Contrary to the dominant media narrative, the Biden Administration—and the world—are poised for a historic victory. The White House has led a drive to launch a much-needed new multilateral financing mechanism to pandemic-proof the planet. Advocates have pushed for a bold, international pandemic prevention initiative since the earliest days of COVID-19, reminding the Biden transition team of earlier pushes for a global health security “challenge fund” and the post-Ebola call to action commissioned by the National Academy of Medicine. After more than two-and-a-half years, the new global fund against pandemics was ratified by the World Bank on June 30, 2022, with support from the G20 and more than a billion dollars in seed funding from the United States (Congress!), the European Union, Indonesia, Germany, the United Kingdom, Singapore, the Gates Foundation, and the Wellcome Trust. The President has listened to activist and experts, and this global fund to end all pandemics should be an enormous victory. But without course correction, Joe Biden’s landmark initiative will be built on a faulty foundation and destined to fail, due to the World Bank’s proposed policy choices that are rooted in extremely disturbing racial and colonialist assumptions.
This is the tale of two years of ignored pleas from the people most impacted by COVID, begging policymakers to enact the simple measures long known to stop pandemic disease outbreaks. This is a tale of a global health establishment accepting as inevitable the sickness and deaths of impoverished (usually Black and brown) people, and choosing to stick with expensive strategies COVID has demonstrated ineffective when used in isolation. After 100-plus NGOs spoke out against the World Bank’s plan to exclude poor people from a say in pandemic preparedness, the board of the World Bank Group has proposed to bully onward, only allowing that perhaps civil society and low- and middle-income countries can eventually be invited to the table, possibly only as advisors, and only after the donors have laid down the rules of the game.
We, the authors, are leaders of organizations transforming grassroots anger and grief over COVID-19’s continuing devastation into a health and economic justice movement. One in 300 people in the United States have died. CDC estimates almost 25 million people in America are living with Long COVID disabilities. Health providers are exhausted and demoralized, and essential workers have had their livelihoods upended, while getting punched in the nose for trying to enforce basic public health and civility.
Our fight for recognition and support honors people who should be alive today, but are not. People like Erika’s father George McKibben, one of the first Black teachers in his Clayton, Georgia area school district, who was killed by COVID after a life in which he went from having “KKK” scrawled on his blackboard to becoming the most popular teacher at Jonesboro Junior High School. People like Mark Urquiza, Kristin’s father, a healthy 65-year-old Latino man whose only preexisting condition was trusting Donald Trump. After one million dead, from a pandemic predicted but not prevented, we are demanding a sea change. In this case, we’re winning – but with an asterisk that must be addressed.
The late-June joint World Bank-WHO initiation of a new global fund against pandemics demonstrated that world health leaders are responding to people power, despite the many declarations of “game over” on COVID. Yet the question remains: Will these leaders challenge the internalized racial and colonial biases that threaten Joe Biden’s enormous accomplishment?
Biden’s Golden Opportunity
At the beginning of the pandemic, a former President openly neglected pandemic preparedness, while peddling insults and quack medicine that made a grievous situation colossally worse. Candidate Biden presented a much-needed salve, meeting with health workers, activists, and experts, and running on a refreshingly detailed, comprehensive plan to stop COVID. Marked By Covid’s Kristin Urquiza gave a fiery speech at the Democratic National Convention, hoping to inspire those made hopeless or furious by pandemic neglect to elect a President who was going to do better, and take their pain seriously.
After the election, we all hoped to see the Biden plan enacted, but progress has been slow. Destructive opposition from congressional Republicans has been a major barrier. The Administration bears responsibility for sometimes unclear mitigation messaging and policy, uncoordinated interagency efforts, and haphazard dealings with Congress on pandemic prevention and COVID funding, as well as obsequiousness with vaccine manufacturers. The rush to hang a “Mission Accomplished” banner by some in the Administration while infections, disabilities, viral mutations, hospitalizations, and deaths continue to add to our grief.
