Is a global pandemic treaty within reach? A key public health thinker lays out the path.
The COVID-19 pandemic which engulfed every corner of the globe in early 2020 has exacted a catastrophic toll, sowing 186 million infections and 4 million deaths by mid-July 2021. It also badly dented (and even shattered) the world economy and the interconnected supply chains that help nourish it – creating even more widespread misery.
Yet the political earthquake unleashed by COVID-19 upon a world already riven by nationalism and increasing state violence is also significant, and it has created immense impediments to collective action to fight the outbreak.
For instance, the pathway to the emergence of the novel coronavirus remains a scientific mystery. But conspiracy theories about COVID-19’s origins have taken hold in many nations, with potentially-seismic foreign policy implications.
Weaknesses in the mechanisms of globalization also have been laid bare in closed borders, interrupted transit, and canceled flights. And as the world struggles with issues of vaccine equity, major powers see the race to develop, manufacture and distribute vaccines as an exercise in soft power.
Prospects for the planet’s comprehensive recovery (as well as the prevention or amelioration of future outbreaks) may depend upon a global treaty on pandemics. And a number of international organizations and world leaders are already signaling their support for such a measure.
Charles Michel, President of the European Council, called for such a treaty in December 2020. He was joined in that effort in late March by World Health Organization Director General Dr. Tedros Adhanom Ghebreyesus and almost 30 other world leaders who co-authored a commentary in support of a measure.
In only two months, sufficient momentum had gathered for the World Health Assembly to declare a special session in November 2021 to explore a pandemic treaty. Yet major players such as China, Russia, and the United States still have not joined the explicit calls for a global agreement.
Ilona Kickbusch is among the most prominent figures in global health advocacy and reform in government, international organizations, and academia. Her career at the World Health Organization (WHO) included a central role in creating Ottawa Charter for Health Promotion in 1986. Kickbusch has also been deeply involved in making and executing public health policy in various roles in the German government, and her academic expertise has led to appointments at Yale University and in her current position as founding director and chair of the Global Health Centre at the Graduate Institute of International and Development Studies in Geneva.
In a recent conversation with The Wilson Quarterly, Kickbusch spoke about the obstacles in the way of an agreement, and how nations might come together to act against future pandemics. She also debunked faulty presuppositions about the WHO’s authority, flexibility, and potential effectiveness as a venue for a treaty.
Kickbusch says inequity and delay are costing more lives and creating geopolitical tensions, especially as the world sees images “of people in the global North happily going to football matches and to the beach…and other parts of the world not having access to vaccines.”
The new dangers posed by COVID-19’s recent march though India and Africa, she says, as well as the spread of variants such as Delta through countries with high vaccination rates, “have created a new nervousness. It's slowly sinking in that the pandemic is not over – and it's not going to be over for quite some time.”
In this “difficult and tense” moment, adds Kickbusch, “nobody really knows where we're going to be at the end of November when the decision on the treaty will be taken.”
“We’re All In This Together”
Pandemics such as COVID-19 do not respect borders. So collective global effort to battle outbreaks is imperative.
The urgency of the COVID-19 crisis has led to impassioned arguments in favor of far-reaching measures, such as a May 5, 2021 article in The Lancet by Johnathan H. Duff and 20 other contributors titled “A global public health convention for the 21st century.”
Duff and his co-authors write that:
Given the clear and present danger posed by COVID-19 and future pandemic diseases, there is a need for the international community to establish a more effective system to ensure observance of international pandemic regulations such as the [International Health Regulations (IHR)]…. The inexistence of an adequate system to ensure coordination, collaboration, and compliance with international public health security agreements (such as the IHR bolsters) the need to create a new convention that addresses these shortcomings.
Kickbusch has been forthright about the need for an international pandemic treaty. But in a response she published alongside the May 5 Lancet paper – “A pandemic treaty for a fragmented global polity” – she argued that the “forceful WHO-like global entity” proposed in that paper and elsewhere would boast “powers beyond the reach of geopolitics today.”
She sees forging a global pandemic treaty that balances effectiveness and global buy-in as foundational.
“A treaty always does more than one thing,” Kickbusch observes. “It is a political manifestation that countries take this issue seriously, and a signal that it's an issue that's really important for everyone…. The WHO Framework Convention on Tobacco Control was very much of that nature. Tobacco is a danger for all of us, and, therefore, we need rules that apply to all of us and support all of us. So I think this notion of ‘We're All in This Together’ is actually becoming even clearer.”
Balancing the political and legal dimensions is also essential: “What is it – in terms of content of the treaty – that we can only do with a treaty?”
Centering essential elements is crucial. “The minute you talk about a treaty in the global health space,” says Kickbusch, “everyone will ask: ‘Can I get my issue into this treaty as well?’ There is tension about how much a treaty should focus on pandemics. The European Union clearly said we want a pandemic treaty. We don't want a global health treaty. But there is a community out there that would like to see a broader treaty—which I don't think would stand that much chance, quite honestly.
