India must show leadership on the Pandemic Accord

During the COVID-19 pandemic, which saw upwards of 700 million infections and 7 million reported deaths globally, the world made impressive progress in developing diagnostics and vaccines. Vaccines saved about 20 million lives in just the first year of use.

However, these life-saving vaccines were not equally accessible to all. Low-income countries with about 700 million people could only get 330 million doses (0.47 dose per person), whereas high-income countries used 2.84 billion doses for their 1.24 billion people (2.3 doses per person). Africa with 1.46 billion people could only manage 0.86 billion vaccine doses (0.58 dose per person).

The Pandemic Accord under discussion at the World Health Organization since May 2021 aims to correct that by enhancing international partnerships to report and characterize newly emerging diseases, and by fairly and equitably sharing resources. But time may already be running out with the final vote expected at the 77th World Health Assembly (WHA) this month.

Will the Pandemic Accord work and in what form?

A legally binding global health agreement is not new. The WHA adopted International Health Regulations (IHR) in 1969, which was modified in 2005, and is now up for another review. However, treaties based entirely on voluntary reporting by member states without independent monitoring are beset with problems. Despite being a signatory to IHR 2005, China delayed reporting COVID-19 and international access to early patient data and samples.

In its 13 March 2024 draft, the Intergovernmental Negotiating Body (INB) highlighted several articles to which countries must commit. While there is broad agreement on the need to improve preparedness and promote international cooperation, several disagreements have also been voiced. Industrialized countries are unhappy at waiving intellectual property rights and transferring technology during emergencies. However, COVID-19 showed that a geographically diverse and distributed production system would increase equity and be more sustainable. A 2022 study found that better equity in the distribution of COVID-19 vaccines could have prevented 296 million infections and 1.3 million deaths. It concluded – “vaccine distribution proportional to wealth, rather than to need, may be detrimental to all”.

Common but differentiated responsibilities, a concept taken from the Climate Accord, which places greater obligations on rich countries remains contentious. In the WHO’s Pathogen Access and Benefit-Sharing (PABS) system, countries are required to share genomic data and samples to facilitate production of pandemic products (diagnostics, drugs, and vaccines), and manufacturers are asked to provide 10% of these products free of charge and another 10% at cost to poor countries.

Considering the disagreements, member states may delay the vote and seek more time to negotiate. Even if they go to vote in May 2024, several outcomes are possible. Under Article 21 of the WHO Constitution, a treaty would be legally binding on member states that ratify it, but will require a two-thirds majority. A regulation would come into force immediately, with an ‘opt-out’ choice, and would be limited in its scope. A resolution being a statement of support without any legal obligations, is the weakest option.

The world needs a legally binding treaty with support from an independent monitor, like the International Atomic Energy Agency for nuclear safety. In its present form, the Pandemic Accord falls short of that goal.

What should India do?

Besides being the world’s most populous country, India is important for the role it can play in disease surveillance and global vaccine supply.

India built a consortium for genomic surveillance during COVID-19 and is now developing capacity for wastewater disease surveillance, a pilot for which is being implemented in Bengaluru. India also supplies about 60% of global vaccines, and used 2.2 billion doses of locally produced COVID-19 vaccines for its population.

But India also faces future public health threats under the impact of climate change. Besides poor biorisk assessment, new research places India at high risk for climate change driven new disease emergence. This supports earlier work on the risk of zoonoses – diseases jumping from animals into humans.

Oblivious to these challenges, there is a push in India to oppose the pandemic treaty. While some of it is based on pragmatism and current flaws in the WHO structure, others are based on emotion and flawed science.

At the last INB meeting held on 28 March, India and African countries insisted on greater fairness in vaccine and drug distribution. Technology transfers will remain important for future supply chains, especially for manufacturing pandemic products at scale, and keeping those affordable for low-and-middle-income countries.

India must use its diplomatic acumen and negotiation skills to ensure an international pandemic treaty that is based on the principles of equity, fairness and justice. And one that works. Not having a good treaty is not an option.