The World Needs a Post-Pandemic Health Treaty With Teeth

The COVID-19 pandemic has revealed the devastating and deadly shortcomings of current global health cooperation and governance, leading 25 world leaders to call for a powerful upgrade: a pandemic treaty. The International Health Regulations (IHR) is the world’s current global health treaty, but from the beginning of the pandemic the regulations failed.

China’s lack of transparency during the 2002-2003 SARS epidemic sparked major IHR reforms in 2005—but fast-forward to the COVID-19 pandemic, and China still delayed weeks before confirming the outbreak. The government denied human-to-human transmission, despite widespread community spread. The World Health Organization (WHO) remained powerless to demand transparency and accountability, because it lacked the tools to independently confirm data or operate in a country without its permission.

What would an effective and powerful treaty look like? A joint press briefing from WHO and European Council last week argued for a rapid and verifiable alert system, data sharing, transparency, improved supply chains for vaccines and therapeutics, and equity in the distribution of personal protective equipment and medical countermeasures. The treaty should include much more. To begin with, WHO needs power to independently verify official state reports—and it needs to be honest in alerting the world when countries don’t act responsibly and transparently. There is no sure solution, but one model could be the kind of inspection and notification regime that currently exists on nuclear weapon de-proliferation.

Through chemical and nuclear treaties, for example, independent agencies can deploy independent scientists to inspect facilities. No less is needed for investigating novel and dangerous pathogens. This won’t guarantee that a state with something to hide will not use its ability to control who enters its territory for inspections, but it would raise the stakes of such reluctance and increase the global approbation needed to exert more pressure on noncompliant member states. Realistically, for a country like China that insists rigidly on its sovereignty, it will always be difficult to gain full compliance.

Early in the pandemic, nations struggled to purchase life-saving medical resources such as testing kits, personal protective equipment, and ventilators—just as countries are now struggling to acquire vaccines. The world needs a system to ramp up supplies of life-saving medical countermeasures, and to do so equitably. This includes countries working together to enhance capacities and ensure more efficient supply chains, technology transfer so countries can produce medical resources themselves, and suspension of intellectual property protections that keep vital information secret. It requires open sharing of scientific information, virus specimens, and genomic sequencing data. Information-sharing platforms would range from research and development to practical lessons.

The next time there is a dangerous outbreak, global cooperation must replace price competition.

The IHR requires every country to develop “core health system capacities,” but few have done so. Health systems require laboratories, surveillance (including genomic surveillance to study viral mutations), data systems, and health workers. The regulations also ask rich countries to provide funding and technical assistance for health system capacities. Again, virtually none has done it. The United States had the best idea through the Global Health Security Agenda in the Obama administration, but funding remains inadequate. The pandemic treaty should establish specific funding requirements, both domestic investments in pandemic preparedness and international economic and technical assistance. Or, going forward, the World Health Assembly could increase member states’ mandatory assessments for membership dues to WHO, earmarked for building core health system capacities.

No area is more important than equity. Even as the countries with the most direct COVID-19 deaths spanned the income spectrum, with wealthy countries among the hardest hit, the broadest, longest ramifications are and will be felt in poorer countries. Low-income countries have the least access to testing and vaccines, the health systems least able to cope, and the fewest resources to mitigate economic devastation—with poor people within countries, in turn, suffering most. Pandemic treaty funding mechanisms could extend to fortifying national health systems and strengthening social protection like access to food and education during health emergencies. The treaty should mandate WHO develop a high-level task force to ensure that equity is always at the center of responses—just as President Joe Biden did in the United States.

Indeed, another proposed treaty with the express mandate of health equity through accountability to the right to health—the Framework Convention on Global Health—would address the deeper underlying causes of poor health and health inequities. Features of the framework would enhance pandemic preparedness and response, including standards and mechanisms to foster accountability, participation, and equity—nurturing public trust, strong health systems, and inclusive responses.