“So really it’s focus,” she continues. “We really need something that sets the rules for global sharing. What are we willing to share?” Placing that question at the heart of the matter will “ensure that the treaty – whatever is agreed – will contribute to joint rules, and to sharing, and to greater equity.”
Kickbusch is not surprised by a sentiment among those who think and write in the public health space that something stronger is required. There is ample evidence that existing structures are not coping with the catastrophe.
“Many people are worried about compliance,” she says, “because the International Health Regulations have not been able to ensure compliance. Some people, and I think quite unrealistically, think about sanctions. But if we look at other areas of global treaties and agreements, sanctions have never been particularly successful.”
Circling back to things that bring skeptical nations – especially larger P5 countries such as China and Russia and the United States – to the table is crucial. “What must the treaty contain to be an incentive? Countries will have different interests,” says Kickbusch, “What can be incentives for these countries to be supportive of a treaty?”
Past as Prologue?
Kickbusch suggests that many answers can be found in previous successful agreements. The hard work of shaping a treaty to prevent future global outbreaks has started already in the pages of scientific journals.
“That's what people are doing a lot right now,” she says. “Looking at other treaties and agreements.”
The WHO Framework Convention on Tobacco Control is one example. “The framework is central,” she continues. “How that was negotiated. You actually have a process mapped out. What's helpful is that the process guarantees academic input. It guarantees – and this is something people forget – input from other UN organizations. Straight away, the framework convention had a working group of other organizations, which included the World Bank.”
The benefits can be startlingly useful. “The big study by the World Bank on the economic impact of tobacco,” she recalls, “was a significant contributor to the adoption of the framework convention on Tobacco Control.”
Kickbusch insists the framework process is sturdy enough for a global pandemic treaty. “You might want to change one or two things, here or there,” she says. “But through the established process, you can actually hear the voices of others. You can involve other parts of the UN system.”
Those other parts of the UN system also can offer insight and inspiration to shapers of a global pandemic treaty. How does the Human Rights Council do country assessments? How does the International Atomic Energy Agency assess safety and security?
Kickbusch also sees the Paris Agreement on climate change as another useful model: “[New America CEO] Anne-Marie Slaughter has said that the Paris Agreement is the new type of treaty we will be doing in the future, because it sets a goal, but allows countries to interpret the terms of reaching it. You're responsible to reach the goal, but the treaty doesn't tell you to do steps one, two, three, four.”
While she allows that the Paris Agreement’s open-ended options might prove tricky in a pandemic context, Kickbusch says the concept is worth looking at as new treaties are devised.
“There's a lot of treaty work out there,” she says. “We have to be creative in saying what can we learn from that work. People sometimes forget this, because they always look at the content of a treaty. But one of the things we found with the framework convention is that the process of the treaty itself is important. It keeps the issue on the agenda. It brings partners together who might otherwise not talk to each other. At the national level, because treaties need to be ratified, it takes the issue into parliaments and leads to discussion. So there are five or six process benefits that one must also take into account that can be very, very important, especially depending on which parties you want to involve.”
Assertion and Advocacy
The growing momentum for a global pandemic treaty will certainly aid its prospects. “We have commitment from a significant group of heads of state,” observes Kickbusch. “They are saying: ‘We see this as an issue that goes far beyond our health ministries. It’s an issue that we need to tackle at the highest level.’”
This sentiment also reflects “what is happening now in countries,” she continues. “They are discussing new types of security councils, or including health security in national security councils. All those kinds of things are starting to happen because [these governments] have experienced the gap [between public health and national security].”
Kickbusch observes that bridging this gap is key. Global advocacy for a treaty and better-managed responses must not simply target health ministries. “The International Health Regulations are very health system focused. And the focal points for the IHR, and for outbreaks, are within the health system.”
Informed political leadership is required to act effectively, especially at the earliest stages of a pandemic. “Taking it to heads of state and government level officials has consequences for the internal organization of the issue and the responsibilities within the country.”
Kickbusch says high-ranking diplomats usually have a strong involvement “because they have an interest in what treaties they are getting into. What does this agreement mean? What are our responsibilities?”
High-level leadership also brings significant benefits to treaties in the public health space. She observes that Pandemic Influenza Preparedness (PIP) Framework negotiations were successful in part because “you had the two top diplomats who had the chair at the time – from Norway and Mexico – used all their diplomatic skills as experienced negotiators to get it through.”
“What must the treaty contain to be an incentive? Countries will have different interests. What can be incentives for these countries to be supportive of a treaty?”
Because so many complex issues occur at the intersection of public health and security, the significant momentum for a global pandemic treaty among heads of state, diplomats, and international organizations is key to getting an effective agreement. “All these people are right there at the top,” she says. “That will reflect how the treaty is negotiated. We've seen how geopolitical this is. How it affects the economy and everything else. Everyone's going to say: ‘Hey guys, we're not going to leave that to the health ministers.’”
