At the World Government Summit in Dubai in February 2018, Dr Tedros, the Director-General of the World Health Organization (WHO) gave an alarming caution that the world was unprepared for a global pandemic. Following this meeting several studies and reports identified major weaknesses in pandemic preparedness globally, with stronger capacities reported in Western and some East and South-East Asian countries. [1-5] The first annual report of the Global Preparedness Monitoring Board (GPMB) in 2019 identified the most urgent actions required to accelerate preparedness for health emergencies.  However, as the covid-19 pandemic has spread throughout the world, it has uncovered serious gaps in preparedness almost everywhere and raised concerns about the validity of earlier assessments. Unfortunately covid-19 is still raging with nearly 162 million people infected and over 3.3 million lives lost globally. 
The International Health Regulations (IHR 2005) are a legally binding instrument “for protection against the international spread of disease.”  This key global health instrument was updated in 2005 following the Severe Acute Respiratory Syndrome (SARS) epidemic in the early 2000s to strengthen global capacity to quickly control and curb spread of outbreaks. However, in the face of a global pandemic with a novel coronavirus, SARS-CoV-2, the IHR have proved to be a less effective tool.  Several of the failures of the global response to the ongoing pandemic are rooted in either poor compliance with the IHR (2005) or are beyond the domain of the IHR (2005), including inadequate political leadership, governance, and financing [10,11].
On 30 March 2021, 26 heads of government joined the WHO’s Director-General and the President of the European Council, to unanimously call for an international treaty for pandemic preparedness and response. [12,13]. Although all these leaders urged “solidarity” and greater “societal commitment,” there was no indication that any country would change its own approach to the pandemic response.  This was soon followed by global health policy experts highlighting the need for better compliance with and more robust enforcement of IHR (2005). As debate grows regarding the merits of the treaty, major questions remain regarding the willingness of countries to commit to and ratify another legally binding instrument designed to promote health security by complementing—not replacing—the IHR (2005).  This topic will be a major point of discussion at the upcoming 74th World Health Assembly which will take place virtually from 24 May to 1 June.
What should an international treaty contribute to pandemic preparedness and response? Firstly, it should aim to mobilize political and financial commitments from the highest levels of government, something urgently needed as the covid-19 pandemic has shown. Secondly, it should provide a legally binding framework for the establishment of the principles, priorities, and targets. Thirdly, it should address some of the key gaps that have been identified in the course of the covid-19 pandemic that are beyond the purview of the IHR (2005). Among these are improved global health architecture for pandemic preparedness and response; improved mechanisms for sharing specimens and genomic data; an effective global pandemic supply chain mechanism; a global health workforce that could surge in support of countries; and accelerated research and innovation for countermeasures. At national level, it could promote a whole-of government and whole-of society approach that would build the necessary IHR capacities and public health infrastructure, promote community readiness, and invest in health.
The concept of such a treaty is very appealing given the collective failures of the current response. In fact, the power of international treaties for public health has long been under-appreciated, and the only successful example is perhaps the adoption of the WHO Framework Convention on Tobacco Control in 2003 (FCTC). 
The benefits of such a treaty would be widespread, with those living in low and lower middle-income countries benefitting the most. While absolute case numbers may have been lower in developing countries compared to high-income countries, the economic and social impact of the pandemic have disproportionately impacted the poorest. This has been due to the related disruptions of exports, tourism, remittances, and foreign aid from the developed world which are estimated to have pushed between 117 – 130 million people into severe poverty during 2020. [17, 18] Committed implementation of the proposed provisions of the treaty, together with more rigorous compliance with IHR (2005), would not only promote global health security, they would protect lives and livelihoods across the globe.
We see significant value in an international treaty in the WHO’s Eastern Mediterranean Region (EMR) where nearly 700 million people live in a mosaic group of 22 countries and territories from the Middle East and North Africa, and South and West Asia. Many countries face poverty, lack of health infrastructure, security upheavals, population displacements, and present overall poor health profiles. Over the past two decades several of the countries of the region have experienced outbreaks from emerging infectious diseases with a potential to cause epidemics or pandemics.  Currently, covid-19 has substantially impacted the EMR, while some Gulf countries in the region had earlier experienced another novel coronaviruses outbreak (MERS-CoV). 
The EMR is prone to rapid spread of infectious diseases, as there is frequent cross-border movement, and many countries are travel hubs, with millions of international travellers visiting the region each year for tourism, business, and pilgrimage.  The decision of the Kingdom of Saudi Arabia to drastically restrict Hajj pilgrimage and to cancel the Umrah pilgrimage during the covid-19 pandemic has offered a good model for other countries.  A new treaty could help foster similar measures of decisive actions during disease outbreaks.
It is not only vulnerable EMR countries that lack the capacity to invest in pandemic preparedness, but many other countries in the world do not prioritize preparedness either. Therefore, the lessons we are learning from the current pandemic should be used to inform our policies to respond better to future pandemics. A lack of willingness to share data and information, or to partner with other countries (a “go solo” approach), as well as weak implementation of existing international laws, have dangerously hindered the containment of the ongoing pandemic. The proposed treaty should seek to foster mutual accountability, shared responsibility, transparency, and cooperation for data and information, and should ensure equitable and universal access to health technologies as well.  Such a treaty should prevent the widespread inequalities in access to healthcare that have been demonstrated with the covid-19 pandemic.
For us, a group of public health policy makers and professionals working for health and wellbeing in one of the world’s most volatile regions, the proposed treaty is not an option rather an urgent necessity. We join the call given by the Independent Panel for Pandemic Preparedness and Response that “covid-19 should be the last pandemic and with our failure to take preparedness seriously, we will condemn the world to successive catastrophes.”  However, the success of the proposed treaty on preparedness lies in its specificity. The overall objectives of such a treaty, ideally rooted in the WHO constitution, can be summarized as: to strengthen national, regional, and global capacities and resilience to future pandemics by adopting an all-of-government and all-of-society approach; to prevent poor collaboration and unwillingness to share information that can obstruct future pandemic responses; and being accountable or our actions which can either secure or threaten global health security. Ultimately, in a pandemic no one is safe, until everyone is safe.
Faouzi Mehdi, Minister of Health Tunisia, Ahmed Mohammed Obaid Al Saidi, Minister of Health Oman, Fawsiya Abikar Nur, Federal Minister of Health & Social Care Somalia, Yves Souteyrand, WHO Representative Tunisia, Jean Jabbour, WHO representative Oman, Mamunur Malik, WHO Representative Somalia, Abdinasir Abubakar, Manager WHO Health Emergencies Programme, WHO Regional Office for the Eastern Mediterranean, Wasiq Khan, Team Lead WHO Health Emergencies Programme, WHO Regional Office for the Eastern Mediterranean, Richard Brennan, Regional Emergency Director WHO Regional Office for the Eastern Mediterranean, Rana Hajjeh, Director Programme Management WHO Regional Office for the Eastern Mediterranean, Ahmed Al-Mandhari, Regional Director WHO Regional Office for the Eastern Mediterranean.
Disclaimer: The views expressed herein are personal and do not necessarily reflect the views of the World Health Organization
Competing interests: none declared
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