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,
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
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.
Ten priority actions
Origins: track down the origins of the virus in an open, scientific, and unbiased
way not influenced by geopolitical agendas
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
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
Timely and consistent data: collect and publish timely and internationally consistent
data on the state of the pandemic, including humanitarian and economic consequences
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
Emergency financing: secure access of developing countries to financing from international
sources, especially from the International Monetary Fund and World Bank
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
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
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
Global peace and cooperation: support UN institutions and the UN Charter, resisting
any attempts at a new cold war
The Lancet COVID-19 Commission was launched on July 9, 2020, to assist governments,
civil society, and the 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 caused by the pandemic, including
poverty, hunger, and mental distress; 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.2, 3 Many creative solutions are already being implemented,
and a key aim of the Commission is to accelerate their adoption worldwide. A glossary
of key terms for this Commission Statement can be found in the appendix (pp 1–8).
This initial Statement of the Commission marks the occasion of the opening of the
75th Session of the UN General Assembly on Sept 15, 2020.
Section 1: the origins of COVID-19 and averting zoonotic pandemics
1. 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 the transmission of pathogens from animal
populations to humans.
Such diseases also result from the recombination of the pathogen's genetic materials
within animal populations, as in the case of H1N1 and probably severe acute respiratory
syndrome coronavirus 2 (SARS-CoV-2). These zoonotic events are becoming more frequent,
probably because of the rising intensity of contact between humans and animal reservoirs,
as the result of deforestation,
land degradation, poverty, food insecurity, and the uncontrolled encroachment of humans
into new habitats.
2. To protect humanity from these zoonotic diseases, we need to put more emphasis
on the One Health approach.
We require new precautions on many fronts: ending deforestation, respecting and protecting
conservation areas and endangered species, intensifying the monitoring and surveillance
for zoonotic events, and ensuring safe practices in the animal trade,
meat production, and markets.
3. The origins of SARS-CoV-2, the virus that causes the COVID-19 disease, are yet
to be definitively determined, but the evidence to date supports the view that SARS-CoV-2
is a naturally occurring virus rather than the result of laboratory creation and release.
The possibility of laboratory involvement in the origins of the pandemic should be
examined with scientific rigour and thoroughness, and with open scientific collaboration.
It is extremely important that the research into the origins of SARS-CoV-2 should
proceed expeditiously, and in a scientific and objective way that is unhindered by
geopolitical agendas and misinformation. The origins of the virus must be understood,
both to help end the current pandemic and to prevent the next one.
Baseless and uninformed allegations and conspiracy theories that are unbacked by evidence
are detrimental to this cause.
Section 2: the urgency of suppressing the pandemic
4. The COVID-19 pandemic can be suppressed through non-pharmaceutical interventions
(NPIs) that reduce the transmission of the virus, which should be followed by the
introduction of effective and safe vaccines as rapidly as scientific advances permit.
The core strategy of the world community should be to introduce a comprehensive set
of NPIs in every country, provide urgent financial and humanitarian support during
the pandemic, hasten the introduction of one or more effective vaccines on a globally
equitable basis, and build back better, both in terms of pandemic preparedness and
more generally in terms of sustainable development. Countries should prioritise prevention
through NPIs and vaccines as soon as they are available, because the prevention of
illness is always vastly less expensive and burdensome than treatment.
5. As of Aug 30, 2020, there had been more than 850 000 deaths and 25 000 000 confirmed
infections due to COVID-19.
The actual numbers of deaths and infections are likely to be far higher; despite some
progress, testing is still relatively low in most countries, and actual case numbers
are likely to be substantially underestimated. In many countries and regions with
the requisite data, excess deaths during 2020 compared with earlier years are far
higher than are confirmed COVID-19 deaths.
Moreover, serological (ie, antibody) tests that show past exposure to the virus indicate
that the actual number of infections has been many times higher than the infections
confirmed by testing by polymerase chain reaction.
6. The burden of disease is far higher than deaths alone, as COVID-19 is increasingly
understood to cause a number of chronic ailments and disabilities (eg, cardiovascular,
neurological, pulmonary, and psychiatric illnesses).12, 13 In addition, the pandemic
has unleashed a secondary crisis by disrupting the supply and demand for health services.
Experts project an additional 1·4 million tuberculosis deaths during 2020–25,
up to 673 000 HIV deaths in Africa in 2020,
the possibility of an additional 1·2 million deaths of children younger than 5 years,
an additional 56 700 maternal deaths in a 6-month period,
and 80 million children at risk of vaccine preventable diseases because of disruptions
caused by the pandemic.
Further, a WHO survey
of 155 countries on the effect of COVID-19 on the prevention and treatment of non-communicable
diseases showed that health services have been disrupted, particularly for hypertension,
diabetes, cancer, and cardiovascular emergencies.
7. In addition to addressing the SARS-CoV-2 virus itself, countries must respond to
the mental health consequences of the pandemic, which are considerable and expected
to persist. Rates of anxiety and depression are rising, and in the United States there
is evidence of high levels of psychological distress and loneliness.
Recent surveys, including in Belgium,
and the United States,
reveal elevated levels and symptoms of depression and anxiety, along with substance
abuse and suicidal ideation. Furthermore, COVID-19 appears to cause depression and
cognitive disturbances (sometimes referred to as “brain fog”) of unknown duration.
8. The economic effects of this pandemic are unprecedented. 90% of countries are in
recession in 2020, possibly exceeding the economic downturn during the Great Depression
in the 1930s. The decline in work hours in the second quarter of 2020 was equivalent
to 300 million full-time workers.
Remittance income, crucial to many low-income countries in Africa (eg, Ghana, Kenya,
Nigeria, South Sudan), Central and South America (eg, El Salvador, Guatemala), and
Asia (eg, Philippines), is expected to plummet by 20%.
Hunger is rising, with dire forecasts that at least an additional 83 million people—and
up to 132 million people—might experience extreme hunger in 2020.
COVID-19 could push at least 71 million people into extreme poverty (ie, living on
less than US$1·90 a day), assuming no change in in-country inequality.27, 28 Additionally,
a 1% increase in the Gini coefficient of each country would translate into an extra
19 million people falling into extreme poverty.
9. Uncontrolled epidemics come to an end when a sufficiently high proportion of the
population has become infected, assuming that a bout of infection confers acquired
immunity against a subsequent infection. At that threshold, known as herd immunity,
new infections no longer set off a chain reaction. For COVID-19, most studies have
put the threshold to reach herd immunity at 40–60% of the population.
If the acquired immunity from a past infection is lost over time, in months or years,
herd immunity would also be time-limited.
10. Countries should not rely on the development of herd immunity to suppress the
epidemic. The amount of disease and death that would accompany infection of 40–60%
of the population would be unacceptably high, as would be the strain on health systems.
With 7·8 billion people in the world, herd immunity would imply 3–5 billion people
becoming infected, with many millions dead. Even if one country were to reach herd
immunity, the pandemic would still be spreading elsewhere, thereby disrupting trade,
travel, and supply chains of all countries.
11. With 25 million confirmed infections globally (as of Aug 30, 2020), confirmed
cases to date are just 0·3% of the world population, far below herd immunity. Even
if confirmed cases would constitute just a tenth of the actual infections (assuming
that a high proportion of infections have not been tested), the global infection rate
would be 3% of the world population. Seroprevalence studies that estimate the proportion
of people infected by screening the population for antibodies confirm that rates of
infection to date are rarely close to the herd immunity threshold, even in hard-hit
countries such as Spain, where seroprevalence in early May was determined to be around
12. The infection fatality rate (IFR) of COVID-19 is the proportion of infections
that result in death from COVID-19. The IFR is different from the case fatality rate
(CFR), which is the proportion of confirmed (ie, tested) cases that result in death.
The CFR is much higher than the IFR, because the IFR includes in the denominator all
infections, including mild and asymptomatic infections that are never tested and do
not cause death. The CFR is observed in practice and the IFR is determined either
by imputing the number of unconfirmed infections or through ex-post serological studies.
