Lopes H, Middleton J. Learning from the pandemic, building increased international cooperation. (Position paper). SEEJPH 2021, posted: 26 September 2021. DOI: 10.11576/seejph-4760 P a g e 1 | 9 POSITION PAPER Learning from the pandemic, building increased international cooperation Henrique Lopes1, John Middleton2 1 Institute of Health Sciences, Universidade Católica Portuguesa, Lisbon, Portugal; 2 Association of Schools of Public Health in the European Region, UM Campus Brussels, Av de Tervuren 153,1150 Brussels, Belgium. Corresponding author: Prof. Henrique Lopes; Address: Institute of Health Sciences, Universidade Católica Portuguesa, Lisbon, Portugal; Email: henrique.lopes@ucp.pt Lopes H, Middleton J. Learning from the pandemic, building increased international cooperation. (Position paper). SEEJPH 2021, posted: 26 September 2021. DOI: 10.11576/seejph-4760 P a g e 2 | 9 Abstract The COVID-19 pandemic highlighted a fragile preparation by countries and regions for epi- demic events, exposing exacerbated nationalisms in pandemic mitigation and control actions. Both conditions decisively compromise the effectiveness and efficiency of pandemic control capacity. It is important to develop frameworks that help overcome frailties in response to epidemics. Based on a thematic literature review and discussions with multiple national and international entities an attempt was made to build a tool for responding to future epidemics, the Pandemic Preparation Framework (2PF). The proposed 2PF tool is aligned with the Sendai Framework for Disaster Risk Reduction and with international bodies, such as the European Health Emergency Preparedness and Re- sponse Authority (HERA). It aims to be a framework for operationalizing these agreements. The response to pandemics must be based essentially on international action and closer col- laboration between countries and regions. Keywords: crisis management, framework, internationalization, strategic management, pan- demic. Acknowledgments: The authors acknowledge Diogo Franco of the USP-ICS/UCP scientific secretariat for his support in this article. Authors’ contribution: The authors contributed equally to this article. Conflict of interest: None declared. Sources of funding: None declared. Lopes H, Middleton J. Learning from the pandemic, building increased international cooperation. (Position paper). SEEJPH 2021, posted: 26 September 2021. DOI: 10.11576/seejph-4760 P a g e 3 | 9 Background Although the appearance of a pandemic such as the one caused by the SARS-CoV- 2 virus has been alerted since 2007 (1) and the Center for Disease Control and Preven- tion (CDC) warned in 2013 (2) about the risks of accidents with laboratories at lev- els 3 and 4 of 0.2%/year, the frameworks and necessary reactions were not devel- oped so that one could not act with full preparedness. The very nature of the cur- rent pandemic’s origin is not yet defini- tively identified as stated recently (https://covid19commission.org/). Pandemics and epidemics will undoubted- ly return in the current century. All the conditions for increased circulation of in- dividuals, goods, climate change, contact with wildlife and devastation of ecosys- tems previously untouched by humans are currently gathered and will worsen in the predictable horizon. The latter conditions are estimated to generate around 60-70% of new diseases and epidemics (3). There- fore, we must prepare so that the Public Health catastrophe of COVID-19 will not be repeated. The countries judged to be most well-prepared for pandemic in 2018, often performed poorly. Many of the fail- ures were attributable to political positions and indecision (4). We identified at least seven weaknesses in Western countries: • Passive, indecisive and slow. • Bureaucratic-Normative. • Without conceptual preparation for surveillance, preparation, or coor- dination of actions. • Without strategic reserves of Pro- tective Personal Equipment (PPE) material norsignificant hospital re- serves (facilities and capacity). • Lacking pandemic response tools at the macro, meso and micro level. • Nationally centered, paying little attention to WHO or other interna- tional authorities. • Low knowledge management and knowledge transfer. In our reading, much of this result is due to consecutive years of disinvestment in Health, especially in the last decade and because Public Health is usually the poor branch of health, the one in which little is invested, where little