Featured Journal Content
Lancet COVID-19 Commission Statement on the occasion of the 75th session of the UN General Assembly
The Lancet COVID-19 Commissioners, Task Force Chairs, and Commission Secretariat
[Editor’s text bolding in red]
The Lancet COVID-19 Commission was launched on July 9, 2020, to assist governments, civil society, and UN institutions in responding effectively to the COVID-19 pandemic. The Commission aims to offer practical solutions to the four main global challenges posed by the pandemic: suppressing the pandemic by means of pharmaceutical and non-pharmaceutical interventions; overcoming humanitarian emergencies, including poverty, hunger, and mental distress, caused by the pandemic; restructuring public and private finances in the wake of the pandemic; and rebuilding the world economy in an inclusive, resilient, and sustainable way that is aligned with the Sustainable Development Goals (SDGs) and the Paris Climate Agreement. Many creative solutions are already being implemented, and a key aim of the Commission is to accelerate their adoption worldwide.
The origins of COVID-19 and averting zoonotic pandemics
The COVID-19 pandemic is the latest—but certainly not the last—emerging infectious disease, preceded by HIV/AIDS, Nipah, severe acute respiratory syndrome coronavirus, H1N1 influenza, Middle East respiratory syndrome coronavirus, Zika, Ebola, and others. These diseases are zoonoses, resulting from pathogens being transmitted from animals to humans. To protect against zoonoses, we require new precautions, such as ending deforestation and protecting conservation areas and endangered species. The origins of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are yet to be definitively determined, but evidence to date supports the view that SARS-CoV-2 is a naturally occurring virus rather than the result of laboratory creation and release. Research into the origins of SARS-CoV-2 should proceed expeditiously, scientifically, and objectively, unhindered by geopolitical agendas and misinformation.
The urgency of suppressing the pandemic
The COVID-19 epidemic can and should be suppressed through non-pharmaceutical interventions, including effective community health services, that cut transmission of the virus, to be followed by the introduction of effective and safe vaccines as rapidly as science permits. Countries should not rely on herd immunity by natural infection to suppress the epidemic. The disease and death that would accompany natural infection rates to reach herd immunity, typically estimated as 40–60% of the population infected, would be unacceptably high. Uncertainty also remains about the duration of acquired immunity from past infections.
The great divide in the outcomes of the epidemic has been the relative success of the Asia–Pacific region compared with western Europe and the Americas. The Asia–Pacific region has largely suppressed transmission and mortality (less than 10 deaths per million). Western Europe and the Americas have had very high transmission and mortality (several hundred deaths per million in several countries). Many low-income countries have suppressed the epidemic, such as Cambodia, Lao People’s Democratic Republic, and Viet Nam.
To implement non-pharmaceutical interventions, we urge countries to scale up with all urgency their public health workforces, including epidemiologists, public health technicians, nurses, testers, contact tracers, and community health workers. Community health workers can contribute to controlling community spread and protecting vulnerable people in the community, particularly through testing, education on prevention and treatment, and education on the mental health effects of social isolation.
The vexing question of whether to close schools is perhaps the single most challenging non-pharmaceutical intervention. Schools can safely reopen when community transmission is low and school facilities and staff have been appropriately prepared. When it is not safe to open schools, countries and localities should aim to implement online education accessible to all students.
One reason for failure to suppress the epidemic is a style of political leadership that has been called medical populism; Lasco has described political leaders as “simplifying the pandemic by downplaying its impacts or touting easy solutions or treatments, spectacularizing their responses to crisis, forging divisions between the ‘people’ and dangerous ‘others’, and making medical knowledge claims to support the above”. Lasco makes three cases in point: the US President, Donald Trump, the Philippine President, Rodrigo Duterte, and the Brazilian President, Jair Bolsonaro.
We call on governments to prioritise advice from the professional public health community, working in cooperation with international agencies and learning from the best practices of other nations. All countries should combat decisions based on rumour-mongering and misinformation. Leaders should desist from expressing personal viewpoints that are at odds with science.