13. Both the IFR and CFR are specific to location because they depend on factors such
as distribution of the population by age,
pre-existing health conditions, access to hospital facilities, and possibly other
factors (eg, ambient air pollution,
nutrition). The IFR of COVID-19 is generally estimated to be in the range of 0·5–1·0%
but to be very low for younger populations (about 3 deaths per 100 000 for people
aged 0–19, 4 deaths per 10 000 for people aged 20–49, and 6 deaths per 1000 for people
aged 50–69), and much higher for older people (5 deaths per 100 for people older than
We note that reaching herd immunity at the low estimate of 40% of the world population
and with IFR at its lower bound of 0·5% would still lead to a staggering 15·6 million
deaths (based on a world population of 7·8 billion).
14. The high CFRs that have been measured in the United States and western Europe
generally result from older populations, scarcity of intensive care units (ICUs) during
peak infection rates, inadequate protection of care centres for older people, and
relatively higher rates of ambient air pollution in hard-hit regions, such as northern
Italy compared with southern Italy.
15. Identifying the dominant modes of COVID-19 transmission is an urgent public health
priority. There is growing consensus from the aerosol science and infectious disease
communities that aerosol inhalation is a key contributor to COVID-19 transmission.
The US Centers for Disease Control and Prevention (CDC) and WHO have widely communicated
a narrowed scope of possible transmission routes, limited to large droplets expelled
by coughs and sneezes, and contact with contaminated surfaces. However, this notion
is based on an incorrect assumption that 5 μm particles settle out of the air within
2 m (6 ft). Basic aerosol physics shows that people shed an entire continuum of particles
when they cough, sneeze, breathe, or talk. Some of these are very large particles
that do settle out of the air quickly because of gravity (influencing the 2 m [6 ft]
distancing rule), but the vast majority are smaller particles that stay aloft for
between 30 min and several hours, and travel beyond 2 m (6 ft). Mitigating airborne
transmission is especially crucial for reducing the risk of superspreader events.
These events appear to occur mainly or exclusively indoors, although large outdoor
events are often preceded or followed by indoor crowds at bars, pubs, and restaurants.
16. The evidence argues for a greater emphasis on building-level controls to reduce
the risk of airborne transmission in indoor environments. More generally, a much better
understanding of indoor environments and buildings is crucial to making decisions
about when people can return to work, school, or other public spaces. Proper conditions
indoors have the potential to reduce the spread of COVID-19; conversely, improper
conditions, such as limited ventilation and filtration, can make indoor environments
17. Suppressing the epidemic means that the number of active cases declines over time.
Conceptually, the effective reproduction number, designated R, for a given population
(eg, city, nation, world) signifies the average number of infections resulting from
an infectious case. When R is 1, the number of active cases in the population tends
to be stable: each infectious individual passes along an average of one new infection.
When R is less than 1, the number of active cases in the population declines. When
R is greater than 1, the number of active cases rises. On a conceptual level, suppression
of the epidemic requires keeping R below 1 on a sustained basis.
18. Epidemiologists report daily estimates of R by country or subregion. These estimates
are useful for assessing the direction of change of the epidemic, and yet we also
note several limitations. Most importantly, R measures the change of the epidemic,
not the rate of transmission, which is better measured by incidence: the number of
new cases per million population per day. When R is 1, the number of active cases
is unchanging from day to day, but that could be in the context of low incidence (few
new infections per million per day) or high incidence (many new infections per million
per day). Moreover, all estimates of R are fraught with error because they are based
on confirmed (ie, tested) cases, not actual infections, which are a much larger number
including asymptomatic and mild infections that are not confirmed by tests.
19. In the figure, we compare the dynamics of COVID-19 for the month of August, 2020,
across 91 countries with sufficient data. We report four measurements of the pandemic.
The first measurement is incidence: the number of newly confirmed cases per million
population per day, averaged over the 31 days of August. The second is the mortality
rate, measured as the deaths per million per day, averaged over the same period. The
third indicator is the number of COVID-19 tests done in August relative to the number
of new cases in August, which functions as a proxy measure for the scale of testing.
Because each new confirmed case potentially has dozens of close contacts (eg, family
members, workplace colleagues, shopkeepers), the number of tests per case should be
in the dozens (or higher). It should be noted that the WHO testing guidelines refer
to a related measure, the positivity rate (ie, the proportion of tests that come back
positive), which they recommend should be less than 10%. A low number of tests indicates
an inadequate scale of contact tracing. The fourth measurement is the average effective
reproduction rate, which is the effective reproduction number averaged over the month,
indicating whether the epidemic was rising or falling.
20. The countries in the figure are classified according to the number of new cases
per day per million population, because this is the most straightforward measure of
rate of transmission of the virus. We classify a country as being in suppression if
there are 5 or fewer new cases per million population per day (in August), provided
that the rate of testing is ample, which we define here as at least 20 tests per new
case. We classify a country as having low transmission if there are 10 or fewer new
cases per million population per day but the country is not in suppression. We classify
a country as having moderate transmission with 10–50 new cases per million per day.
High transmission is 50–100 new cases per million per day, and very high transmission
is 100 or more new cases per million population per day.
21. 19 places achieved suppression in August: Taiwan, Province of China; Thailand;
Viet Nam; Lao People's Democratic Republic; Cambodia; China; Myanmar; Malaysia; New
Zealand; Uganda; Togo; Pakistan; Latvia; Luxembourg; Uruguay; Republic of Korea; Finland;
Cuba; and Rwanda (figure
). We note that ten of the 19 are in the Asia–Pacific region, the highest performing
region globally. 11 countries incurred very high transmission: Bolivia; Spain; Kuwait;
the United States; Argentina; Israel; Brazil; Bahrain; Colombia; Panama; and Maldives
(figure). We note that six of the 11 countries are in the Americas.
The COVID-19 pandemic in August, 2020, selected measures
ERR=effective reproductive rate. *Data presented reflect an average for the period
Aug 1–31, 2020; the complete COVID-19 dataset is a collection of the COVID-19 data
maintained by Our World in Data, which is updated daily and includes data on confirmed
cases, deaths, and testing, as well as other variables; data on the effective reproductive
rate are from Marioli and colleagues
and can be accessed on the Tracking R platform.
22. The difference across countries in the rate of transmission of the virus is stark
and remarkable, ranging from less than one new case per million population per day
to several hundred new cases per million population per day. This enormous range underscores
that countries with high or very high rates of transmission are failing to undertake
sufficient NPIs to control the pandemic. The pandemic can be controlled, as shown
clearly by the countries that have largely suppressed it.
23. As shown in the second column of the figure, countries also differ enormously
according to the mortality rate, measured as new COVID-19 deaths per million population
per day during August. Note that deaths per million is the product of (cases per million) × (deaths
per case). Countries have high mortality rates when they have high rates of transmission
of the virus (cases per million) and when they have high CFRs (deaths per case). As
already noted, high CFRs result from several structural factors, including a high
proportion of older people (aged ≥70 years) in the population, insufficient protection
of care centres for older people from infection, a low number of ICU beds per population,
poor treatment protocols and health-care coverage (eg, late diagnosis and treatment),
high prevalence of pre-existing health conditions (eg, high blood pressure, pulmonary
disease, diabetes), and contributing environmental factors (eg, high rates of air
24. Mortality rates vary by two orders of magnitude, from zero or near-zero deaths
per million per day in the countries in suppression, to more than one death per million
per day in the very high transmission countries (figure). To translate these numbers,
the US death rate in August of 3·0 deaths per million per day signifies around 1000
deaths per day, and the Brazil death rate of 4·4 deaths per million per day signifies
around 900 deaths per day.
25. The third column of the figure, reporting tests per new case, shows that most
countries with high and very high transmission have very low levels of testing (with
<20 tests per new case or even <10 tests per new case). This low level of testing
is both cause and effect. Insufficient testing and tracing lead to high disease transmission,
and high transmission overwhelms the limited capacity of testing and tracing.
