REPPARE Progress: September 2024

The REPPARE project is just over the midway point. This document outlines progress made and some of the key impacts it has had so far. We have broken down the update into key categories. 

The REPPARE Team

In addition to two Co-Principal Investigators (Dr Bell and Prof Brown), REPPARE has a full-time post-doc level researcher (Dr Tacheva) and full-time PhD (von Agris) working at the University of Leeds, with formal collaboration with the University of Ghent, including a full-time post-doc (Dr Ketels), and part-time Professor as a Co-Investigator (Prof Annemans) specializing in disease burden. Further international collaboration partners include a post-doctoral researcher (Dr Bridge) providing technical research support, a post-doctoral researcher providing support on understanding pandemic disease burdens (Dr Kaskirbayeva), and expert research support on network analysis (Dr Fonsecea).

In addition, REPPARE is collaborating with several researchers and research organizations to advance our general findings and engage in policy debates. This includes communication and infographic support from Research Retold, information, systematic review, and data analysis support (Dr Natalie King), and targeted research inputs from partner academics (Dr Van Dinh; Dr Paul; Dr Williams; Dr Dolea).

Research and Outputs to Date

Examining the Strength of the PPPR Evidence Base

REPPARE initially prioritized deep reviews of the underlying evidence for the proposed pandemic instruments of the WHO and their urgency (henceforth the PPPR agenda). This initial work: (1) investigated the evidence base of key WHO, World Bank, and G20 documents and cited references supporting this PPPR agenda, and (2) provided robust academic appraisals of stated estimates regarding pandemic risk and PPPR financing requirements. This resulted in the publication and dissemination of three extended reports:

1. Rational policy over panic: A report on zoonosis spill-over risk assessments in pandemic preparedness and response policy (2024): https://essl.leeds.ac.uk/downloads/download/228/rational-policy-over-panic
2. The cost of pandemic preparedness: An examination of costings and the financial requests in support of the pandemic prevention, preparedness and response agenda’ (2024): https://essl.leeds.ac.uk/downloads/download/234/the-cost-of-pandemic-preparedness-an-examination-of-costings-and-the-financial-requests-in-support-of-the-pandemic-prevention-preparedness-and-response-agenda
3. When models and reality clash: A review of predictions of epidemic and pandemic mortality. Report submitted to the New Zealand Royal Commission on Lessons from COVID-19. To be made publicly assessable once discussed within the commission. 

These reports demonstrated a very weak evidence base regarding pandemic risk assessments and costings, with major cited references being misinterpreted and misrepresented in key documents, and a re-analysis of key PPPR cited references leading to quite different conclusions than the published policy documents. Our reports were used as the basis for two policy briefs, which we believe have had impact within policy circles and on the ongoing negotiations involved with PPPR (See below).

The research associated with these reports has resulted in three academic publications:

1. Urgent pandemic messaging of WHO, World Bank, and G20 is inconsistent with their evidence base, Global Policy (2024): https://doi.org/10.1111/1758-5899.13390.
2. An investment just too good to be true: Assessing the official return-on-investment estimates for pandemic prevention, preparedness, and response, Health Economics, under review.
3. The Devil’s in the Detail: An Appraisal of the Use of Innovative Financing Mechanisms for Pandemic Prevention, Preparedness and Response, Globalization and Health, under review.

The research has also contributed to two additional academic publications on PPPR:

1. Challenges in international health financing and implications for the new pandemic fund. Global Health 19, 97 (2024). https://doi.org/10.1186/s12992-023-00999-6.
2. How feasible is it to mobilize $31 billion a year for pandemic preparedness and response? An economic growth modelling analysis Globalization and Health (2024): https://globalizationandhealth.biomedcentral.com/articles/10.1186/s12992-024-01058-4.

Understanding Whether the Right Lessons Have Been Learned from Covid-19

REPPARE examined several emerging PPPR policies to assess what lessons they purport to have learned from Covid and whether these are defendable lessons from a public health perspective. This included: (1) a comparative study of WHO guidance on non-pharmaceutical interventions (NPIs) pre- and post Covid-19. This analysis revealed a normalization of NPIs introduced during Covid-19 in the post-Covid recommendations.

