Updated: May 15
“Global health governance is not fit for purpose, and it doesn’t represent a vast majority of global needs and wants and desires, and people on the ground and what’s going to affect them. It gets captured.”
Today I sit down with Garrett Brown, professor of global health policy at the University of Leeds. Brown has been working on strengthening health systems in the African context for decades.
“You can talk about rights and freedoms, but none of those matter if you don’t have good health. You can’t exercise any of those things,” he says. “It’s a fundamental part of what it means to be human and have any minimally decent life.”
Brown and his research team were recently hired by the World Health Organization to determine whether its $31.1 billion plan for pandemic preparedness and response was justifiable, or even feasible.
“The worry is that if you’re asking nations to pony up roughly $26 billion, where are they going to find that money? They’re going to find it from existing programs,” says Brown. “Indonesia has just basically suspended their polio program and moved those human resources into vaccines.”
Brown is troubled by the high cost of the WHO’s pandemic plan, which would require resources for basic health to decrease by 34 percent, and basic nutrition by 10 percent.
“We saw this with malaria, tuberculosis, HIV, AIDS, reproductive health—that resources were being shifted from certain national budget lines into pandemic preparedness,” says Brown.
Jan Jekielek: Garrett Brown, such a pleasure to have you on American Thought Leaders.
Garrett Brown: Thank you for having me.
Mr. Jekielek: Garrett, you run a research group at the University of Leeds that provides quite a bit of information to the WHO.
Mr. Brown: Yes.
Mr. Jekielek: In your unique role, you have a view into how this very opaque system operates. Here we are, and we’re going to take a look. But for starters, how did you end up being someone that provides this profound pandemic research information to a group like the WHO?
Mr. Brown: In the early days of the pandemic, I wrote a piece for the BMJ, which is the British Medical Journal, suggesting that we have five paradigm failures in the way we’re thinking about the pandemic. That was read by the head of evidence and analytics at the WHO. He said, “My unit is trying to think of a different way of approaching these things. Would you look over some stuff for me?” I said, “We need to evidence this better.”
He invited me to do that and we provided 343 pieces of evidence for this new framework that was coming out. Then, I just started getting more and more involved in different committees. The more recent work we’ve been doing for them is thinking about financing these massive costs for pandemic preparedness that people are talking about, and the feasibility of actually financing these numbers.
Mr. Jekielek: $31 billion a year was the number that’s been floated, unbelievable in scale. We’re going to definitely talk about this. Before we jump into that, what were these paradigm problems that you saw at the beginning?
Mr. Brown: The first one is the way we think about health security. Instead of thinking about preparedness and prevention, we always talk about preparedness and response. I was saying that there are many things we can do to prevent these things, and not just prepare for them. We can encourage better population health, look at upstream determinants, and think about how to do that with more sophistication.
The main one that I was talking about is what I called the pastorium paradigm. You wait for a pathogen, you sit, and in this case, lockdown, and then you wait for the cure to come. Then, you roll that out to as far as you can to 100 percent and you’re saved. Where are the therapeutics in that?
There are other things you can do to think about this with more of a systems approach to preparedness and prevention, rather than just that model. We would need to start thinking about health systems and how you create more resilient health systems and create more adaptive health systems. It can’t just be this pastorium paradigm, which we ended up doing, and I was quite critical of that.
The WHO got it and said, “We’re working on something. We’re calling it health systems for health security, and we want to think about a more sustainable way of preparing and preventing these types of events.”
Mr. Jekielek: First of all, this is one of the few hopeful things I’ve heard about this system, that they were actually interested in your work and invited you to contribute. The response didn’t seem to go the way you were suggesting, but at least there was interest.
Mr. Brown: Yes. They knew they couldn’t change the course of the way the momentum was heading. This was a long-term project for them thinking about how to strengthen health systems in a way that actually has routine health effects for the average person on a daily basis. It can also cover some of the concerns we have about health security, and not have this 1980s war-like mentality about health security. Let’s talk about population health, and let’s talk about other things like that.
I thought that was refreshing. I’ve been working on health systems and health systems-strengthening in the African context for ages. It’s really dear to me that you need robust systems that can take shocks and do routine health for people to make them healthier, in order for them to be more resilient. More resilient people are more secure. It just makes sense.
Mr. Jekielek: Most recently you’ve been working on providing analysis and research on how to create a $31 billion a year global infrastructure for pandemic preparedness.
Mr. Brown: And response.
Mr. Jekielek: And response, if I understand it. So, $31 billion a year?
