Lawrence O. Gostin is “confident” that countries will adopt a pandemic accord at the 2024 World Health Assembly. 

The question is whether it will include the kind of “robust norms” necessary to ensure that the new accord is “transformative” with respect to correcting disparities and injustices uncovered in the last pandemic, and effective in its enforcement of new norms. 

As the head of Georgetown’s WHO Collaborating Center in national and global health law, Gostin is playing a key behind-the-scenes role in negotiations.

Here is his take on what is at stake and what choices need to be made.

Health Policy Watch: What is a pandemic treaty? What does it entail?

Lawrence Gostin: The Pandemic Accord, currently in development, has the potential to be a landmark in global governance, akin to the Paris Agreement. Its impact will depend on its final content, mainly if it includes strong norms.

These norms should ensure equitable sharing of lifesaving resources, promote a “One Health” approach to prevent zoonotic diseases and establish robust compliance mechanisms. The Accord could transform global health law by emphasizing equity, a holistic health strategy, and effective enforcement.

HP-Watch: Based on your observations of the draft versions of the treaty, where are the opportunities for an “accord”?

Gostin: I’m confident governments will adopt a Pandemic Accord at the May 2024 World Health Assembly. However, I’m concerned it might lack the robust norms I mentioned. This could weaken its impact. Bold norms and strong accountability mechanisms could make it powerful, but high-income countries might hesitate to ratify it.

It could be diluted during negotiations, potentially failing to ensure equitable access to lifesaving resources or overlooking the “One Health” strategy. I urge all nations to seize this once-in-a-lifetime opportunity. Let’s make the world safer, more secure, and fairer. Failing to do so would be our own responsibility.

HP-Watch: There has also been a lot of “discord” during the pandemic accord negotiations. Which countries are contributing to these disagreements, and why?

Gostin: Failing now could postpone meaningful global health reforms for decades. The main hurdles lie in disagreements between high-income and low-income countries, particularly African nations and the US/Europe. Rich countries prioritize full access to scientific data for governments and scientists, like pathogen samples and genomic sequencing.

This data is crucial for understanding and responding to pathogens. However, lower-income countries view these samples and data as their only bargaining power for equitable resource sharing. They’re concerned about sharing scientific information used to develop vaccines and drugs but not getting access to these lifesaving resources in return.

HP-Watch:  What are the main stumbling blocks to a robust treaty?

Gostin: Key obstacles revolve around equity, funding, compliance, and accountability. Like climate change discussions, a significant factor in these debates is the principle of “common but differentiated responsibilities” (CBDR). CBDR, established as Principle 7 in the 1992 Rio Declaration, means that countries have distinct obligations based on their socioeconomic status and historical contributions to the issue, such as preventing pandemics.

While all nations must protect the environment, wealthier countries have greater responsibilities in compliance and funding. However, disagreement persists regarding the application of this principle to pandemic governance. Currently, the CBDR principle is only an “option” for varying implementation of the Accord.

HP-Watch: What are the gaps in the draft treaty? What are their origins, and what are some suggested solutions?

Gostin: Various drafts of the Pandemic Accord are extensive, but the final version might have significant omissions. Throughout the drafts, “options” range from robust action to inaction. For instance, one draft offered two choices: establish strong obligations for the One Health approach or take no action. This dichotomy leaves little room for compromise.

The Accord’s direction depends on whether governments advocate for strong or weak norms. Those favoring weak norms may do so to safeguard their sovereignty, dilute obligations, emphasize sovereignty as a principle, distrust the WHO, or resist international obligations. Populist nationalist governments often oppose UN treaties.

If governments opt for weak norms, critical areas like equity and One health will suffer from significant gaps. Equally important are deficiencies in what I call “good governance,” with inadequate mechanisms for ensuring transparency, compliance, enforcement, or accountability of state obligations.

HP-Watch: What are your thoughts on the treaty’s negotiation mechanisms for promoting timely information sharing in the context of national interest conflicts?

Gostin: During the COVID-19 pandemic, and even well before, the world suffered from two failures of cooperation. First, nations failed to promptly report novel and dangerous outbreaks or share pathogen and genomic sequence data. The second is that countries failed to equitably share those lifesaving resources once vaccines and therapeutics were developed.