space is given to the preparation of people and logistics (5,6). This cycle should be reversed placing Pub- lic Health as a strategic tool for national and international cooperation. Much can be done without relevant effort if the les- sons of COVID-19 and the accumulated experience of decades in the surveillance and mitigation of effects caused by natural risks are considered. Therefore, we pro- pose the creation of a framework for ap- proaching biological risk with pandemic danger–the Pandemic Preparation Frame- work (2PF). The proposed Pandemic Preparation Framework (2PF) With the 2PF, we propose a way of dealing with future epidemics/pandemics that can at least partially address the difficulties and problems of the seven weaknesses in Western countries’ health response during the COVID-19 crisis, as summarized above. − Pandemics and major epidemics are overcome in the Prevention phase. − When it is no longer possible to maintain either situation with very high certainty in the preventive phase, there must be a Planning and Preparation phase for a con- crete risk. − Proactive response to the pan- demic when it is already installed on the field. − The identification, prevention, planning of preparation and com- bating a pandemic or major epi- demic can only be successful through intensive International Cooperation. https://covid19commission.org/ Lopes H, Middleton J. Learning from the pandemic, building increased international cooperation. (Position paper). SEEJPH 2021, posted: 26 September 2021. DOI: 10.11576/seejph-4760 P a g e 4 | 9 The strategic idea is that the coordination of the response to an epidemic/pandemic must be essentially achieved at a suprana- tional level, through adequate prior prepa- ration and based on knowledge manage- ment. The need for this paradigm shift was recently addressed at the European Union level, with the regulation entity proposal entitled “European Health Emergency Pre- paredness and Response Authority” (HE- RA) (4). However, with emerging diseases having the potential of becoming a global threat, a more global approach was rein- forced by the signature of a Global Pan- demic Preparedness Treaty by 24 world leaders and the World Health Organisation (WHO) (5). During the Twentieth century, the world has progressed from national to supranational entities whenever the Com- mon Good is to the parties' advantage, of which the ultimate example will be the United Nations (UN). Countries have also learned that major crises are faced by co- operation and have created mechanisms for that purpose within supranational or- ganizations. In addition, there is an in- creasingly globalized world where every- thing tends to occur almost simultaneous- ly. Only international solutions based on cooperation will be able to respond to ma- jor issues since what affects a country can quickly become a global threat. Therefore, it is in the direct interest of all nations to participate in the elimination or mitigation of a risk in any country in the world. For example, since 2005, with the signing of the UN Hyogo Framework (6) for response actions to disasters, and later with the Sen- dai Framework for Disaster Risk Reduc- tion (7), global targets were defined to- wards reducing disaster consequences such as: mortality, affected people, economic loss in GDP, infrastructural damage and service disruption, national/local risk re- duction strategies, international coopera- tion, availability and access to multi- hazard warning systems. The COVID-19 pandemic has shown beyond a reasonable doubt that the capacity to control a pan- demic is something that goes beyond the national dimension, as declared by many politicians (8) and scientists (9). Only through the highest international coopera- tion is it possible to find appropriate solu- tions, supply equipment volumes at an adequate time and acceptable prices, with universal standards and applicability, and exchange experiences to debug national procedures. International cooperation in a pandemic state has immense scope for progression in all fields (10). The degrad- ing spectacle of government officials re- directing clinical equipment at airports should not be acceptable (11). Many na- tional strategies have sought only to con- centrate the maximum level of resources with those who can afford them. For ex- ample, in the case of worldwide vaccine distribution there is the need of interna- tional agreement on its optimal and ade- quate allocation