September 20, 2023
On September 20, 2023, United Nations (UN) Member States held a historic High-Level Meeting at the UN Headquarters in New York to adopt a Political Declaration on Pandemic Prevention, Preparedness, and Response. It was an opportunity to shine a spotlight on and build high-level political support for major global reforms to make the world safer and fairer. The UN High-Level Meeting in New York was held as the World Health Organization (WHO) is negotiating two fundamental reforms: a new Pandemic Accord and revisions to the International Health Regulations (2005) (IHR). Since the founding of the UN and WHO in the aftermath of World War II, there has perhaps never been more consequential moment for global health security. The processes in New York and Geneva come in the wake of the COVID-19 pandemic, the greatest threat to global public health in a century.
Yet, UN members are squandering a historic opportunity to right the wrongs of the COVID-19 pandemic. The Political Declaration, as adopted, is purely aspirational and contains few concrete commitments, funding, or accountability mechanisms. The first five of its thirteen pages offer mere recognition of COVID-19’s devastation on human life and economies; acknowledgement of the ceaseless threat of disease and the role of universal health care; and the importance of building solidarity between public and private sectors, and governments small and large. The language is self-congratulatory for taking strides toward reform through the Intergovernmental Negotiating Body (INB) (which is drafting and negotiating a Pandemic Accord) and the Working Group on Amendments to the International Health Regulations (WGIHR). Yet, both the INB and WGIHR appear bogged down in Geneva, and are themselves watering down earlier bold commitments.
Meanwhile, the UN Political Declaration’s “call to action” contains no actual commitments to action, no new norms, no accountability, and no funding pledges.
The only firm commitment is to hold another convening in 2026. By that time, much, if not all, of the political momentum as a result of the COVID-19 pandemic will be lost.
The Political Declaration represents a missed opportunity to hold leaders’ feet to the fire in ensuring that the negotiations in Geneva result in true commitments from heads of state for equitable and effective global governance for the next pandemic. Support from heads of state and government for bold norms in the Pandemic Accord and revised IHR could be transformative. Above all, leaders must commit to equitable and affordable access to life saving medical resources everywhere — rich or poor, North or South.
We examine key aspects of the Political Declaration, how they purport to correct governance failures during COVID-19, and why they fall far short.
Equity in Health and Medical Countermeasures
The COVID-19 pandemic had its most dire consequences for the world’s most vulnerable. The fatality rate was two to three times greater in low-income countries compared to higher-income ones. Within wealthy countries like the United States, racial minorities and indigenous people were over twice as likely to die from COVID-19 than white people. Half a billion were pushed or pushed further into poverty, largely those who already lacked stable employment, safe living conditions, or access to health care — driving epidemics of hunger, violence, and mental health vulnerabilities. Health care systems were inundated, short-staffed, and under-resourced. Delayed diagnoses and treatment are increasing deaths from cancer, diabetes, and heart disease. We fell behind on childhood vaccination rates. Children, especially girls, lost access to education; many still have not returned to school.
Wealthier countries used export controls and bought out short supplies of medical resources on the global market, forcing lower-income countries to rely on charity and global aid. The starkest inequities were in the distribution of COVID-19 vaccines. As acknowledged in the Political Declaration, as of April 2023, 75 percent of the population of high-income countries were fully vaccinated compared to 27 percent of low-income countries.
When low- and middle-income countries (LMICs) entered the marketplace to purchase vaccines, pharmaceutical companies exploited them, demanding unreasonable commitments to strict liability protections and charging higher prices than offered to high-income countries. For example, during the height of the pandemic, Johnson & Johnson charged South Africa 15 percent more per dose of its COVID vaccine than it charged the European Union, while Pfizer-BioNTech charged South Africa nearly 33 percent more than it reportedly charged the African Union. And all the while, pharmaceutical companies insisted on keeping their contracts with LMICs confidential. Without transparency, there was little accountability.