“The closeness and the interrelationship to traditional security issues is something that some of the P5 countries are always particularly very concerned about,” says Kickbusch. “When the [current] International Health Regulations were negotiated, the link to traditional security, biosecurity, etcetera, was absolutely essential for some countries. They wanted to make sure that any kind of health surveillance on biosecurity did not become undercover surveillance that might have military implications.”
A number of issues will generate significant scrutiny, and even conflict. “Safety for whistleblowers could be something in a treaty,” Kickbusch says. “The rights to access and investigation. All the transparency issues that you might want to see in a treaty. These issues all have significant consequences for countries with different types of regimes.”
Making the WHO Work
The World Health Organization is central to global health. Yet the WHO has been a magnet for intense criticism during the COVID-19 pandemic. Many question whether it will be an effective venue for negotiating a global pandemic treaty, especially given the immense security issues surrounding any potential agreement. Will the WHO have the gravity and the authority to be the platform to forge a treaty?
Kickbusch says that the WHO has the power, flexibility, and track record that will set the stage for success – and bring in every major player needed to do so.
“There is a misunderstanding that if you negotiate such a treaty within the World Health Organization,” she observes, “you would limit it to health ministers. That is not the case at all. The constitution of the WHO is very open as to who negotiates. In many cases, it is high-level diplomats. So if you negotiate in the context of the World Health Organization, it does not mean that you cannot achieve that larger agenda.”
The flexibility of the WHO means that a global pandemic treaty need not be a UN endeavor. “Some people argue we have to go to New York,” says Kickbusch, “because we can't reach all those other people of importance [outside of public health]. But that's not a valid argument. If you look over the past few years – and actually longer, since the German G20 in 2017 – you see the extent to which the World Health Organization is involved with the G20 and the G7.”
She amplifies her point with examples: “Now you have all these heads of state speaking at the World Health Assembly. And I don't know how many heads of state Dr. Tedrous talks to daily. So [the landscape] has shifted. That's not really an argument.”
Indeed, Kickbusch argues that negotiating a pandemic treaty in the WHO “would significantly strengthen the World Health Organization. There has been so much talk about this. Look at G7 and G20 declarations. We want to strengthen WHO. Well, this is one way you can do it. Negotiate a high-level treaty within the umbrella of the WHO constitution.”
The WHO’s constitution provides pathways to effectively manage any treaty. “One has to look at the constitution,” urges Kickbusch. “Not the organizational body. Because if you’ve negotiated a treaty, you also get a treaty Secretariat. That's also something many people don't realize. They think the treaty is going to be sucked into the WHO in some indeterminate manner. But the minute you have a treaty – as happened with the framework convention on tobacco use – then you create a framework secretariat, which works with the parties to the treaty.”
Pathways to the Future?
The delicate but essential interplay between the urgency of this moment and the nitty gritty of diplomacy leaves Kickbusch wishing for speedier progress made on a global pandemic treaty.
“It's a great pity we’re losing four to six months because of the decision at the World Health Assembly,” she observes. “Even though I am happy that there was no decision against a treaty, and a decision to explore the benefits more [deeply], so that countries have more opportunities to think about it. But if we had those four months or six months, depending when you start counting, we’d be in better shape.”
Framework conventions are a useful way to accelerate the process, claim early victories, and win time needed to settle thornier issues. “The beauty of a framework convention is that you set the principles,” says Kickbusch. “You set some basic agreements. But you also give a work plan for difficult issues that are taken up in the conference of the parties that follows, because we do know difficult issues can take up to three years and longer to resolve.”
History provides clear example, she adds. “We moved forward quite quickly in negotiating the agreement on the influenza sharing,” says Kickbusch, “once one had the breakthrough discussions with the private sector.”
"It's slowly sinking in that the pandemic is not over – and it's not going to be over for quite some time.”
That is why Kickbusch feels so strongly that such a framework convention, created at the World Health Organization “is actually the type of agreement that could be achieved reasonably soon.”
The central issue, she reiterates, is “What are we willing to share?” Agree on that, Kickbusch continues, and “I think you could have a framework convention in a reasonable period of time. If the treaty process were to start at the end of 2021, you could agree on a treaty – if you work hard – by late 2023 at a special session of the World Health Assembly.”
Even nations that cannot join the treaty formally might support the effort in tangible ways, she argues, giving the example of the strong U.S. support for the Ottawa Treaty on Anti-Personnel Mines– which it has never formally joined. “If one major country is not a full party to the treaty,” observes Kickbusch, “there are still many ways in which that nation can be part of those parts of the agreement that they think are important and that would suit their own interests.”
A treaty agreed in 2023 might not alleviate the world’s present suffering. But it would be down payment on stopping the next deadly (and inevitable) pandemic in its tracks not only in wealthy societies, but across the globe.
Richard Byrne is the editor of The Wilson Quarterly.
Cover photograph: A volunteer helps a woman fill out paperwork before her COVID-19 vaccine in Rwanda in March 2021. (WHO / Andre Rugema)