Health of nations: How Europe can fight future pandemics

Venue ahead of the European Union-African Union Summit in Brussels on 16 February 2022
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Summary

  • As the crisis phase of covid-19 recedes, there is a chance to improve international cooperation on global health – but also a danger that competing reform proposals will lead to inaction.
  • The EU can best support reform of pandemic preparedness and response if it takes account of the concerns of different global powers.
  • The union should combine a push for reform of and increased funding for the WHO with support for a new fund for health emergencies, overseen by a representative group of countries.
  • The EU should promote a new global compact on health, matching countries’ commitment to surveillance and reporting of pathogens with support for stronger healthcare systems and greater equity in the allocation of countermeasures.
  • The EU-Africa relationship offers a chance to pioneer such an approach, but the EU will need to go further in this than it has so far.
  • The EU should promote African vaccine manufacturing, including by pressing European pharmaceutical companies to transfer knowledge and technology to Africa.

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Introduction

In mid-November 2021, a medical researcher in South Africa spotted an unusually large set of mutations in a handful of coronavirus samples. Worryingly, the identification of the mutations coincided with an uptick in covid-19 cases in the local region, Gauteng province, which had already experienced high levels of infection. Concerned about the upsurge, the head of a South African genomic surveillance network launched a wider investigation. Within 36 hours, his team had confirmed the widespread distribution of the variant, worked with the South African government to make a public announcement, and notified the World Health Organization (WHO), which the next day classified Omicron as a variant of concern.

In one way, the discovery of Omicron showed the system of global public health working effectively in the fight against covid-19, given that it quickly identified and publicised a new and threatening mutation. But the story of Omicron also underlined the persistent international divisions that have marked the world’s response to the pandemic. When many countries put in place travel bans targeting southern African countries, it amplified the perception in Africa that the rich world was only looking out for itself. “We are honestly tired of this” – Tulio de Oliveira, leader of the team that detected Omicron, told an interviewer – “after not having access to vaccines, having to pay more expensive prices, having to get in the back of the queue, and still doing some of the best science on covid in the world.” While it seems that Omicron may have originated in the period before vaccines were developed, the variant focused attention on the threat of further mutations among unvaccinated populations around the world.

Two years into the pandemic, many medical experts believe that at least some parts of the world may soon escape the acute phase of the outbreak. The WHO’s Europe Director, Hans Kluge, said in January 2021 that it was plausible to think that Europe was “moving towards a kind of pandemic endgame”. A combination of testing, vaccines, and over-the-counter antiviral treatments could allow countries that have access to these countermeasures to resume something like normal life. But many nations continue to be held back by shortages of vaccines and by their limited capacity to distribute and administer the supplies they have. Some countries fear, too, that the distribution of promising new antiviral medication will follow the same unequal pattern as vaccines, with wealthy states monopolising initial supplies.

At the global level, the greatest remaining challenge of the pandemic is in ensuring that all countries have the resources they need to contain covid-19. But states should not see the campaign against the SARS-CoV-2 virus as a one-off effort. Instead, given that the virus is likely to become endemic and that it is only a matter of time before there are further outbreaks of highly transmissible diseases, the world needs to improve the way in which it prepares for and responds to health emergencies more broadly. The catastrophic impact of covid-19 and the weaknesses in global cooperation on public health it revealed have led to a series of high-level reviews and a slew of recommendations for change. Intensive international negotiations under the auspices of the WHO are under way to decide how these suggestions should be put into practice. And the subject is also on the agendas of the G7 and the G20 meetings this year.

What is the best way to improve global cooperation against covid-19 and prepare for future pandemics? To answer this question, one needs not only to assess the failures exposed by covid-19 but also to understand the political concerns and agendas that shape states’ policies on global health. Of course, global institutions, agreements, and processes have an impact on how states behave – but, at the same time, national political considerations impose limits on the reforms to the global health system that they are willing to sign up to and affect the way they interpret those commitments in practice. The world’s response to the pandemic has been defined both by national interests and geopolitical rivalries. Yet the effort to promote a more cooperative global approach to health emergencies should not be defeatist in the face of these interests. Rather, it should try to supersede and harmonise states’ interests as far as possible.

