By Suerie Moon
2023 may make-or-break efforts to prepare the world for the next pandemic and to deal with pressing day-to-day diseases that touch the lives of billions. Governments have committed to an ambitious timeline to agree on not just one, but two, sets of international rules by May 2024: 1) amending the pre-existing International Health Regulations (IHR) that govern the cross-border spread of infectious disease, last updated nearly 20 years ago, and 2) crafting a broad, ambitious “pandemic instrument” (frequently referred to as a treaty) that could address many issues beyond the IHR’s scope. Everything is still open to negotiation, but the final agreements could have far-reaching consequences for how quickly we are able to detect and contain the spread of new pathogens at their source, who will get access to lifesaving vaccines and treatments, and how well day-to-day health systems function for their people, among other issues.
As of late 2022, governments had agreed to work from a “conceptual zero draft” of a pandemic treaty, a precursor to the zero draft that is to kick off negotiations in earnest starting in late February 2023. The road to this document has been long, but progress steady, even if slow. In late 2020, the idea of a pandemic treaty first began to circulate. In late 2021, World Health Organisation (WHO) Member States agreed to move forward with negotiations, and in mid-2022, they agreed that the instrument should be legally binding. Now the question is what obligations governments will be willing to make.
Five big questions loom.
The first is inequality. Here in Geneva, power disparities between countries often manifest in the size of diplomatic missions. Larger, wealthier countries often have dedicated teams of generalist health diplomats backed up by even larger teams of subject matter experts in their capitals. In contrast, many smaller countries – both wealthy and developing countries – often have just one diplomat expected to cover not just health but also human rights, disarmament, humanitarian crises, migration and the many other issues governed in Geneva. Some countries have no health representative in Geneva at all. This disparity makes it extremely challenging for many countries to influence pandemic treaty negotiations in a meaningful way; in turn, this may dampen the political buy-in required to implement these commitments down the line. Once international rules are agreed it can be very difficult to change them. In this way, international rules can institutionalise power inequalities at the time they were agreed upon, with repercussions for decades to come.
The second question is how delegates will contend with IHR negotiations that are currently picking up steam in parallel to the pandemics treaty negotiations. The IHR were the main international rules for governing pandemics prior to Covid-19. If this sounds a bit confusing, it is. The fact that we now have two international pandemic rulemaking negotiations taking place in parallel is, naturally, the result of a political compromise: between countries that found the IHR too weak during Covid-19 and pushed towards a pandemic treaty, and those that found the IHR more feasible to amend. We are already seeing a complex two-arena political negotiation as diplomats pursue their countries’ most important priorities in both. For example, obligations on governments to share sensitive information on new disease outbreaks, or to share technology, are likely to be negotiated in both the IHR and pandemic treaty simultaneously. This raises the very real possibility that nothing is agreed until everything is agreed and that all of this will take much longer than the 12-16 month timeline that governments have given themselves.
"Many countries agreed to pursue a treaty primarily to inject more equity into international rules."
A third question is how effectively the treaty will address longstanding concerns from developing countries regarding access to vaccines and other health technologies. On the one hand, intellectual property (IP) is the most obviously contentious issue in the current pandemic treaty draft, with extensively bracketed text and the longstanding North-South political divides. Talks at the World Trade Organisation (WTO) on temporarily lifting IP protections during the Covid-19 pandemic may outlast the pandemic itself, and have largely been a zero-sum game. On the other hand, the pandemic treaty may offer an opportunity for a package deal – if industrialised countries agree to share IP and technology, developing countries may agree to share the pathogen samples and related genomic sequencing data that is essential for both surveillance and the rapid development of diagnostic tests and vaccines. Many countries agreed to pursue a treaty primarily to inject more equity into international rules. A failure to agree on how to develop and share technology globally so that all can access them in the next pandemic could lead to a collapse of the entire project of regulating pandemics.
The fourth question is how geopolitical tensions will affect the ability to reach consensus. So far, with a few notable exceptions, global health has seemed relatively immune to the geopolitical divides that shaped 2022. For instance, the US, European and Russian proposals to amend the IHR emphasise different priorities but are not radically different. China has not put forward any IHR proposed amendments at all. But the real negotiations have yet to begin. Both the IHR amendments and pandemic treaty draft have taken great pains to reiterate the cardinal principle of sovereignty – meaning, for example, no mandatory international inspections of outbreak sites and no mandatory financing obligations. So far, the proposals seem to tiptoe gently around the possibility that WHO could interfere with the wishes of any sovereign state, relying primarily on the power of reputation, transparency and naming-and-shaming to persuade governments to cooperate better in the next pandemic.
"The negotiations are still likely to be challenged by conspiracy theorists who have protested at global health gatherings against fears of an overreaching international organisation."
Although it seems unlikely that countries will grant major new authorities to WHO, the negotiations are still likely to be challenged by conspiracy theorists who have protested at global health gatherings against fears of an overreaching international organisation. Mistrust in “what is cooking in Geneva” needs to be taken seriously. A backlash against governance by elite “experts” has already been felt during the pandemic, and could still block the adoption of a treaty in many countries if and when it reaches the stage of national ratification.
A final big question is what all of this means for the global health system – or “architecture” — that is based in Geneva. For the past two decades, development assistance has driven the growth of this system, with the creation of large funding bodies like the Global Fund, Gavi and Unitaid. Developing and expanding access to drugs, vaccines and diagnostics has often been a driving force for these funders, as well as for more specialised entities like the Geneva-based Foundation for Innovative New Diagnostics, the Drugs for Neglected Diseases initiative (DNDi) or the Medicines for Malaria Venture. At the same time, more developing countries are largely financing their own health needs, and donor countries may shift their priorities elsewhere to pandemic preparedness, climate change, the war in Ukraine or inward-facing priorities like inflation, energy insecurity or trade competitiveness. The confluence of these trends suggests that major changes are afoot in Geneva and for global health in the years to come, with 2023 a particularly critical one for international pandemic rulemaking.
About the Author
Suerie Moon is Co-Director of the Global Health Centre and Professor of Practice in the Department of International Relations & Political Science, Graduate Institute of International and Development Studies, Geneva, which she joined in 2016. Together with Professor Gian Luca Burci, she co-leads the Centre’s Governing Pandemics initiative, which tracks, analyses and supports efforts to strengthen the global governance of pandemics. Her research sits at the intersection of global governance and health, with a particular interest in technology, power, politics and equity. She received a BA in history from Yale, an MPA in international relations from Princeton, and PhD in public policy from the Harvard Kennedy School of Government.
The opinions expressed in this publication are those of the authors. They do not purport to reflect the opinions or views of the Geneva Policy Outlook or its partner organisations.