Mr. Brown: $31.1 billion is the estimated need for pandemic preparedness response at all national, regional, and global levels. This is what the WHO, the G20 and the World Bank are estimating is the requirement.
Mr. Jekielek: For starters, how is this going to work?
Mr. Brown: Let’s put it in perspective. The total operating budget for the global fund, which is responsible for AIDS, malaria, and tuberculosis, three of the biggest communicable diseases, is around four billion a year. Those are already hard to finance. That is already complicated.
You have these annual replenishment models, and there’s a lot of squabbling about who’s going to pay what. They are already complicated with high transaction costs, because you have to replenish them all the time. Suddenly, you’re talking about $31.1 billion.
Mr. Jekielek: Before we go there, can you give us a sense of where that money comes from?
Mr. Brown: You mean the money for the global fund?
Mr. Jekielek: The global fund of the WHO.
Mr. Brown: A mixture of donors, usually high income countries, the United States, the UK, the Bill & Melinda Gates Foundation. The usual funding sources. Overseas development. Aid for health is what they call it. On an annual basis, the State Department will relinquish a certain amount of money to these institutions.
The leaders at the G7 will commit a replenishment package to the global fund. They are willing to pay a certain amount on an annual basis for the next two years or three years. That’s where the money is generated from. Usually, high income countries pay into this.
Mr. Jekielek: It’s mostly from high income countries, and then also from these large private foundations?
Mr. Brown: At the moment, the big one is the Bill & Melinda Gates Foundation, obviously, but there’s others. The Wellcome Trust has moved from a research organization to a policy organization, and they’re putting money into health.
Mr. Jekielek: All right. Let’s go back. $31 billion is an extraordinary number. Please tell me about this.
Mr. Brown: The $31.1 billion, I’m not quite sure how that cost was calculated. My research team gave some raw material and lots of others gave raw material and then a report was suddenly generated saying that these are what the costs are. One of the questions is whether or not this is really what pandemic preparedness and response should cost, and how we can justify those numbers. But those are the numbers being used.
The idea at the moment is that $4.7 billion is what’s required at the global level in terms of coordinating surveillance and coordinating other mechanisms that they think are necessary. There’s something like 92 indicators called buckets.
At the national level, we’re asking states for their national programs to be aligned with the global programs. That’s going to be about $26 billion a year. The problem with this now is you’re asking low-income countries to pony up this money, and so the donors will have to cover that as well. They’re thinking that at the global level, donors will be required to come up with around $10 billion to $15 billion a year to cover those costs and the global level costs.
Mr. Jekielek: You don’t even know exactly how this $31 billion was reached. There’s different groups that contributed. Now, your job is to try to figure out how to do that.
Mr. Brown: Can we finance that? What are the warring trends around current financing of pandemic preparedness and response? We tracked the official development assistance [ODA] for health. Every year the OECD [Organization for Economic Co-operation and Development] comes out with line items. What are we spending our development aid on? They added one for Covid for 2020, and it was an extraordinary amount of money.
Mr. Jekielek: It’s funny when you say that. They added a line item, but it was big.
Mr. Brown: It was a huge line item. If you start unpacking it, almost all the new development aid money went to Covid or into infectious disease control. A lot of them were Covid-based and a lot of that money went into vaccines. We started to ask, “What are the effects of this?” We saw some staggering numbers.
Basic health is a line item, and basic health fell by 34 percent. You’re shifting money from basic health into pandemic preparedness and response. Basic nutrition fell by 10 percent. Nutritional programs have seen money depleted. We started looking into this further and what about task shifting at the national level? We saw that too.
For example, there’s a study out of Indonesia where Indonesia has just basically suspended their polio program and moved those human resources into vaccines to administer vaccines. We saw this with malaria, tuberculosis, HIV, Aids, and reproductive health.
Those resources were being shifted from certain national budget lines into pandemic preparedness. The worry is that if you’re asking nations to pony up roughly $26 billion, where are they going to find that money? They’re going to find it in existing programs.
Mr. Jekielek: You said this is close to your heart. On the ground in Africa, when you pull 34 percent from basic health and 10 percent from nutrition-
Mr. Brown: It has impacts.
Mr. Jekielek: What are the real world impacts on people?
Mr. Brown: There will just be less resources available to combat malnutrition, and there will be less resources available to strengthen health systems. If you think about some of these health systems, definitely in very remote areas, they have difficulty staffing them because no one wants to live out there. They have difficulty getting materials out there, and they have difficulty keeping the lights on sometimes.