This policy brief explores how the European Union and its member states can best promote multilateral cooperation on global health and pandemic preparedness in a world of growing geopolitical competition. It does not try to add to the plentiful expert analysis of ways to improve the global health architecture but instead looks at opportunities for progress that account for countries’ political concerns. The paper argues that it is important to move quickly to take advantage of governments’ heightened attention to global health issues and an administration in the United States that shares at least some of the EU’s goals. The EU should work both to strengthen the WHO and to support moves by like-minded powers to increase funding for national healthcare systems and health surveillance capacity around the world.

Above all, the EU needs to do more to support global equity in access to medical technology and expertise to fight epidemic diseases, particularly by increasing vaccine manufacturing capacity and the availability of vaccines in Africa and other parts of the global south. The best way to improve international cooperation on public health is through a new and open global compact. In this arrangement, countries around the world would commit to step up health surveillance and share information about potential outbreaks, while wealthy states would increase their investment in health systems and take steps to ensure a more equitable distribution of medical goods.

Priorities for pandemic preparedness and response

“We have no shortage of reports, reviews and recommendations” – WHO Director-General Tedros Ghebreyesus said in November 2021 about the lessons of the world’s response to covid-19 – “but we have a shortage of action”. Indeed, there have been multiple analyses of the failures of international cooperation during the pandemic – so many, in fact, that they have generated a secondary literature of studies that compare the conclusions of these expert reviews. One WHO analysis tallied no fewer than 215 recommendations for improving pandemic preparedness and response in 11 reports or papers issued by intergovernmental or expert bodies. Nevertheless, most analyses of the problems revealed by covid-19 converge on a similar set of broad themes, which can be summarised as follows.

Failure to share information about an outbreak

The WHO’s member states agreed in 2005 to the International Health Regulations (IHRs), a set of binding commitments to quickly share information about emerging health threats. However, China was slow to release significant information about covid-19, including important early evidence of human-to-human transmission, and imposed tight restrictions on WHO teams’ visits to the country. Information about covid-19 emerged through the internet and informal channels: the genetic sequence of the virus was first posted online by a Chinese scientist who worked in consultation with international researchers, in defiance of these restrictions.

The WHO’s role in sounding the alarm

The WHO’s main alert mechanism in the face of potential pandemics is to declare a public health emergency of international concern. The organisation waited until 30 January 2020 to do this for covid-19. And it repeated Chinese statements that downplayed the risk of human-to-human transmission at a time when some scientists were sceptical of these accounts. One review found that “the precautionary principle was not applied to the early alert evidence when it should have been.”

International responses

Even after the WHO declared an emergency, countries were slow to react and failed to coordinate their responses. Many states lacked the medical equipment and public health capacity to protect their populations and slow the spread of the disease. There was no consistency in their approaches to testing and travel restrictions. And they placed export restrictions on vital protective equipment. There was insufficient leadership at the international level, while political divisions further limited coordination.

A lack of readily available financing

With funding for global health spread across a range of institutions, there was no central pool of money available to quickly deploy when the pandemic struck, and no mechanism to rapidly scale up financing as the extent of the emergency became clear. Covid-19 also highlighted the world’s failure to invest sufficiently in preparedness for highly infectious diseases at the national level.

Countermeasures development and sharing

As vaccines became available, enormous inequalities developed in governments’ ability to acquire them. High-income countries monopolised early supplies through contracts with manufacturers. The COVAX initiative – part of the broader Access to Covid-19 Tools Accelerator (ACT-A) – was set up to pool global procurement, but it quickly became a vehicle only for the provision of vaccines to low- and middle-income countries. In trying to provide these vaccines, COVAX was held back by export restrictions, limited supplies, and an initial shortage of money.

Parallel processes

International bodies have launched several processes designed to deal with all these issues. The WHO’s working group on pandemic preparedness and response is considering amendments to the IHRs. The WHO has also agreed to set up an intergovernmental negotiating body to consider the adoption of a new treaty on pandemics. The G20 established the Joint Finance and Health Task Force, comprising its members’ health and finance ministers. And the US announced the formation of a new fund designed to improve countries’ defences against pandemics. The World Trade Organization (WTO) continues to debate whether to remove intellectual property (IP) protections on medical products related to covid-19, as India and South Africa first proposed in October 2020.

The danger of these parallel processes is that they could lead to inaction: with different groups of countries focusing on their preferred solutions, the momentum to enact changes could be lost. If states are to avoid this outcome, they will need to identify areas in which their differing agendas create opportunities to build coalitions and conduct joint initiatives.

