (129)
While these variants are still being evaluated, modelling and clinicalfindings suggest increased transmissibility. (130) These variants are now
seen in several countries and regions, including through the European
Union, United States, Asia, and Australia.
All viruses mutate. The question is what impact variants will have on
the path of COVID-19, and whether it will become endemic. (131) Already,increased transmissibility has led to renewed border closings, restricting
travel and extending lockdowns, and keeping schools closed. The
start-stop and variable guidance both on containment and on vaccine
rollout has hampered communication and epidemic control progress indifferent countries. Decision makers need to operate on the assumptionthat COVID-19 is here to stay and that it may continue to circulate inpopulations for the foreseeable future as an illness that flares up in waves
at intervals from a baseline level of infections.
Vital information is needed on the kinds of immunity conferred by vaccinesand viral infection and how severe reinfections may turn out to be. A lotof data is coming in from global surveillance and genetic testing about
SARS-CoV-2 mutations; there are some suggestions about what thevariants mean for vaccines, but it is far from clear what they will mean for
vaccine strategies and for the pandemic itself.
Without doubt, the world is feeling, as one OECD report put it, “the needfor speed” in vaccine rollout: every vaccinated person is a brake on thevirus, and the fewer bodies the virus travels through, the fewer chances it
has to mutate. (89) For vaccination to be a strategy to contribute to exiting
the pandemic, clear estimates are needed of the rate-limiting factors at…every vaccinated person is a brake on the virus, and thefewer bodies the virus travels through, the fewer chances
it has to mutate.
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each stage of rollout. Different bottlenecks require distinct solutions —resources, financial or technical, logistics at scale, readiness of facilities,
workforce training, and public awareness and engagement.
Contemplating coexistence with COVID-19 is complicated. Will it befeasible to pursue zero-COVID-19, vaccine-aided virus elimination
strategies: severe lockdowns or restrictive measures with the aim ofceasing transmission, keeping a population as airtight as possible against
reintroduction of the virus? Or will the aim be mitigation and suppression,
managing COVID-19 as best as possible while vaccines slowly subdue thepandemic? Will strategies be pursued on a global basis, or will there bediffering national aims, with resulting needs to maintain border controls in
perpetuity? How can nonpharmaceutical interventions be maintained?
Much will hinge on whether vaccines produce functional immunity, howlong that immunity lasts, how effective the virus is at escape, how severe
reinfection will be in humans, and the extent to which SARS-CoV-2 isestablished within animal reservoirs. One reason controllable diseases
persist is because pathogens in animal reservoirs, such as insects or
mammals, come back into contact with humans. This is what happens
with Ebola virus disease, yellow fever, chikungunya, and rabies. (132)
Smallpox remains the only pandemic ever to have been really vanquished;polio nearly so. The campaign to eradicate smallpox, a disease old as
can be, took 20 years. The Salk vaccine for polio was introduced in the
United States in 1955; the disease was eliminated there in 1979. Global
eradication of polio became a goal in 1988, coming tantalizingly closeto achievement in the past 5 years. Pandemics and epidemics throughhistory produce profound changes in social, urban, everyday life —in sanitation, in hygiene, in handling water, in the ways people relate
to one another.
And if SARS-CoV-2 becomes endemic, it will be an open question how
large-scale vaccine strategies, at whatever periodic scale required,
will manage to cope, keeping in mind that the urgency of purpose will
inevitably fade along with memory of the pandemic. Researchers are
already investigating avenues to develop a “universal” vaccine, effective
against all strains of SARS-CoV-2 — those extant now and in future.
Will a new paradigm of universal, periodic, adult vaccination emerge
and be pursued with the same unity of purpose that is applied tochildhood vaccination?
Further tricky questions of both science and policy will continue toarise. Already, experiments are under way with vaccine passports, travel
permissions, or other documentation to allow for movement and social
participation. If SARS-CoV-2 immunity is waning, what will it mean forthese documents? Countries which have brought the level of new cases
to very low levels have put in place policies for snap lockdowns in thecase of even very small outbreaks. Is this the possible future much more
broadly, even in locations that look very different? How will that play out
on a political and social level?
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In SummaryMoving from the mindset of fighting to stop a pandemic to acknowledging
it will be with us for the future is going to be difficult.
It requires judgements as to what level of ongoing COVID-19 spread anddisease impact would be acceptable, and whether to tolerate different
degrees of impact in different communities and countries. Countries
which have adopted elimination strategies are unlikely to want toabandon them.
A world living with endemic, seasonal SARS-CoV-2 infection will requirecontinuous, vigorous, and effective surveillance and public healthmeasures. There will be challenges of both logistics and equity —viral variation will in all probability produce the need for repeatedvaccinations. Leaving out countries will not only be inequitable, but
a danger to public health.