26. The fourth column of the figure shows the direction of the epidemic. Even countries
in suppression (ie, ≤5 cases per million per day) are vulnerable to new outbreaks,
as indicated when R is greater than 1. At every level of transmission, from suppression
to very high, there are some countries with transmission falling (R<1) and some with
transmission rising (R>1).
27. 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, with most
of the rest of the world somewhere in between. The Asia–Pacific region has largely
suppressed the epidemic or at least kept it to very low levels and low mortality rates
(less than 10 deaths per million). Western Europe and the Americas have had very high
spread of the epidemic and, in many cases, very high mortality rates (several hundred
deaths per million). There are notable exceptions within each region. In western Europe,
four of the five Nordic countries (all but Sweden) did relatively well in suppressing
transmission and mortality rates of the virus. In the Americas, Canada outperformed
the United States, and Uruguay and Paraguay outperformed their neighbouring countries.
28. We note that data limitations continue to hamper the proper measurement, and hence
control, of the pandemic. All data on cases, deaths, tests, and R are fraught with
errors in measurement, including under-testing and under-reporting, and different
and changing definitions of COVID-19 deaths. Comparisons of testing data and serological
(ie, antibody) surveys show that most cases of COVID-19, and notably cases that are
asymptomatic or mild, are undermeasured and under-reported. Comparisons of reported
COVID-19 deaths and excess mortality in a country during the same period compared
with previous years imply that many COVID-19 deaths are not being reported as such.
For all of these reasons, we emphasise the urgent need for improved and intensified
data collection, more extensive testing in general, and coherence across countries
in the science-based metrics of COVID-19 cases, deaths, and other epidemiological
parameters (including behavioural parameters such as face mask wearing, physical distancing,
contact tracing, isolation and quarantining, and other relevant data). We also note
that politicians might aim to subvert transparent data reporting to suppress information
on the extent of the epidemic or deaths due to COVID-19, and such efforts should be
Section 3: pathways to successful implementation of NPIs
29. The successful outcomes to date in suppressing the epidemic have been achieved
by implementing a combination of NPIs that are designed to keep infectious individuals
from spreading the infection to others in the population. Key NPIs are described in
. These include actions by individuals (eg, wearing face masks, hand washing, physical
distancing, avoiding large gatherings, and self-isolating in case of symptoms), by
businesses (eg, ensuring safe workplaces with distancing of customers, protection
of staff, better building ventilation and filtration, and monitoring for symptoms),
and by governments (eg, testing individuals according to symptoms or close contacts
with confirmed cases, quarantining in public facilities when self-quarantine or self-isolation
is not feasible, ensuring safe working conditions for health workers and others including
adequate personal protective equipment [PPE] and reasonable working hours, establishing
restrictions on international arrivals, moving education online when necessary, and
banning large gatherings and events). In many cases, public health measures have been
reinforced by mandatory regulations, restrictions, and lockdowns. An understanding
of what influences individual behaviour and what the appropriate interventions are
can help deliver more successful outcomes with or without mandatory regulations.
Key non-pharmaceutical intervention checklist
Personal hygiene (eg, hand washing and covering sneezes and coughs)
Physical distancing (ie, spacing)
Banning large public events (eg, sports, arts and entertainment, and religion)
Special protection of populations who are vulnerable in terms of health (eg, older
people and people with comorbid conditions)
Special protection of populations who are socially vulnerable (eg, children, people
who are poor, people with disabilities, refugees, minorities, and Indigenous peoples)
Special protection of congregate settings (eg, care centres for older people, nursing
homes, prisons, worker hostels, and refugee camps)
Testing (ie, rapid, comprehensive, and free, with follow-up on tracing and isolation)
Quarantine and isolation at home when that environment is safe, and in public facilities
when the home environment is inadequate
Social support for those in isolation
Safe public transport
Safe international travel (ie, bans and quarantines)
Social protection (in terms of hunger, income, unemployment, and mental health)
Public awareness, trust, and appropriate risk communication
Community leadership and community health workers
30. Taken as a whole, NPIs offer a package of measures that have proven sufficient
to keep R below 1 while enabling the economy to function at a moderate level, albeit
with the ongoing closure of some facilities and events and with reduced travel. The
effective and timely implementation of NPIs also avoids excessive burdens on hospitals
and other health facilities, and it enables continuity in the treatment of non-COVID-19
diseases. It is important to note that there are also effective mental health and
social support interventions to preserve wellbeing, and that in countries where wellbeing
stays relatively high, adoption of NPIs is greater.
31. In addition to NPIs to suppress transmission of the virus, special measures should
be taken to protect vulnerable populations (eg, older people, people with previous
chronic health conditions, people who are homeless, people who are incarcerated, frontline
workers, refugees, migrant labourers). Among these measures, special attention should
be given to preventing the spread of the virus in congregate residential settings,
such as care centres for older people, prisons, refugee camps, detention centres,
and worker hostels. Special support services should be directed to protect older people,
people who are homeless, people living with disabilities, people with existing chronic
health conditions, Indigenous peoples, and ethnic and racial minorities. These services
should also be directed to people affected by increased rates of domestic violence
and child abuse during the lockdowns.
32. NPIs should respect human rights and human dignity. Restrictions to human liberty
should be limited, transitory, proportional, and clearly justified. The pandemic should
not be an excuse for oppression, xenophobia, mass incarceration, or the mistreatment
of migrants and minorities. One way to support this ideal is to include communities,
Indigenous peoples, non-governmental organisations (NGOs), civil society organisations,
faith-based organisations, and other stakeholders in the processes to design and implement
NPIs. This initiative has the added benefit of building bridges between these groups
and public health organisations, academia, and the private sector, increasing community
solidarity, and building trust to respond to future health threats. A key initiative
that helped the Republic of Korea to contain COVID-19 transmission was engagement
with local governments, which were involved in testing and care.
33. We note with satisfaction that many low-income countries have achieved sustained
successes by deploying the NPI package to suppress the epidemic. Notable examples
include Cambodia, Lao People's Democratic Republic, and Viet Nam, which had some recent
experience in dealing with the severe acute respiratory syndrome epidemic, and Uganda,
which has had extensive experience with the AIDS epidemic.39, 40 In these four countries,
cumulative death rates have been held below one per million, compared, for instance,
with more than 570 per million (as of Sept 2, 2020) in the United States. Effective
public health implementation of NPIs requires rigorous management, professionalism,
and social trust, rather than high budgetary outlays.
34. To implement NPIs effectively, countries should with urgency scale up their public
health workforces, including epidemiologists, public health technicians, nurses, testers,
contact tracers, and community health workers, to implement the package of NPIs efficiently,
quickly, and with maximum coverage.
This scale-up might entail considerable reallocation of public spending, but we maintain
that public health is the best investment for suppressing the pandemic and laying
the foundation for sustainable development. New cadres of public health workers can
be trained online, and can also carry out many of their functions online. WHO and
other relevant UN agencies should intensify their work with national and local governments
to implement urgently needed curricula, training materials in local languages, online
courses, and other needs for rapid scale-up. Countries should further reaffirm their
commitments to primary health care, as made in the Declarations of Alma-Ata (1978)
and Astana (2018).
35. We urge special support for community health workers working within community
health services as the key interface between the community and health facilities.
Community health workers promote essential trust, local context, culturally sensitive
interventions, and essential public health information for the community. Community
health workers can contribute to controlling community spread and protecting vulnerable
people, particularly through testing, education on prevention, and treatment. They
can also address the mental health effects of social isolation. Community health workers
are especially important for the successful implementation of behavioural changes
in communities, for the trust needed to implement NPIs, and eventually for the high
uptake of effective vaccines. Examples of effective and rapid scaling up of community
health worker response can be observed in western Kenya, where 200 000 people in one
district were covered by these efforts.
36. Because of the importance of community health services in prevention and medical
intervention, all countries, particularly low-income countries, need to establish
functioning community health services. To support this process during this COVID-19
emergency, we encourage the setting up of a global fund for integrated primary health
care much like the Global Fund to Fight AIDS, Tuberculosis and Malaria, which facilitated
a global response for meeting specific needs.
