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In March, officials from 194 countries came together to agree on a global plan to deal with a threat known as “Disease X”.
The ominous code name refers to the as yet unknown illness expected to one day ravage the world in a repeat of Covid-19 — or perhaps inflict even worse damage.
This fear has now driven nine rounds of painstaking international negotiations on the text of the world’s first pandemic treaty, which must be nailed down before the World Health Organization’s decision-making annual assembly meets in May.
The accord is aimed at helping governments, institutions and populations avoid the mistakes of the Covid crisis — but getting there is causing deep divisions.
In the talks that have taken place online and in person in Geneva, low and middle-income countries are pressing rich nations and pharma companies to go much further than they have previously done on sharing life-saving health resources.
Some conservatives in the US and beyond argue the treaty is already too far-reaching. When the latest round of talks closed without agreement on March 28, the headline of a Fox News story railed: “Disease X: Critics say Biden admin selling out US sovereignty with WHO treaty.”
In the background, growing geopolitical tensions between powerful countries and political changes within some of them threaten to derail the treaty’s aims.
At the heart of the storm is WHO director-general Tedros Adhanom Ghebreyesus, who remains confident that countries will agree some version of the accord by its deadline. “They know who wants what,” he says. “So it’s time for give and take now.”
Yet other observers are anxious that the historic deal, the most ambitious of a number of initiatives to improve pandemic preparedness, could yet founder.
Such an outcome would damage wider efforts to remedy the serious failures of monitoring, responsiveness and international co-operation that contributed to millions of deaths and the severe economic and social damage caused by Covid-19.
“I hope the experience of the pandemic reminds people that when these events happen, certainly at that scale, they do truly become global security concerns,” says Richard Hatchett, chief executive of the international Coalition for Epidemic Preparedness Innovations (Cepi). “Health security, economic security and even national security are imperilled when infectious diseases spin out of control.”
Countries must take the opportunity to overhaul the world’s healthcare architecture rather than simply let the lessons from Covid-19 dissipate, says Ashley Bloomfield, a former New Zealand health official who is co-chair of a parallel global negotiation to amend the WHO’s International Health Regulations.
Responses to disease outbreaks have historically been a “cycle of panic and neglect”, he says. “Because we are so good at moving on to the next things as humans — that’s part of our survival strategy — there’s almost this collective global amnesia.”
But currently “there’s a huge degree of engagement by countries; they recognise their responsibility — and that the moment is now”.
For as long as humans have been plagued by infectious diseases, the next pandemic has been a question of when rather than if.
But the Covid-19 outbreak highlighted how many risk factors are greater now than at any time in history. There are more people in the world, living more densely and in a more mobile way.
These trends, plus increasingly intensive livestock agriculture and poorly-regulated trading in animals, have increased the danger of zoonotic diseases, where pathogens transmit from animals to humans.
Zoonotic threats have long been with us — rabies and salmonella are two examples — and they account for many newly identified infectious diseases and some of the most worrying recent health threats, such as the Ebola virus that broke out in west Africa in 2014.
These factors, combined with the grim experience of Covid-19, spawned the idea of an international treaty for pandemic preparedness and response.
It was also supposed to be a way to heal ruptures after the spectacle of powerful rich countries buying up billions of vaccine doses for themselves, while much of the world had minimal access to jabs.
In a joint article published in March 2021, two dozen leaders of countries including the UK, France, South Africa and Indonesia proposed the agreement to “foster an all of government and all of society approach”. Their aim was to improve global co-operation on alert systems, data sharing and research, as well as the production and distribution of health “countermeasures”, such as vaccines, medicines, diagnostics and personal protective equipment.
The finished pandemic treaty would be a framework of ethical obligation rather than legal compulsion. Its specific funding demands are limited and it will not contain a mechanism to hold countries accountable for breaching it.
Nonetheless, the draft treaty has sparked accusations that it is a WHO power-grab, despite the global health body’s insistence it is anything but.
The accord has revived criticisms from people who are suspicious of multilateral institutions. They question the WHO’s fitness for purpose and point to concerns about its pandemic performance, such as the time it took to fully embrace the crucial point that Covid-19 spreads through airborne transmission. In its defence, the WHO says its thinking evolved with the evidence and that it always advised people to be cautious.