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About the Panel
The Independent Panel for Pandemic Preparedness and Response
has worked steadily to fulfil its vision to be trusted as an independent,
evidence-based, impartial, respectful and diverse body the world canrely on to make bold recommendations which help safeguard every
person’s health, economic and social well-being.
The mission of the Panel has been to provide an evidence-based path forthe future, grounded in lessons of the present and the past to ensure thatcountries and global institutions, including WHO, can prevent an outbreakfrom becoming a pandemic; and if a pandemic occurs, to prevent thatfrom becoming a global health and socioeconomic crisis.
The Panel was initiated by the Director-General of WHO in response
to World Health Assembly resolution WHA73.1.
The Panel’s Co-Chairs, Her Excellency Ellen Johnson Sirleaf, former
President of Liberia and Nobel Laureate, and the Right Honourable
Helen Clark, former Prime Minister of New Zealand, were appointed
by the Director-General. The Co-Chairs were then mandated to selectpanellists, establish their terms of reference and recruit an independent
Secretariat. The Co-Chairs announced the full membership of the Panelon 3 September 2020.
The Panel comprises people with the experiences and expertise tofocus on pandemics, health and the broader impacts of COVID-19.
Their mix of skills and expertise covers a wide range of areas including
infectious disease, global and national health policy and financing,
public administration, outbreaks and emergencies, economics, youth
advocacy and the well-being of women and girls. Panellists also shareknowledge of the international system, including WHO, and otherrelevant international processes.
The Panel was charged with reviewing the spread, actions and responses
to the COVID-19 pandemic, compile facts, distil lessons and make evidencebased recommendations to ensure countries and global institutions,
including WHO, can more effectively address health threats.
In May 2021, the Panel delivered its main report to the 74th World Health
Assembly, accompanied by this evidence-based narrative report, anda series of background papers including an authoritative chronology
of events of the early alert and response to the pandemic.
The members of the
Independent Panel are:
Co-Chair HE Ellen Johnson
Sirleaf, Co-Chair the Rt
Hon. Helen Clark, Mauricio
Cárdenas, Aya Chebbi, Mark
Dybul, Michel Kazatchkine,
Joanne Liu, Precious Matsoso,David Miliband, Thoraya
Obaid, Preeti Sudan, Zhong
Nanshan and Ernesto Zedillo.

References
1

World Health Organization. Coronavirus disease 2019 (COVID 19) Situation Report 79 [Internet].
2020 Apr. Available from: https://www.who.int/docs/default-source/coronaviruse/situationreports/20200408-sitrep-79-covid-19.pdf

2

Air transport, passengers carried. In: Data [website]. Washington (DC): World Bank; 2021
(https://data.worldbank.org/indicator/IS.AIR.PSGR, accessed 25 April 2021).

3

Global Preparedness Monitoring Board. A world at risk: annual report on global preparedness
for health emergencies. Geneva: World Health Organization; 2019 (https://apps.who.int/gpmb/
assets/annual_report/GPMB_annualreport_2019.pdf, accessed 25 April 2021). Licence: CC BYNC-SA 3.0 IGO.

4

Average of 13 International Health Regulations core capacity scores, SPAR version. In: World
health data platform [website]. Geneva: World Health Organization; 2021 (https://www.who.
int/data/gho/data/indicators/indicator-details/GHO/-average-of-13-international-healthregulations-core-capacity-scores-spar-version, accessed 25 April 2021).

5

IHR States Parties annual reporting global submission status per year, 23 April 2021. In: e-SPAR
Public [website]. Geneva: World Health Organization; 2021 (https://extranet.who.int/espar/#capacity-score, accessed 25 April 2021).

6

Haider N, Yavlinsky A, Chang M, Hasan MN, Benfield C, Osman AY et al. The Global Health
Security Index and Joint External Evaluation score for health preparedness are not correlatedwith countries’ COVID-19 detection response time and mortality outcome. Epidemiol Infect.
2020; 148: e210. doi: 10.1017/S0950268820002046. pmid: 32892793.

7

Global Preparedness Monitoring Board, A world in disorder: Global Preparedness Monitoring
Board annual report 2020. Geneva: World Health Organization; 2020 (https://apps.who.int/
gpmb/assets/annual_report/2020/GPMB_2020_AR_EN_WEB.pdf, accessed 25 April 2021).
Licence: CC BY-NC-SA 3.0 IGO.

8

Milanovic B. Beware of mashup indexes: how epidemic predictors got it all wrong. In:
Globalinequality [blog, 19 April 2021]. https://glineq.blogspot.com/2021/01/beware-of-mashupindexes-how-epidemic.html, accessed 25 April 2021).

9

Fukuyama F. The pandemic and political order. Foreign Aff. July/August 2020 (https://www.
foreignaffairs.com/articles/world/2020-06-09/pandemic-and-political-order, accessed
25 April 2021).

10Bell J. The U.S. and COVID-19: leading the world by GHS Index score, not by response. In: Atomic
Pulse [website, 21 April 2020]. Washington (DC): Nuclear Threat Initiative; 2020 (https://www.nti.
org/analysis/atomic-pulse/us-and-covid-19-leading-world-ghs-index-score-not-response/,
accessed 25 April 2021).

11

Schneider MC, Munoz-Zanzi C, Min K, Aldighieri S. “One Health” from concept to applicationin the global world. In: Global Public Health [website]. Oxford: Oxford University Press; 2019(https://oxfordre.com/publichealth/view/10.1093/acrefore/9780190632366.001.0001/acrefore9780190632366-e-29, accessed 25 April 2021).

12

World Health Organization, Food and Agriculture Organization of the United Nations, World
Organisation for Animal Health. Taking a multisectoral, one health approach: a tripartite guideto addressing zoonotic diseases in countries. Geneva: World Health Organization; 2019(https://apps.who.int/iris/handle/10665/325620, accessed 25 April 2021).

13

van Nieuwkoop M. Staying focused on ‘One Health’ to prevent the next pandemic. In: WorldBank Blogs [blog, 11 November 2020]. Washington (DC): World Bank; 2020 (https://blogs.
worldbank.org/voices/staying-focused-one-health-prevent-next-pandemic, accessed
25 April 2021).