37. Broad lockdowns of the economy, as were implemented by the government in many
countries, are emergency measures that are necessary when the pandemic is raging out
of control with very high rates of incidence and when R is greater than 1.
In such an urgent context, the shutdown of workplaces other than essential operations
causes a rapid decline in transmission and brings R down substantially. Yet the period
of the lockdowns must be used efficiently to scale up longer-term NPIs that are key
to keeping R below 1, even after lockdown is lifted. Many countries engaged in periods
of lockdown but undertook insufficient efforts to instate necessary NPIs. As a result,
when the lockdown was lifted, R soared above 1 again, and the epidemic reverted to
its exponential upwards path. Insights from behavioural science can provide tools
for communication with citizens, to encourage people to adopt safe behaviours during
and after lockdowns, and for governments to feel more confident in implementing them.
38. Government responses should be firmly grounded in a human rights perspective.
Although lockdowns and similar measures are necessary, they must also be legal, proportional,
temporary, and subject to judicial and parliamentary review. Parliaments should have
a key role in ensuring that the voice of the people is heard and considered when designing
public policy. Parliaments everywhere must be encouraged and supported to ensure that
people's human rights are upheld and addressed when responding to the pandemic and
when designing post-pandemic recovery plans.
39. The assurance of safe schooling is one of the most challenging NPIs.
Reopening schools should be prioritised over reopening less essential activities.
Safety permitting, there is a strong case for on-site education rather than online
education. Schools provide food, safety, nurturance, sociality, cognitive development,
and education, resources permitting.
Student accountability and engagement are considerable concerns in remote learning
environments. Additionally, it is more difficult for teachers to assess student learning,
progress, and growth in the absence of in-person learning. On-site schooling and childcare
also enable working parents to do their own work activities with their children presumably
in safe hands. The risks of long-term school closures are tremendous.
40. There is currently limited evidence of widespread viral transmission within schools;
evidence on their role in community spread is mixed. Within schools, there are examples
of school-wide outbreaks when schools have opened during high levels of community
spread and have not implemented strong risk reduction measures (eg, no face mask wearing,
overcrowding, no ventilation). Other schools have stayed open without incident when
stringent risk reduction measures were in place. As for their role in community spread,
there is some suggestive evidence that school closures might have a role in reducing
R, although studies have not been able to disentangle the effect of school closures
from other interventions that occur simultaneously, such as more widespread NPIs and
closures of other businesses. Opening schools when the epidemic in an area is not
under control is unadvisable, as it is likely to be a short-lived policy, followed
by rapid closure of facilities if many children and teachers are quickly infected.
Teachers might also refuse to work unless assured of workplace safety.
41. A Science Magazine report
on schooling and COVID-19 in July, 2020, described ongoing uncertainty, but summarised
the situation as follows: in areas where the epidemic is under control and schools
take proper precautions (eg, physical distancing, small class sizes, face mask wearing,
good indoor air quality), there is evidence that schools can safely reopen. In places
where community transmission of the virus remains high, students and staff are more
likely to bring COVID-19 into their classrooms. A prudent course of action is for
schools to open when two conditions are met: low community spread and effective implementation
of school-specific NPIs.
42. When it is not safe to have children in school, all countries and localities should
aim to implement distance learning, particularly through online education, or e-education.
UN agencies, led by the UN Educational, Scientific and Cultural Organisation (UNESCO),
UNICEF, and the International Telecommunication Union (ITU), should intensify cooperation
with telecommunications industry and funding organisations, including the World Bank,
to ensure universal access to online digital technologies for schools and students
43. Therefore, plans to open schools should be a priority once community transmission
is under control, based on the incidence of cases, R, test positivity, and adequate
overall testing with rapid results, to support the accurate measurement of these metrics.
School facilities must also follow preventive measures, particularly social distancing,
small class sizes, and mandatory face mask wearing. Some countries, such as the Netherlands,
have successfully reopened schools with the proper precautions once transmission rates
44. A focus on safe air travel is extremely important. Airplanes are known vectors
of disease, efficiently transporting infectious individuals across the globe and within
countries. During the early stages of a pandemic, minimising air travel between regions
can slow the introduction of cases to new areas. Within the airplane cabin, disease
spread is limited by the environmental control system on airplanes, which provide
localised ventilation and high-efficiency filtration, although sporadic cases have
been reported. A challenge in ascertaining where a person was infected is that air
travel nearly always includes other exposure locations (eg, subways and buses, time
in airport, time in hotels) that cannot be separated from time on the airplane. Airlines
and airports must implement and coordinate risk reduction strategies, including managing
queues efficiently to avoid overcrowding, wearing face masks, and improving ventilation
and filtration conditions, particularly in high-density areas.
Section 4: sources of recent failure in pandemic control
45. Several countries have persistently failed to suppress the epidemic, sustaining
long periods of R above 1 and incurring some of the world's highest rates of infections
and deaths per million population. As a proximate cause, these countries utterly failed
to implement the basic package of NPIs that proved successful in other countries.
In the United States, for example, the federal government undermined key decisions
on business closures, face mask use, testing, contact tracing, and other NPIs, that
were made by state and local authorities, who were themselves highly variable in their
capacity to address the pandemic. Testing was also in chronically short supply, particularly
after early failures of the federal CDC to provide working test kits to the states
and local governments.
46. High inequality, which in turn exacerbates low social trust and polarised politics,
is a major cause of failure of response to the pandemic.
It is no coincidence that the pandemic is soaring throughout the Americas, a region
of high and chronic inequality. The United States is the most unequal economy of all
high-income democracies, and Brazil is among the most unequal countries in the world.
We discuss the special vulnerabilities of people who are poor in section 5.
47. Another reason for failure to control the pandemic is a style of political leadership
that has been termed medical populism, which Lasco has described as political leaders
“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
Lasco uses three case studies to make this argument: US President Donald Trump, Philippine
President Rodrigo Duterte, and Brazilian President Jair Bolsonaro.
Not only does medical populism frustrate the implementation of NPIs, but it also stokes
opposition to simple measures such as wearing face masks, and it breeds misinformation
and rumour trafficking.
48. As a result of medical populism, the wearing of face masks has become increasingly
politicised in several countries in Europe and the Americas, with some protesters
demanding the freedom to dispense with the use of face masks. We emphasise that individuals
do not have the right to infect others during a pandemic, and that wearing a face
mask is therefore a matter of personal responsibility and legitimate public policy.
We call on political leaders to emphasise the importance of society-wide use of face
masks to suppress the pandemic.
49. We also call on all 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 learn from the success
stories of countries that have suppressed the pandemic, or at least achieved very
low levels of transmission (figure). Additionally, we call on all nations to combat
the rampant rumour-mongering and misinformation that abounds on COVID-19, and we call
especially on leaders to desist in expressing personal viewpoints that are at odds
with the scientific and public health experts of their nations. We also warn against
political leaders who are calling for unproven treatments that do not have supporting
data and evidence, thereby politicising the process of drug and vaccine discovery.
50. The scarcity of quality research accompanying COVID-19 has been another source
of failure in controlling the pandemic. This includes many poorly designed observational
studies that cannot inform on whether a particular treatment is effective because
the studies ignore the basic requirements for well designed randomised trials.
More generally, research needs to be better targeted, including more research on early-stage
than late-stage treatments, with careful delineation according to age, gender, comorbidities,
race, and other potentially important factors.
51. Governments need to support more research on all aspects of the pandemic with
public funds, even in the face of rising national debts. Both parliaments and the
executive branch should be active in promoting research and development to fight this
and future pandemics.
52. Shortages of key medical equipment and supplies (eg, face masks, ICU beds, chemical
reagents for testing) also slowed the initial response to the pandemic and continue
to hamper the response in many countries. Countries need to deploy urgent funding
to procure needed supplies, and low-income countries continue to require emergency
financing for this purpose. Pre-pandemic benchmarks of country preparedness have proved
to be poor predictors of the response to COVID-19,
because these benchmarks did not have the specificity to predict policy responses
and shortages of key supplies.
