The G20’s High Level Independent Panel (HLIP) on pandemic preparedness convened through 2025 to provide a report entitled Closing the Deal: Financing our Security Against Pandemic Threats to the November G20 Leaders’ Summit in South Africa. The report was as a follow-up to the HLIP’s 2022 report on A Global Deal for our Pandemic Age where the panel outlined their financial estimates for pandemic preparedness and response (PPPR). In the face of funding cuts for development assistance for health (DAH), the 2025 report was intended to reiterate the necessity of its financial request and to increase the pressure on all countries to allocate more public money to save humanity from the scourge of pandemics. As noted by the HLIP:
“pandemic risks continue to rise – fuelled by our connected world, zoonotic spillover, humanitarian crises, and the increasing likelihood of both accidental and deliberate threats. Outbreaks emerge ever more frequently…” (HLIP, p. 9).
Indeed, it would seem a good cause, but a recent report from REPPARE at the University of Leeds finds quite the opposite. The problem with the statement, as we summarize in the report and here, is simply that it is disconnected from the world in which the G20 operates. Policy, at least good policy, must be based on reality.
The Risk of Pandemics
A “connected world” indeed allows certain pathogens to spread more quickly, but with no real difference in expected outcome. New variants of influenza and other respiratory viruses have routinely spread across the world for well over a century – not necessarily a new problem. Global integration also ensures that these viruses avoid landing upon large populations with complete lack of immunity. In other words, the catastrophes of measles and smallpox in the time of colonization of the Americas, Australia, or the Pacific Islands will not recur, at least not due to natural outbreaks.
Put simply, the big killers of the past will remain in the past. We have good yellow fever vaccines, smallpox is eradicated, we know how to avoid cholera, and antibiotics address bubonic plague and typhus as they would have also prevented most Spanish flu deaths. None of this is seriously challenged, with the greatest risk of reemergence due to either a major lack of access to known measures or from anti-microbial resistant strains driven largely by the inappropriate use of medicines. Will a new pathogen arise from natural spillover to cause a sudden, catastrophic global outbreak? SARs-CoV-2, the worst in a hundred years, was mainly a threat to the unwell elderly, and its origins look increasingly uncertain.
Will they arise from a laboratory? Perhaps, but that is another story with a very different prevention strategy. A strategy completely ignored in the 2022 HLIP report on financing PPPR and with just a brief mention in its latest 2025 report (perhaps a weak, but newfound acceptance of laboratory escape risks).
These days we ‘see’ outbreaks like MERS, SARS, avian flu, Nipah virus, and Zika because we can detect them. Before 1980, we simply did not have the major methods to do this – namely, PCR tests, genetic sequencing, point of care antigen, and serology tests. However, this oversight is almost undoubtedly the main basis for a rapid (or “exponential”) increase in reported outbreaks (particularly in the mid-1980s after the invention of PCR) that drives the international pandemic agenda. It explains why this increase first happened in industrialised countries and only later in those that were technologically less developed. Not just the G20’s high level panel, but reports from the World Health Organization and the World Bank ignore this reality in order to improve their chances of getting funding for PPPR from countries.
It is also possible to produce frightening estimates of the average number of people dying from pandemics each year – such as 2.5 million (twice total tuberculosis deaths). A US-based company, Ginkgo Bioworks, has done this as discussed elsewhere, and the G20 HLIP relies on this assessment in their report. This average mortality is achieved by including Medieval pandemics such as the Black Death and other outbreaks from the time when science advocated that a rose be hung under the nose as the best preventative measure. While other aspects of public health science have moved on, modelling has not. Most people can see the flaw in suggestions that the Black Death – passed by rat fleas in the absence of basic antibiotics and in unhygienic cramped environments – could happen again tomorrow.
The problem with this modelling is that by including an ancient disease that killed a third of the population at the time, it will boost averages and significantly skew the results. Even the first three years of Covid-19, based on reports to the WHO, did not reach this average level. Yet, such assumptions based on unrepresentative historical accounts are driving advice to our governments.
The Cost of Pandemics
The HLIP considers Covid-19 to have cost $13.8 trillion (or $700 billion per year). With this sort of costing, almost any conceivable cost in preparation and prevention seems worthwhile. This may be more persuasive to governments than mortality, but such costing assumes the response was effective and would be repeated the next time.
The $13.8 trillion costing thus assumes that the next time an outbreak occurs with an infection fatality rate around 0.15% (similar to influenza) and an average age of death in many countries of over 80 years, we would close most workplaces, shut small businesses down, close schools in which children are at near zero risk of dying, and stop most international travel and tourism. And then our governments would print trillions of dollars for support and compensation programs.