Europe

During the first year of the pandemic, Europe emerged as a leader in attempts to preserve a functioning multilateral system in global health at a time of heightened geopolitical rivalry between the US and China. The EU sponsored a resolution at the World Health Assembly in May 2020 that brokered a compromise on the contentious question of reviewing the world’s response to covid-19, and that reaffirmed the WHO’s central place in the fight against the virus. The European Commission and France were involved in the launch of ACT-A. European countries such as Germany and the United Kingdom have been among the largest donors to the WHO. Germany recently overtook the US as the leading contributor to the organisation.

In line with its traditional commitment to normative development and the rule of law, the EU has been the main supporter of efforts to create a new pandemic treaty under the WHO. The proposal follows a characteristic European impulse to contain political disagreements through legal means. The idea was first proposed by European Council President Charles Michel in a speech at the Paris Peace Forum in November 2020. It quickly won the backing of the WHO director-general and a collection of countries in the global south. According to EU officials, the treaty would need to have a legally binding element to provide a clear basis for the kind of collective action necessary to prepare for and fight pandemics. However, they believe that the treaty could take the form of a framework convention that establishes a minimum set of obligations (as do the conventions that underpin global cooperation on climate change and tobacco control). States would then supplement this through additional protocol agreements.

EU officials argue that a treaty is the best way to overcome the lack of international coordination and the pursuit of national interest that were evident in the world’s response to covid-19. In their view, the treaty could create a comprehensive framework to meet a range of needed improvements, committing states and the WHO to: conduct surveillance to detect emerging pathogens; share information; strengthen health systems; provide alerts about health emergencies; coordinate responses; equitably distribute tests, vaccines, and other medicines; and strengthen links between health organisations and those working in related fields, such as animal health, climate, and food security (known as the ‘One Health’ approach). EU officials largely dismiss the notion that the treaty could include effective sanctions and concede that it could be difficult to compel states to live up to their commitments. But they hope that the treaty would promote compliance through peer pressure and the political visibility of public commitments. The treaty could also provide incentives for states to share health information when dealing with epidemics – by, for example, guaranteeing that they would receive supplies of equipment, countermeasures, or other support.

While EU member states support the proposal, some national officials privately express reservations about it. These officials fear that any treaty will take a long time to negotiate – especially if it needs additional protocols to set out substantive commitments – and could ultimately take the form of the lowest common denominator in states’ differing agendas. Others feel it is unwise for the EU to campaign so actively for a binding treaty that its most important ally, the US, does not support (as discussed below). Some national officials also say that the EU should have consulted member states more before Michel announced the idea. EU member states may have united behind the proposal, but they are not universally enthusiastic about it.

Europe has also focused on efforts to strengthen the collective multilateral system of global health in other ways, particularly by increasing the independence and capacity of the WHO. German health official Björn Kümmel, who chairs the WHO’s working group on sustainable finance, strongly advocates increases in the level of assessed contributions: funding that countries automatically transfer to the organisation’s general budget. He argues that such increases would give the WHO greater capacity to set its own priorities. This goal is broadly shared across Europe – although some countries, such as the Netherlands, also want better oversight of how the money is spent. “The WHO must remain central – there is no alternative to it in global health and it should be strengthened,” argues another EU official. Germany has agreed to host a new pandemic preparedness hub under the WHO to collate and assess information about new covid-19 strains and other emerging infectious diseases.

The most controversial European position on global health issues is opposition to a waiver of IP rights for vaccines and other medical goods used against covid-19. The EU, the UK, and Switzerland have been the most outspoken critics of the waiver initiative – arguing that, in the short term, it would not help contain the pandemic. While European leaders such as Commission President Ursula von der Leyen say they are open to discussing the issue, more hard-line opponents in countries such as Germany insist that, as former chancellor Angela Merkel said, “the protection of intellectual property is a source of innovation and it must remain so in the future.” Some hoped that the coalition government headed by her successor, Olaf Scholz, might rethink the country’s position. But Economy Minister Robert Habeck – co-leader of the greens, who once backed a waiver – recently announced that he had changed his views after intensive consultations with the country’s pharmaceutical industry.

France initially signalled its support for a compromise on an IP waiver. President Emmanuel Macron, in a disarming moment, told the European Parliament in January 2022 that it had been relatively easy for him to take this position because France had not developed a vaccine that was protected by a patent. But he has now backed off, meaning that there is little chance the EU will readily give way on the issue. The EU’s stance reflects the fact that it, along with China, has been the main exporter of covid-19 vaccines throughout the pandemic, with the union maintaining a dominant position in the export of technologically advanced and sought-after mRNA vaccines. Nevertheless, there are signs that the EU is looking for a compromise. In negotiations at the WTO, the EU has advanced proposals on compulsory licensing (whereby countries have the right to override patents when faced with an urgent need) as an alternative to the removal of IP protections. But these proposals have only won limited support internationally. In his recent speech to the European Parliament, Macron said this approach should be combined with greater pressure on pharmaceutical companies to share knowledge and technology.

