Is a global pandemic prevention pact within reach?

The World Health Organization’s governing body is scheduled to meet on May 27 to discuss a critically needed plan for global pandemic preparedness.

The organization’s 194 members began discussing a global agreement more than two years ago, as the ravages wrought by the COVID-19 pandemic became apparent, but a pact intended to ensure equitable resources for all member countries has thus far failed to generate an accord.

As the meeting looms, WHO chief Tedros Adhanom Ghebreyesus has sounded the alarm that the organization has hit a wall in its push for an agreement.

Supporters of the agreement in its current form say the plan is essential to protecting humankind from catastrophic outbreaks by ensuring that all nations have the capacity to detect and share information on emerging or evolving pathogens and the ability to provide timely access to tests, treatments, and vaccines. While accepting that an agreement is necessary, some critics have aired concerns that the proposal, in its present form, could give WHO unfettered power to impose severe measures.

Ghebreyesus has rejected those claims and said that a failure to reach agreement would be “a missed opportunity for which future generations may not forgive us.”

Harvard Medical School global health expert Margaret Bourdeaux, an assistant professor of medicine and of global health and social medicine and a member of the HMS-led Massachusetts Consortium on Pathogen Readiness, told Harvard Medicine News that an agreement could help ameliorate serious gaps in preparedness that could impede an effective collective response to a new pathogen.

Bourdeaux, whose research and fieldwork focus on health systems and institutions in conflict-affected states, is also the research director for the HMS Program in Global Public Policy and Social Change.

What is the heart of the WHO agreement? What are its most essential elements?

The proposed agreement is meant to address some of the most egregious problems the world experienced during the COVID-19 pandemic, including access to vaccines, medicine, and personal protective equipment based on country wealth rather than on need.

For example, one analysis estimated that 1.3 million people died in lower-income countries due to inequitable distribution of vaccines.

Other problems this agreement is meant to address include poorer countries’ dependence on richer ones to conduct research, to develop and manufacture countermeasures, to address the variable and patchy surveillance across countries, and the uneven reporting and health care delivery capabilities within and across countries that lead to delays in warnings and situational awareness.

The importance of these elements cannot be overstated because poor planning and gaps in social protection systems lead to gross inequities within countries with respect to exposure, diagnosis, and care.

These and other problems are detailed in the 2023 report of the Independent Panel for Pandemic Preparedness & Response. This is the report that launched the pandemic agreement negotiations.

There are currently 39 articles in the draft pandemic agreement and at least two key sticking points. The first is the concept of “common but differentiated responsibilities,” which specifies when and how much countries will commit to pooling stockpiled countermeasures through the WHO, which would then distribute them based on need. There are also some controversial provisions promoting sharing of pathogen data and sequences, technology transfer, and intellectual property waivers so countries can more easily produce their own countermeasures.

The other sticking point is how this agreement will be governed, including how much authority will be given to the WHO to oversee it and how binding a commitment countries will need to make to be signatories.

The debate centers around a possible trade-off between an agreement that is maximally binding and quick to implement, but narrower in scope, versus a more comprehensive treaty that is less binding and takes longer to implement. The question then is do we want to be fast and nimble, narrow in scope but maximally proscriptive, or deliberate and slow but broader in scope.

What is at stake with the passage or failure of this measure?

It is in everyone’s interest to keep deadly pathogens from circulating and outbreaks from growing and spreading. Even for the most self-interested country, it makes little strategic sense to develop and hoard countermeasures and keep them from going to where they will make the biggest difference in stopping transmission of a deadly pathogen.

Thus, logically, it stands to reason for all countries to sign on to a commitment to pool resources through the WHO so countermeasures can go to where they are needed most and help everyone produce their own countermeasures.

However, countries don’t all see it that way: Some feel they have an obligation to their people first and foremost and don’t ever want to have to tell any of their citizens that they can’t have a vaccine, for example, because their risk is lower than that of a citizen of another country.

Many are naturally reluctant to make commitments to any political entity outside their country, relinquishing control of their resources to the WHO. Finally, there are concerns about undermining their own research and development industries, which can be powerful influencers.

So, this is a formidable collective action problem—it is strongly in everyone’s interest to work together, but everyone must give up something they value to achieve the desired outcome, trust everyone else to live up to their promises, and trust that the collective approach will work.

What’s broadly at stake is no less than the world’s ability to effectively respond to pandemics in the future and its ability to address a collective action problem where everyone wins, or everyone loses.

What do you think will be the fate of this proposed agreement, and what do you hope would be its fate, which may not be the same?

What excites me is that this agreement sets the table for a paradigm shift in pandemic response. The old paradigm is “every country for itself,” which is, well, one model. Maybe not the most effective model, but certainly the most expedient and one that arguably incentivizes countries to make investments in preparedness themselves.

The new “global immune system” paradigm imagines all of humanity as a single body, and no matter where a pathogen emerges, every locality, country, and region will have the ability to detect, investigate, report, and respond to an outbreak in that community, producing the medical and nonmedical countermeasures on-site or regionally to contain and extinguish it.

Just like when an individual gets a cut on their arm, there is a local immune reaction that tries to stave off infection, recruiting elements of the body’s immune system as needed to contain and mitigate any infection that does take hold. In this paradigm, pandemics can be viewed as sepsis events, when infection spreads to the entire population. Not ideal. In this paradigm, trying to keep people in your country disease-free during a pandemic is as foolish as trying to keep a single part of a person’s body, say, their foot, free from infection when a pathogen is circulating in their blood.

The parts of the pandemic agreement that I think are most interesting and crucial are those that spark investment and strengthen the abilities of countries or regions to develop, manufacture, and distribute their own countermeasures, regulate manufacturing supplies, and set common goals and standards about sharing information on emerging pathogens.

If some countries want to play party pooper and not commit to giving up any of their countermeasures, at least other countries wouldn’t be left with no recourse but to beg and plead. And if they have their own countermeasures, they may even have some leverage to negotiate with others.

My hope, of course, is that a robust treaty draft will be presented, voted on, and adopted at the World Health Assembly—one in which countries make firm commitments to countermeasure pooling and set standards for pathogen information sharing, and one that furthers poorer countries’ efforts to build out their countermeasure research and development and manufacturing capabilities.

However, going into the World Health Assembly on May 27, it looks like the chances of this happening are slim. In that case, my hope is that they will continue to negotiate after the meeting, rather than pass a watered-down agreement in the interim.