instead of being focused in profits (12) and realpolitik (13). Interna- Lopes H, Middleton J. Learning from the pandemic, building increased international cooperation. (Position paper). SEEJPH 2021, posted: 26 September 2021. DOI: 10.11576/seejph-4760 P a g e 5 | 9 tional authority is needed to ensure re- sources go to areas where they can be globally most useful and effective in com- bating the pandemic (14). The absolute need for knowledge management was veri- fied, proving to be the central element for an adequate fight against the pandemic. This element can only be appropriately developed in a wide-ranging, fully interna- tionalized way and with the greatest trans- parency. Finally, it should not happen again that the strengthening of local re- sponse capacities through international means is minimal and appears as an insuf- ficiency of the local political response. In the COVID-19 pandemic, the international reinforcements that existed were vestigial (14,15) concerning the means deployed in each country and always with difficulties articulating with the local structures that led to situations in which even the smallest help made available was not used: lan- guage, local procedures and other com- plexities (15). Only the creation of au- tomatisms can change this framework for the integration of Health Services. The tactical-operational idea is that nation- al/local actions must be part of an articu- lated whole composed of three dimen- sions: Prevention, Planning and Prepared- ness, Proactive response to the pandemic. This means that there must also be a high level of international operational coopera- tion, presenting the great challenge of re- quiring mutual knowledge and preparation work. Things as simple as consolidating new positive cases or the lethality of a dis- ease among countries can, in practice, be an impossibility when each country works in its own way. Consistency in case defini- tions and ascertainment is needed, for ex- ample, to secure cross border intelligence and enable accurate inter-country compari- sons. With the ongoing COVID-19 pan- demic threat, it must not be forgotten that there are other biological threats still emerging, as seen recently with avian in- fluenza (H5N8) in Russia (16) and the African Swine Fever in Poland (17). These examples and other situations have been mainly dealt with by the national structures in which the threat emerges, a context that, despite being local, may reach the plane- tary scale if not controlled and for which there is little to no international response. It is important to note that every nation has a responsibility in preventing and reducing disaster risk, surpassing the national-level interventions, including cooperation with other nations and regions (18). Following this approach, reacting promptly to a threat requires having previously allocated, trained, certified resources in sufficient quantity and the capacity to travel to an- other part of the planet, if accepted and allowed, to immediately integrate the na- tional structures in an environment of full informational transparency. Pandemic pre- paredness investment is beyond almost all countries' capabilities, which greatly rein- forces the need to be thought out globally. Structures such as the WHO, ECDC, CDC and FEMA (national level) did not have the resources that would have been desira- ble at the beginning of the pandemic, ca- pable of being sufficient to mobilize coun- tries with the needed tenacity and re- sources (19,20). Namely, the WHO is the organization naturally dedicated to having the above mentioned global competencies. However, to be able to address this issue, it is essential to have a great reinforcement of human, financial and technological re- sources. In Western countries, the main Cooperation Bodies are the WHO, the Eu- ropean Centre for Disease Prevention and Control (ECDC) or the Federal Emergency Management Agency (FEMA) of CDC. These coordinating organisations need to have their skills and resources strength- ened to be able to deal proactively and appropriately with the epidemic/pandemic risk. Proposal of an operational mesostruc- tured In addition to strengthening international bodies whose nature leads them to a macro health policies approach, we propose the creation of a new entity, on a continental Lopes H, Middleton J. Learning from the pandemic, building increased international cooperation. (Position paper). SEEJPH 2021, posted: 26 September 