How can we come together to address future pandemics?

The Independent Panel for Pandemic Preparedness and Response was set up by the World Health Organization (WHO) in September 2020. The Panel published its report, ‘COVID-19: make it the last pandemic’, in May 2021. In March 2021, 20 world leaders and senior figures from across the world called for a more joined-up approach to pandemics in the future. This call was picked up by the Working Group on Strengthening WHO Preparedness and Response to Health Emergencies (WGPR) who have been drafting a Pandemic Preparedness Treaty. How is the treaty being drafted, what does it propose, and what might it mean for rural communities? Jessica Sellick investigates. ………………………………………………………………………………………………..

The Independent Panel for Pandemic Preparedness and Response began its work in September 2020. It was established by the World Health Organization (WHO) Director-General in response to the World Health Assembly resolution 73.1. The Panel was given a mandate to review the experiences gained and lessons learned from the WHO-coordinated international health response to COVID-19. In October 2020, the Panel published its programme of work. This contained 4 interconnected enquiry themes: 

  1. Build on the past: learn from previous pandemics and the status of the system and actors pre-COVID-19. 
  2. Review the present: analyse the accurate chronology of events and activities in relation to the COVID-19 pandemic, the recommendations made by WHO, and the responses by national governments.
  3. Understand the Impacts: review how health systems and communities responded and assess the direct and indirect impacts of both the pandemic and the response measures.
  4. Change for the future: an analysis and vision for a strengthened international system ideally equipped for pandemic preparedness and response.

The Panel provided scheduled briefings and reports to WHO Governing Bodies. This included: a briefing to the WHO Executive Board Special Session in October 2020; presenting its first progress report in November 2020; producing its second progress report in January 2021; and publishing its main report in May 2021. The main report was supported by a companion document describing 13 defining moments which shaped the course of the pandemic; and by 15 background papers including the chronology of the pandemic, and reflecting the voices heard in townhall meetings. The main report contained the following key findings: 

  • Early failings
    • The world had been warned of an inevitable pandemic threat, but many countries were not prepared and had not learnt from the past. 
    • Valuable time was lost as the formal notification and emergency declaration procedures under the International Health Regulations were too slow. 
    • Too many countries took a ‘wait and see’ approach rather than enacting an aggressive containment strategy. 
    • Countries with delayed responses were also characterised by a lack of coordination, inconsistent strategies, and the devaluing of science in decision-making. 
  • Preparedness was under-funded and response funding too slow
    • Financing at the scale required was not available to supply medical equipment, kick-start the search for diagnostics and therapeutics, or ensure vaccines would be available to all. 
    • International financing was too little, too late. 
  • Lack of planning and gaps in social protection resulted in the pandemic widening inequalities, particularly for:
    • Women and vulnerable and marginalised populations, including migrants and workers in the informal sector. 
    • People with underlying health conditions. 
    • The most disadvantaged children whose education was terminated early by the pandemic. 
  • Some successes:
    • Health workers have been stalwart in their efforts. 
    • Open data and open science collaboration were central. 
    • Vaccines were developed at unprecedented speed. 
    • Successful national responses. 
    • Country wealth was not a predicator of success. 

The Panel presented its recommendations in two parts. The first part made immediate recommendations to curb COVID-19 transmission. The second part contained recommendations which if adopted, as a package, are intended to transform the international system for pandemic preparedness and response. Seven recommendations were made in Part two: 

  1. Elevate pandemic preparedness and response to the highest level of political leadership – including the establishment of a Global Health Threats Council and the adoption of a Pandemic Framework Convention. 
  2. Strengthen the independence, authority, and financing of the WHO – including resourcing and equipping WHO Country Offices and prioritise the quality and performance of staff at each WHO level. 
  3. Invest in preparedness now to prevent the next crisis – ask all national governments to update their preparedness plans. 
  4. Establish a new agile and rapid surveillance information and alert system – using state-of-the-art digital tools. 
  5. Establish a pre-negotiated platform for tools and supplies – to deliver global public goods of vaccines, therapeutics, diagnostics and essential supplies. 
  6. Raise new international financing for pandemic preparedness and response.
  7. National Pandemic coordinators should have a direct line to the Head of State or Government. 

The main report identified a need for stronger leadership and better coordination at national and international levels. 

