Moving beyond the “subterranean machinations” of Franco-American rivalries, I revert back to my preoccupations with the prospects for global and multi-stakeholder collaboration on the COVID-19 pandemic. And I do so with renewed inspiration, perhaps reinforced by the very sudden global panic about the Omicron variant, which the World Health Organization has identified as a new “variant of concern”. My inspiration, however, had already been reviving as a result of my personal tracking of the interviews and personal appearances of key “pandemic players” in the past couple of months. Most strikingly, we all saw the signs in October of more collaboration between the WHO and WTO Directors-General but also their further collaboration with the heads of the IMF and World Bank, I was also encouraged anew by the opportunity also in October to sit in on interviews with two major American figures, Dr. Rochelle Wilensky at the US Centers for Disease Control and Dr. Anthony Fauci at the National Institute of Allergy and Infectious Diseases. And then, through the past few weeks, I have found additional hopefulness in the health-related outcomes of both the G20 Leaders Summit in Rome and and the Conference of the Parties (i.e. “COP 26”) in Glasgow – yes, even there!
So I am back to being more optimistic about a revitalized COVAX Facility and perhaps an even more comprehensive framework for global cooperation. And more importantly, I am hopeful that equitable vaccine distribution could conceivably meet the targets of 40 per cent coverage per country by the end of this year and 70 per cent coverage by mid-2022. At least, I sense that the political leadership is finally being consciously attentive to these targets and even to focusing in a genuinely multi-stakeholder way on trying to reach them. And the reaction to the omicron variant does appear to reinforce this momentum. Much of what I have to say here was written before the WHO announced this new variant of concern, but I do think that its appearance will stimulate the momentum already under way of promote both global collaboration and multi-stakeholder engagement.
Continued Confidence in the WHO and Dr. Tedros
My optimism has been inspired by what appears to be a solid taking charge of respective mandates on the part of the WHO and WTO Directors-General – Dr. Tedros Adhanom Ghebreyesus and Dr. Ngozi Okonjo-Iweala. For starters, at the WHO (the World Health Organization), I was aware that the first term of Dr. Tedros as Director.-General was due to end in 2022, with formalities for the nomination of candidates for the next four-year term to be completed by the end of October. It was relieving to learn as of a 29 October official WHO announcement that Dr. Tedros was the only candidate nominated.
The worry here was two-fold. First, he had been seen initially as too accommodating of the Chinese in the early stages of the pandemic but then also more boldly outspoken in criticizing the Chinese – but, furthermore, taking a strong stand in support of equitable vaccine distribution and even technology transfer. And second, the domestic politics of his home country had turned against him. What a relief, then, to see that he had been nominated for a second term by a host of 28 other countries in lieu of his home country of Ethiopia. This included at least three other African countries (Botswana, Kenya and Rwanda) sixteen European countries (including France), and enough balance from the Caribbean, the Middle East and Southeast Asia to show a strong vote of confidence for his continued tenure at the WHO. Thus, the public voice of Dr. Tedros constantly reminding us about current inequities in vaccine distribution has gained credibility as the leading voice of global health going forward.
The Complementarity of Different IO Perspectives
This reaffirmation of continuity at the WHO was a good thing in itself. But I also found encouragement in the involvement of other international organizations – from the perspectives of their different mandates – on this issue. In fact, it was the contrasts of their perspectives that gave me renewed hope. To explain what I mean by this, I refer back to the remarkable jointly issued announcement among the four heads of WHO, WTO, IMF and World Bank back in June. This was a common statement among the four heads in support of the 40 per cent target for vaccine coverage by the end of 2021 and the 60 per cent target for mid-2022. And yet, this joint statement didn’t seem to have any real impact on reaching those targets. While all four have continued to speak out – and together – for rapidly ramping up vaccine distribution, it was in October that their different perspectives became more visible and gave more depth to their appeal for action. This was especially evident in a forum on 12 October during the annual meetings of the Bank and Fund on “Ending the Pandemic: The Road to an Inclusive Recovery” (still available for download).
