A year and a half has passed since a microscopic virus changed every aspect of life throughout the world. Yet, we may never fully understand how it began: most probably through a naturally occurring zoonotic spillover, but a leak from the Wuhan Institute of Virology remains a viable alternative theory. The novel virus, SARS-CoV-2 (which causes COVID-19), spread silently yet rapidly between persons, sweeping first through Wuhan and across mainland China, reaching the rest of Asia, then on to devastate Europe, and soon after arriving in the Americas. Within months, no corner of the world was unscathed. And still today, devastating new outbreaks — with the emergence of even deadlier variants — circulate in South Asia, the Americas, and Central and Eastern Europe. The last 18 months have brought previously unimaginable human suffering and death, the unraveling of relationships and livelihoods, and the reversal of progress in global health and human rights that could take decades to fully recover.
Yet, there are reasons for hope. Science and human ingenuity left us awestruck with the unprecedented speed with which vaccines were developed. In fact, vaccines are so safe and effective, they offer a clear pathway to ending the pandemic. When the best science is backed by funding and legal instruments to assure safety and effectiveness, humanity can counter nature’s greatest threats. Perhaps most important, the benefits of scientific technologies must be shared equitably with everyone on the planet.
But why did the world fail so abysmally to prevent the SARS-CoV-2 outbreak or control it before it produced so much suffering and death, especially among the world’s most marginalized and disadvantaged? A lack of preparedness across all levels of government, weak and underfunded national and global health institutions, poor leadership with diminishing public trust, and the rise of nationalist populist politics are all part of the answer. The next global health tragedy can be averted; but to do so, major changes in global health law, financing, and governance are needed. Below I examine the most pressing ones.
Prevent Zoonotic Spillover
The international framework for pandemic preparedness, the International Health Regulations (2005) (IHR), establishes a global surveillance and reporting system for detecting and responding to pathogens of international concern. But there remains a major gap in regulating how those pathogens emerge in the first place — usually by zoonotic leaps. Wildlife trade, wet markets, inhumane animal husbandry, and other intense human-animal interchange create significant risks of zoonotic leaps. Irrigation and deforestation similarly increase risks of vector-borne diseases emerging, bringing human and animal populations ever closer together as we destroy animal habitats. By regulating the human-animal-environment interface, whether by extending the IHR or through new legal instruments, we can prevent many novel outbreaks. There are major collateral benefits of such regulation, too — preventing deforestation assists the climate and regulating factory farming can reduce antimicrobial resistance.
Even if a lab leak were to be ruled out as the origin of SARS-CoV-2, laboratory safety remains dangerously underregulated globally. The release of dangerous pathogens can occur intentionally, such as in the anthrax attacks following the 9/11 crisis. They can also be unintentional, which has occurred even in the most secure labs, such as those run by the National Institutes of Health or Centers for Disease Control and Prevention. Gain-of-function research, moreover, can enhance the transmissibility or pathogenicity of dangerous microbes. Governments, the private sector, and academic researchers should agree to international biosafety and security measures to prevent and detect accidental and intentional leaks from the world’s laboratories — from the smallest “garage labs” to the largest institutions — that deal with dangerous pathogens (e.g., smallpox, influenza, Ebola, and coronaviruses).
Robust Health Systems
Every sector (e.g., governments, businesses, civil society) has an interest in global preparedness, yet health systems remain the first line of defense for rapidly detecting and responding to novel disease outbreaks, as well as caring for patients. Without strong national health systems, every country remains at risk of a rapidly spreading infectious disease. Every government has primary responsibility for building and sustaining resilient health systems. This requires robust domestic investments in core health system capacities, including a strong health workforce, laboratories, surveillance and data systems, as well as surge capacities in a health emergency. Global instruments and institutions can also strengthen health systems, including global health assistance, strengthen the WHO’s joint external evaluations (JEE), and implement the recommendations of the IHR Review Committee, with strong compliance-enhancing mechanisms.
Strengthen Global Health Institutions
We will not prevent the next global health tragedy without stronger global health institutions. The World Health Organization (WHO) is the pivotal United Nations agency for global health preparedness and response — even as other UN agencies (e.g., Food and Agriculture Organization and UNHCR), as well as non-UN agencies (e.g., World Animal Health Organization and the World Trade Organization), have important roles to play. For decades, countries have refused to increase their assessed contributions to WHO, leaving it reliant on voluntary contributions, which are often earmarked to align with donors’ preferences. Such reliance results in a fundamental misalignment of global health priorities and spending. To operate effectively, WHO must have sufficient and flexible funding commensurate with its global health mandate.