European leaders have also tried other approaches to show their commitment to reduce global inequalities in access to vaccines. Beyond funding ACT-A and donating vaccine doses to COVAX, the EU and its member states have highlighted the efforts they are making to help scale up vaccine manufacturing around the world, particularly in Africa. At the G20 meeting in May 2021, the Commission announced a ‘Team Europe’ initiative on manufacturing and access to vaccines, other medicines, and health technologies in Africa that it said would receive €1 billion in funding. According to the EU, a central part of that effort will focus on the establishment of hubs for manufacturing mRNA vaccines. With support from the initiative, German pharmaceutical company BioNTech announced agreements to establish manufacturing sites in Rwanda and Senegal that would involve end-to-end production of mRNA vaccines. The firm said that it would eventually transfer its manufacturing capacity and know-how to its local partners. The construction of the Rwanda site will begin in mid-2022. Once complete, the facility will have the capacity to produce 50m doses per year.

The US

President Joe Biden has often spoken of his determination to restore US leadership of multilateralism on global health, along with other international issues such as climate change. In many respects, he has restored the US to a central role. He reversed former president Donald Trump’s move to withdraw the US from the WHO and has contributed a significant amount of funding to ACT-A. Under Biden, the US initially ensured that almost all vaccines produced in the country were directed to Americans. But, since mid-2021, the country has been the world’s largest vaccine donor. Its vaccine donations recently reached 400m doses, which have been distributed principally through COVAX. The US also deferred delivery of large numbers of contracted vaccine doses to allow the African Union to take precedence, and has donated $1.6 billion to ensure that vaccines can be successfully distributed and administered around the world, particularly in Africa.

Nevertheless, there are significant differences between Biden’s and Europe’s approaches to multilateralism on covid-19. The US favours a stronger role for coalitions of like-minded states that operate under its leadership rather than that of universal membership bodies such as the WHO. And the country appears to hold a more critical view of the WHO’s performance during the pandemic. Biden’s position is also shaped by the constraints imposed by domestic concerns, including a political culture that is more distrustful of binding international commitments and multilateral institutions. Finally, at times, the US approach has had a stronger ideological component – a greater sense that global health is an arena for democracies to show that they are leading the world’s efforts to confront global problems.

The US has not supported the EU’s initiative for a legally binding pandemic treaty. Washington did not block the decision to set up a negotiating body to work on the treaty, and US Health Secretary Xavier Becerra has said his country is “not reluctant” about such an agreement. But European officials have little doubt that the US would try to ensure that any treaty is non-binding. Europeans generally attribute this position to the difficulty that the Biden administration would have in winning Senate approval for a legally enforceable convention.

Instead of supporting a new treaty, the US has focused on the reform of the IHRs. According to a statement from Becerra and Secretary of State Antony Blinken, covid-19 revealed weaknesses in the IHRs, particularly their provisions on early warning systems, coordination of the international response, and information sharing. Accordingly, the US has put forward proposals such as a graduated level of alerts for health emergencies, faster information sharing in the event of a possible outbreak, and the implementation of the IHRs through greater accountability among members of the WHO. While these proposals address a range of issues, they place significant emphasis on the idea that the IHRs should make it harder for countries to withhold information about potential epidemics on their territory – apparently in response to China’s approach to covid-19. Indeed, Biden has been much more vocal than European leaders about China’s failure to cooperate with investigations into the origin of the pandemic. The proposals would inevitably take WHO reform into the most geopolitically contentious areas of public health – and, since any amendments would need to be adopted by consensus, the US would struggle to push the organisation to approve them.

Biden has also embraced the suggestion that the UN General Assembly should establish a new global council for health emergencies made up of heads of state, with the aim of lending greater political weight to collective action against potential pandemics. The most significant new proposal that he has made, however, is to set up a $10 billion fund for improved preparedness, which the US has kick-started with a donation of $250m. Apparently, the fund would be structured as a financial intermediary mechanism based at the World Bank (similar to the Global Fund to Fight AIDS, Tuberculosis and Malaria) and would probably channel money through other implementing organisations, aiming to build up health systems around the world and improve countries’ capacity to detect new pathogens. Much about the governance of the new fund remains unclear. Some European countries regard it with suspicion, fearing that it could be controlled by the agendas of donors and could undermine the role of the WHO.