Nonetheless, and thanks greatly to President Biden’s leadership, the world is moving, at long last, toward operationalizing a $10 billion per-year funding pool, administered by the World Bank—a sum that, if reached, will go a long way towards ending the current accelerating cycle of deadly diseases. This sum pales in comparison to the economic losses due to COVID-19, estimated by economists at a whopping $16 trillion for Americans alone. In other words, donors could pay $20 billion annually for 800 years before the sum total would equal the cost of one single COVID-19 level event.
The new fund to end the Pandemicene era stands to be as historic and important as America’s widely heralded global AIDS programs, including another previous multilateral program, the Global Fund to Fight AIDS, Tuberculosis and Malaria, as well as the President’s Emergency Plan for AIDS Relief (PEPFAR). President Biden had a role in launching both of these landmark initiatives during his Senate career—as did some of the activists now leading our COVID justice movement. This new initiative that makes the world safer for everyone will be a proud part of President Biden’s legacy—if we can ensure it works.
Unfortunately, the World Bank’s proposal, in its current form, is inherently problematic, with a scope limited by racial and colonial bias that sharply reduces the efficacy of the enterprise. The underlying assumption is as deadly and deeply offensive as the “expert consensus” circa 2000 that treating AIDS in Africa and Haiti was simply impossible. This uninterrogated bias is the same one that permits the leaders of wealthy nations to hoard more vaccines than they need, or to flatly ignore monkeypox until it arrives on whiter, wealthier shores—even when effective vaccines already exist. The casual assumption, then as now, is that poor people are simply not worth the trouble. Activists and experts, including the authors, have plead with officials at the Bank to correct their mistake: We cannot build a wall to keep out the diseases of the poor. We need to prevent pandemics at the source.
For the duration of COVID, we have fought for a multilateral initiative to both stop outbreaks before they happen, and, to also contain them if there is a spillover. For the entirety of the last two-plus years, we have found that the very idea that disease outbreaks could be stopped before they begin has been almost unintelligible to the global health establishment, holding court in policy silos across the Global North. This bias is particularly embedded within the World Bank.
Ron Klain, in these very pages, declared that “Ebola outbreaks are inevitable.” Indeed, every pandemic plan for decades, from the WHO’s international Health Regulations to President Obama’s Global Health Security Agenda has overwhelmingly focused solely on one strategy: stopping the spread of disease, after an outbreak. But in fact, outbreaks are not inevitable, and risk can be sharply and affordably reduced.
Existing models have already proven that preventing spillover is not only possible, but also a critical complement to the often desperate, expensive emergency measures that must be rolled out to stop a new disease from becoming an epidemic. Simple interventions exist to steeply reduce outbreak risk, such as supporting Indigenous communities at tropical rainforest edge to reverse deforestation and stop wildlife (bat) migration. Rather than incorporating measures that bridge health and the environment, policymakers—including those who will determine the scope of work for a new global pandemic fund—cannot imagine a world in which preventable diseases are not killing people in developing countries.
As a result of this ingrained bias, and fed by competition for funding, some in and around the World Bank are therefore advocating for a pandemic fund that only contains outbreaks, rather than also preventing them. This is akin to deciding to send buckets of water to a fire only after it has started, when the other option was to blow out the match.
The myopic expert consensus of the global health security establishment is that preventing zoonotic outbreaks is “out-of-scope,” or “too broad.” Some well-regarded experts have filed a comment with the World Bank, making an unsupported argument that “mitigating the risk and consequence of spillover events… could sap resources from …containment of pandemic threats that will remain inevitable.” (Emphasis added.) To be generous, those making this poorly informed, zero-sum policy choice must be unaware (and incurious) of widely documented, peer-reviewed evidence and examples, such as those in this essay, demonstrating both efficacy and affordability.
Buried shallowly under the surface of the well-intentioned critique is, again, this brutal bias: Poor people just die sometimes. Once nominally examined, this operating assumption starkly reveals a colonial mindset: Global responsibility begins and ends with stopping diseases from escaping poor, Black, brown, and Indigenous communities, where zoonotic spillover hotspots overwhelmingly lie. Like Donald Trump’s wall, a containment-only strategy relies on the erroneous assumption that we can insulate the Global North, letting wealthier nations off with a permission-slip to continue business as usual. Meanwhile the Global South absorbs the consequences.
