The headquarters of the World Health Organization. Credit: ©Yann Forget/Wikimedia Commons. CC-BY-SA 3.0.
Throughout wave after wave of COVID-19, a range of voices have called for reforming the way governments manage pandemics. From mixed messages to inequitable vaccine distribution, the global response to COVID-19 just hasn’t cut it. In particular, critics have highlighted the World Health Organization (WHO) as a primary target for reform efforts, and, by now, several groups inside and outside of the organization have begun developing proposals that range from reforming the WHO to developing whole new international forums specifically designed to prepare for and mount an effective pandemic response.
Last December, at a special meeting of the World Health Assembly, the governing body of the WHO, country representatives agreed to kick off reforms when they voted for negotiating an international agreement or pandemic treaty. With the vote, the conversation seemingly moved beyond simply reforming the WHO and towards the creation of a stand-alone legally binding instrument: a new international structure to address pandemics.
Pandemics could become more frequent in the years to come as the world grows even more interconnected, increased agricultural production leads to more contact between humans and animals with the potential for further spread of zoonotic diseases, and humans encroach further into wildlife areas. While an international pandemic organization sounds important in theory, organizations like the UN Security Council can’t necessarily solve the problems they were intended to solve. Creating a new pandemic response system will likely require years of difficult negotiations and could still result in a structure unable to forcefully respond to an outbreak, or an agreement supported by only some countries and perhaps not all of the key global leaders. By looking at the reform ideas that people and organizations have put forward, one can begin to see the contours of what a new global response system might look like.
Reform at the WHO. Each major public health emergency during the last 20 years has led to the pervasive conclusion that the WHO has serious shortfalls that have prevented it from effectively communicating with and supporting member nations and the broader global community in response to health crises.
The WHO was established in 1948 as the health policy body within the UN system and was given the responsibility to “direct and coordinate the world’s response to health emergencies.” The centerpiece for WHO pandemic preparedness and response are the International Health Regulations, which trace their roots back to the cholera epidemics of the mid-1800s. The regulations have been updated in response to subsequent public health emergencies, and the most recent major update happened after the 2003 Severe Acute Respiratory Syndrome (SARS) coronavirus outbreak, a virus related to the one that causes COVID-19. The 2005 rules require all countries to detect, assess, report, and respond to public health events.
Despite efforts at reform over the last 20 years, fundamental flaws remain. The WHO’s International Health Regulations don’t allow the organization to conduct independent investigations of international public health emergencies or to compel countries to act during such crises. The organization can’t even enforce its regulations. Furthermore, it can employ only the limited authorities, capacities, and funding that the 194 member nations have given it. This lack of agency is not an oversight, but rather a deliberate limitation of the WHO’s power—many countries do not want to have an international organization interfering in the internal affairs of sovereign nations. Given the WHO’s lack of authority, countries that violate the International Health Regulations are unlikely to face any repercussions. It also means that the WHO must take a collaborative approach in dealing with nations to gain their cooperation.
COVID-19 shortfalls. SARS-CoV-2 has exposed key shortfalls in pandemic preparedness and response. The WHO remains underfunded and has limited power. It’s had trouble effectively offering guidance and coordination to its member states.
Several high visibility missteps provide poignant examples of underperformance at the organization.
Early on, the WHO was slow to declare COVID-19 an international emergency, and at times, provided inconsistent and inaccurate information. For example, the organization revised a global risk assessment from “moderate” to “high” in late January 2020 after admitting it made a mistake in previous reports. The WHO was also slow to call for a comprehensive investigation of the origins of the virus, which contributed to a loss of confidence in the organization by some member countries. As a result, some have accused the WHO of failing to be independent or even of being too “China centric.”
Recognizing the need to examine its early COVID-19 actions, the WHO commissioned an independent panel in May 2020. The group’s year-long deliberations “found weak links at every point in the chain of preparedness and response.” The panel found, for example, threat warnings were not acted on, funding allocated by nations to their responses was not adequate, and coordinated global leadership was absent. These shortfalls were well documented and highlighted actions necessary to end the current pandemic—as well as longer-term recommendations for ensuring that future outbreaks do not become pandemics.
The panel recommended developing a “global health threats council” which would be led by heads of state. Separate from the WHO, the council would be able to hold countries accountable for controlling epidemics. Specific long-term recommendations of the independent panel included elevating pandemic preparedness and response to the highest level of political leadership; strengthening the independence, authority, and financing of the WHO; investing in new preparedness measures; building a new surveillance and alert system; and giving national pandemic coordinators a direct line to heads of state or government.
World leaders, infectious disease experts, and worried citizens alike have also voiced concerns about the WHO’s COVID-19 response and what it portends for ending the current crisis and preparing for the future. The calls for reform have been resounding, and reform advocates have identified at least six discrete reform initiatives. These initiatives are certainly not the only calls for change, but they reflect an interesting range of transformational activities that might change the way world governments prepare for and respond to pandemics. Each seeks to address the shortfalls of the COVID era.
A WHO-adjacent organization. WHO members agreed to start the reform process when they met at the World Health Assembly in May 2021. Informed by the independent panel, members called for a special meeting on reform to be held in the fall, signaling that a new organization would likely be related to, but not under WHO leadership. The proposed global health threats council led by heads of state could serve as a model for this agreement.
At the November 2021 special meeting, countries formally agreed to initiate a process “for negotiating a pandemic treaty or other international pact.” The move was seen as an important step that could lead to “sweeping reforms of global health if it succeeds.” WHO Director General Tedros Adhanom Ghebreyesus called the decision a “cause for hope”—the goal would be to begin negotiations in March 2022 and to develop a “global agreement to strengthen pandemic prevention and response” by as early as May 2024.