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These include recommendations for the increased use of masks for any outbreak threat, a new definition of pandemic emergency, encouragement for new governmental regulations, controls against ‘infodemics’ and misinformation, and recommendations for ‘equity’ measures to assure more rapid procurement of pharmaceutical products; (2) collaborative input to examine and contextualize recent declarations for increased Mpox vaccine manufacturing as a response to the outbreak, and; examination of ‘Disease X’ and its use at the World Economic Forum to promote additional spending on PPPR with a particular focus on vaccine strategies. The research resulted in the following academic publications:

1. WHO’s pandemic response recommendations after COVID-19: Lessons learned or learnings lost?, Critical Public Health, Revise and resubmit, under 2^nd review.
2. Monkey See Monkey Do: Why an Overemphasis on Vaccines for Mpox Skewes Important Lessons from COVID-19, International Journal of Infectious Diseases, under review.
3. The World Economic Forum and the deus ex machina of Disease-X. International Health Policies (2024): https://www.internationalhealthpolicies.org/featured-article/the-world-economic-forum-and-the-deus-ex-machina-of-disease-x/.

Pandemic and Comparative Disease Burdens – What Is the Risk and How Do We Prioritize Global Health Resources?

We are at the end stages of a systematic review of all studies calculating the disease burden of the Covid-19 outbreak. This is critical for subsequent work on understanding the relative burdens of outbreaks vs other health priorities. The review has included over 2,000 articles. The analysis will focus on methodological challenges in calculating pandemic/Covid disease burdens, the policy implications of weak/incomplete estimates for pandemic burdens, and comparative pandemic burden in relation to three major communicable and three major non-communicable diseases.

The results will be published in three to four academic articles, which will present how Covid-19 disease burdens have been calculated, methodological strengths and weaknesses of the various ways disease burden has been calculated, and the need for an alternative approach to understanding pandemic disease burdens (signaling our next phase of research where we will fill this gap). A policy-focused article will also be written to inform policy makers of the limitations involved with current estimates, methods, and evidence-base. This work is being led by the Ghent team with heavy involvement of Brown and Bell.

In related work, REPPARE is undertaking a thorough review of the University of Washington IHME/Lancet Global Burden of Disease (GBD) estimates for Covid-19 mortality and burden. Through screening several hundred pages of background methods and results, it has become clear that the numbers produced through this globally-recognized collaboration on disease burden are highly unreliable, being based on a series of assumptions and modeling drivers that are contrary to much current literature. Due to the nature of the GBD – recognized as the world’s leading estimates for disease burden – and the critical nature of the results to other REPPARE outputs, REPPARE is diverting significant time to understanding the methodology used and will publish a detailed analysis when this is complete.

Ongoing Research

REPPARE continues to conduct research on zoonosis risk, PPPR financing, and disease burdens. However, REPPARE has just launched new research on PPPR governance with the aim to generate a series of recommendations for rethinking its role in global health governance and policy. This work is crucial, since there is no current research that thoroughly examines and responds to emerging trends in PPPR. Our work includes the following research streams:

