digest

COVID-19 Recovery Summit

Prepared by. Dr. James Orbinski Director, Dahdaleh Institute for Global Health Research, Aria Ilyad Ahmad, Dahdaleh Institute for Global Health Research

Period. 14 - 17 September 2020

Global Public Health

Briefing document in preparation for The Recovery Summit (Sep 14-17) • Agenda: www.recoveryproject.org/ • Livestream: https://youtu.be/LIHJRku6-Oc The COVID-19 Pandemic is the worst global public health emergency in over a century, and described by the United Nations Secretary-General as the “most challenging crisis since World War II.”^[1] In less than three months since it was first internationally reported on New Year’s Eve 2019, the virus has rapidly spread to almost every country with varying patterns and waves of infection, contributing to almost a million deaths and 30 million confirmed cases as of September 12, 2020.^[2] Its unique epidemiological characteristics and diverse range of clinical manifestations contribute to one reputable study estimating that 1.7 billion people – or 22% of the global population – could be at an increased risk of severe COVID-19 if infected.^[3] As the first waves of infection rapidly swept across Asia, Europe, the Americas and Africa, we are reminded that the second and third waves of the 1918 influenza pandemic killed significantly more people.^[4] Limited disease detection and testing capacity, not only in lower income countries but also advanced economies, obscure the true toll of the COVID-19 pandemic, including community spread and deaths. Public health experts and governments have turned to rapid surveillance of excess mortality as a key indicator of overall epidemic impact and trajectory.^[5]In Africa, up to 190,000 people could die of COVID-19 by the end of 2020, and an additional 44 million people could be infected.^[6] Beyond the direct effects on morbidity and mortality, COVID-19 also contributes to secondary health impacts. Disruptions in essential care as well as food shortages with self-evident health impacts are projected to contribute to 1.2 million additional under-five deaths, representing the first increase in global childhood mortality since World War II.^[7] Immunization campaigns have also been suspended globally, as Médecins Sans Frontières describes the “devil’s choice” that countries and aid organizations face in balancing pandemic response while maintaining vaccination programs.^[8] Indirect maternal deaths are likewise expected to rise from 8% to 38%, undermining major gains in Maternal and Child Health over the past decade.^[9] Global shortages in personal protective equipment, uncertainties around transmission dynamics as well as weak infection prevention and control measures have also contributed to elevated risks among front-line health workers that make up more than 11% of all cases worldwide.^[10] COVID-19 also threatens plans to eliminate and control infectious diseases, with widespread interruptions to HIV, TB, and malaria care. Many countries are also reporting challenges in maintaining chronic disease care, including 80% of countries in Central and South America, as manageable cases risk becoming active infections.^[11] Recent projections indicate public health containment, control and mitigation measures such as hand washing, wearing masks, widespread COVID-19 testing, contact tracing and social distancing, may need to be maintained into 2022, further straining health systems and exacerbating social and economic impacts.^[12] The impacts of the pandemic cascade beyond health across all sectors, compounding existing vulnerabilities and emerge as network hyper-risks that ramify across systems and geographies. Like all natural and health hazards, COVID-19 has also shown how marginalized and vulnerable communities are disproportionately impacted, while exacerbating existing inequities and vulnerabilities such as malnutrition, insecurity, gender-based violence and the impacts of natural hazards, among others.

