What should we ask of a new global treaty for pandemic preparedness?

Supra-national health action agencies are needed in every WHO region or continent, to predict, prevent and respond to pandemics

Twenty five of the world’s leaders recently called for a new global treaty for pandemic preparedness and response for the future. Joe Biden, President of the US, recently asked US Congress for funding for two agencies to tackle health and climate change. The UK government has invoked a term first proposed by the UN in 1994health security, for the new incarnation of its national health protection service. The European Union proposes a Health Emergency Response Agency (HERA) set in the context of a wider European Health Union. There has long been a need for more concerted global action on climate change, migration and conflict, human trafficking, environmental degradation, loss of biodiversity and gross inequality in economic resources across the globe. Until now this has not been sufficiently compelling for politicians to take a world view. Pandemic flu has for many years featured in national risk registers. Covid-19 appears to have finally brought the realisation that the 21st century could become the era of pandemics. This is prompting political calls for global machinery for response.  

We should learn from the current pandemic to inform how our global leaders might fund and develop real tools to respond better to pandemics in the future, through a new treaty. Many of the countries judged to be most well prepared for a pandemic in 2018, have performed poorly. Many of their failures are attributable to political positions and indecision. Health systems were positioned in a bureaucratic-normative way, with a naive and arrogant view that they could accommodate the pandemic within existing healthcare capacity. There was little conceptual preparation for surveillance, response, or coordination of actions in the field, and in many cases a disconnect between local and national actions. There were no strategic reserves of personal protective equipment, nor significant hospital reserves (facilities and capacity). Governments were, and still are, nationalistically centered, paying little attention to World Health Organization (WHO) or other international authorities. There has been limited knowledge transference and adoption of policies from the countries that had the earliest experience, and know more about SARS-CoV-like viruses and infectious diseases preparedness. There has also been little evidence that governments adopted the priorities of the Sendai major disaster response framework 2015-2030 namely: understanding disaster risk; strengthening disaster risk governance; investing in disaster risk reduction, and enhancing disaster preparedness for effective response and to “Build Back Better” in recovery, rehabilitation, and reconstruction. 

Investing in pandemic preparedness is beyond almost all countries’ capabilities so must be thought out on a global scale. The WHO is the organization naturally dedicated to having these global competencies. However, to be able to address this issue, it is essential to greatly reinforce its human, financial, and technological resources. Our leaders need to propose the tools by which such a treaty would have meaningful resources to deliver on its aims. 

We can consider pandemic response at “global,” “regional/continental” and “national” levels. There is visible international agreement on what needs to happen on vaccines, but so far the distribution across the globe has been more about realpolitik and profiteering.

At a global level any new treaty on pandemic preparedness will need to be moved through tortuous processes to be ratified. New UN treaties should, and can be applied to problems which are of global concern and growing significance. These cannot be managed by single nations. Current international regulations have proved inadequate for control or prevention. To back up a treaty, resources are needed to grow capacity and expertise in the organisations charged with global action on our behalf, principally United Nations Organisations, including the WHO. Governments must commit to new policies, new global governance, and invest in additional human resources, equipment, and services to make action happen. National leaders will need to be willing to cede authority to supranational structures and services, and to call on these themselves. Reliance on international assistance should not be minimal and be seen as a failure of the local political response. In the covid-19 pandemic, international reinforcements that existed were vestigial, for example, in the case of Portugal and now India. Governments also need to share information fully and transparently, for the greater effectiveness of global pandemic response.

At the WHO regional, or continental level, there needs to be a commitment to setting up hands-on supra-national health action agencies. These must be well resourced and able to mobilise in response to unfolding emergencies. They could be extended operational arms of WHO regional offices and related to UN capacity in other fields such as the Food and Agriculture Organisations and other international agencies. The Health Emergency Response Agency (HERA) proposed for the European Union may offer an alternative model. In the fields of volcanology and forest fire management supranational organisations have been well established and effective for many years. 

The supra-national health action agencies will need to hold knowledge and data management competencies for pro-active monitoring of potential risks, anticipating as far as possible which biological agents have pandemic capacity while designing strategic and tactical response plans to contain threats in their initial moments. They will also need intelligence and logistic capacity, having plans, for instance, to respond to a “jump to humans, of viruses such as the African Swine flu virus in Poland, or the H5N8 avian flu virus in Russia, or other health threats like locust infestation or volcanic eruption. These supra-national health action agencies will need to hold reserves of critical medical devices, personal protective equipment (PPE), vaccines and other equipment, that enable instantaneous action against a pandemic, until industrial supply chains are adapted to the new reality. Time will be critical for prompt action and efficient crisis management. 

During the twentieth century, the world developed supranational bodies where it clearly benefited the common good of nations; the ultimate example of this is the United Nations. In an increasingly globalized and small world where everything tends to occur almost simultaneously, only international solutions based on co-operation will be able to respond to major issues since what affects one 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. Only through this highest commitment to international cooperation will it be possible to find appropriate solutions, to supply equipment volumes at an adequate time and acceptable prices, and with universal standards and applicability, and to exchange of experiences to debug national procedures. 

The leaders’ call for a new global treaty on pandemic responses is not yet realistically matched by recognition of the need to prevent pandemics. The destruction of ecosystems by humans—plundering rainforests and the oceans, throwing together humans and animal species in ways previously limited, and setting the conditions through which microorganisms can jump species. The conditions for the growth of pandemics are set in humankind’s insatiable lust for land, international travel, accumulation of consumer goods, combined with the capacity for exploitation and conflict. The lethality of a pandemic is manifest in grotesque inequalities in the burden of ageing, obesity, addiction, and non-communicable disease within and between countries, ethnic groups, genders, and minorities. 

Politicians need to commit resources to prevent pandemics, to build new international meso-structures—supra-national health action agencies—and to build an expanded and enhanced role for the WHO. If they can demonstrate willingness to do this, to pool sovereignty and recoil from the narrow minded nationalism that has cost three million lives so far in this pandemic, the world will be a safer place and humanity will have stepped back from the cliff edge. 

Henrique Lopes, Catholic University of Lisbon.

John Middleton, President, Association of Schools of Public Health in the European Region. 

Competing interests: none declared.