1. A mapping of all post-Covid PPPR institutions and policies. Currently there is no authoritative resource outlining the post-Covid PPPR architectural landscape and emerging policies. Our research aims to identify the key organizations involved with PPPR, the new policies that have emerged from these processes, and to analyze what implications and power considerations are involved. This research will include major actors such as the WHO, World Bank, and GAVI, but will also consider non-governmental actors such as Gates, CSOs, NGOs, and corporate entities. A key focus of this research stream is to design frameworks to understand the key conceptual underpinnings in which these organizations reflect (intentionally or not) and the political dynamics driving PPPR. 
2. Analysis of pandemic definitions and the new political processes for declaring pandemic emergencies PHEIC. This research is critical to interpreting the WHO instruments and on what thresholds pandemics are declared. The preliminary research suggests that conceptual contestation regarding how to define a pandemic render it a case-by-case process where contextual factors require flexibilities in approach. As a result, the absence of technical fixes suggests a refocus on the political process (WHO PHEIC) and its current strengths and weaknesses as found in the literature. The research aims to problematize and update PHIEC processes to expose major areas of concern when it comes to how a pandemic is declared and with what epistemic authority.
3. Analysis of comparative disease burdens between pandemics and Covid-19, and other endemic and non-communicable diseases, as discussed above.
4. Analysis to better understand the legal implications and formal relationship between the new International Health Regulations and any future Pandemic Agreement. This research focuses on ‘legal standing’ in terms of international law and compliance, while examining historical power differentials in terms of who is likely to be agenda setters, agenda followers, and who will be coerced to comply via financial conditionalities associated with PPPR.
5. Analysis of the multilayered and complex PPPR policies that have been generated post-Covid at the WHO. The analysis will focus on how these policies are meant to intersect as a ‘holistic’ vision of PPPR and with what implications for global health policy and outcomes.
6. Analysis of the multilayered and complex set of PPPR polities that have been generated post-Covid within the UN system. This includes a mapping of key organizational players (UNDP, UNSC, UNICEF) and their policies, focusing on how these policies have been created, by whom, and with what implications for global health.
7. Given the above, our aim is to produce a series of practical and realistic policy recommendations to help assure that PPPR plays a proportionate and sensible role in global public health. These recommendations will focus on enhancing global level accountability, scientific deliberation, political legitimacy, effective and efficient health outcomes, and human-centered health. 

We foresee that this research stream will produce a significant number of academic outputs as well as reports.

Policy Engagement, Advocacy, and Impact

To facilitate the effective communication of our research to non-experts and policymakers, REPPARE produced two tailored policy briefs and a bespoke report for key stakeholders and media outlets:

1. The Cost of Pandemic Preparedness: Unclear and unaffordable? 
2. Rational Policy Over Panic: The evidence base of the pandemic preparedness agenda does not support the current urgency
3. When models and reality clash: A review of predictions of epidemic and pandemic mortality.

These materials have been disseminated widely and have accompanied presentations given to various stakeholders since the launch of REPPARE. This has included the following:

1. Multiple oral, written, and visual presentations to the UK Parliament All Party Parliamentary Group (APPG) to inform the UK Parliament debate on the WHO instruments. REPPARE was also requested by the APPG to prepare some questions to be asked in Parliament in early 2024.
2. A three-hour presentation and Q&A session in Geneva with 28 Member States on the International Negotiating Body (INB) for the Pandemic Agreement. REPPARE was one of two expert groups invited to speak in this session.
3. A one-hour presentation in Geneva to the Ambassador to Brazil who chairs the INB Article 20 Subcommittee on pandemic financing. Brazil was opposed to key aspects of the Pandemic Agreement and used REPPARE risk assessments to challenge dominant narratives in the INB.
4. A series of consultations with the Canadian government on pandemic risk and financing. REPPARE was requested to provide material on why the INB should delay a vote on the Pandemic Agreement.
5. A two-hour presentation and Q&A session with the UK Department of Health and Social Care (DHSC) on pandemic risk, preparedness, and finance. REPPARE was asked to review their 2025 Global Health Strategy document.
6. Presentation to the UK FCDO, Wellcome Trust and other organizatIons at the Royal United Services, Institute, London.
7. Presentations of findings to the UK All Party Parliamentary Group on Pandemics, and the Democratic Unionist Party weekly parliamentary caucus.
8. Presentation to press conferences and public meetings in Australia and New Zealand on invitation of the Aligned Council of Australia and New Zealand RealityCheck Radio
9. Submitted evidentiary report to the New Zealand Royal Commission on Lessons from COVID-19.
10. A one-hour consultation with the Indonesian government on pandemic risk and costs to inform their INB negotiations. They adopted REPPARE’s recommendation to delay a vote on the Pandemic Agreement.
11. A series of consultations with the INB Head of the African Group on the Pandemic Agreement. They used REPPARE’s costing report to reject the World Bank as the official Coordination Mechanism and to question the associated PPPR costs for African states.
12. Weekly consultations with the Co-Chair of the INB. She was interested in our findings and their implications for African Member States.
13. Consultation with the INB delegate for Zambia. She adopted REPPARE’s recommendation to delay the vote on the Pandemic Agreement.
14. Evidence material provided to The Telegraph (UK newspaper) for an article on inflated estimates of pandemic risk.
15. Evidence material provided to The Wall Street Journal (US newspaper) for an article on inflated estimates of pandemic risk.
16. Evidence and interview material provided to The Daily Mail (UK newspaper) for an article on whether we’ve learned the wrong lessons from Covid-19 and what mistakes are being made in current policies.
17. Geneva session held with 12 INB Member States on the Article 20 Subcommittee (financing). The subcommittee agreed that the cost estimates for PPPR are unreliable and seemingly inflated. They requested additional evidence in written form, which was provided.
18. Initial findings were also related to the WHO and private consultants working on costings and an investment case for the new International Pathogen Surveillance Network (a new WHO post-Covid PPPR platform). They were receptive to concerns raised about cost/risk assumptions in the investment case and agreed that horizontal returns on investment (routine day-to-day system strengthening) were likely more demonstrable than returns on pandemic risks/costs. They have invited REPARRE to input into their conceptual framework and strategy in early 2025.
19. REPPARE sat on a panel of non-governmental organizations in Geneva to discuss concerns about pandemic financing and the financialization of health. This was attended by 12 media outlets and 20 NGOs, resulting in quotations in a number of online articles (International Health Policy, Geneva Health Files, and WEMOS).
20. Evidence and presentation provided to the STEG-HI WHO committee on ‘The Future of Surveillance.’ Our findings had no effect on the report’s outcome, but it did generate a dynamic debate within the committee.
21. Presentation to the UK Foreign Commonwealth and Development Office (FCDO) on pandemic preparedness, risk, and resource implications. Aspects of REPPARE’s costing report were cited in their analysis.
22. Consultation with the South African INB delegate on PPPR implications for East and Southern Africa. Focused on inflated risk assessments, poor return on investment predictions, and opportunity costs. Unsure whether this resulted in South Africa’s ‘redlining’ certain articles within the Pandemic Agreement.
23. Currently Planned: Presentation of findings at ICS meetings in Japan (Sept 2024) and at the African Bar Association annual conference in Zambia, October 2024.

Next Stages

REPPARE is the only academic research collaboration dedicated to unpacking, examining, and challenging the emerging PPPR agenda. The lexicon is dominated by the usual suspects who have encouraged the mindset that ‘more is better’ without serious reflection on what is being asked, for whom, and at what cost.

In this context, REPPARE sees the next three to five years as crucial for how the PPPR evolves and the level of influence it will have. The Pandemic Agreement vote is not dead, merely postponed until before May 2025, and there is still a need for reliable evidence and insights to inform that debate. 

Moreover, new organizations have already emerged, such as the International Pathogen Surveillance Network, the Pandemic Fund, and the Medical Countermeasures Platform. In all cases, these institutions are now making their investment cases, defining their remits, and seeking to enlarge their jurisdictions. In all cases, REPPARE has found that these considerations are based on poor evidence, faulty logics, and a small handful of epistemic authorities.

Furthermore, there are now an unknown number of new policies and guidelines for PPPR, including the amended IHRs, 100 Days to Vaccines, and Managing Epidemics. These have been designed quickly by established institutions eager to carve out a space within this emerging agenda, such as GAVI, CEPI, WHO, Global Fund, several UN agencies, G7, G8, and, more recently, by multisectoral actors keen to make climate change and pandemic preparedness policies synonymous. Each organization, and department within those organizations, is trying to ‘put their stamp’ on PPPR and own a piece of the pie. Yet, many of these policies remain underdefined, including very basic issues such as what constitutes a ‘pandemic emergency,’ an ‘infodemic,’ and One Health. This provides opportunities for the agenda to be captured by those that have the means to do so.

Thanks to the generous funding from Brownstone REPPARE will continue to monitor, map, analyze, and respond to these developments in real time. REPPARE has made quick strides to influence policymakers and stakeholders with evidence of impact, especially on delaying the Pandemic Agreement. The next year will be a continuation of these research and advocacy efforts in an attempt to breathe rationality and fit-for-purpose public health considerations into these discussions.