1. Humanitarian Issues and Implications

As the world engages in unprecedented containment, control and mitigation measures, COVID-19 has exposed inequities and vulnerabilities. In low- and middle-income countries, fragile health systems and inadequate financial safety nets compound the triple challenge of pandemic response, social protection, and economic collapse. Global and national economic fragility and massive public debt are new realities, as are unprecedented job losses. Among the approximately two billion informally employed workers globally, containment measures are projected to lead to a decline of 82% in earnings, as the International Labour Organization estimates the pandemic could push 500 million people into poverty.^[13]^,[14] The World Bank has moreover projected the sharpest historic decline in global remittances that could push 40-60 million further people into extreme poverty.^[15]^,[16] Six months of lockdown have also reversed advances on the rights of women and girls, including an estimated 31 million cases of gender-based violence as well as 7 million additional unintended pregnancies.^[17] Lockdowns and border restrictions have also disrupted agricultural production, with the Food and Agriculture Organization and World Food Programme warning that even best-case scenarios will result in global famines that see acute hunger increase by more than 130 million people by the end of 2020.^[18] The pandemic is upending food supply chains, crippling economies and eroding consumer purchasing power. The populations most at risk of famine are predominantly in ten countries that are concurrently affected by conflict, economic crisis and climate change.^[19] In complex humanitarian settings, COVID-19 can further amplify existing stressors among vulnerable populations, including among the 70 million forcibly displaced people that often live in displacement camps that are overcrowded, and lack access to health care, sanitation and clean water.[20] Another billion people around the world live in informal peri-urban slums and barrios without safe potable water or adequate health or sanitation services face additional vulnerabilities, while the recent Tropical Cyclone Harold in Fiji illustrates the compounding challenges of natural disasters hitting communities experiencing COVID-19.^[21] Many advanced economies have responded to the pandemic by passing major stimulus packages, as the International Monitory Fund estimates G20 countries have spent upwards of US$11 trillion in new fiscal measures, representing one tenth of global GDP.[22] The gap between donor commitments and the funding needed to respond to the pandemic in low- and middle-income countries, meanwhile, continues to grow reinforcing global inequities in the distribution of resources and fiscal support capacities.[23] The UN Office for the Coordination of Humanitarian Affairs (OCHA) has tripled its unprecedented and “Extraordinary Appeal” for an immediate Global Humanitarian Response to COVID-19 in fragile countries to US$10.3 billion, that as yet remains only 24% funded.[24] Protecting the most vulnerable 10% of the world (or 700 million people) across 32 countries from the worst impacts of COVID-19 in complex humanitarian settings would require US$90 billion, or less than 1% of the stimulus packages that G20 countries have underwritten.[25] The UN Emergency Response Coordinator warns that the pandemic and the associated global recession are about to wreak havoc in fragile states, while describe the response by wealthier countries as “grossly inadequate and dangerously short-sighted.”[26] Health emergency preparedness requires effective, agile systems for prevention, detection, response, and recovery with the flexibility and scalability required to cope with a variety of emergencies, commensurate with the required response.[27] Planning for emergencies requires prioritizing systems building across the whole of society, in a variety of contexts, testing different models, and creating environments and mechanisms for sharing best practices, among countries at all economic levels. This lack of multisectoral preparedness left many societies scrambling to figure out how to maintain essential services and mitigate economic disruptions.[28] The potential impact of pandemics on non-health sectors and the private sector has been a known risk for years; yet, health emergency preparedness remains siloed and with little reach beyond public health.[29] As COVID-19 has shown, pandemics require a comprehensive response, encompassing health, mental health and psycho-social support education, and other aspects of the social and economic sectors. Many sectors lacked plans to mitigate not only the public health risks but also the potential socioeconomic impact of the pandemic, including strategies for managing breaks in supply chains, school and childcare closures, food shortages, and unemployment, in a way that was least disruptive to personal finances, commerce, and daily lives.