2021. DOI: 10.11576/seejph-4760 P a g e 6 | 9 scale, with national representation in each country for connection to health systems. Therefore, it has a different nature and is complementary to the existing bodies with a vocation for field action in biological risk situations and the capacity to strength- en local structures designed to deal with disruptive health situations such as pan- demic contexts. Considering the pandem- ic/epidemic generating factors strongly related to contacts with wildlife, this entity should also integrate and consolidate vet- erinary and agricultural knowledge within the Public Health dimension. It is possible to capacitate this entity for action regard- ing other health threats besides pandemics (18): large-scale earthquakes, large indus- trial accidents as happened in Bhopal (21), or others that by nature exceed the coun- try's response capacity in the healthcare action sphere. Similar to the other risks already covered with this type of response, aid must not be read as a weakness in a given country but as a collective response to a common threat. Biohazard plans must be directly linked to the preparation for action on the field. The entity must know the concrete field where the threat occurs, the existing and missing resources, and the hierarchy of supply priorities for a given risk in a given location when the event occurs. The entity must also have the first materials available to support risk mitiga- tion. To properly perform its functions, the entity needs two fundamental competen- cies: knowledge management and emer- gency logistics (heavy materials as modu- lar hospitals fully equipped with devices, personnel and light materials as PPE/medicines stocks). In addition to be- ing guided by the latest scientific evidence and WHO advising, it must have the ca- pacity to analyze risk and advise policy- makers before substantial evidence is gathered, whenever the need to act is more pressing than the evidence available at that time. The difficulty of many governments and authorities in providing clear direc- tives was evident in the absence of scien- tific evidence, which resulted in numerous delays (22). Countries that opted for the proposed forms of decision that were sometimes more crisis management than scientific, ended up having better results as happened in South Korea and New Zea- land. 2PF-Strategy-operations concept Knowledge management The international body should have knowledge management competencies for the proactive monitoring of potential risks, anticipating as far as possible which bio- logical agents have pandemic capacity while designing strategic and tactical re- sponse plans that help containing the threat in early stages. The entity should promote training to national and international agents to interconnect, in case of a biologi- cal threat, and field exercises to test the respective systems' weaknesses and pro- vide them with tactical tools. We propose that the entity works on an association between risk and probability (Table 1). This will result in each continental zone having a Biohazard Letter that will allow governments to prepare conveniently, or at least have that opportunity. Table 1. Risk identification and action priority rankings Risk Probability High Medium Low High 1 2 3 Medium 2 3 4 Low 3 4 5 Note: The intersection of each risk level is identified as a scale from 1 to 5, in which 1 represents a primary priority and 5 repre- sents a lesser priority. Lopes H, Middleton J. Learning from the pandemic, building increased international cooperation. (Position paper). SEEJPH 2021, posted: 26 September 2021. DOI: 10.11576/seejph-4760 P a g e 7 | 9 The creation of data quality assurance tools about the threat must also encompass knowledge management work, such as ensuring easy consolidation of data and semantic sharing. Logistics Another competence of this supranational entity is to have a minimum reserve of protective materials (field Hospitals, criti- cal medical devices, PPE and other equip- ment) that enable the first action against a pandemic, at least in the early days, until industrial supply chains are adapted to the new reality. Under this view, time is criti- cal for prompt action and efficient crisis management. All threats contained in a first moment will be much easier to deal with than after spreading to large areas, as happened with COVID-19. The set of pro- cedures deployed in countries should also be worked on towards