“We Need a New Thing”
For decades, world leaders have been aware of intensifying pandemic threats, turbocharged by rapid deforestation, and climate change. The G20’s High Level Panel for Pandemic Preparedness and Response reported that, “The current pandemic was not a black swan event. Indeed, it may ultimately be seen as a dress rehearsal… There is every likelihood the next pandemic is coming within a decade or even in the next year, and could be even more profoundly damaging to human health and the global economy than COVID-19.”
In the earliest days of lockdown, activists identified the need to create an enduring way to get funding for pandemic prevention to impoverished nations. We saw, as many have previously, that developing countries need external funding to meet WHO’s International Health Regulations (IHRs)—a legally binding set of rules to report and contain diseases and stop outbreaks from becoming pandemics. We also saw the steep limitations of existing strategies. Countries with the highest “preparedness” rankings, like the United States, suffered the worst outcomes, while nations that followed the rules and reported new variants, like South Africa, were punished with travel bans, instead of receiving support. (Meanwhile, a handful of rich nations stonewalled India and South Africa’s 100-plus nation campaign for a WTO waiver on private drug company monopolies on life-saving vaccines, tests, and therapeutics.)
The incentive structure of the WHO’s IHR standards is inherently skewed: Adherence to the WHO’s important-but-unfunded mandate can (and did) lead to injury to a poor countries’ economies, with flights turned away, little if any financial support, and, at the end of the day, no vaccine intellectual property or technology transfer either. The benefits of the current system substantially flow to countries that are not experiencing an outbreak, while the costs are borne by the country fighting a new disease. Effectively: “Neighbor, let me know if you are in trouble, so I can pull up the drawbridge.”
We also saw the profoundly missing link: the functional defect of trying to stop pandemics, while allowing outbreaks—and misinformation—to proliferate. It is beyond pound-foolish to wait for a disease before taking action—and surveillance is not outbreak prevention. For a new global initiative to be successful, it must include the root-cause environmental changes that are making pandemics come faster and be more destructive.
The Good News
Pandemics are the product of policies. Policies can be changed.
The World Bank’s ratification is an (enormously) good (and enormously overdue) start, demonstrating global consensus, and that the Biden Administration is carrying an important idea toward fruition. Further, even though the World Bank Group’s costing models for the G20 included only containment estimates, the Bank has not opposed spillover prevention as part of the new fund’s scope of work. There is still an opening to counter the prevailing “expert” view that excludes funding to stop outbreaks before they happen.
Evidence is on our side: Deforestation and climate and land-use change are the primary drivers of pandemics, caused overwhelmingly when a pathogen “spills over” from wildlife to humans. Every percentage reduction in wildlife trade and destruction of tropical forest is a reduction in risk of new outbreaks. Scientists have already proven it’s possible to steeply reduce the risk of new outbreaks: Brazil in the recent past has reduced deforestation by 70 percent, with a combination of incentives and enforcement. Communities in Borneo have used modest investments in health care and jobs training to transform rainforest logging communities: $5 million invested over 10 years reduced the number of logging families by 90.6 percent (with a corresponding steep decline in zoonotic spillover risk), alleviated poverty, cut infant mortality by two-thirds, protected endangered species—and conserved $65 million in above-ground carbon, almost 13 time greater than the investment cost. Similar pragmatic, community-based models exist to affordably clean up and regulate wildlife markets, reduce wildlife trade, and support safer livestock husbandry—all of which are powerful steps that can be taken quickly to sharply reduce spillover.
Excluding the Experts
Incoherent aversion to preventing disease outbreaks is not the only challenge. Amplifying this racially and culturally blind insult to efficacy is the World Bank’s almost comically villainous insistence on excluding those disproportionately impacted by pandemics. In an initial white paper, not only did the Bank’s proposed governance structure exclude civil society and low-and middle-income countries from the board of the new pandemic fund, but also, astonishingly, from even directly receiving funding.