These concerns are amplified by the fact that, like Brazil and Japan, the US is one of the countries that are most sceptical about an increase in mandatory contributions to the WHO’s budget. At the WHO Executive Board meeting in January 2021, one Biden administration official said that the US wanted to “better understand the current funding mechanisms, efficiencies and decision making” before considering an increase in assessed contributions. In the eyes of European officials, the administration’s approach to the issue reflects distrust of the WHO – as well as the political criticism that such an increase could draw domestically, particularly if it was not accompanied by other reforms. The discussion on the issue has now been deferred to the World Health Assembly in May 2022.

Biden reversed American opposition to an IP waiver in May 2021, with one US official saying that covid-19 called for “extraordinary measures”. However, the US has not followed through by tabling substantive proposals on how a waiver should be structured, leading some European officials to criticise the move as opportunistic and politically motivated. The Biden administration has called on US pharmaceutical companies Pfizer and Moderna to do more to allow production of their mRNA vaccines around the world, albeit with limited success. Pfizer and its partner BioNTech signed a deal with South African firm Biovac to produce vaccine doses in South Africa. But this is merely a “fill-and-finish” operation, with the most important parts of the vaccine produced elsewhere. Moderna announced it would build an mRNA production plant in Africa that would produce up to 500m doses a year, but it has not provided further details on the plan.

China and Russia

Since the beginning of the pandemic, China has adopted an extraordinarily political approach to covid-19. The country has not only done everything it could to block investigations into the origins of the virus, but has also presented its success in containing covid-19 as evidence of the superiority of its political model. One official from an EU member state who follows Chinese health policy closely described it as a core component of the regime’s domestic legitimacy and external strategy. As part of this geopolitical approach, China has structured its engagement with multilateral bodies to limit any scrutiny of its actions while engaging in a series of initiatives that present it as a champion of the global south.

President Xi Jinping has repeatedly emphasised China’s commitment to take an active part in international cooperation against covid-19. However, China has largely resisted joining collective multilateral processes, preferring to engage in its bilateral initiatives or cooperation with a group of like-minded partners. China contributed only a small amount of funding to ACT-A, having donated just $100m to COVAX, and directed all its vaccine donations directly to its chosen partners. In November 2021, Xi announced at a China-Africa forum that his country would provide one billion doses of covid-19 vaccines to Africa over the next three years, including through joint production on the continent. In a mirror image of Biden’s global covid-19 summit, Xi organised an international forum on vaccine cooperation in August 2021 with a range of friendly countries.

Russia, for its part, has not contributed funding to ACT-A or donated vaccine doses to COVAX. At the WHO, the country has joined forces with China to try to block any reforms that would give the organisation greater powers to compel cooperation or override the sovereignty of its member states. Because the WHO works by consensus, China was able to prevent the working group that reviews pandemic preparedness from suggesting, as part of its road map for reform, that the organisation should have speedy access to outbreak sites. In the recent meeting of the WHO Executive Board, Russia indicated that it opposed the idea of setting up a universal review mechanism (such as that undertaken by the Human Rights Council) to monitor countries’ readiness to deal with health emergencies. All this is indicative of the difficulties that would arise from attempts to revise the IHRs or negotiate a new pandemic treaty if they included stronger provisions on accountability.

While China and Russia reject any increase in the WHO’s oversight powers, they have also opposed steps that would set up alternative bodies to supervise preparedness for and response to epidemic outbreaks. Both countries have signalled that they are against the idea of a new global council for health emergencies and the fund the US is setting up. At the G20, President Vladimir Putin rejected “steps that would infringe on the prerogatives of the WHO, which works under the auspices of the United Nations”. Unsurprisingly, European officials see these positions as motivated by geopolitical competition with the US and a desire to prevent the creation of new forums that could scrutinise China’s and Russia’s internal affairs.

Africa and India

Covid-19 is likely to mark a turning point in Africa’s position in the international health system. The combination of persistent inequities in access to vaccines and growing scientific confidence and expertise in many African countries means that the current situation is unsustainable. Backed by much of the rest of the global south, African leaders insist that equity must be at the heart of any changes to the global health system after the pandemic. Increasingly, they are demanding not merely a greater share in the allocation of vaccines and other countermeasures made elsewhere, but also greater support for their capacity to make their own. Prominent medical scientists Christian Happi and John Nkengasong expressed a common view when they wrote recently that the continent should look beyond short-term aid organised by unaccountable donors and aim for greater self-sufficiency within a more balanced multilateral system.