What is the Pandemic Preparedness Treaty? On 30 March 2021 the then Prime Minister Boris Johnson, along with 20 other world leaders and senior figures from international organisations, published a joint article calling for a more joined-up approach to pandemics in the future. In noting that the world would face major health emergencies in the future, world leaders emphasised how “we must be better prepared to predict, prevent, detect, assess and effectively respond to pandemics in a highly co-ordinated fashion”. In the article the leaders proposed a Pandemic Preparedness Treaty which would “greatly enhance international co-operation to improve…alert systems, data-sharing, research and local, regional and global production and distribution of medical and public health counter-measures”.   

In October 2021, the Working Group on Strengthening WHO Preparedness for and Response to Health Emergencies (WGPR) published a zero draft report outlining the benefits of developing a new instrument to promote high-level political commitment and strengthen health systems and their resilience. A special session of the World Health Assembly (WHA) was held to discuss the report where it was agreed that the WHA would establish an Intergovernmental Negotiating Body (INB) to draft and negotiate “a WHO convention, agreement, or other international instrument on pandemic prevention, preparedness and response”. 

How is the Treaty being developed? The INB describes how its work is based on the principles of inclusiveness, transparency, efficiency, Member State leadership and consensus. Following the special session, the INB have held a series of meetings and put a timeline in place with the final outcome of its work to be presented at the 77th World Health Assembly in May 2024. 

While developing a Treaty involves negotiating and seeking consensus amongst the WHO’s 194 member countries, article 3 in the Zero Draft sets out the main objective of having a treaty: “The WHO CA+ aims to comprehensively and effectively address systemic gaps and challenges that exist in these areas, at national, regional and international levels, through substantially reducing the risk of pandemics, increasing pandemic preparedness and response capacities, progressive realisation of universal health coverage and ensuring coordinated, collaborative and evidence-based pandemic response and resilient recovery of health systems”.   

The INB is consulting and negotiating on:

  • The definition, means and procedure for declaring a pandemic, and what this means in practice for states. 
  • How the treaty will work alongside the International Health Regulations. 
  • Key international principles that will guide the treaty (e.g. human rights, equity, accountability). 
  • How states and the WHO should be coordinating and cooperating in pandemic preparedness and response. 
  • How to finance pandemic preparedness and response initiatives. 
  • Setting up a new Governing Body for the treaty. 
  • General legal issues (e.g. amendments, disputes, withdrawal). 

This involves a series of public hearings and informal, focused consultations. The public hearings have explored what substantive elements should be included in a new international instrument, and what can be done at the international level to better protect against future pandemics. At its meeting in July 2022, the INB agreed that the new international instrument on pandemic preparedness should be legally binding.  

How is it being received? The group of Friends of the Treaty argues that “the world cannot wait until the COVID-19 pandemic is over to start planning for better pandemic preparedness and response and implementing the lessons from the crisis…the key to the success of this endeavour will be a collective approach that puts aside business-as-usual”. 

A petition calling on the UK Government not to sign a new treaty without a public referendum received some 156,087 signatures when it closed back in November 2022. The petition led to a parliamentary debate in April 2023. In response, the Government said the UK would “work towards building a consensus on how the global community can better prevent, prepare for, and respond to future pandemics and will actively shape, develop and negotiate the text. The new instrument would only be adopted by the World Health Assembly if the text achieves a two-thirds vote of the Health Assembly…once adopted, the instrument would only become binding on the UK if and when the UK accepts (ratifies) it in accordance with its constitutional process”.   

The European Council is a proponent of the treaty and has identified the following potential incentives and benefits of it: 

  • Better surveillance of pandemic risks – including knowledge sharing on new infectious diseases. 
  • Better alerts – supporting real-time communication and early warnings which would trigger a more rapid response. 
  • The ability to deploy medical equipment and highly-skilled international medical teams on the ground. 
  • The development of timely medical solutions (e.g. vaccines, treatments, diagnostics). 
  • Collective instruments to address global needs equitably in future pandemics. 
  • To improve the flow of reliable and accurate information as well as tackle misinformation globally. 

For some the treaty is rooted in ideals of what perfect pandemic governance should look like and that it has little regard for practical realities where state security and the health of the few has been prioritised. Some commentators argue that it will take years to negotiate the scope and powers of the treaty – citing how previous protocols that took 3-7 years to develop, and 10-11 years to enter into force.  

The German Alliance on Climate Change and Health, King’s College London and the LSE have suggested protocols, guidelines and standards could be used to lay out specific commitments – similar to the UN Framework Convention on Climate Change approach. They also acknowledge that there is unlikely to be consensus on all issues, especially those that are seen to infringe on trade or sovereignty.  