14

Qun L, Guan X, Wu P, Wang X, Zhou L, Tong Y et al. Early transmission dynamics in Wuhan,
China, of novel coronavirus–infected pneumonia. N Engl J Med. 2020;382:1199-207.
doi:10.1056/NEJMoa2001316.

15

Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y et al. Clinical features of patients infected with 2019
novel coronavirus in Wuhan, China. Lancet. 2020;395(10223):497–506 (https://doi.org/10.1016/
S0140-6736(20)30183-5, accessed 25 April 2021).

16

WHO-convened global study of origins of SARS-CoV-2: China part. In: World HealthOrganization [website]. Geneva: World Health Organization; 2021 (https://www.who.int/
publications/i/item/who-convened-global-study-of-origins-of-sars-cov-2-china-part,
accessed 25 April 2021).

How an outbreak became a pandemic by The Independent Panel for Pandemic Preparedness & Response

68 of 74

17

Novel coronavirus (2019-nCoV) situation report -3, 23 January 2020. In: World HealthOrganization [website]. Geneva: World Health Organization; 2020 (https://www.who.int/docs/
default-source/Coronaviruse/situation-reports/20200123-sitrep-3-2019-ncov.pdf, accessed
25 April 2021).

18

Report of the WHO-China joint mission on coronavirus disease 2019 (COVID-19). Geneva: World
Health Organization; 2020 (https://www.who.int/docs/default-source/coronaviruse/whochina-joint-mission-on-covid-19-final-report.pdf, accessed 25 April 2021).

19

WHO Director-General's statement on IHR Emergency Committee on Novel Coronavirus (2019nCoV). In: World Health Organization [website]. Geneva: World Health Organization; 2020
(https://www.who.int/director-general/speeches/detail/who-director-general-s-statementon-ihr-emergency-committee-on-novel-coronavirus-(2019-ncov), accessed 25 April 2021).
Report by the Director-General. Geneva: World Health Organization; 2020.

20

WHO Director-General’s opening remarks at the media briefing on COVID-19 — 11 March 2020.
In: World Health Organization [website]. Geneva: World Health Organization; 2020 (https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-atthe-media-briefing-on-covid-19 — -11-march-2020, accessed 25 April 2021).

21

Byambasuren O, Cardona M, Bell K, Clark J, McLaws ML, Glasziou P. Estimating the extent
of asymptomatic COVID-19 and its potential for community transmission: systematic review
and meta-analysis. J Assoc Med Microbiol Infect Dis Can. 2020;5(4):223–4 (https://jammi.
utpjournals.press/doi/10.3138/jammi-2020-0030, accessed 25 April 2021).

22

Coronavirus disease 2019 (COVID-19) situation report -70, 30 March 2020. In: World HealthOrganization [website]. Geneva: World Health Organization; 2020 (https://www.who.
int/docs/default-source/coronaviruse/situation-reports/20200330-sitrep-70-covid-19.
pdf?sfvrsn=7e0fe3f8_4, accessed 25 April 2021).

23

China building 1,000-bed hospital in 5 days to treat coronavirus. CBC News, 24 January 2020
(https://www.youtube.com/watch?v=cmgPVhubmQA, accessed 25 April 2021).

24

Hinjoy S, Tsukayama R, Chuxnum T, Masunglong W, Sidet C, Kleeblumjeak P et al. Selfassessment of the Thai Department of Disease Control’s communication for international
response toCOVID-19 in the early phase. Int J Infect Dis. 2020;96(2020) :205–10(https://www.ijidonline.com/article/S1201-9712(20)30258-7/pdf, accessed 25 April 2021).

25

Pollack T, Thwaites G, Rabaa M, Choisy M, van Doorn R, Tan LV et al. Emerging COVID-19
success story: Vietnam’s commitment to containment. In: Our World in Data [website]. Oxford:
Our World in Data; 2021 (https://ourworldindata.org/covid-exemplar-vietnam, accessed
25 April 2021).

26

Goh T. Wuhan virus: MOH sets up multi-ministry task force, advises against non-essential
trips to Wuhan. Straits Times, 4 March 2020 (https://www.straitstimes.com/singapore/health/wuhan-virus-3-more-suspected-cases-in-singapore-avoid-non-essential-travel-to-wuhan,accessed 25 April 2021).

27

WHO-AUDIO Executive Board EB146 Coronavirus Briefing, 04 February 2020. In: World HealthOrganization [website]. Geneva: World Health Organization; 2020 (https://www.who.int/docs/
default-source/coronaviruse/transcripts/who-audio-executive-board-eb146-coronavirusbriefing-script-04feb2020-final.pdf?sfvrsn=70a66dfc_2, accessed 25 April 2021).

28

Coronavirus disease 2019 (COVID-19) situation report -40, 29 February 2020. In: World HealthOrganization [website]. Geneva: World Health Organization; 2020 (https://www.who.int/docs/
default-source/coronaviruse/situation-reports/20200229-sitrep-40-covid-19.pdf, accessed
25 April 2021).

29

Coronavirus disease2019 (COVID-19) situation report -47, 7 March 2020. In: World HealthOrganization [website]. Geneva: World Health Organization; 2020 (https://www.who.
int/docs/default-source/coronaviruse/situation-reports/20200307-sitrep-47-covid-19.
pdf?sfvrsn=27c364a4_4 accessed 25 April 2021).