In February, Brad Wenstrup, the Republican chair of the US House select subcommittee on the coronavirus pandemic, criticised the treaty’s proposed funding implications for the US and its call for companies to consider sharing proprietary information. The accord must not “violate international sovereignty or infringe upon the rights of the American people or the intellectual property of the United States”, he said.
Such critiques have already shaped the treaty. It has a special clause listing powers it will not confer upon the WHO, such as “to ban or accept travellers, impose vaccination mandates or therapeutic or diagnostic measures, or implement lockdowns”.
The inclusion of such language shows how member states are “really worried” about disinformation and misinformation about the treaty’s impact, the WHO’s Tedros says. “The sovereignty of countries will not be compromised.”
But for all the intensity of the arguments over the treaty’s reach, the negotiations themselves have so far been dry and drawn-out.
Draft text is displayed on screen and then marked with brackets or suggested alternative wordings where countries want to make changes. “It becomes very difficult to read,” says one participant, who asked not to be named because of the sensitivity of the talks. “But it’s the way you have to decide, so it’s transparent to all delegations.”
One big source of disagreement has been over detecting and sharing information about new pathogens. The Group for Equity, made up of Asian, African and Latin American countries, wants firm rules in place.
This would involve pharmaceutical companies helping to fund the monitoring of new pathogens, which would in turn speed efforts at vaccine development. Genetic information would be disseminated through a mechanism known as the Pathogen Access and Benefit-Sharing System (Pabs).
But the proposal has run into opposition from the pharmaceutical industry. “In the negotiations, there is implicitly the threat that if you don’t pay, they will not share the information,” says Thomas Cueni, outgoing head of the International Federation of Pharmaceutical Manufacturers and Associations, a global industry group. “That would be shooting yourself in the foot. Monetising access to pathogens is a no-go.”
Pharma companies are prepared to help improve aspects of pandemic preparedness, Cueni adds. They would sign up for “binding commitments for allocation” of vaccines, antivirals and other drugs to organisations such as the WHO, the Gavi vaccine alliance and Unicef, the UN’s children fund. These commitments could involve donations and “equity-based tiered pricing” — agreements to provide lower prices on vaccines or other treatments to low-income countries.
But the pharma industry wants to avoid waiving intellectual property rights on vaccines, as exclusive rights to drugs are the foundation of their business model. It proposes instead maintaining voluntary collaboration. This would involve sharing information between companies discovering vaccines and big generic medicines manufacturers that can mass produce them, such as India’s Serum Institute.
Promises to extend vaccine production facilities beyond traditional centres such as the US, Europe and India have so far yielded modest results. Last year, the WHO and South Korea signed a deal to make the East Asian country a global training hub to help low and middle-income countries produce vaccines and other medicines.
In December, BioNTech, the German company that developed the groundbreaking mRNA Covid vaccine mass produced by Pfizer, said it planned to start production at a $150mn mRNA jab production facility in Rwanda by 2025. The facility is made up of so-called BioNTainers — labs fashioned from modular shipping containers.
In South Africa, biotech company Afrigen Biologics and Vaccines will, once licensed, be able to produce about 50mn doses of an mRNA jab in a year in the event of a new pandemic, says its managing director, Petro Terblanche. While the African continent is “much better off” than it was two or three years ago, capacity is still small compared with its more than 1.4bn population, she says. Technical difficulties such as ensuring mRNA vaccines can be refrigerated throughout production, distribution and storage remain pronounced.
“The biggest challenge to this programme is investment,” Terblanche adds.
The question of how much money is actually being spent on improving pandemic preparedness is hard to answer.
The World Bank, with the help of the WHO, has set up a Pandemic Fund to help low and middle-income countries improve their preparedness and responsiveness. The bank said in February that it had raised more than $2bn in seed capital from 27 contributors. It said that each dollar awarded in its first round of project funding announced in July had catalysed a further $6 of investment.
Resource allocation for disease control remains highly contentious. The Covid pandemic showed how rhetorical commitments to share vital supplies often were not reflected in reality, as rich countries prioritised their own citizens.