the greatest harmo- ny possible, at least at a level that allows for the reinforcement teams not to spend several days studying local procedures before starting to work (23). It must also be ensured that at least critical medical devices can interconnect. Furthermore, there is a need to respond to another point that has failed in the current pandemic data management. The entity should be respon- sible for previously defining the metrics of morbidity and mortality, systems of data collection, registration, and consolidation, to prevent information cacophony recur- rence in countries with different data col- lection times, metrics, and regional data, among other aspects. Whatever the data, it must be possible to consolidate with suffi- cient quality to be elements itself in com- bating the pandemic. The entity’s nature is essentially national, but it should not be exhausted. For example, it must provide for the capacity to reinforce other similar national branches when necessary. Again, there is a need to strengthen international cooperation. Still, for it to be effective, the types of action must be aligned between countries. For example, materials are com- patible, procedures are acceptable else- where, national laws and rules are not overlapped. Another critical point in creat- ing an entity of this nature is to support information management/literacy of the populations/literacy of journalists/literacy of politicians about the pandemic through specific and specialized communication tools. This set of proposals represents a significant investment. However, no more than millionths of the cost that has been incurred so far. The current century is like- ly to be the century of pandemics. Conclusions We must start preparing for the next pan- demic. The proposal aims to present an organizational alternative for improve- ments in many points that went wrong in the COVID-19 pandemic: international cooperation, scientific reading, prompt action, transmission mitigation, critical materials supply chains, decision-making processes, preventive action. Most West- ern action comprised waiting and acting with hospital facilities until exhaustion and accepting successive pandemic waves as something natural, which is not. COVID- 19 was worse enough not to repeat without having learned anything. The countries judged to be most well-prepared for a pan- demic in 2018, in many cases performed poorly. Much of the failures were attributable towards political posi- tions and indecision. There is no more room for national approaches. If politicians are able to commit to these new interna- tional mess structures, and an expanded and enhanced role for the World Health Organisation, it will be a demonstration of a willingness to pool sovereignty and recoil from the narrow-minded nation- alism that has cost so many lives in this pandemic. The world will be a safer place, and humanity will have stepped back from the cliff edge. References 1. Cheng VC, Lau SK, Woo PC, Yuen KY. Severe acute respiratory Lopes H, Middleton J. Learning from the pandemic, building increased international cooperation. (Position paper). SEEJPH 2021, posted: 26 September 2021. DOI: 10.11576/seejph-4760 P a g e 8 | 9 syndrome coronavirus as an agent of emerging and reemerging infec- tion. Clin Microbiol Rev 2007;20:660-94. 2. Klotz LC, Sylvester EJ. The conse- quences of a lab escape of a poten- tial pandemic pathogen. Front Pub- lic Health 2014;2:116. 3. Almond RE, Grooten M, Peterson T. Living Planet Report 2020- Bending the curve of biodiversity loss. Switzerland: World Wildlife Fund; 2020. 4. European Comission. European Health Emergency Preparedness and Response Authority (HERA) [Internet]. 2021. Available from: https://ec.europa.eu/info/law/better- regulation/have-your- say/initiatives/12870-European- Health-Emergency-Preparedness- and-Response-Authority-HERA- _en (accessed: March 30, 2021). 5. The Telegraph. No government can address the threat of pandemics alone – we must come together [In- ternet]. 2021. Available from: https://www.gov.uk/government/sp eeches/no-government-can- address-the-threat-of-pandemics- alone-we-must-come-together (ac- cessed: March 30, 2021). 6. UN, ISDR. Hyogo framework for action 2005–2015: Building the Resilience of Nations and Commu- nities to Disasters [Internet]. Kobe, Japan; 2005. Available from: https://www.unisdr.org/2005/wcdr/ intergover/official-doc/L- docs/Hyogo-framework-for-action- english.pdf (accessed: March 30, 2021). 