Section 5: addressing the inequities of the pandemic
53. The COVID-19 pandemic both reveals and exacerbates pre-existing social, economic,
and political inequalities,
including inequalities of wealth, health, wellbeing, social protection, and access
to basic goods and services (eg, food, health care, education). Within countries that
have been badly hit by the pandemic, the poorest and most vulnerable communities are
experiencing the worst economic and health consequences. The SDGs explicitly call
for a reduction of these inequalities within and among nations (SDG 10), a goal that
is even more important in the context of this pandemic.
54. The COVID-19 pandemic is noticeably widening the gap between rich and poor, and
is likely to bring about a sharp increase in income inequality.
In addition to causing a public health crisis, the pandemic has caused an economic
and jobs crisis worldwide.
Responses and efforts to suppress the virus will require deeper efforts to address
income and wealth inequalities, and to ensure universal access to health, education,
and social services. Workers in insecure, low-paid work without access to paid sick
leave are more likely to keep working while infected, and to thereby contribute to
the further spread of the disease.
Low-paid migrant workers living in poor and cramped conditions are also at greater
risk, and account for a high proportion of COVID-19 infections in some countries.60,
61 Providing income support, better working conditions, and safe housing, and reducing
inequality will help to suppress the spread of the pandemic.
55. The poor have far higher rates of infection and mortality than the rich because
poorer communities have greater incidence of underlying chronic health conditions,
such as pulmonary disease, cardiovascular disease, and diabetes, and the social determinants
Those who live in low-income neighbourhoods are at higher risk of exposure to infection
because many work in on-site essential jobs, and are also more likely to live in multigenerational
households with greater risk for intra-household transmission. The rich have the means
to move out of congested urban areas or to shelter more comfortably where they are.
Richer populations can more easily work from home, afford PPE, and otherwise avoid
infection, whereas the poor must circulate in the public to sustain themselves day
to day, thereby risking transmission of the virus in lower-income communities.
56. Low-income communities suffer from inequalities of access to health care and access
to medical supplies.
Health inequalities pose major issues in this pandemic, and according to WHO, as of
December, 2017, half of the world's population do not have access to essential health
services.64, 65 Investments in primary care are urgently needed to address basic health
needs and the high prevalence of comorbidities, including undernutrition and HIV,
which can put people at higher risk of morbidity from the pandemic.
Inequality of access to health services also concerns access to medical equipment
and medication, most of which are manufactured in western countries and imported at
high costs, or licensed under extortive intellectual property agreements.
Production of these items must be scaled up in underserved regions to meet local demand.
Addressing health inequalities is crucial to achieving SDG 3 (universal health and
wellbeing) and building the capacities of countries to respond to future public health
57. Health inequalities are also exacerbated by social inequalities of race, socioeconomic
status, ethnicity, and gender.68, 69, 70, 71 In the United States, for example, COVID-19
has emerged as a major health disparity for people of colour. The CDC has documented
the disproportionate effect of the pandemic on people of colour, and has identified
five underlying reasons: discrimination; health-care access and use; occupation; education,
income, and wealth gaps; and housing.
In the United States, COVID-19 is causing historic decimation of Hispanic communities
across the south, African American communities in the southeast, and Native American
communities in the southwest. The United States is not alone on this front. Across
the G20 nations, there are rising cases of COVID-19 among people who are poor and
living amidst wealth, a situation that has been called “blue marble health”.
58. The vulnerability of Indigenous communities to COVID-19 is worldwide. Throughout
the Americas, more than 70 000 Indigenous people have been infected and 2000 have
died, mostly due to inadequate access to care,
and this number is likely to be an underestimate. In response, Indigenous organisations
have established their own networks and cooperation mechanisms, such as the Regional
Indigenous Platform Against COVID-19. Protective actions are especially crucial for
Indigenous peoples of the Amazon, where 223 Indigenous nations are at risk of extinction.
Effective responses must include the active involvement of Indigenous peoples, especially
59. COVID-19 is the first pandemic of the digital era. Within just a few weeks, as
countries across the world instated lockdowns and shelter-at-home directives, a large
proportion of economic and social life in high-income countries moved from offices,
shops, schools, and clinics to online platforms for working from home, e-commerce,
e-schooling, and telemedicine. However, the abrupt shift to the online economy came
in the context of a pre-existing digital divide both within and among nations.
The digital divide exists along inequalities of income and between high-income and
low-income countries, as well as along the urban–rural divide,
for older populations,
and between professionals and those who do so-called essential work in lower-paid
60. Higher-paid professional and managerial jobs shifted quickly online at the onset
of the pandemic, maintaining pay and employment, whereas millions of lower-paid workers
and informal workers with occupations that are performed on site (eg, retail, sanitation,
care workers) were suddenly eliminated or furloughed. Therefore, in most cases, lower-wage
workers have suffered more economically and in terms of health risk than have higher-wage
workers. Much of the digital work in e-commerce, e-education, telemedicine, offices,
and teleconferencing might shift online permanently.
This shift might lead to long-term jobs losses for on-site workers in shops, offices,
schools, clinics, and business travel, and there is a high likelihood of future persistent
unemployment. The inequalities between countries will become push factors for migration,
putting individuals in fragile positions. Urgent measures are needed to accompany
the transition and the deep changes in the labour market, including employment subsidies
and other types of fiscal and policy support measures.
61. The same digital divide also applies for public services, including education
and health care, where they have shifted online.81, 82, 83 Those with high-quality
digital access continue to obtain key services, whereas those without connectivity
find themselves or their children excluded from basic services such as schooling.
This split occurs both within and among countries because of income inequalities and
insufficient decent work. In addition, lower-income countries often have a much higher
proportion of the workforce doing on-site work rather than online work than do higher-income
62. The most glaring illustration of economic inequality is the stark divide between
the real economy (as measured by jobs and gross domestic product [GDP]), the stock
market (which measures the expected future earnings of the listed corporate sector),
and the online economy. Whereas US GDP declined by about 32% in the second quarter
of 2020—the deepest decline since the Great Depression
—and consumer confidence is at its lowest level in 6 years,
the S&P 500 index has risen by over 50% since its pandemic low on March 23, 2020,
powered especially by big tech, communications, and e-commerce.
American billionaires have had a rise in net worth of $434 billion from March to May,
The result is an utterly unprecedented rise of stock market wealth for a few individuals
in the midst of an unprecedented rise of unemployment and destitution, whereby half
a billion people globally could be pushed into poverty by the pandemic.
In this way, the financial markets have become disconnected from the labour markets.
63. Among the most urgent challenges of the COVID-19 pandemic are hunger and food
insecurity for poor and vulnerable populations.
Decades of decline in hunger have reversed in recent years, and the pandemic has accelerated
this worrying trend.93, 94 Many low-income, food-importing countries, especially in
Africa, have been hardest hit by the COVID-19 pandemic, and the poor within those
countries face rising food prices.
Even in the United States, hunger is an issue, and the US Census Bureau now estimates
that one in six households with children is unable to meet current food needs.
64. The COVID-19 pandemic poses great concerns for mental health,
especially for lower-income populations. Isolation, high stress levels, unemployment,
and deprivation of basic needs contribute to poor mental health. There is high inequality
of provision of services for medical health,
especially in lower-income and middle-income countries.
A CDC study
found that suicidal ideation and psychological distress is particularly high among
essential care workers, Black and Hispanic respondents (compared to non-Hispanic white
respondents), and young people in the United States. One effective solution is to
rapidly train volunteers to staff crisis hotlines, to expand their capacity to respond
to individuals, making help more accessible to disadvantaged communities.
65. The gender dimensions of the effects of COVID-19 must be considered in terms of
economic, health, and wellbeing effects, because the pandemic presents gendered implications
for clinical outcomes, economic and working conditions, education, and agency.
66. The shift in resources towards addressing the COVID-19 emergency has led to changes
in the availability and access of reproductive and maternal health services, which
in turn has led to an increase in unplanned pregnancies for teenage and young women.101,
102 Although men and women are infected by COVID-19 to similar proportions, men appear
to be more at risk for worse outcomes and death, independent of age.
67. There has also been an increase in gender-based violence during the pandemic and
the subsequent economic lockdowns.