2. Global R&D Roadmap and Equity

The COVID-19 pandemic has mobilized the largest global research effort in history.[30] Within weeks of first discovering the SARS-Cov-2 virus, its genome was sequenced while diagnostic tests have been developed at unprecedented speeds. By May, over 1,000 scientific papers were being published every day, as journal publications enabled open and rapid dissemination of critical epidemiological trends and clinical public health guidelines.[31] Despite the scale and speed of the global scientific response, there is still no treatment or vaccine for COVID-19. In addition to persistent uncertainties regarding transmission pathways, the type and duration of immunity is not yet known, while the emergence of viral mutation is a certainty, and can emerge anywhere.^[32] The truth remains that countries that adopted public health interventions quickly and aggressively were able to control transmission: one study estimates that shutdowns in Europe averted 3.1 million COVID-19 related deaths, while another analysis of the six countries with the highest reported cases in June 2020 suggests the public health and containment measures likely prevented or delayed an estimated 62 million cases.[33]^,[34] In the first six months of 2020, billions in public funding have poured into research, contributing to at least 38 COVID-19 vaccine candidates in clinical trials and another 93 preclinical vaccines in actively studies in animal hosts, as of September 10, 2020.[35] While wealthier countries continue to sign agreements to secure advanced access to vaccine – a kind of ‘Vaccine Nationalism’ that is now being condemned – there is an urgent need for new arrangements at the global level to facilitate the development, finance, production, and equitable distribution of COVID-19 vaccines.[36] The international community must ensure that COVID-19 related diagnostics, therapeutics and vaccines are treated as global public goods, and access must be equitable to ensure appropriate containment, control and mitigation of the COVID pandemic. WHO activated the COVID R&D Blueprint and established the Solidarity international clinical trials aimed at rapidly assessing the relative effectiveness of COVID- 19 treatments. As awareness grew of the need for strengthened international coordination of the COVID-19 R&D efforts – and in response to a call from G20 leaders – WHO, together with CEPI, FIND, GAVI, the Global Fund, UNITAID the Wellcome Trust and the World Bank, established the Access to COVID-19 Tools (ACT) Accelerator with support from governments, manufacturers and funders.[37]Through its extensive network of global collaborators, the ACT Accelerator aims to improve the speed and scale of development, production, and equitable access to COVID-19 tests, treatments, and vaccines. It the largest and most diverse COVID-19 vaccine portfolio in the world with ten candidate vaccines under evaluation, with 9 of them in clinical trials, and over 170 countries engaged in the new COVID-19 Vaccine Facility (COVAX). COVAX allows countries to pool resources, share vaccine development risks, allow procurement of sufficient volumes of vaccines to support equitable access materials and medical equipment globally, and where there is oversupply, to donate surplus doses to a central pool.[38] Among the 170 countries that have signed on to COVAX, 55 would finance the vaccines using domestic budgets, while partnering with up to 90 lower income countries that would be supported through the COVAX Advance Market Commitment coordinated by GAVI. While these initiatives hold much promise, it remains to be seen whether they will achieve their goals, and they remain limited to COVID-19.[39] To date, less than 10% of required funding for the ACT Accelerator has been contributed, with US$35 billion urgently needed to ensure its viability. On September 10, 2020 UN Secretary General António Guterres appealed for a “quantum leap in funding,” warning that “without an infusion of US$15 billion over the next 3 months, beginning immediately, we will lose the window of opportunity.”[40] Lessons from previous pandemics show that without mechanisms and procedures to facilitate the equitable sharing of limited medical countermeasures, low- and middle-income countries may be unable to secure access to vaccines and treatments until after wealthier countries have secured enough doses for their populations.[41] Challenges with the financing and coordination of R&D for COVID-19, fragile supply chains and trade restrictions on essential medical goods, and concerns regarding equitable and effective allocation of vaccines have highlight the need for adequate governance frameworks around R&D, trade and access to medical countermeasures. While the WHO focuses on the immediate health response, the UN Research Roadmap will address longer-term downstream socio-economic consequences of COVID-19. Launched in April 2020, the UN Research Roadmap for the COVID-19 Recovery seeks to identify research priorities that will support an equitable global socio-economic recovery from this pandemic and continued progress towards the UN Sustainable Development Goals.[42] The Roadmap aims to transform COVID-19 recovery into a rapid learning initiative, where national and international responses can be informed by rigorous social scientific evidence generated in the anticipated recovery period. It is also intended to ensure national and international strategies are informed by rigorous social scientific evidence generated in anticipation of, and during, the COVID-19 recovery period.[43] It will seek alignment in support of priority areas identified in the UN Framework for the Immediate Socio-Economic Response to COVID-19.[44]Environmental sustainability and gender equality are part of a research Roadmap aimed at building a greener, more inclusive, gender-equal and sustainable world, with specific attention to at-risk populations experiencing greater socio-economic marginalization.