“If there’s anything we learnt from the Covid-19 pandemic, it is that good intentions don’t tend to translate into the same actions in an emergency,” says Ebere Okereke, chief executive of the non-governmental Africa Public Health Foundation and a global health security specialist, speaking in a personal capacity.
The resources dispute is a part of a set of geopolitical differences that must be overcome, or at least managed, if the pandemic treaty and wider preparedness efforts are to succeed.
One festering controversy is over the continued mystery about exactly how Covid emerged in China in late 2019. International investigators have had only restricted access, leaving crucial questions such as whether the virus emerged from a laboratory leak unanswered.
The WHO wrote to China again last week appealing for more co-operation, since understanding how the Covid pandemic started is essential for both scientific and moral reasons, says Tedros. “We still don’t know the answer — and that in some way could blind us when the next pandemic comes along,” he says.
Beijing has participated in the pandemic treaty talks, arguing that the accord should focus on the “practical needs of developing countries and reflect the principles of fairness, solidarity, consensus and inclusiveness”, according to the government-controlled China Daily newspaper.
At the same time, China — like other great powers — wants to preserve sovereignty and flexibility of action, according to a paper analysing the country’s motives and actions published in January in the journal Frontiers in Public Health. “While endorsing global co-operation, China insists on voluntary terms without impinging on policy space,” the authors write.
Another uncertainty for the treaty is US involvement. Supporters of the accord say it must be agreed before the country’s presidential elections in November, in case Donald Trump returns to power. In July 2020, Trump triggered the formal process to pull his country out of the WHO; the following January, Joe Biden reversed that decision in one of his first acts after becoming president.
The US poll is part of a wider political turbulence from scores of national elections being held in 2024. In addition, countries including Nigeria, Pakistan and Egypt are preoccupied with financial crises, notes Chikwe Ihekweazu, a WHO assistant director-general who led the Nigeria Centre for Disease Control and Prevention during the Covid-19 pandemic. All this has a potential impact on an array of factors “required to deliver” pandemic preparedness, including workforce, institutions, fiduciary mechanisms and supply chains, he adds.
Ihekweazu welcomes the creation of institutional infrastructure in more countries to deal with big public health threats. At least 114 countries either have or are developing a national public health agency, the WHO says, although as many as 80 still lack any such provision.
As the head of the new WHO Hub for Pandemic and Epidemic Intelligence, based in Berlin, Ihekweazu’s main work now includes improving international data collection and sharing. Even politically allied countries struggled with information sharing during the pandemic, he says, while some federated nations suffered from poor communications within their own borders.
The hub contains a cluster of initiatives aimed at improving sharing of pandemic-relevant information such as the demographics, distribution, mobility and general health of populations. One, called Epidemic Intelligence from Open Sources, is now used by about 70 countries. A second is an international pathogen surveillance network to collect, sequence and analyse emerging threats.
Despite all these developments, Ihekweazu believes that efforts to improve pandemic preparedness are still hampered by the wounds of the previous crisis.
“You had universal access to information, but no access to vaccines,” he says, recalling the “wrath of public opinion” he faced at the Nigeria CDC. “That, I think, is at the heart of the trust deficit — and at the heart of the very difficult discussions happening.”
The pandemic treaty supporters’ vision of a targeted, equitable and harmonious effort to combat the next global health crisis is still far from realisation. The final negotiations will be a test of whether countries can set aside gripes and in some cases widening divisions.
Even if some of the treaty’s provisions are scaled back, the hope is that the effort will still lead to significant improvements on the previous pandemic response. The WHO’s Tedros says members could at least agree a “high level” text for the accord, even if some details need to be settled later.
It is clear that pandemic preparedness and health security are now “very salient for senior officials and governments all over the world”, says Hatchett of Cepi.
He admits to concerns about the global political atmosphere, but argues that it is in everyone’s interests to prepare better for the inevitable next global health calamity. “It’s particularly important for countries to work together and work across sectors,” Hatchett says. “There are still opportunities for collaboration and co-operation, even in a fragmented world.”
Additional reporting by Sarah Neville and Ian Johnston in London
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