As a result, there is currently considerable distrust in the negotiations. The tensions often exist between higher and lower-income countries. The only real tool WHO currently has to encourage countries to prioritize global solidarity over their own national interests in the negotiations is diplomacy; reminding countries of the immense toll of the pandemic, both in terms of lives lost and economically, and that preventing history from repeating itself can only be achieved through strong norms and global cooperation.

HP-Watch: Could you comment on mechanisms the United States, Africa, and the European Union suggested?

Gostin: African nations advocate waiving intellectual property rights for easier vaccine and drug development during health crises. Lower-income countries endorse “technology transfer” to enable local manufacturing. The WHO backs mRNA manufacturing hubs in countries like South Africa.

The focus should shift from charitable donations to empowering nations for self-reliance, necessitating global cooperation. Meanwhile, the US and the EU emphasize timely, transparent reporting and access to pathogen data, with the EU favoring One Health provisions.

HP-Watch: Why prioritize incentives over sanctions, especially when some experts argue for stronger enforcement measures?

Gostin: The WHO has long been adverse to compulsory measures, including sanctions. Member states often can accept the idea of incentives but are resistant to enforcement measures. In my judgment, we need both carrots and sticks.

Carrots could include financing for health systems in lower-income countries. Sticks might include public disclosure of countries that fail to abide by their international obligations. There could also be some form of adjudication system, such as occurs with the World Trade Organization. Compliance-enhancing measures are vital. These can include incentives but they also need to include other more formal means of encouraging compliance with norms.

One idea that has been floated is that parties would establish a universal health and preparedness review or some other peer review mechanism, enhancing compliance with countries’ preparedness obligations under the Accord.

HP-Watch: How confident are you in incentivizing compliance, given the IHR enforcement issues during the COVID-19 pandemic?

Gostin: I am not at all confident. History with the IHR teaches us that without effective compliance mechanisms, countries often won’t abide by their international obligations. Good governance requires better forms of accountability, such as an independent oversight mechanism empowered to investigate outbreaks or treaty violations and enforce commitments, fair resource allocation, and regular reporting on progress, with some scope for civil society participation.

HP-Watch: How will negotiators balance accountability and sovereignty when implementing compliance measures?

Gostin: Right now negotiators are at a loss. One very interesting compromise might be found in proposals by the US and by the African bloc on compliance and implementation. There are good faith negotiations on those proposals in the IHR reform processes, which include a compliance committee comprised of key member states.

This committee would be tasked with finding means to better ensure state compliance. We need that kind of buy-in for compliance in the Pandemic Accord, which currently includes draft language establishing an Implementation and Compliance Committee comprised of expert members elected by the Accord’s Governing Body.

HP-Watch: Will equity discussions lead to concrete actions for fair access during health crises?

Gostin: This is perhaps the most important topic in the negotiations. Right now we don’t have agreement on reliable and sustainable funding, technical support, technology transfer, and equitable allocation of life-saving resources. There are several innovative methods to seek greater equity. One promising model is the Pandemic Influenza Preparedness (PIP) Framework.

Under the PIP Framework, pharmaceutical companies, laboratories, and academic centers pledge to give doses of vaccines or drugs, or to provide funding to WHO. In return, these actors gain access to pathogen samples.

The WHO then distributes the benefits to countries on an equitable basis. I also mentioned the idea of diversified manufacturing or technology transfer. Ultimately, it is important for low- and middle-income countries to gain the capacity to manufacture emergency products themselves and not rely on philanthropy.

HP-Watch: What are the potential consequences of the draft Accord’s narrow focus on health-centric solutions?

Gostin: The issue of One health is essential. Everyone knows that there are vast connections between human health, animal health and the environment. Yet, this requires intersectoral cooperation and governance.

The Pandemic Accord is a WHO instrument and we must find ways to link to the law and governance of animals and the environment. Relevant bodies include the World Organisation for Animal Health, the Food and Agriculture Organization, the UN Environment Programme and the World Trade Organization. This kind on intersectoral coordination is largely absent in the current draft.

HP-Watch: What’s the debate on equitable access to medical countermeasures, intellectual property, and trade language, and how will it influence the negotiations?

Gostin: There are huge gaps between high and low-income nations. High-income countries are reluctant to sign onto binding obligations to share lifesaving resources. But low-income countries demand that they have a right to fair and affordable access to vaccines and drugs.