Health is important. You can talk about rights and freedoms, but none of those matter if you don’t have good health. You can’t exercise any of those things. It’s a fundamental part of what it means to be human and have a minimally decent life.
Once you start taking from that, there’s a cascading effect on people’s ability to engage in the economy, people’s ability to engage in their government, and the people’s ability to take care of their children. Then, those have knock-on effects.
So, the number is extraordinary. I do question the number. I’m not saying we shouldn’t have pandemic preparedness. I’m just wondering if it needs to be $31.1 billion a year. My guess is, it doesn’t.
Mr. Jekielek: I don’t know if this is the elephant in the room. I’m sure you’ve thought about this, but the pandemic response, as it happened, was largely poor. That’s an understatement. You have a very subdued academic way of talking about these things. Let’s just say it didn’t work very well.
Mr. Brown: Yes, it didn’t work very well.
Mr. Jekielek: The cost of that was 100 million people descending into poverty among other things, with an upward transfer of wealth. Also, I would argue a lot of death that didn’t need to happen, if there was a smarter way of doing things. Is this being looked at?
Mr. Brown: It is being looked at, but I don’t know if it’s being looked at seriously. There’s a recognition, at least where I live, that the lockdowns didn’t have the effect they wanted them to have. In the end, they were highly costly and not very effective.
There were other externalities that came from it like increase in mental health issues, domestic violence, and increase in children not being educated. Those have effects. We haven’t quite calculated all those yet. One of the numbers I hear batted around is that Covid cost us somewhere between $12 and $20 trillion in stimulus packages and lost GDP [Gross Domestic Product], when you factor everything in.
Mr. Jekielek: When you add up everything.
Mr. Brown: No one has come up with a really good solid number yet, but they’re starting to figure that out, and it’s massive.
Mr. Jekielek: It’s unfathomably massive.
Mr. Brown: Those are opportunity costs, because if you just think, “What if we put $20 trillion into something else? What if we did something else with that money or have that money used in other ways at a more micro-level in an individual’s life?” It would be profound. What did we get for that 20 trillion in the end?
Mr. Jekielek: As a society, and certainly among our leadership and policymakers, we forgot about the idea that everything needs a cost-benefit analysis. What you need to undertake is cost-benefit analysis. The profound positive impact that money could have in different places is also unfathomable.
Mr. Brown: Or the money just staying with you, and not coming to you from somewhere else. Ultimately, this is being paid for by sovereign debt. There are massive opportunity costs with $31.1 billion.
Mr. Jekielek: Quickly, just for the benefit of our audience, please explain what opportunity cost is.
Mr. Brown: What could you do with that money otherwise, and what benefits would you get from that? Everything has an opportunity cost. What could have been the opportunities available to you, if you would have done something else with that money or that time?
Mr. Jekielek: Or just kept going with whatever you were doing in the first place.
Mr. Brown: Yes. There are some major health issues that we should think about at the global level, like antimicrobial resistance. There are things that are spooky out there that we are not very good at coordinating responses to, and that we’re not taking seriously. Because of Covid-19 and because people are angry about what happened and the loss, we are now thinking about pandemic preparedness. There’s a lot of focus on it.
We should be prepared. Of course, we should be thinking about these things. But my worry is that there’s so much focus on that and so much interest on it and we’re moving very, very quickly. The pandemic treaty is moving very, very quickly. The pandemic fund, which already now exists in the World Bank, moved very, very quickly.
Are we thinking these things out in the right way? Are we thinking about the opportunity costs here and are we using the right numbers? Is it even feasible to generate $31.1 billion? The answer is, “No, it’s not feasible.”
Mr. Jekielek: Well, and-
Mr. Brown: It’s not going to happen.
Mr. Jekielek: I’m just going to-
Mr. Brown: Maybe that’s a good thing.
Mr. Jekielek: Right. There was some kind of global coordination with the deployment of these genetic vaccines. There was a strong push, not just in the U.S. and Canada, but everywhere. There was very similar messaging that everybody needs to get the vaccine, when the epidemiology from the beginning clearly didn’t demonstrate that.
Is it a good idea to put so much control for a global response in one place? This pandemic treaty and some of these international health regulations, as I’ve been looking through them and talking to experts, really do push a lot of control.
Mr. Brown: You need to have coordination mechanisms at the global level. To suggest that you can operate solely on a national level in today’s world is a non-starter. We do have to have coordination and that could be good. That could also be bad.
There’s a lot of regional laboratory networks in Africa post-Ebola. Great idea. Not every nation needs to ramp up all their laboratory facilities to the same level and have duplicating systems that are literally a hundred miles away from each other. There’s just a border in the middle.