30 Lurie MN, Silva J, Yorlets RR, Tao J, Chan PA. Coronavirus disease 2019 epidemic doubling timein the United States before and during stay-at-home restrictions. J Infect Dis. 2020;222(10):1601–
06 (https://academic.oup.com/jid/article/222/10/1601/5879762, accessed 25 April 2021).
31

Spiteri G, Fielding J, Diercke M, Campese C, Enouf V, Gaymard A et al. First cases of coronavirus
disease 2019 (COVID-19) in the WHO European Region, 24 January to 21 February 2020. Euro
Surveill. 2020;25(9):pii=2000178. doi:10.2807/1560-7917.ES.2020.25.9.2000178.

32

History of the COVID-19 alert system. In: COVID-19 Alert System [website]. Auckland:
Government of New Zealand; 2020 (https://covid19.govt.nz/alert-system/history-of-the-covid19-alert-system/, accessed 25 April 2021).

33

AMSP. Africa Medical Supplies Platform [Internet]. [cited 2021 May 1]. Available from:https://amsp.africa/

How an outbreak became a pandemic by The Independent Panel for Pandemic Preparedness & Response

69 of 74

34

Condes E, Arribas JR and COVID19 MADRID-S.P.P.M. group 1. Impact of COVID-19 on Madrid
hospital system. Enferm Infecc Microbiol Clin. 2020 (https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC7315960/, accessed 25 April 2021).

35

COVID-19: Health worker death toll rises to at least 17000 as organizations call for rapid vaccine
rollout. In: Amnesty International [website]. London: Amnesty International; 2021 (https://www.
amnesty.org/en/latest/news/2021/03/covid19-health-worker-death-toll-rises-to-at-least17000-as-organizations-call-for-rapid-vaccine-rollout/, accessed 25 April 2021).

36 Li Y, Scherer N, Felix L, Kuper H. Prevalence of depression, anxiety and post-traumatic stressdisorder in health care workers during the COVID-19 pandemic: a systematic review and metaanalysis. PLoS One. 2021;16(3):e0246454. doi: 10.1371/journal.pone.0246454.
37

Kristoffersen M. For many frontline health workers, COVID-19 comes with an emotional toll.
In: Yale School of Medicine [website]. New Haven (CT): Yale School of Medicine; 2020 (https://
medicine.yale.edu/news-article/28589/, accessed 25 April 2021).

38

Rahman A, Plummer V. COVID-19 related suicide among hospital nurses; case study
evidence from worldwide media reports. Psychiatry Res. 2020;291:113272. doi:10.1016/j.
psychres.2020.113272.

39

Barasa E, Orangi S, Kabia E, Ogero M, Kasera K. Indirect Health Effects of the COVID-19
Pandemic in Kenya (in press).

40 COVID-19 essential health services policy tracker: interim findings, October 2020. Seattle (WA):
PATH; 2020 (https://path.azureedge.net/media/documents/PATH_Policy_Tracker_Interim_
Findings_FINAL_WEB.pdf, accessed 25 April 2021).
41

UNAIDS World AIDS Day Report 2020: prevailing against pandemics by putting people at thecentre . Geneva: UNAIDS; 2020 (https://aidstargets2025.unaids.org/assets/images/prevailingagainst-pandemics_en.pdf, accessed 25 April 2021).

42

Selden TM, Berdahl TA. Risk of severe COVID-19 among workers and their household members.
JAMA Intern Med. 2021;181(1):120-2 (https://jamanetwork.com/journals/jamainternalmedicine/
fullarticle/2772328?alert=articl, accessed 25 April 2021).

43

The plight of essential workers during the COVID-19 pandemic. Lancet. 2020;395(10237):1587.
doi:10.1016/S0140-6736(20)31200-9.

44 Verner R. Pénurie de masques: pourquoi la France avait décidé de ne pas renouveler ses stocks
il y a neuf ans [Internet]. 2020 [cited 2021 May 1]. Available from: https://www.bfmtv.com/sante/
penurie-de-masques-pourquoi-la-france-avait-decide-de-ne-pas-renouveler-ses-stocks-ily-a-neuf-ans_AN-202003200043.html
45 Finkenstadt DJ, Handfield R, Guinto P. Why the U.S. Still Has a Severe Shortage of Medical
Supplies. Harvard Business Review [Internet]. 2020 Sep 17 [cited 2021 May 1]; Available from:https://hbr.org/2020/09/why-the-u-s-still-has-a-severe-shortage-of-medical-supplies
46 OLAF European Anti-Fraud Office. Inquiry into fake COVID-19 products progresses [Internet].
2020 [cited 2021 May 1]. Available from: https://ec.europa.eu/anti-fraud/media-corner/
news/13-05-2020/inquiry-fake-covid-19-products-progresses_en47

Nkengasong J. Let Africa into the market for COVID-19 diagnostics. Nature 2020;580:565. doi:
10.1038/d41586-020-01265-0 pmid: 32346145

48 Beaucillon C. International and European Emergency Assistance to EU Member States in the
COVID-19 Crisis: Why European Solidarity Is Not Dead and What We Need to Make It bothHappen and Last. Eur Pap - J Law Integr. 2020 Apr 25;2020 5:387401.
49 Meara JG et al., 2015. Global surgery 2030: evidence and solutions for achieving health,welfare, and economic development. Lancet 386: 569–624.
50 Houdek J. Closing the oxygen access gap: Breathing new life into a neglected therapy[Internet]. Clinton Health Access Initiative. 2020 [cited 2021 May 1]. Available from:https://www.clintonhealthaccess.org/closing-the-oxygen-access-gap-breathing-new-lifeinto-a-neglected-therapy/
51