Nevertheless, in the short term, Africa will remain dependent on international assistance to fight covid-19. The continent’s vaccination level remains strikingly low, with less than 12 per cent of Africans being fully vaccinated. A shortage of vaccines is no longer Africa’s main problem, since the number of doses offered to the continent has now exceeded its capacity to absorb them. However, as several African officials have pointed out, this broad truth obscures the wide range of situations across African countries. Moreover, irregular donations – sometimes of vaccine doses that were near their expiry dates – have made it hard for African countries to plan effective vaccination campaigns. ACT-A and other international mechanisms still have an important role in providing a predictable supply of vaccines, helping healthcare systems offer them to patients, increasing the numbers of tests that are available, and making sure new treatments for covid-19 such as Pfizer’s Paxlovid reach African countries, as well as other states in the global south. This last goal will become easier in 2022, once countries scale up generic production of Paxlovid and an antiviral created by Merck – after the companies agreed to issue a voluntary licence for their production to meet the needs of low- and middle-income countries.

The experience of covid-19 has fuelled African governments’ scepticism about the multilateral system’s role in global health. COVAX not only failed to provide the number of vaccine doses they expected but was also seen by some of them as unaccountable and opaque. Although COVAX was improvised quickly in response to an urgent need, many developing countries have argued that it did not give them a sufficient role in its decision-making and was too close to pharmaceutical companies – with the result that it avoided challenging these firms on their lack of transparency and their failures to deliver. This distrust has prompted states in Africa – which now produce only around one per cent of the vaccines used on the continent – to focus on increasing their own production capacity. For example, South Africa recently established a vaccine manufacturing campus and has set up an mRNA hub in association with the WHO that says it has independently replicated Moderna’s vaccine, after the American company declined to share its technology.

The drive by African and other developing countries to put equity at the heart of any change to the global health system shapes their engagement with the multilateral initiatives launched in response to covid-19. African states have sought to hold a special session of the UN General Assembly that would allow them to highlight the importance of equal access to vaccines and other medical countermeasures. And they have supported the creation of a global council for health emergencies, on which they would be represented. The campaign for a patent waiver on covid-related medical goods launched by India and South Africa remains a central concern of African governments. In their demands for a new treaty on pandemics, these governments will prioritise IP, technology transfers, and a more equitable distribution of vaccines and other medicines.

India’s strong domestic pharmaceutical sector has helped it avoid the kind of shortage of vaccines experienced by African countries – indeed, its decision to block vaccine exports for several months greatly contributed to the problems COVAX experienced. Nevertheless, in line with its dominant role in manufacturing vaccines and other medicines under licence, India has joined African countries in their calls for patent waivers. India has also proposed the creation of a formal framework that would match obligations to share information about emerging pathogens that could cause pandemics with defined access to products made using that information, building on an agreement that applies to influenza viruses.

Opportunities for cooperation

The current initiatives and positions of key actors in global health have many implications for Europe’s efforts to promote multilateral cooperation on covid-19 and to prepare for future pandemics. Several of the most important implications are as follows.

In the short term, Europe should support vaccination programmes and access to medical goods around the world. Only ten per cent of people in low-income countries have received at least one vaccine dose. And ACT-A needs an additional $22.8 billion to meet its funding needs up to September 2022. While the purchase of vaccines has attracted the most attention, it is now equally important to help health systems implement vaccination programmes and supply tests and therapeutic medications.

Europe should recognise the urgent need to improve the system for pandemic preparedness and response. The prospect that countries in Europe and elsewhere in the developed world will soon move past the crisis phase of the pandemic creates a chance to make fundamental changes to the global health system. It is crucial to engage in significant reforms before the political momentum to do so dissipates and health officials shift their attention to issues such as the allocation of funding to the Global Fund and other existing structures.

Europeans should expect international negotiations over a new treaty on pandemics to be long and difficult. At a time of intensifying competition and diverging priorities between influential countries, it will be difficult to persuade all WHO member states to agree to meaningful constraints and obligations in the intensely political area of public health. It is likely that any such treaty will be fairly anodyne, leaving individual countries to negotiate separate protocols. This means that it will be some time before any substantive treaty provisions come into force and that the process could create a fragmented landscape of differing legal obligations. While negotiations over the treaty drag on, the EU should take quicker steps to improve cooperation in priority areas between countries that are willing to move forward.