The World Bank has nominated itself for three roles: fiscal host, administrative secretariat, and recipient and implementer, initially proposing only to fund itself and other international development banks (while smugly deeming developing countries and civil society ineligible due to “conflicts of interest.”) After widespread NGO uproar, the World Bank announced that the board’s composition “will be discussed over the coming weeks”, and that “The ultimate decisions will be made by the founding donors.” The Bank now assures that a “dedicated processes to capture the voices of Civil Society Organizations” will be put in place, and grudgingly allows, that a few other major multilateral entities will probably be qualified for funding. The Bank will even go so far as to consider that perhaps poor countries could conceivably serve as (potentially only non-voting) board members—pending determination, of course, about whether or not it is a conflict of interest for poor countries to have any say about donor shenanigans within their national borders.
And while the Bank has (perhaps) given an inch on who is at the table, it has not budged at all on who gets paid. Nowhere in the Bank’s calculus will poor countries or communities directly receive funding. The best we can hope for is that the second layer of major multilateral institutions that do get funded may see fit to drop some coin, hopefully moving quickly and with limited overhead.
The World Bank’s pandemic track record is stained, from COVID back to Ebola. This antiquated governance structure has no place in the twenty-first century. People who live at the frontlines of zoonotic spillover, who have invested in and protected their lands for time immemorial, are necessary expert partners needed at the design stage, and must not be relegated to the children’s table as “non-voting members” to avoid “conflicts of interest.”
Two decades ago, a small group of AIDS activists, including one of the authors, challenged the then-widespread expert consensus that AIDS medications were too complicated for Africa. The pharmaceutical industry and the aid-industrial complex parroted nearly identical talking points, alleging that health systems were too weak, and Africa simply lacked the “absorptive capacity” for AIDS treatment. Funded NGOs, elected officials, and pharmaceutical company agents alike unwaveringly criticized us as “naïve” and made zero-sum claims that AIDS treatment was impractical, and would sap resources away from other important aid (typically the service the international NGO was funded to provide). Drug companies went to great lengths to distract from the millions of lives lost because of monopoly prices on medicines the public paid to invent. After all, Andrew Natsios, George W. Bush’s USAID Administrator, told a journalist that Africans “don’t know what Western time is. You have to take these drugs a certain number of hours each day, or they don’t work. Many people in Africa have never seen a clock or a watch their entire lives. And if you say one o’clock in the afternoon, they do not know what you are talking about.”
After countless meetings, marches, protests, and arrests by people living with HIV around the world in 1999, decision-makers finally met our demands. A Presidential Executive Order was signed in 2000, reversing U.S. trade policy that sanctioned countries considering suspending drug company monopolies. The cost of antiretroviral HIV drugs fell rapidly from $10,000 per-patient, per year in developing countries to $350 (now about $75). Campaigns were rapidly spun up to fight for new global health initiatives to pay for the newly affordable medicines, and the Global AIDS Fund and PEPFAR, were launched in 2002 and 2003, respectively. Since then, 29 million people have received life-saving medication as a result.
Senator Biden listened to activists who challenged the white supremacy of expert opinion 20 years ago, when he shepherded both of these programs through his Foreign Relations Committee. Heading into the midterms, the President would do well to apply those lessons to the present. Much like the ACT UP activists before (but immensely more numerous), an army of COVID justice advocates has challenged the intransigent racism underlying policy choices, asking uncomfortable questions in the polite company of the powerful for more than two years. As much as some political figures may want to wish COVID away, “moving on” isn’t going to cut it for the millions of people—voters—grieving and/or disabled by COVID. What has happened will dominate the political landscape for millions of people for years to come. We cannot forget, and we cannot “get over it” until we have won the changes we need to stop the present pandemic, mark what has happened, support the survivors, and stop the sequel. We will loudly share our stories at campaign events and town halls during the midterms and in the presidential primaries ahead. No more families should face the pain and loss we have experienced. We are fighting with allied movements to dismantle the systems that accept the preventable deaths of Black, brown and Indigenous people as status quo at home and internationally.
President Biden has now led a new global effort poised to bring an end to this terrible era of accelerating, intensifying pandemics. Now, as two decades ago, unquestioned racism props up policies that devalue the lives of the poor, and, in this case, could render a bold new initiative a costly flop. Success is dependent on the President stepping up to shift the paradigm once more, and prevent the World Bank’s fatal flaws from denying the promise of Biden’s second global fund.