3. Pandemic Preparedness

In an increasingly interconnected and interdependent world, human security means that global health is necessarily the responsibility of all countries, requiring long term, predictable, flexible and sustained financing based on global solidarity.[45]) We believe this should be rooted in principles of Human Security, that include: (a) the right of all people to live in freedom and dignity, free from poverty and despair; (b) the pursuit of people-centred, context-specific and prevention-oriented responses that strengthen protection and empowerment of all people and communities; (c) acknowledging the interlinkages between peace, development and human rights; and (d) strengthening national solutions which are compatible with local realities.[46] The protection of health underpins all aspects of a functioning, prosperous society. COVID-19 has made clear that pandemic preparedness and response are not choices between protecting people and protecting the economy: one reputable estimate projects the cumulative global fiscal deficit as a result of the pandemic at US$25-30 trillion, equivalent to 30% of global GDP.[47] Existing emergency funding mechanisms are inadequate for a pandemic response, which include established models of development assistance that depend on a small number of countries, foundations, and development banks.[48] Although the WHO Contingency Fund for Emergencies and the Pandemic Emergency Financing Facility can be deployed quickly, only a relatively small amount of funds is available through these mechanisms and they can be depleted quickly. This has meant that international financial institutions needed to play a critical role at the beginning of the pandemic. The World Bank was able to rapidly mobilize US$14 billion for emergency COVID-19 response in the first three months, as the IMF disbursed US$87.8 billion to date through its US$250 billion Catastrophe Containment and Relief Trust.[49]^,[50] There are nonetheless no dedicated mechanisms to allow the rapid deployment of a large amount of funds at the beginning of a pandemic. A lack of sustainable financing threatens WHO’s capacity to play a central role in global health emergencies but also to deliver on its broader mandate. Among the most difficult challenges beyond the current COVID-19 pandemic is how quickly and effectively nations will be able to develop strategies and mobilize resources should this situation arise in the near or distant future. It is also important to recognize that global preparedness is not simply the sum of national preparedness: a pandemic is a global event demanding global action.[51] That includes stronger mechanisms for collective action that enable countries, businesses, and societies to coordinate and collaborate towards a common goal. While multilateral systems like the UN and G20 have reiterated strong commitments to preparedness, they have struggled to implement a collective response, which has been further hampered by global political tensions undermining multilateral institutions and exacerbating WHO’s financial fragility. A strong multilateral system is foundational of global pandemic preparedness, across public, private and non-profit sectors working together bilaterally, regionally and internationally. Collective action is needed to ensure a common strategy, coordinated and effective clinical and public health action, and equitable access to countermeasures. Interconnected supply chains and international travel mean that all countries depend on the economic, social, and physical health of all others. The Global Preparedness Monitoring Board (GPMB) is an independent monitoring and accountability body, convened by the WHO and the World Bank to ensure preparedness for global health crises. In its first annual report in September 2019 three months before COVID-19 was discovered, the GPMB outlined the urgent need for strong multilateral systems to undertake the following set of core functions for pandemic preparedness and response:[52]

Developing global and regional mechanisms for tracking potential pathogens;
Strengthening early notification and comprehensive information sharing;
Intermediate grading of health emergencies;
Development evidence-based recommendations on the role of domestic and international travel and trade recommendations;
Collaborative mechanisms for R&D, regulatory capacity building and harmonization and allocation of countermeasures; and
Mechanisms for assessing International Health Regulation compliance and core capacity implementation, including a universal, periodic, objective and external review mechanism.