7. UNISDR. Sendai Framework for Disaster Risk Reduction 2015 - 2030 [Internet]. Geneva; 2015. Available from: https://www.preventionweb.net/file s/43291_sendaiframeworkfordrren. pdf (accessed: March 30, 2021). 8. UN. COVID-19 Impacting Global Security with Heightened Volatili- ty, Increased Threats to United Na- tions Personnel, Secretary-General Says in New Report [Internet]. 2020. Available from: https://www.un.org/press/en/2020/ org1711.doc.htm (accessed: Janu- ary 15, 2021). 9. Braithwaite J, Tran Y, Ellis LA, Westbrook J. The 40 health sys- tems, COVID-19 (40HS, C-19) study. Int J Qual Health Care 2020;33:mzaa113. 10. Gaub F, Boswinkel L. COVID-19: the geopolitical implications of a global pandemic [Internet]. Euro- pean Parliament’s Committee on Foreign Affairs. 2020. Available from: https://www.europarl.europa.eu/Re gDa- ta/etudes/STUD/2020/603511/EXP O_STU(2020)603511_EN.pdf (ac- cessed: March 30, 2021). 11. The Guardian. US accused of “modern piracy” after diversion of masks meant for Europe [Internet]. 2020. Available from: https://www.theguardian.com/worl d/2020/apr/03/mask-wars- coronavirus-outbidding-demand (accessed: May 5, 2021). 12. The Guardian. The world needs a patent waiver on Covid vaccines. Why is the UK blocking it? [Inter- net]. 2021. Available from: https://www.theguardian.com/com mentisfree/2021/apr/18/patent- waiver-covid-vaccines-uk- vari- ants?CMP=Share_iOSApp_Other (accessed: April 19, 2021). 13. Wong BLH, Delgrange M, Martin- Moreno JM, Manfred S Green, Middleton J. Covid-19 vaccines: a game of power jabs [Internet]. 2021. Available from: https://blogs.bmj.com/bmj/2021/04 /16/covid-19-vaccines-a-game-of- Lopes H, Middleton J. Learning from the pandemic, building increased international cooperation. (Position paper). SEEJPH 2021, posted: 26 September 2021. DOI: 10.11576/seejph-4760 P a g e 9 | 9 power-jabs/ (accessed: April 19, 2021). 14. Herlitz A, Lederman Z, Miller J, Fleurbaey M, Venkatapuram S, Atuire C, et al. Just allocation of COVID-19 vaccines. BMJ Glob Health 2021;6:e004812. 15. Euractive. Germany, Austria, Spain, Commission to help Portu- gal deal with third COVID-wave [Internet]. 2021. Available from: https://www.euractiv.com/section/p olitics/short_news/germany- austria-spain-commission-to-help- portugal-deal-with-third-covid- wave/ (accessed: March 10, 2021). 16. WHO. Human infection with avian influenza A (H5N8) – the Russian Federation [Internet]. 2021. Avail- able from: www.who.int/csr/don/26-feb-2021- influenza-a-russian-federation/en (accessed: March 30, 2021). 17. ter Beek V. ASF Poland: Virus hits farm in the west with 16,000 pigs [Internet]. 2021. Available from: https://www.pigprogress.net/Health /Articles/2021/3/ASF-Poland- Virus-hits-farm-in-the-west-with- 16000-pigs-724368E/ (accessed: March 30, 2021). 18. UNISDR. Sendai Framework for Disaster Risk Reduction 2015 - 2030. Geneva; 2015. 19. Kuznetsova L. COVID-19: The World Community Expects the World Health Organization to Play a Stronger Leadership and Coordi- nation Role in Pandemics Control. Front Public Health 2020;8:470. 20. Maani N, Galea S. COVID-19 and Underinvestment in the Public Health Infrastructure of the United States. Milbank Q 2020;98:250. 21. Mandavilli A. The World’s Worst Industrial Disaster Is Still Unfold- ing [Internet]. 2018. Available from: https://www.theatlantic.com/scienc e/archive/2018/07/the-worlds- worst-industrial-disaster-is-still- unfolding/560726/ (accessed: Jan- uary 15, 2021). 22. Abbasi K. Covid-19: Politicisation, “corruption,” and suppression of science. BMJ 2020;371:1-2. 23. The Portugal News. German team starts treating first patients today [Internet]. 2021. Available from: https://www.theportugalnews.com/ news/2021-02-08/german-team- starts-treating-first-patients- today/58152 (accessed: March 10, 2021). _________________________________________________________________________ ____________________________________________________________________ © 2021 Lopes et al; This is an Open Access article distributed under the terms of the Creative Commons Attrib- ution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. https://www.theatlantic.com/author/apoorva-mandavilli/ 2PF-Strategy-operations concept Knowledge management Logistics Conclusions References 1. Cheng VC, Lau SK, Woo PC, Yuen KY. Severe acute respiratory syndrome coronavirus as an agent of emerging and reemerging infection. Clin Microbiol Rev 2007;20:660-94. 