In the midst of a growing disaster in the developing world, with deaths mounting exponentially in India and Brazil, we learn from WHO’s latest update that, as of mid-April, wealthy countries had secured some 87 percent of the more than 700 million doses of vaccines dispensed worldwide while poor countries have received only 0.2 percent. The upcoming World Health Assembly (WHA) will be an occasion to try and redress this morally unacceptable situation.
Every year at the WHA, official representatives of the World Health Organization (WHO) members, along with non-government organizations, and the private sector, gather to discuss, debate, agree and disagree, and sometimes make decisions about how to deal with critical health matters. This year its 74th WHA takes place from 24 May to 1 June 2021 (mostly virtually). There is a long list of items to be dealt with on the agenda, with many relating to the COVID-19 pandemic in one form or another.
Certainly, vaccines will be a major item and the application-or not- of the TRIPS Agreement which became effective in 1995, will be very much a part of the discussion. TRIPS was designed to reduce impediments to international trade, while promoting effective protection of intellectual property (IPs), ensuring that measures and procedures to enforce IPs do not themselves become barriers to legitimate trade.
IPs are at the core of the vaccine challenge: vaccines are not the result of one “IP” but made up of hundreds of IP compounds, produced in different countries, each of which may require separate approvals. In fact, both the mRNA vaccines and the adenovirus-mediated vaccines contain around 250-300 specific components, almost all of which are IP protected. They are manufactured in around 20 different countries around the world by different companies.
Given the complexity in the supply chains, it should come as no surprise that many of these components remain sensitive and tentative in terms of supply, quality, amounts, and ability to scale up. For example, phospholipids, which are crucial for mRNA vaccines, are only made by four companies, which are facing major scaling-up challenges.
On the other hand, there are very strong arguments in favor of relaxing patent protection, whether by the World Trade Organization (WTO) or actions taken by individual companies making their products accessible, to provide volume and greater vaccine equity in the short term during the COVID-19 pandemic.
The Biden administration has just announced that it supports efforts to waive intellectual property provisions. WHO Director-General Tedros Adhanom Ghebreyesus welcomed the announcement while the European Commission did not endorse it but declared itself ready to discuss the proposal at the WHA.
As might be expected, much of Big Pharma is opposed along with Germany. But some developing countries including South Africa and India are pushing for amendments to the TRIPS waiver approach for COVID-19 vaccines. However, the WTO operates by consensus so any waiver would have to be fully agreed upon. The WTO’s new leader Dr. Okonjo-Iweala is among the world’s best and most experienced negotiators and will seek to find an acceptable compromise. Nevertheless, the expectation is that the discussions will take months and will probably result in partial waivers.
Whether TRIPS will really help developing countries with COVID-19 containment needs review in technical terms, given it has only been applied once internationally with respect to HIV/AIDS, and not for Ebola in this century. Moreover, adding to the complexity of the issue, India is one of the largest vaccines producing countries in the world and is currently in desperate straits. There are valid arguments on both sides.
But a more fundamental and long-term topic will be about the future role of WHO in early warning and actions related to infectious disease outbreaks. There are a number of countries that will be seeking during the 74th WHA to create a working group to “focus on strengthening the WHO’s preparedness and response to health emergencies”. Amongst its tasks, this working group would also review the ongoing investigations into the international response to the pandemic and report back to the 2022 WHA.
However, scrutiny of the pandemic response is not welcome by several countries. China, Russia, Syria, and Pakistan specifically ask to delete a reference that would include the WHO’s coronavirus origins study in this report. Russia also wants to strike a reference to the work of the independent Global Preparedness Monitoring Board.” The fear now is that all these demands will end up delaying the establishment of the working group, and hence the possibility for timely development of much-needed policy advice for WHO.
This is a problem the WHO has encountered for many years in attempting to reach an agreement on core global issues and mandated responsibilities. In the past, there have been ambitious voluntary efforts to coordinate and organize global health, more successful in the last century than this one.
In 2021, we can expect that there will be efforts at WHO reform, perhaps even beyond the ideas eventually generated by a “working group”. These are likely to include measures for strengthening the International Health Regulations (IHR). The IHR, established in 2005, is an international agreement and legally binding on 196 countries, including the 194 WHO member countries. It provides an overarching legal framework that defines countries’ rights and obligations in handling public health events and emergencies that have the potential to cross borders. Having stronger IHR measures is seen by countries like the United States and many Europeans as essential to the effective functioning of WHO.
In 2020 the Council of the European Union’s official conclusions, broadly supported by many other western countries, included the need for:
- a revision of the alert system for declaration of a Public Health Emergency of International Concern to allow for differentiated levels of alerts;
- a distinction between travel and trade restrictions under the International Health Regulations (IHR) in order to avoid unnecessary harm to economies;
- the possibility of an independent epidemiological assessment on-site in high-risk zones in close collaboration with the concerned state party;
- increased transparency on national compliance with the IHR.
