Time to Create the President’s Emergency Plan for Pandemic Preparedness and Response (PEPPPR)

In 2003, an estimated 3 million people died of HIV/AIDS globally. In May of that year, galvanized by the growing number of preventable deaths given the availability of an effective medicine, the President’s Emergency Plan for AIDS Relief—PEPFAR—was signed into law. According to its website, PEPFAR has invested over $85 billion in the global HIV/AIDS response, saving over 20 million lives, preventing millions of HIV infections, and helping to achieve HIV/AIDS epidemic control in several countries around the world. There is far more to do to fight this pernicious virus globally, but there was clear progress over the last two decades.

This May, as the world surpasses 3.5 million now preventable COVID-19 deaths, it is time for the United States to step up once again. Belatedly, after three weeks of danger signs, the global community acknowledged and reacted to the exponential growth of COVID-19 in India. But India is not the last country that will experience exponential growth in cases; neighboring Nepal is already in the same boat. The cycle repeats closer to home: hospitals in Brazil and Colombia are filling up with cases and we know later another wave of preventable deaths will occur as vaccination efforts lag. The UN has warned of a “rapid and accelerating” wave of coronavirus and shortages of tests and oxygen in Syria, and—given the near absence of health infrastructure after years of war—the outcomes will be catastrophic. In many countries, the factors that led to the Indian surge—government complacency, low levels of immunity, and mass gatherings—are just as present.

A global plan with a global response is needed, and the US can and should lead such an endeavor. This is not business-as-usual; the response to COVID-19 is the global issue that matters most in the next several years – a health, humanitarian, and economic catastrophe.

A cursory review of the international scene clearly demonstrates the lack of a global strategy and the coordinated implementation that will be necessary to immunize the world, minimize further spread, and resume global trade and commerce. The cost of this delay is in the trillions; according to the Economist, $10 trillion in foregone GDP over 2020-2021. Yet the pooled effort to buy and distribute vaccines, diagnostics, and therapeutics—ACT-A—continues to be underfunded, despite resource requirements well below Americans’ annual spending on cosmetics, to give one comparator offered by the WHO. Vaccines originating from the US and other high-income countries are safe and highly efficacious, but less than 10 percent of the population in lower-middle and low-income countries have been vaccinated. Trust in the global system to distribute with equity is at an all-time low. When the limited quantities of COVAX-purchased vaccine finally arrive, too many countries are not prepared to administer doses efficiently resulting in waste or last-minute logistical juggling. Some countries must manage multiple vaccine candidates to complicate the effort. Even in upper middle-income countries (and indeed high-income nations as well), governments have not taken the necessary measures to purchase sufficient vaccine and plan and pay for immunization roll-out. The US—which is making rapid progress on its own vaccination efforts—should spend a modest amount now to support countries around the world to get this done or pay more later in the form of endless emergency requests.

A President’s Emergency Plan for Pandemic Preparedness and Response (PEPPPR) could save lives around the world while protecting Americans from the emergence of COVID-19 variants and other pandemic-potential pathogens that could put hard-won US gains at risk. A dedicated bilateral initiative would also boost global growth with positive impact for the US economy as well. Like PEPFAR, PEPPPR requires a clear strategy to curb the global pandemic with specific goals, outcomes, and quantitative time-bound benchmarks for progress. The effort is not just about money but about dealing with supply constraints and delivery of vaccine and other countermeasures so, like PEPFAR, PEPPPR should enable an on-the-ground response without which even adequate vaccine supply is insufficient. Like PEPFAR, effective US policy requires working across US government agencies and using the full portfolio of US multilateral engagement to leverage other funders and drive progress. PEPPPR could today for example help to vaccinate whole urban areas with high-efficacy vaccines via intense military and humanitarian cooperation and with close to full financing for local costs from partner countries, starting in places where variants are beginning to spread rapidly. A PEPPPR via COVAX could provide indemnity protection that will enable rapid adoption and delivery of the portfolio of effective vaccines without countries having to put their national assets at stake.

A PEPPPR would provide a robust response—adequate and long-term procurement and deployment of vaccine and other medical countermeasures—to those who advocate patent waivers on valuable new vaccine mRNA technologies as a strategy to end the pandemic. And a PEPPPR can get going on vaccine donation and sharing plans at scale while also pushing aggressively on voluntary licensing, technology transfer, and clearer demand trajectories that will incentivize a larger, more disseminated, and efficient global production of vaccines.

A PEPPPR could build in preparedness for the next pandemic or biological threat as its implementation evolves by supporting partner countries and regional and global agencies in setting and implementing clear standards for disease and mortality surveillance, public domain reporting, and timely detection and response to outbreaks, antibiotic resistance, and existing infectious disease threats.

The initiative could bring the benefits of centralized leadership with a single coordinator, empowered via an operational structure and budgetary directives that enable a real inter-agency response.

The US should start with ambitious funding to ACT-A, including but not limited to COVAX. I suggest ambitious funding proportional to the economic costs of the pandemic at home and abroad and a level of effort for a threat similar in significance to global terrorism. For example, $20 billion to immediately put other donors on notice and win the geopolitical messaging battle with China and Russia on vaccines, and an additional $25 billion to be deployed through USG and multilateral partners to pursue measurable progress on vaccination delivery and surveillance, all to be tracked and documented in the public domain.

ACT-A overall requires an additional $27 billion. Researchers at the World Bank and IMF have estimated that COVAX alone requires an additional $4 billion to reach 60 percent coverage while those at Duke University have estimate that 70 percent vaccination coverage in low- and middle-income countries will cost US$74 billion (range $57-$113). We will need to understand how estimates can vary so widely and thereby generate a clearer figure of evolving needs. 

And with the G7 at hand, we will need to see our allies like the UK increase and not cut their support to the fight against COVID-19 and preparedness for the next pandemic. US contributions must be met with other funder responses, and a multilateral financing mechanism can include specific shared financing rules as suggested here. Former UK Prime Minister Gordon Brown has called for $60 billion in aid from the G7 that meets in June, and recent commentary suggests that G7 partners are waiting for leadership from the US.

The US has a short window of opportunity to regain trust and drive rather than react to the ongoing COVID-19 mass casualty event. For an ambitious agenda, the Administration and Congress should work together to authorize new monies, not as aid, but as a vital national security investment, building on the bipartisan-supported domestic biosecurity investments included in the infrastructure bill.