2. Klotz LC, Sylvester EJ. The consequences of a lab escape of a potential pandemic pathogen. Front Public Health 2014;2:116. 3. Almond RE, Grooten M, Peterson T. Living Planet Report 2020-Bending the curve of biodiversity loss. Switzerland: World Wildlife Fund; 2020. 4. European Comission. European Health Emergency Preparedness and Response Authority (HERA) [Internet]. 2021. Available from: https://ec.europa.eu/info/law/better-regulation/have-your-say/initiatives/12870-European-Health-Emergency-Preparedness-and-Re... 5. The Telegraph. No government can address the threat of pandemics alone – we must come together [Internet]. 2021. Available from: https://www.gov.uk/government/speeches/no-government-can-address-the-threat-of-pandemics-alone-we-must-come-together (a... 6. UN, ISDR. Hyogo framework for action 2005–2015: Building the Resilience of Nations and Communities to Disasters [Internet]. Kobe, Japan; 2005. Available from: https://www.unisdr.org/2005/wcdr/intergover/official-doc/L-docs/Hyogo-framework-for-actio... 7. UNISDR. Sendai Framework for Disaster Risk Reduction 2015 - 2030 [Internet]. Geneva; 2015. Available from: https://www.preventionweb.net/files/43291_sendaiframeworkfordrren.pdf (accessed: March 30, 2021). 8. UN. COVID-19 Impacting Global Security with Heightened Volatility, Increased Threats to United Nations Personnel, Secretary-General Says in New Report [Internet]. 2020. Available from: https://www.un.org/press/en/2020/org1711.doc.htm (accessed: Jan... 9. Braithwaite J, Tran Y, Ellis LA, Westbrook J. The 40 health systems, COVID-19 (40HS, C-19) study. Int J Qual Health Care 2020;33:mzaa113. 10. Gaub F, Boswinkel L. COVID-19: the geopolitical implications of a global pandemic [Internet]. European Parliament’s Committee on Foreign Affairs. 2020. Available from: https://www.europarl.europa.eu/RegData/etudes/STUD/2020/603511/EXPO_STU(2020)60... 11. The Guardian. US accused of “modern piracy” after diversion of masks meant for Europe [Internet]. 2020. Available from: https://www.theguardian.com/world/2020/apr/03/mask-wars-coronavirus-outbidding-demand (accessed: May 5, 2021). 12. The Guardian. The world needs a patent waiver on Covid vaccines. Why is the UK blocking it? [Internet]. 2021. Available from: https://www.theguardian.com/commentisfree/2021/apr/18/patent-waiver-covid-vaccines-uk-variants?CMP=Share_iOSApp_Other (ac... 13. Wong BLH, Delgrange M, Martin-Moreno JM, Manfred S Green, Middleton J. Covid-19 vaccines: a game of power jabs [Internet]. 2021. Available from: https://blogs.bmj.com/bmj/2021/04/16/covid-19-vaccines-a-game-of-power-jabs/ (accessed: April 19, 2021). 14. Herlitz A, Lederman Z, Miller J, Fleurbaey M, Venkatapuram S, Atuire C, et al. Just allocation of COVID-19 vaccines. BMJ Glob Health 2021;6:e004812. 15. Euractive. Germany, Austria, Spain, Commission to help Portugal deal with third COVID-wave [Internet]. 2021. Available from: https://www.euractiv.com/section/politics/short_news/germany-austria-spain-commission-to-help-portugal-deal-with-third-cov... 16. WHO. Human infection with avian influenza A (H5N8) – the Russian Federation [Internet]. 2021. Available from: www.who.int/csr/don/26-feb-2021-influenza-a-russian-federation/en (accessed: March 30, 2021). 17. ter Beek V. ASF Poland: Virus hits farm in the west with 16,000 pigs [Internet]. 2021. Available from: https://www.pigprogress.net/Health/Articles/2021/3/ASF-Poland-Virus-hits-farm-in-the-west-with-16000-pigs-724368E/ (accessed: March 30, 2021). 18. UNISDR. Sendai Framework for Disaster Risk Reduction 2015 - 2030. Geneva; 2015. 19. Kuznetsova L. COVID-19: The World Community Expects the World Health Organization to Play a Stronger Leadership and Coordination Role in Pandemics Control. Front Public Health 2020;8:470. 20. Maani N, Galea S. COVID-19 and Underinvestment in the Public Health Infrastructure of the United States. Milbank Q 2020;98:250. 21. Mandavilli A. The World’s Worst Industrial Disaster Is Still Unfolding [Internet]. 2018. Available from: https://www.theatlantic.com/science/archive/2018/07/the-worlds-worst-industrial-disaster-is-still-unfolding/560726/ (accessed: January 15, 2021). 22. Abbasi K. Covid-19: Politicisation, “corruption,” and suppression of science. BMJ 2020;371:1-2. 23. The Portugal News. German team starts treating first patients today [Internet]. 2021. Available from: https://www.theportugalnews.com/news/2021-02-08/german-team-starts-treating-first-patients-today/58152 (accessed: March 10, 2021).