Treaty negotiations have focused on preventing pandemics that resemble COVID-19. However, the Global Leaders Group on Antimicrobial Resistance have emphasised that the next pandemic could be caused by bacteria or other microbes. The Leaders Group also want the negotiations to include measures that prevent infections such as better access to safe water, hygiene and sanitation and higher standards of infection prevention and control.  

It is also not clear what would happen if the measures agreed in the treaty were not followed – would there be a peer-review process or a set of sanctions for non-compliance?  Academics have called for an independent body to be responsible for monitoring the alignment of countries’ commitments to pandemic preparedness with their actions.

It is also unclear how the treaty would fit with the 2005 IHR. Indeed, separate talks on reforming the regulations taking place, with some 300+ amendments proposed.  

Since the release of the main report, the Co-Chairs and Panel members have continued to support discussions focussed on implementing their package of recommendations. In November 2021, the former Co-Chairs released a six-month accountability report. This flagged the need for strengthened leadership and accountability through an inclusive leader-level council independent of the WHO. In May 2022, the former Co-Chairs released a one-year assessment report. This called for rapid announcement of a pandemic threat to be made should one arise before legal reform processes are concluded. In May 2023, the former Co-Chairs released A Road Map for a World Protected from Pandemic Threats. This set out how two legal instruments are needed: revised IHR and a new pandemic agreement. Their recommendation is that the revised IHR should focus on surveillance and alert systems; and a new pandemic agreement on addressing the whole prevention, preparedness and response cycle. 

What does it mean for rural communities?In theory, areas with lower and sparser populations should have been at a lower risk of COVID-19 transmission. Yet global analysis from the OECD found while the virus arrived later in rural areas, COVID-19 case rates exceeded those in urban areas. They provide examples of super-spreader events such as wedding parties and religious festivals; and draw attention to meatpacking plants in rural areas of Germany, Ireland and the United States. Similarly, the analysis found rural populations to be at greater risk of COVID-19 complications and mortality. This is because the virus is particularly dangerous for older people and rural areas tend to have higher proportions of older residents. Rural dwellers were also found to have a higher prevalence of pre-existing conditions and co-morbidities (e.g. diabetes, heart disease, obesity). Rural hospitals were found to be less able to cope with an influx of COVID-19 patients because they had fewer specialists and less technology and capacity (i.e., intensive care beds).   

Back in the UK, analysis from the Nuffield Trust highlights how:

  • COVID-19 had a more detrimental effect on hospital waiting times in rural and remote trusts compared to trusts in more urban areas. Activity fell dramatically in emergency medicine and in referrals for talking therapies. 
  • Remote trusts were already struggling to recruit staff, spending more on temporary staff compared to other areas – the pandemic has exacerbated rural workforce issues. 
  • The underlying financial position of rural and remote services was worse than the position of more urban trusts before the pandemic started. In rural areas trust debt is equivalent to 56% of their annual operating income and they typically do not get their fair share of additional funding that goes into the NHS.    

If we know rural communities have nuanced risks and access to health care and infrastructure challenges, how can we ensure the design and implementation of any pandemic treaty would support rural communities in the event of a pandemic? For example, how will we collect data and undertake surveillance? How can we ensure we have sufficient qualified staff who can be flexible in their response and have the resources they need (i.e., PPE, diagnostics, therapeutics, beds) to deliver pandemic-related health care – including managing any surges?

Where next?The co-chairs of the Panel highlight how “a new pathogen with pandemic potential could emerge at any time, and then there will be no excuse for a wait and see” approach. There has to be investment in preparedness now, not when the next crisis hits”. Dialogues around whether and/or where an international pandemic treaty or other international framework should sit will continue to take centre stage between now and May 2024. It is worth noting that treaty powers of the WHO have only been used once: for the adoption of the WHO Framework Convention on Tobacco Control in 2003. So there is still much work to do to design the treaty and its interaction with the IHR. Will governments think beyond national interests? And if we already know the timing and impacts of pandemics differ in rural areas, will they think rurally? Watch this space. 

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Jessica is a senior research fellow at The National Centre for Rural Health and Care (NCRHC) and a project manager at Rose Regeneration. She is currently evaluating hospital discharge and hospital avoidance schemes, and a service that supports older people to maintain their independence.  Jessica also sits on the board of a Housing Association that supports older people and a charity supporting Cambridgeshire’s rural communities. 

She can be contacted by email jessica.sellick@roseregeneration.co.uk. 

Website: http://roseregeneration.co.uk/https://www.ncrhc.org/ 

Blog: http://ruralwords.co.uk/ 

Twitter: @RoseRegen