Pandemic treaty promoters recognize the need for a “one health” approach, based in the close connections between human heath, animal health, and the environment. The SARS-CoV-2 origins report lists a natural leap from an animal to a human as the likely cause. Around 70 percent of all novel diseases begin with such a zoonotic leap. The treaty could phase out the sale or trafficking of wild animals, with strict regulation of wet markets. It could set norms on land management and deforestation, which bring animals and humans into ever-closer contact.

It’s true that these measures could be politically difficult in countries like Brazil and China. But such bold change is possible, especially in the aftermath of such a devastating pandemic. There is a large global consensus on protecting the Amazon rainforest. Responding to COVID-19 last year, China banned trade in and consumption of wild animals. And the treaty could provide funding to help communities transition to other protein sources and governments to combat illegal deforestation, such as for timber or ranching. The treaty should also encompass antimicrobial resistance, including antibiotic overuse and misuse in people and animals, one of WHO’s top 10 global health threats.

Appropriate enforcement mechanisms for such a bold, wide-reaching treaty will be difficult, but the international community could consider a range of enforcement mechanisms already contained in other treaties and regimes. These include joint external evaluations now deployed for the IHR, where national officials, health experts, and civil society jointly assess implementation. These evaluations are now voluntary but could become mandatory. The treaty could also require binding arbitration. It could consider sanctions, whether travel bans and asset freezes for noncomplying government officials or more extensive trade sanctions.

An independent agency could be established and empowered to conduct investigations as it sees necessary, from outbreak investigations to data-sharing compliance to investigating outbreak origins. Whatever the mechanisms, establishing independent entities—like an inspectorate, or an adjudication mechanism, or one determining sanctions—will be key, isolating these functions from the political pressure that WHO would inevitably face. Investigators should be protected from the potential repercussions of their work and provided with adequate security. Inspectors should not issue findings until they are out of the country, and the treaty could include automatic sanctions for impeding or harming investigators.

Whether countries would agree to forceful enforcement is an open question. Notably, China, Russia, and the United States did not sign the joint letter calling for a new pandemic treaty, and the White House has expressed concern that negotiations could divert resources and attention from urgent action on preparedness and response. Will the devastation COVID-19 has wrought create a new level of political will? One possibility would be to create a framework convention, with more contentious enforcement mechanisms included as protocols to which countries that join the main treaty would need to separately agree. This could draw in countries not yet sold on the need for a pandemic treaty.

WHO is the most likely home of the pandemic treaty, logical given its role as the global health leader. The organization has wide constitutional powers to negotiate conventions and regulations. Yet, WHO must cooperate closely with the United Nations and include mechanisms to mobilize a full U.N. response, in the mold of the U.N. mission to West Africa during the 2014-2016 Ebola epidemic.

Yet, WHO has little political power, and we’ve seen powerful nations manipulate it throughout the pandemic. Health ministers govern WHO, but they have relatively little political power. Though the momentum is now beyond WHO, the U.N. is another possible route for the treaty. With the U.N. being less consensus-driven, a powerful treaty that might be watered down if adopted through WHO could be possible. For example, the U.N. convened a special conference to successfully negotiate the Treaty on the Prohibition of Nuclear Weapons, even as nuclear-armed powers did not participate and opposed a U.N. resolution welcoming the treaty. A U.N. treaty, moreover, could facilitate an all-agency response far beyond health. It also opens the possibility of U.N. Security Council sanctions, although it is hard to gain the agreement of permanent members.

That is why key institutions like the U.N., G-7, and G-20 could provide political backing. WHO Director-General Tedros Adhanom Ghebreyesus spoke of the need to strengthen the global health architecture. A pandemic treaty could dramatically strengthen the pandemic preparedness architecture. But it needs to have strong norms, and it must be able command compliance. Otherwise, when the next pandemic strikes—and it will—it is highly likely we will fail again. We all know what an ineffectual pandemic response feels like, and what it costs us in lives lost and economies ruined. That need not happen again.

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Lawrence O. Gostin Eric A. Friedman and Lauren Dueck