The Political Declaration deals with these startling inequities through weak, rhetorical language. Its provisions “urge” equitable and timely access to countermeasures (para. 31); “call” for equity mechanisms for access to health and social services (para 32); and “promote” the transfer of technology on mutually agrees terms (para. 39). Another provision would “promote the supply and distribution of … affordable medicines”; a watered-down version of a prior draft that asked states to at least “ensure” the same (para. 35). What is most important is that the Political Declaration offers no funding, no commitments, and no mechanism to ensure equitable access to medical countermeasures.
The Political Declaration also uses weak language surrounding the needs of populations left behind. For example, it asks states to “address” the needs of particularly vulnerable populations like women, children, and those living with disabilities or underlying conditions (para. 34); “support” adequate remuneration, resources, and training for health professionals (para. 48); and “commit to strengthening” women’s participation and leadership in pandemics (para. 51).
Instead of this feeble language, it would be far more valuable if states, through the Political Declaration, agreed to establish international obligations to ensure more equitable processes and outcomes during the next pandemic. This could include commitments to back WHO’s mRNA vaccine hubs to diversify manufacturing and help low- and middle-income countries move toward self-reliance in producing pandemic countermeasures. The Political Declaration merely “encourages” the INB and the Working Group on Amendments to the IHR (2005) to prioritize equity and to continue their work in a timely manner (paras. 45 and 46). Further, the Political Declaration puts significant onus on the WHO to “coordinate with partners” (para. 31) in working toward pandemic prevention, preparedness, and response. And though the Political Declaration includes the word “multisectoral” four times, it largely focuses on health systems, negating the broader impacts of pandemics and the role of various sectors.
It is important to remember that UN member states are the same states currently negotiating the Pandemic Accord and IHR revisions in Geneva. Yet, negotiators in Geneva are often from health ministries or attachés and badly need high-level political backing from their prime ministers or presidents. That backing was absent in New York.
Global Governance and Accountability
The collapse of global health governance during the COVID-19 pandemic was alarming. The WHO was prominent in investigating the initial outbreak, but its position was quickly weakened as tensions built between the U.S. and China, the world’s two superpowers. The WHO set emergency recommendations through its authority under the IHR, yet states largely embarked on ad hoc and uncoordinated responses, closing borders to travel and trade against WHO’s advice, and failing to report to WHO when they deviated from the IHR as the rules require. Many wealthier states fully or partially declined to support WHO’s platforms for sharing COVID-19 information, resources, or vaccines, or reneged on their commitments to do so.
At the same time, the pandemic saw a surge of human rights abuses in much of the world. The right to health, as well as other social and political rights, collapsed.
When COVID-19 cases surged in India, the government halted promised exports of vaccines to share with lower income countries. When South Africa promptly and responsibly reported a new variant (omicron), the world should have increased the country’s shared doses of vaccines. Instead, countries instituted more travel restrictions. Yet by design of the global health architecture, WHO lacked the authority to enforce compliance with international norms throughout the pandemic.
Even if strong norms are ultimately established through a new Pandemic Accord and revised IHR, they will have little value if states cannot agree on compliance and implementation mechanisms. Yet the Political Declaration does more to ensure state sovereignty than accountability to global commitments going forward. Its provisions “reaffirm the importance of national ownership” and the primary role of governments in determining their own path to pandemic preparedness and response (para. 59). It asks states to “strengthen legislative and regulatory frameworks” (para. 60) and “take measures to embed multisectoral emergency coordination” (para. 61).
It is a missed opportunity for states to agree on robust, transparent mechanisms for compliance and accountability. While both high- and low-income countries may be averse to strong commitments, there are a myriad of options to build a system of accountability that is not punitive. For example, a peer review mechanism, or independent assessment, can be designed to link gaps in compliance with financial and technical support to improve upon fulfilling commitments. Such an accountability system could also recognize that strong public health systems take time to build. To ensure transparency, it could be in the public domain, with member state oversight. While the new Pandemic Accord and revised IHR can still include such mechanisms, the Political Declaration represents a missed opportunity to galvanize support.