It will be difficult to agree reforms that compel countries to share information about outbreaks when they do not believe this serves their interests. The emergence of covid-19 naturally focused attention on China’s initial failure to share information about the spread of the disease and to allow a full investigation into its origins. However, it is hard to see how countries can overcome this problem, given the current state of global politics and the WHO’s limited power over its member states. There is a risk that focusing too much on this aspect of pandemic response could divert attention away from areas where it would be easier to make progress. In most countries, a lack of capacity in health systems and resentment of global inequity in access to countermeasures are more likely to prevent governments from sharing information than are the kind of political considerations that seemed to guide Beijing’s decisions. Moreover, while China appears increasingly reluctant to engage with Western countries on the pandemic, Europe and the US should consider how their efforts to frame global health initiatives in geopolitical terms could inadvertently reduce the already limited space for informal exchanges between Chinese and Western scientists.

Wealthy countries should offer the global south a new compact on pandemic preparedness. Rather than trying to enforce compliance by unwilling states, it would be more constructive to concentrate on removing the obstacles that could inhibit information sharing by states that are, in principle, committed to openness – above all, a lack of capacity and resentment of global inequity. If states are to strengthen the world’s defences against pandemics, they will first need to recognise that interdependence creates a network of shared interests. Low- and lower-middle income countries should receive more support for their health systems to improve their surveillance of emerging pathogens, with the understanding that information about threats should be quickly shared with the rest of the world (as the IHRs require). At the same time, countries that lead on vaccine development should do more to transfer knowledge and technology to the global south, particularly Africa. They should also develop more robust systems to guarantee access to countermeasures in emergencies and to ensure that IP rights will not stand in the way of efforts to expand production in response to an urgent need. While governments could formalise an agreement on pandemics in a new framework or ultimately as part of a treaty, they could also work through informal initiatives led by a group of developed countries.

The EU could make a start on this agenda with Africa, but it will need to go much further in transfers of knowledge and technology to the continent. The union could use its summit meeting with the AU in mid-February 2022 to sketch the outlines of a new compact. The EU has been influential in supporting the build-up of vaccine manufacturing capacity in Africa. And the two partners have a shared interest in improving the resilience and surveillance capacity of African countries. But their relationship is currently overshadowed by African governments’ resentment of European opposition to an IP waiver. If the EU is unwilling to give way on this point, it will need to take other steps to change the current approach of European pharmaceutical companies. This could involve a package of measures that not only make compulsory licensing easier but also push firms to agree to more voluntary licensing and knowledge transfers, perhaps through regulatory and contractual changes. The EU could combine such an offer with greater cooperation in areas including data sharing and research collaboration.

Europeans should work with their partners in the G7 and the G20 to create a new global framework for preparedness and access to countermeasures. The manufacture of covid-19 vaccines is overwhelmingly concentrated in a small number of places that form a “vaccine production club”, as one group of scholars described it. These places are Argentina, Australia, Brazil, Canada, China, the EU, India, Japan, Russia, South Korea, Switzerland, the UK, and the US. Since all members of this club are part of the G20 (except Switzerland, which has been invited to G20 finance and health ministers’ meetings), the organisation would be a natural launch pad for such an initiative. However, given that there are no low-income countries in the G20, the initiative would have to add new members to become more representative. The initiative could also involve international and public-private institutions that are active in global health; coordinate financial support for pandemic preparedness (as discussed below); work alongside a strengthened WHO to identify areas for improvement; build on recent moves to improve surveillance of emerging pathogens; and try to streamline responses to new emergencies and clear blockages in vaccine supply chains.

Europe should see a fund for pandemic preparedness and increased financial support for the WHO as complementary solutions. There is a division between Europe and the US over funding priorities in global health. However, to prepare for future pandemics, it is necessary to both offer the WHO a larger, more predictable revenue stream (without strings attached) and to increase funding for efforts to strengthen health systems around the world. There is no substitute for the legitimacy of the WHO in offering technical advice and reviewing countries’ readiness to deal with emergencies. But lower-income countries should also have access to a pot of money that will help them prevent, detect, and respond to outbreaks, including by taking those steps identified by the WHO. Governments should not see this money as development spending and, accordingly, deduct it from their development budgets: it is implicit in the notion of a global health compact that investments in preparedness are a global public good and improve the health security of donor countries as well as recipients.