What was especially striking about this forum was the attention given to the infamous “IP” issue and what Dr. Ngozi had to say about it. First, David Malpass of the World Bank expressed the view that there was no scarcity of vaccines for the pandemic – just a challenge for distributing it, which the World Bank was helping countries to alleviate. Dr. Tedros disagreed by pointing out that only 4 per cent of Africans had received vaccines in spite of the abundance elsewhere. Kristalina Georgieva from the IMF responded to that by recognizing that existing contracts should be reallocated to allow for more timely allocation to needy countries – even suggesting more disclosure of who has purchased what for what delivery dates. Dr. Tedros argued that more than that was needed – and that technology transfer to enable more manufacturing capacity was urgently needed for action in these unprecedented times. Why not, he said, a waiver of IP rights and then see what technology transfer is actually needed.
This is where Dr. Ngozi chimed in. She made it clear that the WTO membership was working on this infamous IP issue – over 100 asking for a waiver and others who want to protect innovation. Furthermore, she astutely observed, the pharmaceutical companies are earning far more than ever from their vaccine sales, contributing to the critics’ mantra of “profits before people”. They had to understand, as many of them did, that their goal should be to demonstrate their commitment to people, and that is why the proposed waiver has actually brought the parties to the table. We need a solution to the IP problem – to allow developing countries access to the know how but also to ensure the protection of the manufacturers. The moderator asked, “What will it look like, this balancing of points of view?” She responded that it was still being negotiated, but she was confident that an emerging consensus would take shape in time for the WTO’s Ministerial Conference that was scheduled to be held on 30 November to 3 December 2021 in Geneva.
In spite of the poor record of the WTO for reaching a consensus on divisive policy issues, I was encouraged by Dr. Ngozi’s words. There was a tone of confidence in her voice, to be sure, but I was also impressed that the thrust of her remarks was confirmed by the observations of both Dr. Fauci and Dr. Wilensky in two different October interviews. As the main player in the financing of and relationship with major COVID-19 vaccine manufacturers, the US government is in a significant position to support an emerging consensus at the WTO on this. While US Trade Representative Katherine Tai did announce US support for an IP waiver several months ago, the US negotiating position has clearly been complicated by a strong pharmaceutical lobby and longstanding policy in support of intellectual property rights generally. So the US has not been a vocal advocate in recent TRIPS Council deliberations at the WTO.
Please note here that I wrote most of this commentary, as I previously pointed out, in mid-November, at which time it still seemed possible that the US would help orchestrate a compromise on this issue with Dr. Ngozi. Since then, however, it has become quite evident that the US has chosen to be very unassertive at the WTO – to the lament of those who would like a strengthened and reformed WTO above and beyond this specific but related issue on an IP waiver. So it was not clear that Dr. Ngozi would be able to deliver an agreement on the waiver – or on WTO reform generally. And now, just a few days before the Ministerial Conference (MC12) was to start, the WTO has announced the indefinite postponement of MC12 on account of the global worries about this new omicron variant of COVID-19! One can speculate that the postponement had more to do with the lack of consensus among key negotiators than omicron, but it is true that the global reaction to this new variant was to close down travel from key countries (including South Africa). Maybe this postponement saves the day for a better outcome in the weeks ahead.
Shifting American Momentum Globally
Meanwhile, I do believe that there were other encouraging signs regarding the prospects for global and multi-stakeholder action and especially for the COVAX Facility. For example, Dr. Fauci met with former White House Fellows at their annual gathering on 22 October in which I participated. He remarked about the amazing research capacity and data base of the private sector, with decades of mRNA and immunogen research that was ready to be applied to Covid-19 within days of identifying the virus. Through Operation Warp Speed, the risk-taking capacity of government financing opened up numerous avenues for the private sector to pursue – with what he described as a concomitant obligation by the recipients of these funds to make the technology available to others. When asked about how this concomitant obligation was being implemented, Dr. Fauci explained that the balance between the two was still being worked out. There is, he added, no answer yet. But I found it heartening that he, who has been known to be a staunch defender of intellectual property rights, was so upfront about what he described as a moral obligation to share this very IP on COVID-19 vaccines, even if he also acknowledged that this objective had not yet been realized.
The evidence of forward momentum, however, was further reinforced by Dr. Wilensky in an interview at the Council on Foreign Relations a few days later, on 27 October. She did not specifically address IP issues, but she wholeheartedly endorsed the need to supplement vaccine donations with a ramping up of manufacturing abroad to increase global capacity. She described it as the need for “durable manufacturing capacity around the world”. And she backed up her own words with the reminder that she had herself worked for many years in Africa and fully appreciated the issues of capacity and access. Further, she said, “We weren’t at our best with multilateral collaboration” but we have an opportunity for leadership now. “We need”, she further stated, “a mechanism to know how to leverage assets and people together”.