The truth is we need both and we shouldn’t trade one important value for the other. It is clear that rapid reporting, sharing pathogen samples and genomic sequence data, and sharing scientific and epidemiologic information are vital for global health. It is equally clear that we cannot tolerate a system where all the benefits go to high-income countries and lower-income countries are left behind.

HP-Watch: How does the ongoing United Nations high-level meeting discussion relate to the concurrent negotiations for a pandemic accord and amendments to the IHR?

Gostin: The UN High Level Meeting (UNHLM) on Pandemic Prevention, Preparedness and Response this September is our best chance to gain support and deep engagement of heads of state and government. The UNHLM is expected to adopt a Political Declaration on Pandemic Prevention, Preparedness and Response. Thus far, many civil society organizations have expressed disappointment in the draft Political Declaration.

While the draft Political Declaration is high on lofty principles, it is wholly inadequate on concrete action, such as pledges for funding health systems. And while processes in Geneva and in New York must be synergistic, there has been too little cooperation between the UN and WHO. This is disappointing especially as WHO was the UN’s first specialized agency formed in 1948. 

HP-Watch: What’s behind the resistance to the UN High-Level Meeting, and how might it affect the Geneva discussions?

Gostin: There are longstanding but subtle tensions between Geneva and New York. In my view action by both the UN and WHO is needed. WHO is undoubtedly the health leader. But we also need high-level political support and an all of government approach to pandemic preparedness and response, as the causes and impacts of pandemics go well beyond the health sector. The WHO is a UN agency and we need more cooperation at every level. This shouldn’t be a competition, but sometimes it seems to be. 

HP-Watch: Why is the draft UN Political Declaration not ambitious, and how can it be strengthened, especially regarding the ‘Global Health Threats Council’?

Gostin: The Global Health Threats Council aims to elevate pandemic preparedness discussions to the highest political level. Whether it’s based in New York or Geneva matters less than securing active engagement from heads of state or government. Adequate, sustainable funding is another crucial aspect.

Pandemic preparedness involves various government ministries, and it should encompass an all-of-society approach, including public and private entities and robust civil society involvement.

HP-Watch: What role does the pharma industry play in shaping the treaty, and how do we differentiate responsible advocacy from profit-focused lobbying?

Gostin: Pharmaceutical companies are vital in vaccine development but must act cooperatively. They often prioritize profits, which can hinder global access. It’s crucial they don’t influence treaty negotiations. High-income countries have sometimes prioritized industry interests. Involving pharmaceutical companies in negotiations could risk such influence.

HP-Watch: How can WHO and the UN tackle misinformation while preserving citizen privacy and free speech on social media through collaboration with governments?

Gostin: Misinformation poses a serious health threat, especially in vaccine distribution. Balancing free speech with combating misinformation is challenging. An all-of-society approach is needed, involving medical societies, tech companies, and fact-checking organizations. WHO can lead partnerships between scientific experts and information disseminators to ensure credible information reaches the public.

HP-Watch: What’s your take on the pandemic treaty timeline, balancing speed and thoroughness, and a realistic estimate for an ideal agreement’s timing?

Gostin: Ideally, I would like to see WHO meet its deadline of presenting a draft treaty for adoption to the World Health Assembly in May 2024. I know that is pushing it, and member states are nowhere near to making enough progress. But the reason for speed is compelling. It is clear that the COVID-19 pandemic injected a sense of urgency.

As memories of the pandemic fade, political will declines. If we wait too long, we may lose this historic opportunity. Now is the time to forge [an] agreement. With every passing week and month, the world’s attention shifts to other priorities, such as climate change, the war in Ukraine, and food insecurity.

HP-Watch: How do we address the draft treaty’s health-centric focus criticized by some, considering the need for a broader approach to pandemic response during negotiations?

Gostin. In Geneva, most negotiators come from health backgrounds, lacking a comprehensive perspective. To improve this, we can draw inspiration from the WHO Framework Convention on Tobacco Control (FCTC) negotiations, where civil society played a crucial role.

While the WHO allows civil society input, it often remains formal. Unlike the FCTC negotiations, there’s a lack of robust advocacy in the Pandemic Accord negotiations, which is regrettable. The lessons from tobacco control and the AIDS pandemic highlight that real transformational reforms require strong bottom-up social mobilization. 

HP-Watch: What’s the current status of discussions on the Pandemic Fund, and how might it impact the treaty?