The COVID-19 pandemic has also demonstrated that efforts are also needed to ensure stockpiles, including global supply chains for essential goods are strengthened, developed, sustained, and financed.[53] Here, simulations and exercises that test and demonstrate the capacity and agility of health emergency preparedness systems, and their functioning within societies can be developed using predictive mechanisms for assessing multisectoral preparedness. Lastly, COVID-19 has highlighted a fundamental issue with how we define and measure preparedness. Our understanding of preparedness is based on a narrow set of public health capacities that do not fully capture the range of national and international capacities necessary to ensure preparedness, including R&D, measures to mitigate the socio-economic impacts of epidemics and ensure continuity of essential services, international cooperation, and preparedness of international organizations.[54] In addition, current measures focus more on the presence of an institutional policy rather than a demonstrated capacity to operationalize those capacities, and the critical importance of science-informed political leadership.

Recommendations

The impacts of the COVID-19 pandemic are felt across all sectors, with cascading and compounding social, environmental, economic and political effects that are global in nature, and that cannot be solved by any one country acting alone. Protecting health is critical to economic, social, and political security. The chronic underfunding of WHO and the dearth of global financing for pandemic preparedness has limited the Organization’s capacity to fulfill its mandate in responding to health emergencies and undermined its autonomy, but also has been a major impediment to both national and global preparedness. In addition to direct and secondary health impacts, the global collective experience with COVID-19 has also demonstrated its cascading impacts on social services, reversing economic gains, aggravating gender-based violence, disrupting education, creating food insecurity and exacerbated inequities within and between countries. Perhaps the most important building block to effective pandemic preparedness is governance.[55] It is imperative to pre-emptively build a legal and policy foundation to guide responses to shocks, covering all levels of the health system, private and non-proﬁt sectors, international agencies and inter-sectoral coordination. Planning for shocks, building networks, and appropriate decentralisation to allow decision-making by local managers can help provide a platform for responding to shocks when they occur. Furthermore, shocks often aﬀect countries in multiple ways, and interdependencies with other sectors, such as social protection, water, sanitation, nutrition, and disaster risk management need to be identiﬁed and planned for in advance.

Support the most vulnerable and guarantee funding for the UN Office for the Coordination of Humanitarian Affairs’ US$10.3 billion call for the immediate global humanitarian response to COVID-19 in fragile countries.^[56]
Ensure US$35 billion to fund the Access to COVID-19 Tools (ACT) Accelerator initiative as a global public good and support global scientific collaboration to accelerate the development, production, equitable and affordable access to COVID diagnostics, therapeutics and vaccines.^[57]
Engage proactive collaborative leadership globally, regionally and nationally and provide necessary funding commitments to ensure the implementation of the urgent pandemic preparedness actions that will prepare the world for future health emergencies as set out by the Global Preparedness Monitoring Board.^{^[58]}

References

[1] UN (2020) “This is a time for science and solidarity,” Speech by UN Secretary General António Guterres, April 14, 2020. Accessed September 11, 2020 at <https://www.un.org/en/un-coronavirus-communications-team/time-science-and-solidarity> [2] Coronavirus Resource Center (2020) [... ]about five minutes.