The COVID-19 pandemic manifested what experts have been warning about for many years — the lack of financial investment in pandemic prevention, preparedness, and response. In 2012, the World Bank estimated that $1.9-3.4 billion was required to upgrade zoonotic disease prevention and control systems in developing countries to meet World Organisation for Animal Health and WHO standards. The International Monetary Fund (IMF) now estimates the cumulative economic loss from the pandemic at $13.8 trillion. In short, investing in pandemic preparedness is economically wise.
It will be impossible to prepare for the next pandemic without concrete funding targets and commitments to strengthen both national health systems and the WHO. In 2022, the IMF estimated that it would take $15 billion that year, and $10 billion annually after to fight pandemics and strengthen health systems everywhere. In November 2022, the G20 hosted the launch of the World Bank’s Pandemic Fund designed to invest in low- and middle-income countries to strengthen their pandemic capacities. Yet it remains significantly underfunded. The Pandemic Fund’s first call for proposals in the spring of 2023 generated requests from 129 low- and middle-income countries asking for over $2.5 billion in grants — over 8 times the allotted resource envelope.
The Political Declaration includes no funding targets or infrastructure that could help fill the enormous gaps in pandemic financing. It asks states to “recognize that health financing requires global solidarity” (para. 73); “ensure sufficient domestic public spending on health” (para. 74); and to “leverage existing financial tools” as well as “funding for rapid surge financing” (para. 76).
The time is now for states to fund pandemic preparedness ahead of the next major outbreak. While all states must commit to pandemic financing, commitments should be cognizant of states’ varying resources and capacities. Those with greater financial resources have a greater obligation to secure pandemic prevention, preparedness, and response. Wealthy nations like the United States should be leaders in pandemic financing. Yet, the Political Declaration shies away from establishing any sort of financial obligation.
Pandemic Prevention and One Health
We are living in an age of pandemics, driven by climate change, urbanization, rapid international travel, and intense interchange between animals and humans. Despite loud voices stating that SARS-CoV-2 originated in the Wuhan Institute of Virology, most evidence shows that the virus likely originated from a natural zoonotic spillover, with the Huanan Seafood Wholesale Market in Wuhan, China, as a probable point of origin. Three quarters of human infectious diseases originate from pathogens that circulate in non-human animal species. Human behavior significantly contributes to these spillover events, such as high-density livestock farming and related overuse of antibiotics, trade of live animals, deforestation and encroachment into animal habitats, as well as certain practices in hunting, handling, and consuming animals.
The Political Declaration recognizes “the necessity of a One Health approach that fosters cooperation between the human, animal and plant health, as well as other relevant sectors” (para. 68). It also asks states to take measures to address antimicrobial resistance and strengthen infection control (para. 70), and improve routine immunization to prevent outbreaks and re-emergence of communicable diseases (para. 71). Yet again, it falls far short of committing heads of state to set international obligations with clear rules and roles for preventing infectious outbreaks and spread. For example, it could set universal commitments to ban or restrict harmful wildlife trade, high-density agricultural practices, or the culling of animal habitats, with resources and technical support to help countries fulfill their commitments.
Global Health Security and Equity in the Next Health Crisis
The Political Declaration on Pandemic Prevention, Preparedness, and Response — the first major instrument dedicated to global COVID-19 reforms — leaves considerable doubt and uncertainty as to whether the world will perform better in the next pandemic. At stake are human lives, the education of our children, and social and economic well-being of nations everywhere. Our basic sense of global solidarity and equity were shaken during the pandemic.
While a new Pandemic Accord and revised IHR could still incorporate badly needed commitments, funding, and accountability, world leaders won’t feel the weight of support, pressure, and urgency that a strong Political Declaration could have created. If we again find ourselves unprepared in the next pandemic, with suffering and deaths that could have been prevented, we will remember this historic moment with deep regret.