The G20 panel assumes this, even though there is very good systematic analysis indicating that the lockdown measures had almost no influence on mortality. Countries such as Sweden that did not impose such measures, or were far less restrictive, had similar mortality outcomes. However, increased poverty, reduced healthcare access, domestic violence, substance abuse, poor mental health, education loss, and increased child marriage arising inevitably from these responses will have long-term consequences for health and equality.
So how does any of this really make sense? On a yearly basis, the 1968-69 influenza pandemic had a similar mortality rate, in a younger age group, and instead of near-global lockdowns we had Woodstock. Lockdown was previously a term applied in detection facilities for criminals and specifically argued against by the WHO as counterproductive to overall health and well-being. To use it at scale in the general population during Covid-19 was unprecedented, and if it did not help much then there is, of course, no reason to do it again. This assumes of course, that these evidentiary insights would be taken on board by our policy makers, which is looking not to be the case.
Does the Funding Model Make Sense?
The reason for the new HLIP report to the G20 was the tardy response to the requests for PPPR financing to date. Despite efforts to convince countries to allocate $31.1 billion for pandemics and another $10+ billion on related One Health initiatives, financing has lagged behind rhetoric. The HLIP proposes an allocation of 0.1 to 0.2% of Gross Domestic Income (GDP) from each country allocated to PPPR, and another 0.5 – 1% of their military budgets.
It is unusual for public health bodies to provide recommendations on how countries allocate their military budgets, and this does raise questions as to how such funding will be allocated, and whether public health priorities will be the deciding factor rather than military ones. Together with the suggested allocation based on GDP, however, it also raises a greater concern.
In addition, the negative implications from reallocating 0.1 to 0.2% of domestic GDP for pandemic preparedness are manifold. First, committing these funds to PPPR will divert scarce resources from known health priorities, especially impacting upon low resource countries who already struggle to provide health services. Second, it promotes a ‘one-size-fits-all’ model, even though countries have distinct health needs (disease burdens) and contextual determinants of health (average population age, poverty level, environment, sanitation levels, etc).
Examples here are useful. In the Democratic Republic of Congo (DRC), more than 60,000 children die every year from malaria – all preventable if good access to existing and low-cost methods of diagnosis and treatment can be provided. Malnutrition reduces resilience of its 106 million people against a range of diseases, and life expectancy at birth is 62 years and GDP per person about US$1,650. This is a big improvement from 25 years ago, and fragile, with endemic infectious diseases still being the leading cause of death. Life expectancy of Norway’s 5,5 million people is 21 years longer, and GDP is over 84,000 per person. To suggest that the people of the DRC should divert resources from the known determinants of longer life and join in a Western-driven effort to improve readiness of Pharma for rare pandemics that predominantly impact the aged is not an approach derived from accepted public health principles.
Moreover, there is a concern about fostering tighter links between the military and health, which arguably will further promote the securitization of health. As is often argued in the academic literature, securitization tends to overhyped threats and drive scarce resources to specific security concerns at the expense of wider population health needs. It also highly favours biomedical and commodity-based approaches to health, creating a siloed effect that neglects endemic diseases and upstream drivers of poor health.
Lastly, as alluded to above, a key shortcoming of both HLIP reports is the fact that there is absolutely no separation between the direct costs of pandemic response (hospitalization, medical equipment, therapeutics, etc) and the indirect costs of the Covid-19 response (lost earnings, welfare provisions, stimulus packages, lost GDP, etc). As a result, the $13.8 trillion cost of pandemics estimated by HLIP considers that all these costs were absolute necessities for any future pandemic response, without a hint of reflection about how most of these costs were self-inflicted, unnecessary, and often counterproductive.
Same As It Ever Was
This second HLIP report is unfortunate in that it will undoubtedly have an impact on government resource allocation in international public health, while failing to meet the basic criteria that should be necessary for such decisions. It uses metrics for risk that fail to consider such basic issues as societal changes since the Middle Ages and the invention of modern diagnostic tools and communications. It mentions such issues as increased human movement only in the context of risk, ignoring the modern absence of large immune-naive populations. It costs future pandemics based on direct and indirect costs of a Covid-19 response that was vastly more expensive than prior approaches without clear benefit in disease reduction. Lastly, it ignores the problem of many populations having vastly greater health burdens to deal with that will undoubtedly suffer from the diversion of resources to the PPPR approach that the HLIP advocates. It is not acute outbreaks that drive inequality in health outcomes, and PPPR will therefore not meaningfully address them.
The world needs an approach to pandemics and outbreaks embedded in broad public health and societal priorities. International public health was intended to improve equity and reduce inequality, recognizing the diverse needs of populations to do so. There was a time when the aspirations of Alma Ata, of addressing primary care and the core determinants of well-being, drove public health. If the nations of the G20 seek a more stable and resilient world, a simple step of returning its public health approach to evidence and reality could be a step forward.
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