[1] UN (2020) “This is a time for science and solidarity," Speech by UN Secretary General António Guterres, April 14, 2020. Accessed September 11, 2020 at <https://www.un.org/en/un-coronavirus-communications-team/time-science-and-solidarity> ^[2] Coronavirus Resource Center (2020) “COVID-19 Case Tracker,” Johns Hopkins University School of Medicine. Accessed September 11, 2020 at <https://coronavirus.jhu.edu> [3] Clark, A, Jit, M, Warren-Gash, C, et al (2020) “Global, regional, and national estimates of the population at increased risk of severe COVID-19 due to underlying health conditions in 2020: a modelling study,” Lancet Global Health, 8(8): E1003-E17. [4] Taubenberger, JK, Morens, DM (2006) “1918 Influenza: the Mother of All Pandemics,” Emerging Infectious Diseases, 12(1): 15–22. ^[5] Setel, P, AbouZahr, C, Atuheire, EB (2020) “Mortality surveillance during the COVID-19 pandemic,” Bulletin of the World Health Organization, 98:374. ^[6] WHO (2020) “Up to 190 000 people could die of COVID-19 in Africa if not controlled,” Accessed May 9,2020 <www.afro.who.int/news/new-who-estimates-190-000-people-could-die-covid-19-africa-if-not-controlled> [7] Roberton, T, Carter, ED, Chou, VB, et al (2020) “Early estimates of the indirect effects of the COVID-19 pandemic on maternal and child mortality in LMICs: a modelling study,” The Lancet Global Health, 8(7): E901-8. [8] Measles & Rubella Initiative (2020) “More than 117 million children at risk of missing out on measles vaccines, as COVID-19 surges,” Accessed September 11, 2020 <https://measlesrubellainitiative.org/measles-news/more-than-117-million-children-at-risk-of-missing-out-on-measles-vaccines-as-covid-19-surges> ^[9] See Roberton et al (2020). [10] Nguyen, LH, Drew, D, Graham, M, et al (2020) “Risk of COVID-19 among front-line health-care workers and the general community: prospective cohort study,” Lancet Public Health, 5(9): E475-483. [11] PAHO (2020) “COVID-19 threatens plans to eliminate and control infectious diseases,” Accessed August 11, 2020 <https://www.paho.org/en/news/11-8-2020-covid-19-threatens-plans-eliminate-and-control-infectious-diseases-paho-director> ^[12] Kissler, SM, Tedijanto, C, Goldstein, E, et al (2020) “Projecting the transmission dynamics of SARS-CoV-2 through the post-pandemic period,” Science, 368(6493):860-68. [13] ILO (2020) “COVID-19 crisis and the informal economy Immediate responses and policy challenges,” Accessed September 11, 2020 <https://www.ilo.org/wcmsp5/groups/public/---ed_protect/---protrav/---travail/documents/briefingnote/wcms_743623.pdf> [14] Sumner, A, Hoy, C, Ortiz-Juarez, E (2020) “Estimates of the impact of COVID-19 on global poverty,” United Nations University WIDER Working Paper 2020/43. Accessed September 10, 2020 <https://www.wider.unu.edu/sites/default/files/Publications/Working-paper/PDF/wp2020-43.pdf> [15] UNICEF (2020) “Child poverty and COVID-19,” Accessed September 8, 2020 <https://data.unicef.org/topic/child-poverty/covid-19/> [16] World Bank (2020) “World Bank Predicts Sharpest Decline of Remittances in Recent History,” Accessed September 12, 2020 <https://www.worldbank.org/en/news/press-release/2020/04/22/world-bank-predicts-sharpest-decline-of-remittances-in-recent-history> [17] UNFPA (2020) “Impact of the COVID-19 Pandemic on Family Planning and Ending Gender-based Violence” Accessed September 10, 2020 <https://www.unfpa.org/sites/default/files/resource-pdf/COVID-19_impact_brief_for_UNFPA_24_April_2020_1.pdf> [18] FAO (2020) “Food Security And Nutrition Around The World In 2020,” Accessed Sept 11, <http://www.fao.org/3/ca9692en/online/ca9692en.html#chapter-1_1> ^[19] Food Security Information Network (2020) “Global Report on Food Crises 2020,” Accessed September 12, 2020 <https://docs.wfp.org/api/documents/WFP-0000114546/download/?ga=2.87091864.1423547846.1589235876-170409956.158923587> [20] UNDRR (2020) “UNDRR Asia-Pacific COVID-19 Brief: Reducing Vulnerability of Migrants and Displaced Populations,” Accessed September 11, 2020 <https://www.undrr.org/publication/undrr-asia-pacific-covid-19-brief-reducing-vulnerability-migrants-and-displaced> ^[21] UNDRR (2020) “Extreme weather events in a time of COVID-19,” Accessed September 10, 2020 <https://www.undrr.org/news/extreme-weather-events-time-covid-19> [22] IMF (2020) “World Economic Outlook Update, June 2020,” Accessed September 10, 2020 <https:// www.imf.org/~/media/Files/Publications/WEO/2020/Update/June/English/WEOENG202006.ashx?la=en> [23] WHO (2020) “WHO Director-General's opening remarks at the media briefing on COVID-19 - 10 August 2020, Accessed September 11, 2020 <https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---10-august-2020> [24] UN Office for the Coordination of Humanitarian Affairs (2020) “COVID-19 Global Humanitarian Response Plan,” Accessed September 11, 2020 <https://fts.unocha.org/appeals/952/summary> [25] UN (2020) “COVID-19: UN relief chief urges G20 to step up to avert ‘cascading crises’ in fragile countries,” Accessed September 10, 2020 <https://www.un.org/africarenewal/news/covid-19-un-relief-chief-urges-g20-step-avert-‘cascading-crises’-fragile-countries> [26] Ibid. [27] Global Preparedness Monitoring Board (GPMB) (2019) “A World at Risk: Annual report on global preparedness for health emergencies,” Accessed September 10, 2020 <https://apps.who.int/gpmb/assets/ annual_report/GPMB_Annual_Report_English.pdf> [28] World Bank (2020) “Protecting People and Economies: Integrating Policy Responses to COVID-19,” Accessed September 10, 2020 <http://documents1.worldbank.org/curated/en/879461587402282989/pdf/Protecting-People-and-Economies-Integrated-Policy-Responses-to-COVID-19.pdf> [29] McKinsey & Company (2020) “Prioritizing health: A prescription for prosperity,” Accessed September 10, 2020 <https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/prioritizing-health-a-prescription-for-prosperity> [30] COVID-19 Clinical Research Coalition (2020) “Global coalition to accelerate COVID-19 clinical research in resource-limited settings,” The Lancet, 395(10233): P1322-25. [31] Wadman, M et al (2020) “How does coronavirus kill? Clinicians trace a ferocious rampage through the body, from brain to toes,” Science, April 17, 2020. Accessed 10 September 2020 <https://www.sciencemag.org/ news/2020/04/how-does-coronavirus-kill-clinicians-trace-ferocious-rampage-through-body-brain-toes> ^[32] Pachetti, M, Marini, B, Benedetti, F et al (2020) “Emerging SARS-CoV-2 mutation hot spots include a novel RNA-dependent-RNA polymerase variant,” Journal of Translational Medicine 18, 179. [33] Flaxman, S, Mishra, S, Gandy, A (2020) “Estimating the effects of non-pharmaceutical interventions on COVID-19 in Europe,” Nature, 584:257–261. [34] Hsiang, S, Allen, D, Annan-Phan, S (2020) “The effect of large-scale anti-contagion policies on the COVID-19 pandemic,” Nature, 584:262–267. [35] Lancet (2020) “Global governance for COVID-19 vaccines,” The Lancet 395(10241):1883. [36] Canadian Coalition for Global Health Research (2020) ”Joint CCGHR-CSIH Statement and Call to Action: Defeating COVID-19 Calls for Global Solidarity, not vaccine Power play,” Accessed September 11, 2020 <www.ccghr.ca/ joint-ccghr-csih-statement-call-action-defeating-covid-19-calls-global-solidarity-vaccine-power-play/> [37] WHO (2020) “ACT-Accelerator update. June 26, 2020,” Accessed September 12, 2020 <https://www.who.int/news-room/detail/26-06-2020-act-accelerator-update> [38] WHO (2020) “More than 150 countries engaged in COVID-19 vaccine global access facility,” Accessed September 11, 2020 <https://www.who.int/news-room/detail/15-07-2020-more-than-150-countries-engaged-in-covid-19-vaccine-global-access-facility> [39] Callaway, E (2020) “The unequal scramble for coronavirus