The European approach. The European Union also offered a proposal for a standalone international treaty on pandemics. The proposal identifies areas that would be covered under an agreement: improved early detection and prevention of outbreaks; increased pandemic resilience; more rapid pandemic response; a stronger international health framework; and more complete integration of so-called “One Health” policies that recognize the interconnections among people, animals, plants, and their environment. At this stage, it is the most encompassing of the six proposals, but would undoubtedly require negotiators to make sure that it does not conflict with current (and likely overlapping) WHO authorities. Given the comprehensive approach, negotiating a treaty that might give countries new responsibilities for reporting—and even require they submit to inspections—will likely be a challenge. At the special November World Health Assembly, supporters believed they had gained critical international receptivity for the EU proposal to serve as the basis for a “treaty or pact.”
An outside-of-government proposal. A group of non-governmental, concerned citizens have offered a third proposal, the Pandemic Mitigation Project. It calls for the adoption of a more modest agreement that would require countries to provide immediate notification of potential epidemic/pandemic events, grant immediate access to pre-vetted specialists “to assist in identification, isolation and mitigation of the pandemic threat,” and accept enforcement provisions that would encourage compliance. As with the EU proposal, the Pandemic Mitigation Project proposal would be a legally binding, standalone agreement that would need to be negotiated.
The G20 way. Another proposal comes from a statement of G20 nations’ science academies. The statement urges their governments to “promote the creation of a global surveillance network that could detect the harbingers of a potential new pandemic.” It calls for not only a global biosurveillance network but also the capacity for manufacturing and delivering medical countermeasures and other supplies as well as working toward a formal international treaty. However, at the G20 meeting in Rome in October 2021, the discussion on pandemics focused on the more immediate issue of gaining additional vaccine commitments for developing countries rather than longer-term and broader pandemic preparedness and response issues. It is noteworthy that on the eve of the G20 leaders’ summit, health and finance ministers established a Finance-Health Task Force to strengthen both “public health measures and the funding to support them.”
The UN or Biological Weapons Convention routes? Other ideas worth considering include actions within existing international organizations other than the WHO. For example, governments could develop a UN Security Council resolution for pandemics. Under the UN charter, resolutions adopted by the Security Council are considered binding, carry the force of law, and can be used to compel nations to act. Security Council resolutions have been successful in other areas such as nonproliferation of weapons of mass destruction. One Security Council resolution, 1540, for example, calls for countries to adopt policies to keep the financing, technologies, and materials needed to create weapons of mass destruction out of the hands of terrorists.
The final initiative considers the possibility of using the Biological Weapons Convention, the treaty that bans bioweapons, as an avenue for international reform. This could have the most relevance in outbreaks and pandemics where the origin is suspected to have come from deliberate use of biological pathogens or release from an illicit bioweapon’s lab. The first step could be a discussion along these lines at the upcoming 2022 Biological Weapons Convention review conference, where representatives meet every five years to discuss the treaty. The convention includes provisions for bilateral or multilateral consultations in the event of questionable activity and a route for bringing intractable issues to the UN Secretary General.
Using the Biological Weapons Convention would take advantage of an existing arms control convention. The legally binding instrument, however, lacks verification and compliance mechanisms to ensure countries are adhering to the treaty, a frequent source of complaints from member nations.
Which path to reform? No single path seems superior at this point; more detail would be required before making a decision on which to choose. However, each of the six initiatives provides interesting elements that could be useful in a future international mechanism to ensure global preparedness and response capabilities are in place and functional.
The decision on a path forward should also account for the realities of international cooperation and collaboration. Developing new agreements and treaties is normally a time-consuming process that does not ensure that the final product will achieve the desired outcomes. Intensive negotiations can also expose fissures within the international community. For example, the discussion of a legally binding treaty has put the European Union, Britain, and some 70 other countries on opposing sides with the United States, Brazil, and India, which have been reluctant to commit to such an approach. Politico Europe cited one European Union official as characterizing the United States as “one of the most difficult partners” in talks to develop a legally binding agreement. Given these differences, a May 2024 agreement might be overly optimistic for a comprehensive pandemic agreement.
Several proposals would likely have significant costs associated with them. Sweeping reforms, such as those proposed by the European Union, or foreshadowed by the WHO independent panel, could include expansive new public health measures; the plans might be costly both to establish and maintain. More narrowly focused proposals such as the Pandemic Mitigation Project and UN Security Council proposals would undoubtedly have less upfront and sustaining costs.
Adapting existing organizations such as the WHO and the Biological Weapons Convention could also be challenging as their long histories often get in the way of comprehensive reform efforts. Even updating the International Health Regulations—which were developed for pandemic detection, assessment, reporting, and response—would likely require negotiators to extensively rewrite WHO policies to grant the organization greater authority and to develop the new enforcement mechanisms necessary for reform to have a meaningful effect.
The acceptability and terms of a pandemic agreement would also be key. Any agreement that includes only a “slice of the world’s countries” but not major powers like the United States would be problematic; economically powerful countries would likely be the source of the funding and technical capability necessary for successful implementation of a treaty. Likewise, agreements that rely on consensus might result in “least common denominator” solutions, hardly what the world needs from reform.
Still, the six proposals provide grist for thought and even potential starting points from which deliberations could begin; however, unless WHO member nations are willing to expand a future pandemic organization’s authorities, capacities, and funding beyond what the WHO currently has, the prospects for success will be limited. Whatever pathway reform efforts proceed down, one thing is clear: The death; sickness; and political and economic destabilization of the last two pandemic years make it clear that the world needs to do something different next time.
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Aren't there existing problems with adherence to the Biological Weapons Convention? Wouldn't using a model like the WHO antigenic cartography model for influenza surveillance potentially be better?