Reports confirm that domestic violence against women and girls has risen by as much
as 30% in some countries. Women's support services, such as shelters, are struggling
to keep up with rising demand.
Urgent action is needed to consider and prevent all forms of violence against women
in the COVID-19 pandemic, and to designate domestic violence shelters as essential
services, while ensuring they are properly funded.
68. Women in many countries have higher rates of unemployment due to the recession
than do men.
In addition, when schools close and children are at home, women shoulder a triple
burden of frontline work, unpaid care work, and community work.107, 108 Women make
up 70% of the global health workforce, putting them at greater risk of infection and
stress from overworking.
There is an urgent need to develop policies and programmes using a gender lens.
In particular, women health workers need equal pay and meaningful participation in
higher levels of health leadership.
69. Women are crucial agents of change, but great gender disparity remains in women's
political participation. Female heads of state and government have been successful
in addressing the pandemic, showing great leadership skills and making science-based
These leaders have shown outstanding wisdom and leadership in responding to COVID-19,
and yet women represent less than a quarter of all elected politicians worldwide.
Recovery packages should also include new governance arrangements to boost women's
political participation and include women in positions of power.
70. 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 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 people who are 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
Section 6: meeting the urgent fiscal needs of low-income and middle-income countries
71. One of the defining characteristics of the global crisis has been the sharp drop
in public revenues at national, provincial (or state), and local levels as a result
of the collapse in economic activity and fiscal measures. Public debts around the
world are rising rapidly, with budget deficits at historic levels as a share of GDP,
particularly in high-income economies. The US federal government, for example, will
run a budget deficit of around $3·7 trillion during 2020, about 16% of GDP.
The public debt–GDP ratio in high-income economies is expected to exceed 130% of GDP
by the end of 2020, on the basis of the International Monetary Fund (IMF) June 2020
forecast, the highest ever recorded.
72. The situation for LMICs will become increasingly dire because many countries are
facing tight financing conditions. These countries will have to prioritise health
care, social protection, and public investment to preserve lives and livelihoods and
to avoid the risk of social crises. Fiscal space to do so is limited, however, because
many LMICs were already facing debt sustainability concerns before the pandemic, with
more than 30 countries in high risk of or current debt distress. Depending on the
structure of their economies and their dependence on external flows (such as remittances),
LMICs might be particularly vulnerable to the crisis.
73. Moreover, many LMICs 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. These programmes must urgently be put in place and
financed both domestically and internationally. Using digital technologies that enable
governments to make e-payments directly to households, governments need to implement
emergency direct transfer programmes to impoverished, hungry, and destitute households.
74. Such countries will require considerable international concessional financing
(ie, grants and low-interest, long-term loans) from the international financing institutions,
notably the IMF, World Bank, and regional development banks. Some of these LMICs will
also need 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 GDP as official development aid.
As international concessional funding is expanded, special efforts must be made to
ensure transparency and to guard against corruption, to ensure that the new flows
reach the intended beneficiaries.
75. We urge special attention to the least developed countries, small island developing
states, landlocked developing countries, heavily indebted countries, and countries
in humanitarian crisis or fragile situations as a result of such factors as environmental
shocks or violent conflicts.
76. As governments take measures to respond to COVID-19, they might become vulnerable
to claims by foreign investors under various investor–state dispute settlement clauses
in trade and investment agreements, particularly in LMICs.
The Commission takes note of the proposals put forward by several unions, trade associations,
and NGOs to address this legitimate concern.
77. Although countries have announced more than $11 trillion in fiscal measures (half
of which consists of additional spending or revenue-reducing measures, and the other
half consists of loans, guarantees, or equity injections by the public sector) to
combat the COVID-19 emergency, most of these announcements have been in high-income
or middle-income emerging economies.
Some countries, notably Germany, have increased their development assistance for COVID-19-related
outlays in low-income and middle-income partner countries. The bulk of emergency financing
for low-income countries has come from the IMF and the World Bank.
78. The IMF is at the centre of the global financial safety net. It has provided rapid
access to emergency financing to countries that need it. IMF financing during the
pandemic has so far totalled $87 billion for 80 countries.
The IMF's rapid credit facility (for low-income countries) has a 10-year maturity,
zero interest rate, and 5·5-year grace period,
whereas the IMF's rapid financing instrument (for other countries) must be repaid
within 3·25–5 years.
There are also smaller amounts of grant relief in the catastrophe containment and
relief trust, to help low-income fund members to pay debts that are owed to the IMF.
79. The World Bank Group is working to help countries to boost health spending, strengthen
social safety nets, and maintain both public services and a thriving private sector.
They plan to deploy as much as $160 billion, including the frontloading of $51 billion
worth of grants and highly concessional resources from the IDA19 replenishment. To
deal with the health emergency, the World Bank deployed $6·3 billion to support 108
countries within 3 months. Other multilateral development banks have committed to
adding another $80 billion to their response, bringing the total to $240 billion.122,
80. In addition, the G20 extended debt relief during 2020 to low-income countries
in the debt service suspension initiative, which in total could postpone payments
of around $11·5 billion.
The implementation of the debt service suspension initiative is supported by the IMF
and the World Bank. However, to date, several low-income countries have not availed
themselves of this opportunity for various reasons, including fear of damaging their
credit rating. Further, for many countries, a temporary delay of payments will be
insufficient to overcome this crisis and restore debt sustainability, so that some
measure of permanent debt forgiveness will be needed.
81. Central banks have played a decisive role in preserving financial stability. In
early March, as the number of COVID-19 cases increased rapidly in the north Atlantic
region, global financial markets were faced with a sudden rush to liquidity and unprecedented
volatility, affecting even the safest assets. The federal reserve system of the United
States and major central banks (eg, European Central Bank, Bank of England, Bank of
Japan) reacted quickly by providing liquidity and purchasing large quantities of assets.
This helped to reestablish orderly global market conditions, including for emerging
and frontier markets.
82. Other central banks in high-income economies and emerging market economies have
followed suit, and have responded to the crisis in a forceful and flexible way through
cuts in policy interest rates and an expansion of credit to combat the COVID-19 downturn.
Success in these policies has reflected the credibility of central banks that has
been earned through years of successful inflation targeting, which has now given them
space for active monetary policies to fight depression-level downturns.
83. In this context, high-income economies and large emerging markets have been able
to finance sizable budget support at rock-bottom interest rates, thereby maintaining
or even expanding public services and social protection payments at the national level
despite the severe decline in budget revenues. By contrast, low-income countries that
have been shut out of international markets or are facing higher borrowing costs have
been severely constrained in the provision of additional public services and social
protection for those in need.
Section 7: achieving universal digital access as a key to inclusion
84. Digital technologies and online digital access are crucial to effective responses
to the pandemic. As previously addressed, unequal digital access has greatly exacerbated
inequalities. Online connectivity and literacy are essential for access to income
transfers (eg, payments of emergency relief), e-schooling, telemedicine, working from
home, e-commerce, e-payments, e-counseling for mental health, and other key needs.
Online connectivity supports testing and contact tracing, monitoring of the epidemic,
and accessing information and social support for individuals and families in need.
Digital access is also crucial for social connection during the pandemic.
85. We call on all relevant UN agencies, led by the ITU and UNESCO, with the support
of the ITU–UNESCO Broadband Commission, to take concrete steps with the digital industry
and governments to accelerate universal access to digital services, including new
forms of public–private financing to extend connectivity to hard-to-reach populations.
We strongly support the UN Secretary-General's roadmap for digital cooperation, with
the goal of achieving universal connectivity by 2030, and we urge its immediate implementation.
86. UNICEF has recently estimated that a third of the world's schoolchildren were
unable to access digital learning during the recent school closures.
We call on the Broadband Commission to intensify its work with UN agencies, led by
UNESCO and UNICEF, technology companies, and the telecommunication industry, to ensure
that online schooling is available to all learners as necessary during the duration
of the pandemic.
