Rational Policy Over Panic
The evidence base of the pandemic preparedness
agenda does not support the current urgency

Background
International health institutions are emphasizing an urgency to prioritize
prevention and response to pandemics.
Pandemic risk is characterized as an “existential threat to humanity”
and is being used to justify proposed amendments to the International HealthRegulations and a new legally binding Pandemic Agreement. This agenda is
supported by unprecedented annual financial requests for over $10 billion in newOverseas Development Assistance and over $26 billion in LMICs investment,with over $10 billion additional for ‘One Health’ interventions.
The World Health Assembly will vote on the WHO instruments in May-June 2024.

Problem

MethodThe urgency and unprecedented scope of thisagenda depends on interpretations of evidence
claimed to demonstrate increasing pandemic
frequency and burden. If these interpretations
are poor, or the evidence flawed, then investment
may cause net harm,degrading competing
health, social andeconomic priorities.

We analyzed the data and evidentiary materialcited within 8 key policy documents used tosupport these assumptions, including from theG20 (n=3), World Bank (n=2) and WHO (n=3).
Our analysis included key secondary citations(n=3) and academic sources referenced in thepolicy documents to support these claims.
Our analysis focused on reported mortality andoutbreak frequency to determine trends in risk
and demonstrated harm.

ResultOur analysis found that the data andevidence is poorly supportive of current
pandemic risk assumptions.
In contrast, the data suggests that anincrease in recorded natural outbreaks
could be largely explained by technologicaladvancements in diagnostic testing over thepast 60 years, while current surveillance,
response mechanisms and other publichealth interventions have successfully
reduced burden in the past 10 to 20 years.

Analysis
The G20 report and High-Level Independent Panel (HLIP)
A GLOBAL DEAL
FOR OURPANDEMIC AGEREPORT OF THE
G20 HIGH LEVELINDEPENDENTPANELIn 2022 the G20 convened the HLIP to review pandemic risk and the budget
required to address it. The HLIP’s report relies on two main sources for its
claims of exponential risks of outbreaks:
An analysis by Metabiota, a former private US-based corporation, and an
uncited table of outbreaks from the year 2000 to 2020. Both fail to support
HLIP claims.

The Metabiota analysis is claimed by the HLIP todemonstrate an exponential increase in outbreakfrequency from 1960 to 2020. Yet, the noninfluenza increase seen over the past six decades
takes no account of the invention and rising useof the core technologies used to detect and reportthese pathogens, including PCR, antigen tests
and digital communications. Most could not be
detected in 1960. If Ebola outbreaks are excluded,
Metabiota’s data shows a decline in mortality
from non-influenza outbreaks over the past 20years. The parallel Metabiota claim of influenza
outbreaks increasing from near 1 per year in
1995 to 10 per year in 2020 does not correlatewith any known influenza trajectory, and its
methodological basis is unclear.

The other evidence on which the G20 HLIP basetheir findings is a list of outbreaks from 2000
to 2020. Table 1 lists those 13 events, basedon WHO and other sources. It is dominated by
COVID-19, and the 2009 H1N1 influenza (SwineFlu) outbreak. If COVID-19 and Swine Flu areexcluded, the combined burden of all outbreaks
listed is less than 26,000 deaths over 20 years,
with only Ebola Virus and cholera resulting inover 1000 deaths. Swine Flu killed less people
than seasonal influenza normally does, and
we already have well-established surveillancemechanisms for influenza. In this context,
Covid-19 appears as an outlier rather thanreflecting a trend.

Table 1: Events considered by G20 to be major outbreaks 2000 to 2020YEAR

OUTBREAKMORTALITY2019

SARS-CoV-2...

2018

Lassa

114

2017

Zika362

2017

Ebola

32014

Chikungunya

0

2014

Ebola

11,325

2012

MERS858

2010

Cholera

9,792

2009

H1N1 Influenza

163,000

2004

H1N1 Influenza

32

2003

SARS-CoV-1774

2001

Enterovirus 71

26

2001

Nipah54

The World Bank
The World Bank 2022 report, Putting Pandemics Behind Us,
seeks a further $10.3 to $11.5 billion annually to support ‘One
Health’ initiatives to reduce pandemics by reducing zoonotic
spillovers. While claiming an exponential increase in risk ofdisease emergence, the data used actually shows a reduction
over the past decade.