WHO also needs the power to verify state reports, independently publish outbreak data, and investigate novel pathogens with associated rights of access to the places in which they emerged. These powers could be entrenched in a pandemic treaty, along with necessary monitoring and enforcement mechanisms, which will be discussed at a special session of the World Health Assembly this November. I am a member of the Independent Panel for a Global Public Health Convention (GPHC), supported by the O’Neill Institute. Countries should also establish an International Pandemic Financing Facility for rapid financing of pandemic response, as recommended by the Independent Panel for Pandemic Preparedness and Response (IPPPR).
From the wholly disproportionate number of COVID-19 cases and deaths among racial minorities and the skewed distribution of life-saving medical resources and COVID-19 vaccines to the concentration of decision-making powers in high-income countries, the systemic inequities revealed and exacerbated by COVID-19 should no longer be tolerated. To begin correcting deep and unconscionable inequities, we need strong mechanisms to equitably share specimens, genomic sequencing data, and technologies for the development of diagnostics, therapeutics, vaccines, and other essential scientific resources. The WHO’s Pandemic Influenza Preparedness (PIP) Framework for research and development and benefit sharing can be improved and expanded. The PIP Framework currently only covers influenza strains and not other biological materials like Ebola or coronaviruses. Nor does it cover genome sequencing data (GSD), which, if openly shared, could assist scientists in identifying how viruses and viral variants spread around the world. From the very first moment that Chinese scientists sequenced SARS-CoV-2 in early January, the race was on for vaccine development.
Substantial work must also be done to correct social inequities revealed and exacerbated by the pandemic by race, gender, wealth, and education. Embedding equity into not only pandemic preparedness and response but all health frameworks would be transformational in a post-COVID world. A good start would be for countries to endorse the O’Neill Institute’s proposals for a Framework Convention on Global Health or Health Equity Programs of Action. Consideration could also be given to moving the WHO’s headquarters to a lower-income country, exemplifying a commitment to empower — not impose on — all states to advance health. At the least, the WHO should have a stronger presence in low- and middle-income countries, especially sub-Saharan Africa.
Global Health Tools
Rather than hold the majority of scarce medical resources in high-income countries, the world should ramp up production of pharmacological interventions, diagnostics, and other essential medical supplies to be stockpiled in regional resource hubs. This could avoid unequal distribution of resources and lower-income countries’ reliance on charity in an emergency. For when a particular zone is hard-hit by an outbreak, countries should transform the Act-Accelerator into a permanent end-to-end delivery system for essential resources, as the IPPPR recommended. As a WHO-led partnership to stimulate the development, manufacture, and equitable sharing of COVID-19 tests, treatments, and vaccines, the ACT-Accelerator has demonstrated the value of open data sharing and collaboration between diverse stakeholders in science, medicine, government, business, and philanthropy.
COVAX, the vaccine pillar of Act-Accelerator, was weakened by countries’ refusal to share their resources and provide adequate funding (the ACT-Accelerator is $18.1 billion underfunded). Yet funding and donating doses are not enough. Vaccine producing companies and nations must commit to an intellectual property waiver at the WTO, technology transfer, provide raw materials and technical support, and continue to make these goods and knowledge available when a permanent Act-Accelerator platform is established.
Raise pandemic preparedness to a high-political level
Without coordinated global leadership on pandemic preparedness and response, the world risks repeating the tragedy of the COVID-19 pandemic. Countries should quickly act on the IPPPR’s recommendation to create a high-level Global Health Threats Council led by heads of state to elevate pandemic preparedness to the highest political level.
Global health security touches every life and every sector. Everyone has an interest and role in protecting global health — health systems, individuals and families, universities and schools, businesses and financial lenders. While historically underutilized, law can unite actors and leverage interests to create a healthier, safer, more equitable world.
As we concluded in the O’Neill Institute/Georgetown University Lancet Commission on Global Health and the Law, the law — and the rule of law — can be vital tools for advancing the right to health. The O’Neill Institute for National and Global Health Law vows to be at the vanguard for finding and advocating for innovative solutions to the world’s most consequential health threats, backed by effective and ethical national and global governance.
Lawrence O. Gostin is the faculty director of the O’Neill Institute for National and Global Health Law and the founding O’Neill chair in global health law. He directs the World Health Organization Collaborating Center on National and Global Health Law.