Europeans should ensure that reforms of the WHO focus on improvements to its capacity and independence. Because the WHO operates by consensus, it is unlikely to gain greater inspection powers that could be seen as overriding state sovereignty. Some scholars have questioned the value of a system of graduated alerts in response to disease outbreaks: given that many countries did not react to the declaration of the covid-19 public health emergency of international concern, even more of them would probably ignore an intermediate warning. A more promising area for reform would involve an attempt to increase the independence of the WHO, as this should limit countries’ ability to instrumentalise the organisation for political purposes. For instance, it would make sense to establish a single, longer term for the WHO director-general, as the Independent Panel for Pandemic Preparedness and Response recommended.

The EU and its member states should increase European cooperation on global health policy. Before the pandemic, the EU had a limited profile in policymaking on global health. Leading member states such as France and Germany were influential but did not always act in a coordinated way. As this report has discussed, the EU has become more active and cohesive in global health policy in response to covid-19, particularly through the development of the ‘Team Europe’ approach. A first joint meeting of EU foreign ministers and health ministers took place in February 2022 under the French presidency. The EU should continue and deepen these initiatives at a time when the future direction of US policy is uncertain and China is pursuing an agenda that the EU does not support. Global health may also be an area in which the EU can cooperate constructively with the UK, which has traditionally been influential on the issue. By putting the benefits of Europe’s leading role in medical research more fully in the service of global health, the EU would take a constructive and symbolically powerful next step.

Conclusion

As this author argued in an earlier policy brief for ECFR, the EU needs to follow a twin-track strategy for multilateralism in a geopolitically competitive world. The union should also try to preserve and work through universal membership organisations as far as possible, while engaging in deeper cooperation with like-minded states. The EU has an interest in strengthening the WHO as a technical and norm-setting body, but it should also recognise the limits imposed by the WHO’s universal membership and consensus-based approach. It will be difficult, if not impossible, to persuade all states to accept stronger commitments to transparency and inspections given the intense political considerations that public health involves. Similarly, the EU’s cherished project of a new pandemic treaty will be difficult to negotiate; the most important provisions of such a document are likely to bind only a sub-set of states.

There is an urgent need to improve the system for international cooperation on the threat of covid-19 and in preparation for future pandemics. The EU should move ahead on priority areas of global health with its most relevant partners rather than wait for a universal agreement on a comprehensive package. The union’s central goal should be to create a compact between the most scientifically advanced countries and the developing world, in which a commitment to share information on emerging threats and accept robust inspections of healthcare systems is matched by offers of funding for improved preparedness and much greater transfers of knowledge and technology. The EU and the AU could work together to develop such an approach. But this would require the EU to go much further in promoting effective partnerships between European and African pharmaceuticals companies.

At the same time, the EU could cooperate with its partners in the G7 and the G20, particularly the US and the UK, to agree to a broader framework for sharing technology, knowledge, and access to epidemic countermeasures. The union should also work with the US to balance support for a new pandemic fund and increase assessed contributions to the WHO, with a globally representative body overseeing the new fund’s decisions. This approach provides the best chance to improve the world’s capacity to manage covid-19 and respond to the next pandemic.

About the author

Anthony Dworkin is a senior policy fellow at the European Council on Foreign Relations. He leads the organisation’s work in the areas of human rights, democracy, and international order. Among other subjects, Dworkin has conducted research and written on the European Union’s support for multilateralism, political transition in North Africa, and European and US frameworks for counter-terrorism.

Acknowledgments

This paper was made possible by the generous support of the Calouste Gulbenkian Foundation. It is based on off-the-record conversations with several health policy officials in EU institutions and European countries. In addition, the author would like to thank the following people for very helpful conversations and comments: Tobias Bergner, Jens Windahl Pedersen, Maike Voss, and ECFR Council Members Gunilla Carlsson and Caroline Schmutte. The paper also draws on several workshops and seminars in which the author participated, including events organised by ECFR’s Rome office in association with Compagnia di San Paolo and ECFR’s Paris office in association with the French Ministry for Europe and Foreign Affairs. Within ECFR, the author benefited greatly from conversations with Susi Dennison and Theodore Murphy, from research assistance on health from Gosia Piaskowska, and from the skilful editing of Chris Raggett.

The European Council on Foreign Relations does not take collective positions. ECFR publications only represent the views of their individual authors.

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