200 100 -7-

15-20149-220102001

4-200

2005-200

9-00

2095

-1

99

4-99

9-1
1990

-1
1985

1998

4998

97

-1-1

80

1975
19

Figure 1: The GIDEON database, basis of the World Bank claims
on increasing outbreaks, shows a rise consistent with improving
detection from 1975, followed by a reduction in significant
outbreaks over the past decade. (Source: Stephens et al. 2021)-0--

www.royalsocietypublishing.org/doi/10.1098/rstb.2020.0535

Cases> 1000
> 100

300 Frequency

Further papers cited by the World Bank show
similar recent reductions in outbreak frequency,such as Stephens et al. (2021), (Figure 1),
indicating that current mechanisms are actually
successful in managing and reducing risk.

YearThe World Bank report further cites a study by Marani et al (2021) to support a claim that large
outbreaks “could increase up to threefold in the coming decades”. Marani et al. assessed thefrequency of outbreaks over the past 400 years to predict future frequency. They conclude, basedon the most recent outbreak data, that a ‘Spanish Flu’-like event may recur every 292 or 877 years,
while a COVID-19-like event every 129 years. This contradicts the World Bank’s main contentionof urgency due to accelerating risk, instead indicating that such events, if of natural origin, arerelatively rare outliers and unlikely to recur within a short period.

WHO Priority Disease List and Managing Epidemics
WHO identifies 9 priority diseases for research and development in an emergency context. This
includes COVID-19 and a hypothetical outbreak; ‘Disease-X’. Of the other 7 diseases, only Ebola virus
has caused an outbreak of over 10,000 deaths in recorded history. Excluding Lassa fever, which is anendemic West African disease, none have caused over 1000 cumulative recorded global deaths.

Claims of over 3.3. million outbreak deaths per year
Global institutions have been quoting evidence of an annual outbreak burden of over 3 million deaths
per year. These claims are frequently based on analysis in a widely cited study by Bernstein et al (2022),
which claims that a global pandemic cost of $20 trillion per year could be alleviated by 50% with an
expenditure of $10 billion, saving 1.6 million lives with a financial return of 20:1. In fact, the range ofcosts estimated in the study was $350 billion to $21 trillion. The authors do not state why $20 trillion
was chosen as representative.
The Bernstein et al. study estimates are driven primarily through inclusion of the pre-antibiotic 1918-19
influenza (Spanish Flu) outbreak in which most deaths are considered to have occurred from secondary
bacterial infection. The second driver is HIV/AIDS. Both influenza and HIV/AIDS already have strong
global surveillance and response mechanisms in place. The past 50 years of outbreak data considered by
the Bernstein study, with HIV/AIDS and COVID-19 excluded, shows less than 15,000 deaths per year,
globally, from zoonotic outbreaks (rather than 3.3 million).

Implications
Outbreaks do occur and it is prudent to have anappropriate and proportionate policy response.
Other diseases such as tuberculosis and malaria
continue to dominate infectious disease burdens
annually. Both disease burdens are worsening
at present. Globally, cancer and cardiovasculardiseases have still higher mortality.
A reduction in funding
to address these diseases,
through diversion of resources
to outbreak events, would
therefore have major negative
health impacts.

The data on which WHO, the World Bank andG20 base their claims regarding pandemic risk
indicate that diverting investment to this risk
is of lesser urgency than claimed, and risk
may be decreasing. This suggests that newinvestment will need to be carefully weighedagainst investment in diseases of greater burden,
particularly in low-resourced settings.
This raises concern that escalated urgency
based on weak evidence could undermine bothpandemic preparedness and global health 		
policy coherence.

Recommendations
1. There is a clear need to commission better
evidence to accurately determine the scale
and urgency of pandemic risk.

2. An appropriate determination of pandemic
risk must account for recent advancements
in diagnostic capacity, information sharing,and improving disease control mechanisms.

3. Understanding relative disease burden is crucial
for identifying the cost-benefit of pandemic
investment and how to best select interventions
and promote overall public health outcomes.

4. Given the poor evidence underlying risk
assessment, it is prudent not to rush into
new pandemic initiatives such as the proposed
WHO pandemic instruments until underlying
assumptions receive proper assessment basedon robust evidence, recognized need,and overall benefit.

5. WHO Member States should support
proportional pandemic preparedness efforts
based on substantiated evidence, careful
deliberation, and rational reflection.

The full REPPARE research report is available on our webpage here.
Or you can contact Professor Garrett W. Brown: g.w.brown@leeds.ac.uk or reppare2023@gmail.com
This study was supported with funds from Brownstone Institute.
Policy brief edited and designed by Research Retold www.researchretold.com.