By networking your laboratories, you increase information flows between them. You also increase your alert system between them and you get economies of scale. At the same time, you don’t have to have all the expertise in every single state. Those types of coordination mechanisms make sense to me.
What doesn’t make sense to me is when you remove context from these debates. In health systems we always say context matters. Context matters. Contextual moderators, meaning how external factors influence the way a health system can operate, are important. You need to understand those.
The only way you can understand those is by understanding the context. We’ve removed that. I’ll just give you one example. The WHO comes out early on and says, “We need to vaccinate 70 percent of Africa. African countries rightfully said, “A, we can’t afford this. B, we’re not sure about this.”
People like myself were saying, “You should not be sure about this, because your mean age is 19. Your context is different from Italy where you have an older unhealthy population. You have a younger, more healthy population, and this may not be right for you.”
That’s a contextual concern that moderates how you roll out any kind of program. We have to keep that in mind when we think about these coordination mechanisms at the global level, while also thinking there’s nothing wrong with having the right kind of international health regulations.
It would have been very good if China sent this material up within 72 hours. It was open source and people could start working on it. They didn’t do that. But that’s what the IHR [International Health Regulations] say, and that makes perfect sense to me. It’s a cheap thing to do. It’s just about thinking more smartly.
They’re also revising the international health regulations. I’ve had a look at them. A lot of it’s the same old stuff. Some of it’s better, some of it’s worse. These debates are taking place. My concern is to make these debates a little bit longer, more nuanced, and more sophisticated, so that we can get to a better answer.
Mr. Jekielek: I don’t know if you want to comment on this or not, but there’s also this reality that certain players like communist China are interested in co-opting such systems for their own benefit, with not a lot of interest in public health. This is a profound national security issue for any nation.
Mr. Brown: Everyone has interests and that’s what politics is—trying to come to some intersubjective agreement through interest. Of course, communist China has their interest, and so does the United States. We saw this with big pharma, and we saw this with other interests. These interests are playing out. They’re aligning their interests where they can. They’re competing.
Early on, the WHO and the World Bank were competing for control of this pandemic fund. Where is it going to be housed? Is it going to be in the global fund? Is it going to be a new FIF in the World Bank? Which it turns out it is going to be. There was a debate there.
Once decisions were made, you see that contestation moves to cooperation or to alignment. Yes, there are interests at all levels. Years ago, there was this argument that we need to depoliticize health. You can’t depoliticize something as political as health, because politics is about who gets what and why.
It’s not that we need to depoliticize it. We need to make better politics, more legitimate and accountable politics. What we have now is poor politics. But you can never depoliticize health. It’s a deeply political issue. It should be, because that’s how you make decisions.
Mr. Jekielek: My concern is that you have players who say they’re going to play by the rules, but they’re absolutely uninterested in doing that.
Mr. Brown: No. Let’s go back to the IHR. Only 47 percent of countries were compliant with it by 2015.
Mr. Jekielek: That’s the International Health Regulations.
Mr. Brown: That’s what they said. You have five years to become compliant by 2015. No one made it. They extended it and it only got to 47 percent. You can have these regulations and think they’re draconian, but it doesn’t mean that people are actually going to follow them. There’s no enforcement mechanism for them.
You can name and shame, and you can make development aid conditional on you meeting those. You can inject money to try to help them do that. You can relieve sovereign debt to free up money for them to do it themselves. There’s different ways to do it. But one of the problems is people aren’t compliant with the rules that are there. China was a bad citizen on this and that should be noted.
Mr. Jekielek: I keep hearing that the treaties have more force of law. As we’re filming here, we just published an article in The Epoch Times last night, talking about how the current U.S. administration hopes to ratify this treaty without the typical two-thirds Senate approval, and that they have a method to do that.
Mr. Brown: I didn’t know that.
Mr. Jekielek: Again, a lot of these accountability questions are coming to mind.
Mr. Brown: I’m not in favor of the treaty and it’s just going to duplicate problems we already have anyway. But yes, a treaty is the highest form of international law you can have. But even so, country’s break treaties all the time.
That may not be the kind of coordination mechanism we need. It’s really a knee-jerk reaction. No one was following the IHRs, and no one was living up to their requirements, and there were bad citizens. China was a bad citizen on this.
We need to elevate it to this extreme level. I’m just wondering if there’s other measures we can do that can get people together for cooperation without having to be a treaty.
Mr. Jekielek: You’ve already explained why you’re not for the treaty, but please expand on this. Is the main reason just because it’s so inherently coercive?