Park C-Y, Kim K, Roth S, Beck S, Kang JW, Tayag MC, et al. Global Shortage of PersonalProtective Equipment amid COVID-19: Supply Chains, Bottlenecks, and Policy Implications.
2020 Apr 1 [cited 2021 Apr 30]; Available from: https://www.adb.org/publications/shortageppe-covid-19-supply-chains-bottlenecks-policy

52

The COVID-19 Infodemic. The Lancet Infectious Diseases. July 17, 2020. https://doi.org/10.1016/
S1473-3099(20)30565-X

53

Edelman. 2020 Edelman Trust Barometer [Internet]. Edelman. 2020 [cited 2021 May 1].
Available from: https://www.edelman.com/trust/2020-trust-barometer

54 Edelman. 2021 Edelman Trust Barometer [Internet]. Edelman. 2021 [cited 2021 May 1].
Available from: https://www.edelman.com/trust/2021-trust-barometer

How an outbreak became a pandemic by The Independent Panel for Pandemic Preparedness & Response

70 of 74

55 World Health Organization. Coronavirus disease (COVID-19) advice for the public: Mythbusters[Internet]. World Health Organization. [cited 2021 May 1]. Available from: https://www.who.int/
emergencies/diseases/novel-coronavirus-2019/advice-for-public/myth-busters
56 Bogdan-Martin D. More urgent than ever: Universal connectivity to bring 3.7 billion people
online [Internet]. MyITU. 2020 [cited 2021 May 1]. Available from: https://www.itu.int:443/en/
myitu/News/2020/12/11/08/36/Universal-connectivity-urgency-billions-offline-DoreenBogdan-Martin
57

Posetti J, Ireton C. Journalism, Fake News & Disinformation. [Internet]. 2018 [cited 29 March2021];. Available from: https://en.unesco.org/sites/default/files/journalism_fake_news_
disinformation_print_friendly_0.pdf; Fujishiro H. Why Doesn’t Fact-Checking Work?:
The Mis-Framing of Division on Social Media in Japan. SMSociety’20: International
Conference on Social Media and Society. 2020;(Proceedings):309-317.

58 Lim VW, Lim RL, Tan YR, Soh AS, Tan MX, Othman NB, et al. Government trust, perceptionsof COVID-19 and behaviour change: cohort surveys, Singapore. Bull World Health Organ.
2021 Feb 1;99(2):92–101
59 O’Neil C. Weapons of Math Destruction. Crown; 2016.
60 McGregor, L. 2020, April 30., Contact-tracing Apps and Human Rights [EJIL:Talk!].
https://www.ejiltalk.org/contact-tracing-apps-and-human-rights/.
61

Ayman El-Mohandes, Scott C. Ratzan, Lauren Rauh, Victoria Ngo, Kenneth Rabin,
Spencer Kimball, Barbara Aaron, and Nicholas Freudenberg, 2020: COVID-19: A Barometer
for Social Justice in New York City American Journal of Public Health 110, 1656_1658,
https://doi.org/10.2105/AJPH.2020.305939

62

EMBL. Open data sharing accelerates COVID-19 research [Internet]. 2020 [cited 2021 Apr 30].
Available from: https://www.ebi.ac.uk/about/news/announcements/open-data-sharingaccelerates-covid-19-research

63

Kieny MP, Rottingen J-A, Farrar J. The need for global R&D coordination for infectious diseases
with epidemic potential. The Lancet. 2016 Jul;388(10043):460–1. doi: https://doi.org/10.1016/
S0140-6736(16)31152-7

64 Lurie N. Urgent Lessons from COVID-19: why the world needs a standing, coordinatedsystem and sustainable financing for global research and development. The Lancet 2021
doi: https://doi.org/10.1016/S0140-6736(21)00503-1
65 Rizvi Z. BARDA Funding Tracker: Tracker Details Billions in Taxpayer Funds Supporting
COVID-19 R&D Efforts [Internet]. Public Citizen. 2020 [cited 2021 Apr 30]. Available from:https://www.citizen.org/article/barda-funding-tracker/
66 World Health Organization. The Access to COVID-19 Tools (ACT) Accelerator [Internet]. [cited
2021 May 1]. Available from: https://www.who.int/initiatives/act-accelerator
67

BioWorld. Biopharma products in development for COVID-19 [Internet]. [cited 2021 May 1].
Available from: https://www.bioworld.com/COVID19products

68 Kim J-H, Julia Ah-Reum A, SeungJu Jackie O, Juhwan O, Jong-Koo L. Emerging COVID-19 SuccessStory: South Korea Learned the Lessons of MERS [Internet]. [cited 2021 May 1]. (Exemplars in
Global Health). Available from: https://www.exemplars.health/emerging-topics/epidemicpreparedness-and-response/covid-19/south-korea
69 Ferguson N, Laydon D, Nedjati Gilani G, Imai N, Ainslie K, Baguelin M, et al. Report 9: Impact
of non-pharmaceutical interventions (NPIs) to reduce COVID19 mortality and healthcaredemand [Internet]. Imperial College London; 2020 Mar [cited 2021 May 1]. Available from:http://spiral.imperial.ac.uk/handle/10044/1/77482
70

R&D Blueprint. A Coordinated Global Research Road Map: 2019 Novel Coronavirus[Internet]. World Health Organization; 2020 Mar. Available from: https://www.who.
int/docs/default-source/coronaviruse/coordinated-global-research-roadmap.
pdf?sfvrsn=21b0f5c4_1&download=falsee

71

Brauner JM, Mindermann S, Sharma M, Johnston D, Salvatier J, Gavenčiak T, et al. Inferring
the effectiveness of government interventions against COVID-19. Science. 2021 Feb
19;371(6531):eabd9338.