87. Misinformation presents an increasingly difficult challenge in the digital world.
In some respects, in the digital age it has become more difficult to access reliable
and accurate information from legitimate sources. However, misinformation has always
been an obstacle, notably in combating tobacco use and climate change. Today, misinformation
threatens the effectiveness of a COVID-19 response,
especially with regards to vaccines and enforcement of NPIs, including the importance
of face masks.
88. Privacy and security of personal information is of great concern, given that some
countries are pursuing the use of extreme surveillance to track and quarantine COVID-19
cases and to reduce the spread of the disease. This technology is essential for short-term
but it has important implications for privacy and human rights, and potentially dire
consequences for freedom of speech and movement if these extreme measures were to
remain in place in the long term and if they were used to track people for purposes
other than suppressing COVID-19. We call on all stakeholders, especially technology
companies, the telecommunications industry, and governments, to think creatively about
how to combat the negative aspects of digital technology.
Section 8: global justice in access to safe and effective vaccines, therapeutics,
diagnostics, and equipment
89. The pharmaceutical industry and academic community, supported by governments,
have undertaken remarkable efforts to develop new approaches for suppression of the
pandemic, including vaccines,
therapeutics, rapid diagnostics, new treatment regimens, and new equipment, including
90. Vaccines offer a potentially pivotal approach to controlling, and indeed ending,
the COVID-19 pandemic.
Previously, vaccinations have contributed decisively to the control or elimination
of infectious diseases, and there are reasons for optimism that effective vaccines
are within reach for the SARS-CoV-2 virus that causes COVID-19. Nonetheless, many
urgent public policy issues are involved in the development and use of a new vaccine,
which must be scrupulously honoured and are in clear risk in this pandemic. This is
especially the case since the first vaccines are likely to be only partially effective,
and therefore pose many complications and risks in their initial deployment.
91. The vaccines under development will have varying levels of efficacy because of
several unknowns. They might protect individuals against severe disease or death without
preventing infection. They might work for some subgroups of a population but not others.
They might pose differential risks to individuals according to age, gender, ethnicity,
race, previous medical conditions, or other characteristics. They might have efficacy
of varying duration and require repeated boosters.
92. Therefore, it is urgent for safety, public health, and public acceptance, that
the introduction of new vaccines follows rigorous and sound testing and evaluation
through all clinical phases, and that the introduction of new vaccines is not subjected
to dangerous political interference. In this regard, we are concerned by the introduction
in Russia of a new vaccine candidate without the completion of phase 3 trials for
efficacy and safety, and without the publication of supportive data.
We are similarly alarmed at attacks on regulators, such as the recent accusations
that the US Food and Drug Administration is delaying vaccine development for political
reasons, rather than in the interest of human safety.
Such political interference in the operation of technical agencies is inexcusable
and done for obvious political gain.
93. We are concerned about the emphasis and focus on new and unproven vaccine technologies,
such as mRNA, DNA, and viral-vector technologies, which will be expensive and have
not been shown to offer benefits (in terms of vaccine immunity or safety) over traditional
and far less expensive inactivated virus, attenuated virus, and recombinant protein
approaches. The former will be produced primarily by large multinational pharmaceutical
companies, whereas the latter could be produced by members of the Developing Country
Vaccine Manufacturers Network (DCVMN) and are more likely to provide vaccines to low-income
populations and nations. Therefore, there is an urgency to better support DCVMN vaccine
manufacturers to produce low-cost COVID-19 vaccines using traditional technologies,
which are key to global access. Along these lines, there is a need for better acceptance
of low-cost adjuvants with long-standing safety records, such as alum, which have
so far been dismissed by major donors and international partners without scientific
94. Any new vaccine or therapeutic must be developed and implemented with the view
to equitable access across and within countries. No nation or population within a
country should be prohibited from accessing a vaccine because of cost. No country
should have its access predicated on its participation in clinical trials (some governments
are pressured to host such trials in return for future vaccine access).
95. The 73rd World Health Assembly recognised immunisation “against COVID-19 as a
global public good”.
So-called vaccine nationalism,
in which individual nations tie up the intended supplies of future vaccines for their
own use, is counterproductive because no one nation is safe until all are. Bilateral
negotiations on future vaccine access are currently taking place under confidentiality
agreements, with poor transparency in pricing.
96. We strongly support the multilateral initiative Access to COVID-19 Tools (ACT)
Accelerator to promote universal, equitable access to COVID-19 vaccines, therapeutics,
and other tools, and within that initiative, COVAX, the vaccine pillar. We urge all
nations to join the ACT-Alliance and to honour its principles of fair sharing of new
COVID-19 tools, but we emphasise that on the basis of current trends, COVAX will not
be sufficient. Complementary approaches in support of this multilateral initiative
would help to strengthen equitable access across and within countries. This modified
advanced market commitment strategy comes with unique challenges, and it is unclear
how such an initiative will be designed, deployed, and financially supported. Transparency
in clinical trials, price negotiations, and research and development investments is
of paramount importance for ensuring equitable and fair access to vaccines. In addition,
countries should advance national strategies for local production, technological training,
and innovation on vaccines, therapeutics, and diagnostics, to ensure universal access.
97. We support the efforts of the ACT Accelerator towards clear protocols for fairer
rollout of new candidate vaccines, diagnostics, and therapeutics, including clarity
on timing, monitoring of use, affordability, supply chains, personnel, and public
communications. These factors will be urgent for public trust and uptake, and for
repulsing the inevitable onslaught of false information and rumours on social media.
Deliberate efforts to engage communities will be crucial to addressing mistrust. Responsible
and cooperative behaviour among all of the key research and development areas, including
the United States, China, Russia, India, the United Kingdom, and the EU, will also
be essential. However, the voices of LMICs should also be enhanced in the governance
98. The global vaccine community has so far been without adequate situational awareness
to a rising anti-vaccine movement. The anti-vaccine movement has been amplified in
the United States since 2015, when it pivoted to the political far-right. This movement
has now driven down vaccine coverage to the point where measles re-emerged in the
United States in 2019.
In 2020, the American anti-vaccine movement redoubled its efforts against COVID-19
vaccines and expanded its remit to campaign against face masks and contact tracing,
thereby helping to promote the massive resurgence of COVID-19 in the southern United
States this summer.
Also in the summer of 2020, the American anti-vaccine movement expanded its activities
through a major demonstration in Berlin, Germany. There is urgency for the global
community to combat the misinformation of this globalised anti-scientific effort.
We urge an expansion of global efforts to combat anti-vaccine movements that are based
in the United States and Europe but have also begun to expand in Asia, Africa, and
99. We note that although vaccine candidates are likely to begin implementation during
2021, their introduction will not mark the end of the pandemic or the end of the crucial
need for NPIs. Early vaccines are likely to be rolled out gradually, as experts learn
more about their efficacy among subgroups such as health-care workers, older people,
and immunocompromised populations. The first vaccines are likely to be only partly
effective and last for a limited duration, such that transmission of disease might
continue even with increasing vaccine coverage. In addition, countries will need to
put in place systems for the delivery of vaccines and ways to finance vaccine coverage
and delivery. Even under the best circumstances, high levels of immunisation coverage
will require years, not months. During that time, the pandemic will continue, as will
the need for NPIs.
100. In general, the scientific community has produced accurate, trustworthy data
and research through one of the most remarkable mobilisations in history, including
a commitment to make more than 30 000 publications open access, or freely available
to the public.
Continuing this unprecedented commitment to collaboration and transparency is key
to ensuring that reliable sources of information continue to inform policy decisions
at all levels.
101. Global health diplomacy should inspire cooperation between the scientific and
political communities and strengthen global science diplomacy, to ensure that encompassing,
holistic, cross-disciplinary perspectives and cross-border knowledge inform policy
and decision making. Global science diplomacy is strategic to addressing not only
this pandemic, but also other global challenges, such as the climate crisis.
Section 9: promoting a jobs-based green recovery
102. Aggregate demand income and trade will remain disrupted in the medium term (ie,
the next 12–24 months). Uncertainty affects consumption and private investment. In
many parts of the world, including Europe, Japan, and the United States, central banks
do not have much leeway with interest rates at zero or even negative. Policies will
be needed to support the financial system as non-performing loans mount, and fiscal
packages will have to be financed by national debt. Many governments will benefit
from borrowing costs that are at historical lows.