Gostin: I don’t know of a single global health advocate who is optimistic about progress on a Pandemic Fund. The World Bank has an initiative, but the Fund is still significantly below its funding goal, and we have seen the Bank sputter in the past on pandemic funding. And while the G7 and G20 have made promising noises, I don’t see any concrete plans for ample and sustainable funding taking shape.

That is a great missed opportunity because the only way to truly make the world more prepared is through funding, and especially funding of robust health systems. In the Pandemic Accord negotiations, there has been much discussion of funding. Still, there doesn’t seem to be agreement on a mechanism and long-term funding sources. Ultimately, rich countries will have to step up. But that hasn’t happened thus far despite the urgency.

HP-Watch: How do initiatives like medical countermeasures and mRNA tech-transfer hubs fit into treaty discussions, and what’s your perspective on their impact, given the crisis faced by initiatives like ProMED?

Gostin: In addition to all the other suggestions, we must remember that WHO is also working on a new multi-disease platform to coordinate equitable access to health information, tools, and countermeasures right from the onset of the next pandemic to replace fragmented initiatives and better ensure that all populations can be served. This new platform builds on lessons learned from the ACT-Accelerator.

This ambitious platform was developed to share COVID-19 tools and resources but fell short of its goals. The new platform is facing challenges related to how it will function and how it will be governed. But getting such a platform in place before the next major epidemic or pandemic arises, one that reaches and incorporates the voice of all populations will be critical for health equity.

HP-Watch:  What do you think about the Global Preparedness Monitoring Board‘s key asks for the UN HLM declaration on the treaty negotiations, like changing the language from ‘acknowledge’ to ‘commit’?

Gostin: As I have stated above, there is a delicate balance between incorporating actual mechanisms for accountability into the Accord against national interests in sovereignty. We all need to step back and remember that if we fail to meet the moment, it could be many decades before we have the chance for significant reforms in global health.

We need to be bold and an Accord that both high- and low-income countries will ratify. As I discussed above, there are ways to meet these interests through carrots and sticks. I want to reiterate that we genuinely have a historic opportunity to make the world safer, more secure, and fairer. If we don’t grasp this moment, we have no one to blame but ourselves.

HP-Watch: What do you think about the social media backlash WHO has been experiencing, regarding social media listening/surveillance, which seemed to be included in the treaty draft and poses privacy threats to citizens in countries where social media expressions are turned against them?

Gostin: I don’t accept this criticism because it is untrue. The Accord will not require disclosure of personally identifiable or sensitive health data. Privacy laws such as the EU Health Privacy Directive will remain in effect. The Accord would not interfere with a country’s protection of the health and privacy of its citizens. I should add that the public also has the right to accurate, evidence-based information.

Social media often disseminates false or misleading information that can harm the health of individuals and populations, mainly misinformation about vaccinations. Surveillance in the context of the Pandemic Accord means public health surveillance, that is, early detection of infectious diseases in humans and potentially also in animals and the environment. It does not mean intrusive surveillance of citizens or privacy violations; nowhere in the Accord is this even considered.

HP-Watch:  How did the misconception that WHO agreements, like a pandemic accord, would erode national sovereignty start, and what can be done to combat this misinformation going forward?

Gostin: In many nations and throughout social media, there is distrust of international institutions and a fundamental misunderstanding about international law built on state consent to be bound. Nationalism and populism have created a groundswell for “my nation first.” The problem is that the world would be less safe if all nations put themselves first. We need mutual solidarity and shared obligations. No one is safe unless everyone is safe. 

Lawrence Gostin, is the director of Georgetown University´s WHO Collaborating Center on National and Global Health Law.  He holds a JD from Duke University Law School and a BA in psychology from SUNY Brockport. Prior to taking on his current position at Georgetown in public health law/Washington DC, he also taught at Harvard and Johns Hopkins Universities. Gostin also led the development of the Model State Emergency Health Powers Act (a proposed law to give states more authority to handle bioterrorism or disease outbreaks, recommended by organizations like the CDC) and advises on various WHO expert committees. His expertise has been instrumental during global health crises, such as AIDS, Zika, and COVID-19, earning him accolades from organizations like the National Academy of Medicine.

Image Credits: WHO, WHO , UNICEF/Kokoroko, UN Photo/Manuel Elias, WHO .