72

Imperial College COVID-19 Response Team, Flaxman S, Mishra S, Gandy A, Unwin HJT, Mellan
TA, et al. Estimating the effects of non-pharmaceutical interventions on COVID-19 in Europe.
Nature. 2020 Aug 13;584(7820):257–61.

73

Complexity Science Hub Vienna. A Dataset of Government Interventions in Response
to COVID-19 [Internet]. COVID-19 Interventions. [cited 2021 May 1]. Available from:https://covid19-interventions.com/

How an outbreak became a pandemic by The Independent Panel for Pandemic Preparedness & Response

71 of 74

74

Security Council Report. Security Council Resolution on COVID-19 [Internet]. 2020 [cited 2021
May 1]. Available from: https://www.securitycouncilreport.org/whatsinblue/2020/06/securitycouncil-resolution-on-covid-19.php

75

Roojin Habibi et al, The Stellenbosch Consensus on Legal National Responses to Public Health
Risks, International Organizations Law Review (2020). DOI:10.1163/15723747-2020023

76

Lakner C, Yonzan N, Gerszon Mahler D, Castaneda Aguilar RA, Wu H. Updated estimatesof the impact of COVID-19 on global poverty: Looking back at 2020 and the outlook for 2021
[Internet]. World Bank Blogs. 2021 [cited 2021 May 1]. Available from: https://blogs.worldbank.
org/opendata/updated-estimates-impact-covid-19-global-poverty-looking-back-2020-andoutlook-2021

77

United Nations Department for Economic and Social Affairs. World Economic Situation
and Prospects [Internet]. S.l.: United Nations; 2021. Available from: https://www.un.org/
development/desa/dpad/wp-content/uploads/sites/45/WESP2021_FullReport.pdf

78

World Bank. Global Economic Prospects, January 2021 [Internet]. The World Bank; 2021 [cited
2021 May 1]. (Global Economic Prospects). Available from: http://elibrary.worldbank.org/doi/book/10.1596/978-1-4648-1612-3

79World Bank. The Global Economic Outlook During the COVID-19 Pandemic: A Changed World[Internet]. World Bank. 2020 [cited 2021 May 2]. Available from: https://www.worldbank.org/en/
news/feature/2020/06/08/the-global-economic-outlook-during-the-covid-19-pandemic-achanged-world

80 Gopinath G. A Long, Uneven and Uncertain Ascent [Internet]. IMF Blog. 2020 [cited 2021 May 1].
Available from: https://blogs.imf.org/2020/10/13/a-long-uneven-and-uncertain-ascent/81

COVID-19: impact could cause equivalent of 195 million job losses, says ILO chief [Internet]. UN
News. 2020 [cited 2021 May 2]. Available from: https://news.un.org/en/story/2020/04/1061322

82

Barkas P, Honeck D, Colomer ER. International Trade in Travel and Toursism Services: Economic
Impact and Policy Responses During the COVID-19 Crises [Internet]. World Trade Organization;2020 Sep p. 43. Report No.: ERSD-2020-11. Available from: https://www.wto.org/english/res_e/reser_e/ersd202011_e.pdf

83 International Labor Organization. As job losses escalate, nearly half of global workforce atrisk of losing livelihoods [Internet]. 2020 [cited 2021 May 1]. Available from: http://www.ilo.org/
global/about-the-ilo/newsroom/news/WCMS_743036/lang--en/index.htm
84 Closing the Digital Divide: A Time to Stay Connected [Internet]. World Bank. 2020 [cited 2021
May 1]. Available from: https://www.worldbank.org/en/news/feature/2020/10/26/closing-thedigital-divide-a-time-to-stay-connected
85 Causa O, Cavalleri MC. How non-standard workers are affected and protected during theCovid-19 crisis: Stylised facts and policy considerations [Internet]. VoxEU.org. 2020 [cited 2021
May 1]. Available from: https://voxeu.org/article/how-non-standard-workers-are-affectedand-protected-during-covid-19-crisis
86 David AC, Pienknagura S. On the effectiveness of containment measures in controlling the
COVID-19 pandemic: the role of labour market characteristics and governance. Appl Econ Lett.
2020 Nov 1;1–7.
87

Dabla-Norris E, Asia YSZI, Department P. Vietnam: Successfully Navigating the Pandemic[Internet]. IMF. 2021 [cited 2021 May 2]. Available from: https://www.imf.org/en/News/
Articles/2021/03/09/na031021-vietnam-successfully-navigating-the-pandemic

88 OECD. Strengthening Recovery: the Need for Speed [Internet]. OECD. 2021 [cited 2021 May 1].
Available from: https://www.oecd.org/economic-outlook/
89 WHO. Assessment of Gaps in Pandemic Preparedness (Unpublished). 2020.
90 International Task force on Global Public Goods. Meeting global challenges: international
cooperation in the national interest: final report [Internet]. Stockholm: International Task
force on Global Public Goods; 2006. Available from: https://www.regeringskansliet.se/contentassets/02b31f6432494dc2959f98912e66cc65/global-public-goods-main-report-2006
91

UNESCO. Half of world’s student population not attending school: UNESCO launches global
coalition to accelerate deployment of remote learning solutions [Internet]. UNESCO. 2020 [cited
2021 May 1]. Available from: https://en.unesco.org/news/half-worlds-student-population-notattending-school-unesco-launches-global-coalition-accelerate