A Modest Proposal for WHA to consider: Practical Cooperation to Help Vulnerable Countries – Role of CDCs
One can only hope for the success of WHO reform, but neither past history nor present indications are cause for optimism. So perhaps this may be a time to consider a less ambitious approach, to have a Plan B in the wings for the WHA to consider: It could demonstrate that practical cooperation closer to the national health implementation space is able to reach beyond geopolitics among the powerful and do common cause to help vulnerable nations. I speak here of the major Centers for Disease Control and Prevention working in a unified manner in select Sub-Saharan African countries, to bring the breadth of their combined CDC knowledge, competency, and resources to bear on a common and consistent approach to basic disease control and prevention.
The major CDCs are the United States, China, and the European Union – known as the “Big Three CDCs” – with the regional Africa CDC as a new and overarching partner. In considering Plan B here, we need to remember that the CDCs always work closely with WHO as they are the public health agencies on the front lines at the national level.
The Big Three CDCs’ broad mission statements are compatible, or in any case, not in conflict. Their detailed statements are available and contain more in-depth information, but in brief, they are:
United States CDC: … detecting and confronting new germs and diseases around the globe to increase our national security.
China CDC: … strengthen research on strategies and measures for disease control and prevention; organizes and implements control and prevention plans for different kinds of diseases.
European Union CDC: … identify, assess, and communicate current and emerging threats to human health posed by infectious diseases.
Each of these CDCs has been engaged with the Africa Centers for Disease Control and Prevention, founded in 2017 and now playing an increasingly important role on the Continent. For a point of reference, it is useful to understand the aspirational objectives of the Africa CDC which are:
- Establish early warning and response surveillance platforms to address all health threats and health emergencies and natural disasters in a timely and effective manner.
- Assist Member States to address gaps in capabilities required for compliance with the International Health Regulations (IHR 2005).
- Support and/or conduct regional- and country-level hazard mapping and risk assessments for the Member States.
- Support Member States in health emergency responses, particularly those which have been declared a public health emergency of international concern (PHEIC).
- Support health promotion and disease prevention through health systems strengthening, by addressing infectious and non-communicable diseases, environmental health, and Neglected Tropical Diseases (NTDs).
- Promote partnership and collaboration among Member States to address emerging and endemic diseases and public health emergencies.
- Harmonize disease control and prevention policies and the surveillance systems in the Member States.
- Support Member States in public health capacity-building through medium- and long-term field epidemiological and laboratory training programmes.
The Africa CDC is actively pursuing its goals and on 31 March 2021, it announced the launch of its Southern Africa Regional Collaborating Centre (SA-RCC), hosted by Zambia and serving the 10 African Union Member States in the Southern Africa region:
While there was a long history and range of cooperative agreements between the U.S. and China CDCs over decades, the recent past has not served to engender more such efforts.
According to the September 2020 report of the Institute for China American Studies (page 48):
“… cooperation in global health and development was made in 2016 when the Obama administration reached an agreement with Beijing to jointly support the Africa CDC and strengthen links between Chinese, African and American health experts. Regrettably, these budding areas of cooperation have likely wilted prematurely amid increasing friction between the two governments. It remains unclear whether any further progress will be made between USAID and MOFCOM, as very little has occurred since the 2016 China-U.S. Development Cooperation Conference held in Beijing. Furthermore, cooperation between the U.S. and China in funding Africa CDC eroded in February 2020 when the Trump administration made attempts to block China from building an USD 80 million Africa CDC headquarters in Ethiopia, according to a Financial Times investigation.”
But the past is prologue and those instances the U.S. and China did common cause in Africa can provide a basis for the future.
One relatively modest option for the WHA is for it to be an opportunity to explore a new collaborative process, “Plan B” if you will. It would focus on the “soft side” of health preparedness and enhanced implementation, not deal with the “hard” competitive aspects such as facility construction for public sector headquarters or biosafety laboratories; or research and development of drugs, medical supplies, and equipment.
The aim would be, in consultation with the engaged governments and Africa CDC, to achieve a unified approach in areas such as infectious zoonotic disease surveillance, information collection and use, field epidemiological and frontline worker training, messaging such as handwashing, masks, social distancing.
To have “proof of concept” that such a coordinated theory of action is doable, the process would be piloted in two or three Sub-Saharan African countries which are classified as low-income economies, with weak human and financial health system resources, and each representing different ethnic and linguistic compositions.
Plan B would come under consideration by concerned Member States and their CDC leadership and those pilot countries which concur. This should result in an initial agreement of a framework document, to be subsequently finalized and commitments made, monitored during a certain period, and results shared possibly as soon as the World Health Assembly in 2023.
Concrete Steps: What a CDC Based Plan of Action Can Deliver
One may hope for wide-sweeping agreements on global health for timely identification and early action against potential infectious disease threats. In our largely polarized political environment, it would be wonderful, but hard to see it happening this month.
Having the major CDCs join in common cause in prescribed health areas in developing countries, is a more modest “ask”. But if successful it would be a concrete, practical step in moving toward wider global health goals. It is often said and worth remembering that one can often go from small successes to pursue broader goals. Plan B is such an option.
Editor’s Note: The opinions expressed here by Impakter.com columnists are their own, not those of Impakter.com Featured Image: WHO Headquarters where WHA is held, Geneva, Switzerland Photo source: Reuters article with news that G-7 countries back Taiwan’s Observer status in WHA, May 5, 2021.