Addressing the inequities of the epidemic
The COVID-19 pandemic is bringing to light and exacerbating pre-existing social, economic, and political inequalities, including inequalities of wealth, health, wellbeing, social protection, and access to basic needs including food, health care, and schooling. The pandemic is bringing about a sharp increase in income inequality and jobs crises for low-paid workers. Health inequalities also pose major issues in this pandemic; as of December, 2017, half of the world’s population did not have access to essential health services. Vulnerable populations (including the poor, older people, people with previous health conditions, people who are incarcerated, refugees, and Indigenous peoples) are bearing a disproportionate burden of the pandemic.
The abrupt shift to an online economy came in the context of a deep, pre-existing digital divide in high-quality digital access. We call on all relevant UN agencies to take concrete steps with the digital industry and governments to accelerate universal access to digital services, including public–private financing to extend connectivity to hard-to-reach populations.
Among the most urgent challenges of the COVID-19 pandemic are hunger and food insecurity for poor and vulnerable populations. The pandemic also poses great concerns for mental health, especially for lower-income populations, and there is high inequality in the provision of services for mental health, especially in lower-income and middle-income countries. The gender dimensions of COVID-19 must also be prioritised, in recognition of the documented increase in unplanned pregnancies for teenage and young women, and the increase in gender-based violence.
The UN Statistical Commission, working with partner UN institutions and with national statistical agencies, should prepare near-real-time data on highly vulnerable populations and their conditions, with a special focus on infection and death rates, poverty, joblessness, mental health, violence, hunger, forced labour, and other forms of extreme deprivation and abuses of human rights. Urgent surveying should be undertaken to identify humanitarian needs and hunger hotspots, especially among the poor, older people, people living with disabilities, Indigenous peoples, women who are vulnerable, young children, refugees, people who are incarcerated, people working in high-risk jobs (eg, meatpacking plants or guest workers), and other minority populations (including ethnic, racial, and religious minorities).
Meeting the urgent fiscal needs of the developing countries
One of the characteristics of the global crisis is the sharp drop in public revenues at all government levels. The situation for developing countries will become increasingly dire as many countries find themselves facing rising social needs without the means to finance social services. Moreover, many developing countries currently do not have the kinds of social protection programmes that are most urgently needed at this juncture, such as unemployment insurance, income support, and nutrition support.
Some developing countries will require considerable international concessional financing (ie, grants and low-interest, long-term loans) from the international financing institutions, notably the International Monetary Fund, the World Bank, and the multilateral and regional development banks, as well as the orderly restructuring of their sovereign debts to both public and private creditors. Now, more than ever, is the time for countries to meet their commitments to providing 0·7% of gross domestic product as official development aid. Special efforts must be made to fight corruption, to ensure that new aid flows reach the intended beneficiaries.
Global justice in access to safe and effective vaccines, therapeutics, diagnostics, and equipment
The pharmaceutical industry and academic community, supported by governments, have undertaken a remarkable effort to develop new approaches for the suppression of the pandemic, including vaccines, therapeutics, rapid diagnostics, and treatment regimens. The introduction of new vaccines and therapeutics should follow rigorous testing and evaluation through all clinical phases and must not be subject to dangerous political interference.
In the early phases of the COVID-19 pandemic, there have already been breakdowns in the global health governance of vaccine development, even leading to the new term vaccine nationalism. Any new vaccine or therapeutic must be developed and implemented with a view to equitable access across and within countries. No population should be prohibited from accessing a vaccine because of cost or have its access predicated on its participation in clinical trials. We strongly support the multilateral initiative Access to COVID-19 Tools Accelerator to promote the universal, equitable access to COVID-19 vaccines, therapeutics, and other tools, and within that initiative, COVAX Facility, the vaccine pillar. Complementary approaches in support of this multilateral initiative would help to strengthen equitable access across and within countries.
Promoting a jobs-based green recovery
Economic recovery plans should support the transition towards sustainable and inclusive societies based on the SDGs and the Paris Climate Agreement. Public investment should be oriented towards sustainable industries and the digital economy, and should spur complementary private investments. Preventing a wave of bankruptcies among small and medium-sized businesses with viable prospects is an important priority. A major goal of the recovery should be an unprecedented commitment to reskilling and upskilling people, including the skills to prepare workers for the digital economy.