92

World Bank. Realizing the Future of Learning: From Learning Poverty to Learning forEveryone, Everywhere [Internet]. World Bank. 2020 [cited 2021 May 1]. Available from:https://www.worldbank.org/en/topic/education/publication/realizing-future-of-learningfrom-learning-poverty-to-learning-for-everyone-everywhere

How an outbreak became a pandemic by The Independent Panel for Pandemic Preparedness & Response

72 of 74

93

UNICEF. 10 million additional girls at risk of child marriage due to COVID-19 [Internet]. 2021
[cited 2021 May 1]. Available from: https://www.unicef.org/press-releases/10-millionadditional-girls-risk-child-marriage-due-covid-19

94 UNESCO. UNESCO figures show two thirds of an academic year lost on average worldwide
due to Covid-19 school closures [Internet]. UNESCO. 2021 [cited 2021 May 1]. Available from:https://en.unesco.org/news/unesco-figures-show-two-thirds-academic-year-lost-averageworldwide-due-covid-19-school
95 World Health Organization. School closures and teenage pregnancy. Bulletin of the World
Health Organization. 2021 Jan 1;99(1):6–7.
96 World Bank. Pandemic Threatens to Push 72 Million More Children into Learning Poverty—
World Bank outlines a New Vision to ensure that every child learns, everywhere [Internet]. World
Bank. 2020 [cited 2021 May 1]. Available from: https://www.worldbank.org/en/news/pressrelease/2020/12/02/pandemic-threatens-to-push-72-million-more-children-into-learningpoverty-world-bank-outlines-new-vision-to-ensure-that-every-child-learns-everywhere
97

UNICEF. Nutrition crisis looms as more than 39 billion in-school meals missed since startof pandemic – UNICEF and WFP [Internet]. 2021 [cited 2021 May 1]. Available from:https://www.unicef.org/press-releases/nutrition-crisis-looms-more-39-billion-school-mealsmissed-start-pandemic-unicef-and

98 World Bank. The Human Capital Index 2020 Update: Human Capital in the Time of COVID-19[Internet]. The World Bank; 2020 [cited 2021 Apr 30]. Available from: http://elibrary.worldbank.
org/doi/book/10.1596/978-1-4648-1552-2
99 Spinelli M, Lionetti F, Pastore M, Fasolo M. Parents’ Stress and Children’s Psychological
Problems in Families Facing the COVID-19 Outbreak in Italy. Front Psychol. 2020 Jul 3;11:1713.
100 Sellgren K. Parents’ stress and depression “rise during lockdowns.” BBC News [Internet]. 2021
Jan 19 [cited 2021 May 2]; Available from: https://www.bbc.com/news/education-55707322
101 Blake P, Wadwhwa D. 2020 Year in Review: The impact of COVID-19 in 12 charts [Internet]. WorldBank Blogs. 2020 [cited 2021 May 1]. Available from: https://blogs.worldbank.org/voices/2020year-review-impact-covid-19-12-charts
102 UN Committee on Migrant Workers. Joint Guidance Note on Equitable Access to COVID-19
Vaccines for All Migrants [Internet]. [cited 2021 May 1]. Available from: https://reliefweb.int/
sites/reliefweb.int/files/resources/JointGuidanceNoteCOVID-19-Vaccines-for-Migrants.pdf
103 Worley A. COVID-19 is reversing the important gains made over the last decade for womenin the workforce - PwC Women in Work Index [Internet]. PwC Global. 2021 [cited 2021 May 1].
Available from: https://www.pwc.com/gx/en/news-room/press-releases/2021/women-inwork-index-2021.html
104 Price GN. Introduction to the Special Issue: COVID-19 and Its Impact on Racial/Ethnic Groups.
J Econ Race Policy. 2020 Dec;3(4):221–2.
105 Ong P, Ong J, Ong E, Carrasquillo A. Neighborhood Inequality in Shelter-in-Place Burden:
Impacts of COVID-19 in Los Angeles. [Internet]. UCLA: Center for Neighborhood Knowledge;
2020. Available from: https://escholarship.org/uc/item/0d87b0t5
106 UNDP. COVID-19 and the SDGs [Internet]. UNDP. [cited 2021 May 1]. Available from:https://feature.undp.org/covid-19-and-the-sdgs/
107 UNDP-ILO. UNDP-ILO Framework for Action [Internet]. 2020 Sep [cited 2021 May 1]. Available
from: http://www.ilo.org/wcmsp5/groups/public/@dgreports/@dcomm/documents/
statement/wcms_756457.pdf
108 UN Women. COVID-19 and Ending Violence Against Women and Girls [Internet]. 2020. Available
from: https://www.unwomen.org/-/media/headquarters/attachments/sections/library/publications/2020/issue-brief-covid-19-and-ending-violence-against-women-and-girls-en.
pdf?la=en&vs=5006
109 Madgavkar A, White O, Krishnan M, Mahajan D, Azcue X. COVID-19 and gender equality:
Countering the regressive effects. McKinsey and Company [Internet]. 2020 Jul 15 [cited 2021
May 1]; Available from: http://ceros.mckinsey.com/coronavirus-promo-video-desktop110
Oertelt-Prigione S, European Commission, Directorate-General for Research and Innovation.
The impact of sex and gender in the COVID-19 pandemic: case study. [Internet]. 2020 [cited
2021 Apr 30]. Available from: https://op.europa.eu/publication/manifestation_identifier/PUB_
KI0420271ENN
111

