Looking to the future: the need for a conceptual Framework for Biological Risk Prevention and Epidemic Impact Mitigation, the 2PF (Pandemic Preparation Framework)
Pandemics and epidemics will undoubtedly return in the current century. All the conditions for increased circulation of individuals, goods, climate change, contact with wildlife and devastation of ecosystems previously untouched by humans are currently gathered and will worsen in the predictable horizon. The latter conditions are estimated to generate around 60–70% of new diseases and epidemics (34). Therefore, we must prepare so that the Public Health catastrophe of COVID-19 will not be repeated.
Much can be done without relevant effort if the lessons of COVID-19 and the accumulated experience of decades in the surveillance and mitigation of effects caused by natural risks are considered. Therefore, we propose the creation of a Framework for Approaching Biological Risk with Pandemic Danger – the Pandemic Preparation Framework (2PF).
With the 2PF, we propose a way of dealing with future epidemics/pandemics that can at least partially address the difficulties and problems of the seven weaknesses in Western countries health response during the COVID-19 crisis, as summarized above.
Four Principles support 2PF (Fig. 1):
Pandemics and major epidemics are overcome in the Prevention phase.
When it is no longer possible to maintain either situation with very high certainty in the Preventive phase, there must be a Planning and Preparation phase for concrete risk.
Proactive response to the pandemic when it is already installed on the field.
The identification, prevention, planning of preparation and combating a Pandemic or major Epidemic can only be successful through total International Cooperation.
The strategic idea is that the coordination of the response to an epidemic/pandemic must be essentially achieved at a supranational level, through adequate prior preparation and based on knowledge management. The need for this paradigm shift was recently addressed at the European Union level, with the regulation entity proposal entitled “European Health Emergency Preparedness and Response Authority” (HERA) (35). However, with emerging diseases having the potential of becoming a global threat, a more global approach was reinforced by the signature of a Global Pandemic Preparedness Treaty by 24 world leaders and the WHO (36).
During the Twentieth century, the world has progressed from national to supranational entities whenever the Common Good is to the parties' advantage, of which the ultimate example will be the United Nations (UN). Countries have also learned that major crises are faced by cooperation and have created mechanisms for that purpose within supranational organizations. In an increasingly globalized world where everything tends to occur almost simultaneously, only international solutions based on cooperation will be able to respond to major issues since what affects a country can quickly become a global threat. Therefore, it is in the direct interest of all nations to participate in the elimination or mitigation of a risk in any country in the world. For example, since 2005, with the signing of the UN Hyogo Framework (37) for response actions to disasters, and later with the Sendai Framework for Disaster Risk Reduction (38), global targets were defined towards reducing disaster consequences such as: mortality, affected people, economic loss in GDP, infrastructural damage and service disruption, national/local risk reduction strategies, international cooperation, availability and access to multi-hazard warning systems.
The COVID-19 pandemic has shown beyond a reasonable doubt that the capacity to control a pandemic is something that goes beyond the national dimension, as declared by many politicians (39) and scientists (32). Only through the highest international cooperation is it possible to find appropriate solutions, supply equipment volumes at an adequate time and acceptable prices, with universal standards and applicability, and exchange experiences to debug national procedures.
International cooperation in a pandemic state has immense scope for progression in all fields (40). The degrading spectacle of government officials re-directing clinical equipment at airports should not be acceptable (41). Many national strategies have sought only to concentrate the maximum level of resources with those who can afford them. For example, in the case of worldwide vaccine distribution there is the need of international agreement on its optimal and adequate allocation instead of being focused in profits (42) and realpolitik (43). International authority is needed to ensure resources go to areas where they can be globally most useful and effective in combating the pandemic (44).
The absolute need for knowledge management was verified, proving to be the central element for an adequate fight against the pandemic. This element can only be appropriately developed in a wide-ranging, fully internationalized way and with the greatest transparency.
Finally, it should not happen again that the strengthening of local response capacities through international means is minimal and appears as an insufficiency of the local political response. In the COVID-19 pandemic, the international reinforcements that existed were vestigial (44, 45) concerning the means deployed in each country and always with difficulties articulating with the local structures that led to situations in which even the smallest help made available was not used: language, local procedures and other complexities (45). Only the creation of automatisms can change this framework for the integration of Health Services.
The tactical-operational idea is that national/local actions must be part of an articulated whole composed of three dimensions: Prevention, Planning and Preparedness, Proactive response to the pandemic. This means that there must also be a high level of international operational cooperation, presenting the great challenge of requiring mutual knowledge and preparation work.
Things as simple as consolidating new positive cases or the lethality of a disease among countries can, in practice, be an impossibility when each country works in its own way. Consistency in case definitions and ascertainment is needed, for example, to secure cross border intelligence and enable accurate inter-country comparisons.
With the ongoing COVID-19 pandemic threat, it must not be forgotten that there are other biological threats still emerging, as seen recently with avian influenza (H5N8) in Russia (46) and the African Swine Fever in Poland (47). These examples and other situations have been mainly dealt with by the national structures in which the threat emerges, a context that, despite being local, may reach the planetary scale if not controlled and for which there is little to no international response. It is important to note that every nation has a responsibility in preventing and reducing disaster risk, surpassing the national-level interventions, including cooperation with other nations and regions (48). Following this approach, reacting promptly to a threat requires having previously allocated, trained, certified resources in sufficient quantity and the capacity to travel to another part of the planet, if accepted and allowed, to immediately integrate the national structures in an environment of full informational transparency.
Pandemic preparedness investment is beyond almost all countries' capabilities, which greatly reinforces the need to be thought out globally. The WHO is the organization naturally dedicated to having these global competencies. However, to be able to address this issue, it is essential to have a great reinforcement of human, financial and technological resources. In Western countries, the main Cooperation Bodies are the WHO, ECDC and CDC/FEMA, which also need to have their skills and resources strengthened to be able to deal proactively and appropriately with the epidemic/pandemic risk.