vaccines — by the numbers,” Nature Explainer, Accessed September 11, 2020 <https://www.nature.com/articles/d41586-020-02450-x> [40] WHO (2020) “Access to COVID-19 Tools-Accelerator Facilitation Council holds inaugural meeting,” Accessed September 12, 2020 <https://www.who.int/news-room/detail/10-09-2020-coronavirus-global-response-access-to-covid-19-tools-accelerator-facilitation-council-holds-inaugural-meeting> [41] McKinsey & Company (2020) “Not the last pandemic: Investing now to reimagine public-health systems,” Accessed September 10, 2020 <https://www.mckinsey.com/industries/public-and-social-sector/our-insights/not-the-last-pandemic-investing-now-to-reimagine-public-health-systems> [42] Canadian Institutes for Health Research (CIHR) (2020) “UN Research Roadmap for the COVID-19 Recovery,” Accessed September 11, 2020 <https://cihr-irsc.gc.ca/e/52101.html> [43] Ibid. [44] UN (2020) “A UN framework for the immediate socio-economic response to COVID-19,” Accessed September 11, 2020 <https://unsdg.un.org/sites/default/files/2020-04/UN-framework-for-the-immediate-socio-economic-response-to-COVID-19.pdf> [45] See GPMB (2020). [46] UN (2016) “Human Security Handbook,” Human Security Unit. Accessed September 11, 2020 <https://www.un.org/humansecurity/wp-content/uploads/2017/10/h2.pdf> [47] McKinsey & Company (2020) “The great balancing act: Managing the coming $30 trillion deficit while restoring economic growth,” Accessed September 11, 2020 <https://www.mckinsey.com/industries/public-and-social-sector/our-insights/the-great-balancing-act-managing-the-coming-30-trillion-dollar-deficit-while-restoring-economic-growth> [48] Rivers, C, Martin, E, Meyer, D, et al (2020) “Modernizing and Expanding Outbreak Science to Support Better Decision Making During Public Health Crises: Lessons for COVID-19 and Beyond,“ Johns Hopkins University Center for Health Security. Accessed September 10, 2020 <https://www.centerforhealthsecurity.org/our-work/pubs_archive/pubs-pdfs/2020/200324-outbreak-science.pdf> [49] World Bank (2020) “World Bank Group Increases COVID-19 Response to $14 Billion To Help Sustain Economies, Protect Jobs,“ Accessed September 10, 2020 <https://www.worldbank.org/en/news/press-release/2020/ 03/17/world-bank-group-increases-covid-19-response-to-14-billion-to-help-sustain-economies-protect-jobs> [50] IMF (2020) “COVID-19 Financial Assistance and Debt Service Relief,” Accessed September 11, 2020 <https://www.imf.org/en/Topics/imf-and-covid19/COVID-Lending-Tracker> [51] WHO (2020) “WHO COVID-19 Preparedness and Response Progress Report - 1 February to 30 June 2020,” Accessed September 10, 2020 <www.who.int/docs/default-source/coronaviruse/srp-covid-19-6month.pdf> [52] See GPMB (2019). [53] McKinsey & Company (2020) “Prioritizing Health: A Prescription for Prosperity,” Accessed September 11, 2020 <http://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/prioritizing-health-a-prescription-for-prosperity> [54] See GPMB (2019). [55] Oxford Policy Management (2020) “What does it take to build the preparedness of health systems to manage shocks like COVID-19?,” Accessed September 10, 2020 <https://www.opml.co.uk/blog/what-does-it-take-to-build-the-preparedness-of-health-systems-to-manage-shocks-like-covid-19> ^[56] UN Office for the Coordination of Humanitarian Affairs (2020) “COVID-19 Global Humanitarian Response Plan,” Accessed September 11, 2020 <https://fts.unocha.org/appeals/952/summary> ^[57] WHO (2020) “Access to COVID-19 Tools (ACT) Accelerator,” Accessed September 10, 2020 at <https://www.who.int/who-documents-detail/access-to-covid-19-tools-(act)-accelerator> ^[58] Global Preparedness Monitoring Board (GPMB) (2019) “A World at Risk: Annual report on global preparedness for health emergencies,” Accessed September 10, 2020 <https://apps.who.int/gpmb/assets/ annual_report/GPMB_Annual_Report_English.pdf>