Furceri D, Loungani P, Ostry JD, Pizzuto P. COVID-19 will raise inequality if past pandemics area guide [Internet]. VoxEU.org. 2020 [cited 2021 Apr 30]. Available from: https://voxeu.org/article/
covid-19-will-raise-inequality-if-past-pandemics-are-guide

112 The Race for Global COVID-19 Vaccine Equity [Internet]. Launch and Scale Speedometer. [cited
2021 May 1]. Available from: https://launchandscalefaster.org/COVID-19

How an outbreak became a pandemic by The Independent Panel for Pandemic Preparedness & Response

73 of 74

113 Washington Post. Bright says covid-19 vaccine is at least 12-18 months away [Internet]. 2020
[cited 2021 May 1]. Available from: https://www.washingtonpost.com/video/politics/brightsays-covid-19-vaccine-is-at-least-12-18-months-away/2020/05/14/f92fcab5-e881-4d68b302-7b4a08133fdc_video.html
114 Gavi. COVAX vaccine roll-out [Internet]. Gavi The Vaccine Alliance. [cited 2021 Apr 30]. Available
from: https://www.gavi.org/covax-vaccine-roll-out
115 WHO. First COVID-19 COVAX vaccine doses administered in Africa. 2020 Mar 1 [cited 2021 May
1]; Available from: https://www.who.int/news/item/01-03-2021-first-covid-19-covax-vaccinedoses-administered-in-africa
116 Covax: How will Covid vaccines be shared around the world? BBC News [Internet]. 2021 Apr 8[cited 2021 Apr 30]; Available from: https://www.bbc.com/news/world-55795297
117 Farge E, Blenkinsop P. New WTO chief calls for tripling of vaccine production. Reuters [Internet].
2021 Mar 1 [cited 2021 Apr 30]; Available from: https://www.reuters.com/article/uk-trade-wtoidUKKCN2AT1YS
118 Knowledge Ecology International. COVID-19 Vaccine Manufacturing Capacity [Internet].
Knowledge Ecology International. [cited 2021 May 1]. Available from: https://www.keionline.org/
covid-19-vaccine-manufacturing-capacity
119 UNICEF. COVID-19 Vaccine Market Dashboard [Internet]. UNICEF. [cited 2021 Apr 30]. Available
from: https://www.unicef.org/supply/covid-19-vaccine-market-dashboard
120 KEI Notes on Vaccine Manufacturing Capacity [Internet]. Google Docs. [cited
2021 May 1]. Available from: https://docs.google.com/spreadsheets/d/1IhLaGt5dEOVegy4eksgs4T6vDl6L6NbY_YJdvDonBI/edit?usp=embed_facebook
121 Foley KE. Syringe shortages could cause Pfizer vaccine bottlenecks [Internet]. Quartz. 2021
[cited 2021 Apr 30]. Available from: https://qz.com/1976718/syringe-shortages-are-causingpfizer-vaccine-bottlenecks/
122 KEIWashDC. WIPO Side event: Appraising Progress of WHO’s COVID-19 Technology Access
Pool (C-TAP) [Internet]. 2020 [cited 2021 Apr 30]. Available from: https://www.youtube.com/
watch?v=bRFC-Baw_ec
123 Menon S. India coronavirus: Can it make enough vaccines to meet demand? BBC News
[Internet]. 2021 Apr 29 [cited 2021 May 1]; Available from: https://www.bbc.com/news/worldasia-india-55571793
124 Reuters. Rich, developing nations wrangle over COVID vaccine patents. Reuters [Internet].
2021 Mar 11 [cited 2021 May 1]; Available from: https://www.reuters.com/article/us-healthcoronavirus-wto-idUSKBN2B21V9125 Buehrle DJ, Nguyen MH, Wagener MM, Clancy CJ. Impact of the Coronavirus Disease 2019
Pandemic on Outpatient Antibiotic Prescriptions in the United States. Open Forum Infect Dis.
2020 Dec 1;7(12):ofaa575.
126 Kemp-Casey A, Turnidge J, Roughead EE. Impact of the COVID-19 pandemic on utilisation of
antimicrobials in Australia. (In Press). Open Forum Infect Dis.
127 World Energy Council. Post-Pandemic Recovery: Towards a More Diverse and Impactful
Energey transition [Internet]. 2020 Dec. Available from: https://www.worldenergy.org/assets/
downloads/December_2020_World_Energy_Transiton_Radar_-_Brief_2.pdf
128 OECD. COVID-19 and global food systems [Internet]. OECD. 2020 [cited 2021 May 1]. Available
from: https://www.oecd.org/coronavirus/policy-responses/COVID-19-and-global-foodsystems-aeb1434b/
129 Zimmer K. A Guide to Emerging SARS-CoV-2 Variants [Internet]. The Scientist Magazine®. 2021
[cited 2021 Apr 30]. Available from: https://www.the-scientist.com/news-opinion/a-guide-toemerging-sars-cov-2-variants-68387
130 WHO. SARS-CoV-2 Variants [Internet]. WHO. World Health Organization; 2020 [cited 2021 Apr
30]. Available from: http://www.who.int/csr/don/31-december-2020-sars-cov2-variants/en/
131 Lavine JS, Bjornstad ON, Antia R. Immunological characteristics govern the transition of
COVID-19 to endemicity. Science. 2021 Feb 12;371(6530):741–5.
132 Phillips N. The coronavirus is here to stay — here’s what that means. Nature. 2021 Feb
18;590(7846):382–4.

How an outbreak became a pandemic by The Independent Panel for Pandemic Preparedness & Response

74 of 74