103. An important element for sustained global economic growth in the coming years
will therefore be public investment, which provides an opportunity to accelerate the
transformation of societies towards sustainable and inclusive growth. In turn, public
investments in infrastructure, for example, will provide major support for private
investments in new sustainable sectors, such as renewable energy, electric vehicles,
and the digital economy.
104. Economic recovery plans should support the transition towards more sustainable
and inclusive societies based on the SDGs and the Paris Climate Agreement.2, 3 Public
investment should be oriented towards sustainable industries and the digital economy.
Unlike in the 2008–09 financial crisis, which led to a sharp rise in carbon dioxide
emissions when economic activity started picking up,
governments should use the COVID-19 health and economic crises to launch transformative
actions that support decarbonisation and decouple economic growth from negative impacts
on the climate and biodiversity. Carbon pricing and other mechanisms, including investment
in clean energy infrastructure and policies to promote the development and deployment
of key technologies, should be emphasised during the recovery. Subsidies to unsustainable
industries should be progressively phased out.
105. Preventing a wave of bankruptcy of solvent small and medium-sized enterprises
is an important priority. New forms of public–private partnerships might be needed
to accelerate the green transition and the rollout of digital solutions and technologies,
including those for public services. In the short term, it is crucial that governments
strengthen social protection mechanisms and maintain (for long enough) the exceptional
measures that have been introduced to support jobs and people who have lost their
jobs. Although this approach will probably lead to sharp increases in public debt
in many countries, fiscal retrenchment earlier than warranted would present an even
greater risk of derailing the recovery, and could ultimately be more costly.
Governments should ensure full transparency, good governance, and costing of all fiscal
106. Few global shocks have dealt such a pervasive blow to so many people's jobs,
career and life prospects, and economic security. The long-term effects of this crisis
will particularly affect young people,
who are more likely to be unemployed and working in informal jobs.
The world will be afflicted by high and pervasive unemployment for years to come,
putting hundreds of millions of individuals at risk of poverty, financial insecurity,
hunger, and mental health problems, including clinical depression and anxiety disorders.
A major goal of the recovery, therefore, should be to ensure economic dignity for
all, through robust social protection, and opportunities for meaningful workforce
and community participation (which is also crucial to mental health). Development
and implementation of criteria to assess whether post-COVID-19 stimulus packages integrate
the essential aspects of equity, health, decarbonisation, and employment are strongly
107. A jobs-based recovery will require global cooperation and new forms of partnerships
between the public and the private sector. Many of the hundreds of millions of jobs
that have been eliminated during the pandemic will not return. Many businesses will
have closed. Many activities will have shifted permanently from the brick-and-mortar
economy of offices, shops, schools, and clinics, to the online world of working from
home, e-commerce, e-education, and telemedicine. Yet the new online world of work
will also create new opportunities for skills and employment. A just recovery will
require an unprecedented commitment to reskilling and upskilling people throughout
working life, including skills to prepare workers for the digital economy. If the
new digital economy is implemented justly and inclusively, there is an opportunity
for more shared leisure time. The digital economy can be transformative, supporting
not only decent jobs but also the green economy. For this change to occur, however,
reskilling and retraining must be embarked upon at an unprecedented scale.
108. The restoration of work must be based first and foremost on making sure that
workplaces are safe, diminishing the risks of transmission of the virus. Businesses,
universities, and public health authorities should prepare clear guidelines on safe
schools, offices, shops, construction sites, factories, transportation facilities,
and sites of recreation and entertainment. These guidelines should include provisions
for public hygiene, physical distancing, symptom monitoring, controls for safe and
healthy indoor environments (such as increased ventilation and air filtration), and
other measures of workplace safety.
109. To finance the green recovery, new methods of financing will be needed for LMICs,
including new or more efficient allocations of special drawing rights,
increased debt relief, and a major scale-up of green financing from institutions such
as the Green Climate Fund.
110. 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 the circular economy, together with a comprehensive
€1·8 trillion budget.
This approach can serve as an exemplar for other regions of the world as they devise
strategies to rebuild their national and regional economies. 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).
Investing in renewable energy, sustainable transport, and other policies that reduce
air pollution exposure are of particularly urgent concern because fine particulate
air pollution increases the risk of respiratory disease, heart disease, stroke, diabetes,
and other conditions that are risk factors for poor outcomes from COVID-19. This form
of air pollution also often disproportionately affects low-income and minority communities.
Conversely, modernising energy systems can contribute to job creation and economic
growth while also protecting the climate, but this requires public sector leadership
111. These economic transformations should be complemented by new metrics to measure
progress and wellbeing. Measuing of growth in GDP alone will not help in monitoring
a more inclusive and sustainable economy; rather, frequent, publicly accessible reporting
is needed on SDG indicators, happiness and subjective wellbeing, and environmental
112. Global recovery will be greatly facilitated by cooperation at the regional and
international levels, not only in controlling the epidemic, but also in designing
and 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 (such as those of the EU
and African Union
). Regional integration has enormous potential and benefits, from the possibility
of regional debt relief negotiations to procurement agreements on equipment, tests,
treatments, and vaccines. Trade and financial sanctions, other isolationist policies,
and talk of a new cold war between the United States and China are deeply dangerous
hindrances to global recovery and to peace itself.
Section 10: supporting the urgent role of UN institutions
113. The COVID-19 pandemic hit during the 75th anniversary year of the UN. Before
the pandemic, the reinvigoration of the UN multilateral system was already being widely
discussed, but the COVID-19 pandemic has raised scrutiny on the effectiveness of multilateral
A new culture of multilateralism is needed, based on strong leadership, collective
action, and greater participation in multilateral decision making. The indispensable
role of the UN has been evident throughout the course of the pandemic, especially
for the world's most vulnerable populations, and yet the UN system has come under
attack from populist politicians, and international law has been undermined. The United
States has even taken the unprecedented and dangerous step of announcing its withdrawal
from WHO at this crucial moment in world affairs.
114. We strongly support the UN, and we 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 decision to withdraw from WHO, the Paris
Climate Agreement, UNESCO, and the UN Human Rights Council.
115. We strongly support the unique role of the IMF, 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 more affluent shareholder countries to provide additional concessional
116. We strongly support the indispensable role of WHO in controlling the COVID-19
pandemic, and we call on all nations to increase, rather than decrease, their funding
support and political backing for the work of 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 and unique role in global public health.
Section 11: the work of the Lancet COVID-19 Commission going forward
117. This Statement summarises the views and recommendations of the Lancet Commission
on COVID-19 on current key issues related to the worldwide pandemic as of mid-September,
2020. In the coming months, the Commission will develop a portfolio of COVID-19 metrics
to track how the recommendations herein are being implemented, and will report on
them quarterly. The metrics will cover four dimensions of the crisis: suppression
of the epidemic worldwide through NPIs; transparency in the development of safe and
effective vaccines and therapeutics; health systems response and access; and sustainable
and equitable transformations, including effects on equity, labour markets, jobs,
greenhouse gas emissions, and other environmental metrics.
118. The Commission will also consider recommendations on how to counter misinformation
on science, not only with regard to COVID-19, but also concerning other related issues,
including vaccines, biodiversity, and climate change.
119. The Commission recognises that the global pandemic raises a series of complex
issues that are still evolving and that will need further timely evaluation, such
as rising humanitarian and hunger crises; financing for the health response and economic
recovery plans; the institutional and financial arrangements within the UN system
for coordinated responses to risks regarding health, climate, and the economy; the
future of education and work in a post-COVID-19 world; and the long-term physical
and mental effects of the virus. The Commission is establishing specific task forces
that will be releasing policy briefs and white papers in the coming months on these
120. The Lancet COVID-19 Commission will release its next Statement in early 2021,
which will highlight the progress or regression in various aspects of its work and
recommendations, with an updated analysis of the evolution of the pandemic.
121. The Commission will issue its final report in early 2022.