The EU Green Deal, long-term budget (2021–27), and new recovery fund marks an exemplary framework for long-term recovery, including mid-century goals on climate safety, energy transition, and circular economy, with a comprehensive €1·8 trillion budget. This approach can serve as an exemplar for other regions. In general, recoveries should be smart (based on digital technologies), inclusive (targeting lower-income households), and sustainable (featuring investments in clean energy and reduced pollution).
Multilateralism and the UN system
Global recovery will be greatly facilitated by cooperation at the regional and international level, both in controlling the epidemic and in adopting new green recovery programmes. We strongly urge the United States, EU, China, Russia, India, Mercosur, the African Union, the Association of Southeast Asian Nations, the Community of Latin American and Caribbean States, the Caribbean Community, and other nations and regional groupings to put aside rivalries and beggar-thy-neighbour policies (such as trade and financial sanctions) in favour of coordinated regional responses. Trade and financial sanctions, or other isolationist policies, and talk of a new cold war between the United States and China, are dangerous for global recovery and peace.
The COVID-19 pandemic hit during the 75th anniversary year of the UN. The indispensable role of the UN has been evident throughout the course of the pandemic to date, especially for the world’s most vulnerable populations, and yet the UN system is also under attack and international law has been undermined. We strongly support the UN and call on all nations to honour the UN Charter and the Universal Declaration of Human Rights, and to contribute to the efficacy of the UN multilateral system, including through crucial financing of UN institutions. We call on the United States to reverse its decisions to withdraw from the WHO, the Paris Climate Agreement, the UN Educational, Scientific and Cultural Organisation, and the UN Human Rights Council.
We strongly support the unique role of the International Monetary Fund, the World Bank, and multilateral development banks in providing urgent financing and technical assistance for emerging and developing economies. We call on their shareholders to consider scaling up the already unprecedented efforts at securing larger financing for these countries through an increased allocation or more efficient use of special drawing rights, or through debt restructuring when needed. We also urge the more affluent shareholder countries to provide additional concessional resources.
We strongly support the indispensable role of the WHO in controlling the COVID-19 pandemic, and call on all nations to increase, rather than decrease, their funding support and political backing for the work of the WHO at this fraught time. In this regard, we also support the call for an independent analysis of the WHO response, to strengthen the institution and its central, unique role in global public health.
Future work of The Lancet COVID-19 Commission
The Lancet COVID-19 Commission will monitor the global progress in suppressing the pandemic and making an inclusive and sustainable recovery with a new set of metrics that it will regularly publish. The Commission Task Forces will consider in detail many of the complex issues already raised, including the best ways to promote decent jobs and sustainable development. The ten priority actions of the Commission are summarised in panel 1. The next scheduled Statement of the Commission will be in early 2021.
[Panel 1] Ten priority actions
1 Origins: track down the origins of the virus in an open, scientific, and unbiased way not influenced by geopolitical agendas
2 Non-pharmaceutical interventions: suppress the epidemic through the proven package of non-pharmaceutical interventions, as accomplished by several countries including several in the Asia–Pacific region
3 Science-based policy making: base policy making on objective scientific evidence and stop politicians and others in positions of power from subverting clinical trials and other scientific protocols
4 Timely and consistent data: collect and publish timely and internationally consistent data on the state of the pandemic, including humanitarian and economic consequences
5 Justice in access to tools to fight COVID-19: ensure universal access to the tools to fight COVID-19, including test kits, therapeutics, and prospective vaccines
6 Emergency financing: secure access of developing countries to financing from international sources, especially from the International Monetary Fund and World Bank
7 Protect vulnerable groups: direct urgent protection towards vulnerable groups, including older people, people in poverty and hunger, women who are vulnerable, children, people with chronic diseases and disabilities, the homeless, migrants, refugees, Indigenous Peoples, and ethnic and racial minorities
8 Long-term financial reform: prepare for a deep restructuring of global finances, including debt relief, new forms of international financing, and reform of monetary arrangements
9 Green and resilient recovery: economic recovery will be based on public-investment-led growth in green, digital, and inclusive technologies, based on the Sustainable Development Goals
10 Global peace and cooperation: support UN institutions and the UN Charter, resisting any attempts at a new cold war