Straight to the point

In December 2021, the World Health Assembly established an Intergovernmental Negotiating Body (INB) to draft a new international pandemic preparedness instrument, under the Constitution of the World Health Organization. The stated aim of this instrument is ‘strengthening pandemic prevention, preparedness and response.’

As part of this process, the INB is undertaking public hearings to inform its deliberations, consisting of either a spoken component of two minutes, or a written component of 250 words. The first round of public hearings occurred in April 2022, with a guiding question for consideration, as follows:
“What substantive elements do you think should be included in a new international instrument on pandemic preparedness and response?”

The second public hearings were scheduled to take place in mid-June 2020. However, with just 2 weeks to go, the WHO postponed them, ‘to ensure that the input to be gathered in that second round supports the continued work of the INB.’

In the absence of a timeline for the next round of hearings, PANDA has decided to publish its submission in advance. PANDA’s aim is to encourage open debate to ensure global pandemic preparedness is underpinned by a strong evidence base, which gives full consideration to the COVID-19 response. 

PANDA’s submission is fully in line with the founding principles of the WHO and orthodox principles of public health.

Rationale

Proportionality, risk and the social determinants of health

When developing a strategic public health instrument, such as the one currently being proposed by the WHO, it is imperative that a strict evidence-based approach is followed. Moreover, any instrument must be proportional to the level of threat, ensuring that resources are not diverted from areas where they could have more impact (e.g., higher disease burden). Therefore, pandemic preparedness and response should properly consider both the risks and benefits of every intervention to minimize ‘harm’ to all aspects of health (physical, mental, and societal). Proper attention must be given to the social determinants of health, including minimizing socioeconomic damage to individuals, communities and economies. Fundamental rights and freedoms must also be protected.

Who should influence public health policy?

Throughout most of its history, the WHO was largely funded by member states. This public funding model reduced the likelihood that major conflicts of interest would influence policy development. PANDA recognizes the challenges that have arisen now that a significant part of the WHO’s funding – including in the area of pandemic preparedness and response – is provided by private entities. The WHO was formed to represent the needs of the populations of the world, rather than private foundations and corporations in the health field. Therefore, it is essential to exclude non-state actors with conflicts of interest from negotiations – for example, companies producing health commodities whose investors stand to financially benefit from certain potential responses to pandemics and health emergencies. This clearly includes all representatives and/or agents of such companies. 

The response to COVID-19

In the past 120 years, prior to the COVID-19 outbreak, the WHO has recorded just 4 pandemics – one per generation. These pandemics had little impact on all-cause mortality, apart from the 1918-1920 influenza pandemic which occurred in the pre-antibiotic era. Meanwhile, the response to COVID-19 has resulted in collateral damage, particularly to children and young people, who will ultimately bear the ongoing socioeconomic burden of the response in the years ahead. Food security is also declining globally due to the resultant impact of supply line disruption, most notable in low-income counties. This can be expected to impart significant impact on mortality, particularly in children, that is likely to exceed the highest estimates of mortality from COVID-19.

Given these realities, and the importance of competently managing disease outbreaks when they occur, the impacts of the COVID-19 response need to be properly quantified prior to the development of further policies that would promote repetition of this approach. Any future pandemic preparedness instrument should be proportional in its approach; it must consider pandemic risk and available resources, in the context of the total health burden and competing priorities. 

Submission to the Intergovernmental Negotiating Body

Pandemic preparedness must be evidence-based and proportionate, balancing potential benefits with costs, including collateral costs to health and wider society. Therefore, PANDA suggests the following questions must first be addressed:

• What is the true frequency of pandemics?
  The WHO lists only five pandemics in the past 120 years, with the highest mortality before antibiotics and modern medicine.
• Is the proposed expenditure proportionate to the health burden from pandemics?
  Other infectious diseases, including malaria, tuberculosis, HIV/AIDS, non-communicable diseases and malnutrition, have exacted higher burdens than COVID-19 in the past 2 years (based on life years lost).  WHO also considers mental and societal well-being within ‘health’.
• Does the response fit with WHO principles regarding community empowerment and control?
  These principles of horizontal over vertical approaches were reiterated by the WHO at Astana in 2018.
• Should non-state actors with conflicts of interest be excluded from interim negotiation processes?
  The pandemic ‘treaty’ zero-draft includes a role for private and corporate entities, who fund WHO directly and through partners in pandemic response. Such conflicts of interest were formerly avoided.
• Did the response to COVID-19 reduce overall disease burden, or increase it?
  Previous WHO recommendations cautioned against measures used against COVID-19. WHO partners report high collateral mortality, including in children.

A full, transparent and inclusive review process is required, utilising the WHO’s established evidence-based guideline approach, incorporating assessed strength of evidence. This review should occur prior to considering further application of these new approaches to pandemic management.