As I have noted previously, this talk about diversifying manufacturing capacity goes well beyond the mandate of GAVI and its COVAX Facility. I have been an enthusiastic supporter of the COVAX Facility because of its having been created by a variety of stakeholders who mobilized for a global response to the pandemic in spite of the absence of American leadership – and in fact, in spite of American refusal to cooperate on this front. I have been disappointed that the Biden Administration has been less than wholehearted in reversing the American position. And Dr. Wilensky might have been referring to the Trump years when acknowledging that the US wasn’t at its best with multilateral cooperation. But I would speculate that the US position hasn’t yet come around to where it should be. Fair enough, President Biden has announced huge donations of doses as well as funds for the COVAX Facility, but he has also announced doses and dollars through bilateral and other foreign policy channels. And regardless of the announcements, we still see a running tally (537 million doses shipped to 144 recipients as of 26 November 2021) on the GAVI website that is well below the target of a minimum of 2 billion doses by the end of the year that the GAVI organizers had estimated would be needed just to meet minimal global coverage.
To be sure, vaccines are also being distributed through other means, and there is now a new tracking system jointly powered by the ACT-Accelerator and the Multilateral Leaders Task Force. In this tracking system that includes both the COVAX Facility’s record and that of all other distribution channels (including a newly consolidated and independent African facility), it shows a gap of some 500 to 640 million doses to reach a 40% coverage rate in the 91 lower income countries of the world. Maye now, with the omicron variant scaring more leaders to support a global approach to vaccine coverage, one can hope that more support will be directed to channeling doses through the COVAX Facility. In this sense, one could argue that the postponement of the WTO’s MC12 is a good thing – diverting attention away from the contentious issues of diversifying manufacturing capacity and enabling technology transfers.
But these issues are still looming. Once we move past the immediate crisis of the omicron variant, with the attention shifting to one of diversifying actual manufacturing capacity around the world, this is no longer just a COVAX Facility issue. In a sense, it has become more intergovernmental rather than multi-stakeholder,. Although it is vaccine manufacturers who are the focus, we know that several specific negotiations for licensing and technology transfer have been underway in South Africa, in Senegal, Rwanda, Brazil and Argentina, as well as existing and new agreements in India. But the key seems to be the WTO negotiations on some kind of IP waiver, a setting that is emphatically intergovernmental. (Of course, we know that the pharmaceutical companies and the major NGOs are there, too, but the WTO has yet to open itself up to non-state actors of any sort inside their negotiating rooms.)
New Mechanisms on the Horizon?
Beyond this immediate WTO issue, however, the longer-term momentum for what Dr. Wilensky described as the need for a new mechanism to leverage assets and people together is clearly moving beyond the GAVI mandate. And here I need to encourage readers to take a look at the jumble of recommendations for a new mechanism that might not be as multi-stakeholder as one would like. But they merit our attention, with the additional hope that the COVAX experience, with its significantly multi-stakeholder profile, won’t be dismissed as an aberration. Most importantly, a special session of the World Health Organization is meeting from 29 November to 3 December 2021 in its typically intergovernmental way to deliberate on the merits of a “pandemic treaty”. WHO Director-General Dr. Tedros has even described this as an important step toward a binding international agreement on pandemic management, since, he claims “voluntary mechanisms don’t work”.
So what is next? I had observed in my previous commentary that Vice President Kamala Harris was proposing a new “Global Health Security Financial Intermediary Fund” for future pandemics, to operate out of the World Bank. This is consistent with the recommendations from at least one of the several task forces that have been convened (by the WHO, the G7 and the G20) to look to the future. A review of the previous task force recommendations may well be timely, and I have found a comparative study done by the Global Fund in August to be especially useful from a multi-stakeholder perspective.
In the G20 context, one should note that a special “joint task force” of health and finance ministers actually met just the day before the G20 heads of state (on 29 October prior to the Summit’s 30 to 31 October event), with its own set of recommendations. See the joint communiqué of this pre-summit meeting here. And at the Summit itself, the heads of state endorsed continuing this joint task force on future pandemic preparedness and even called for it to present “modalities to establish a financing facility, with a central coordinating role for the WHO” by early 2022! See the G20 Rome Leaders’ Declaration here.
On specifics for the current pandemic, this same G20 declaration endorsed a “broader base for vaccine manufacturing” while also urging health ministers to explore ways to accelerate global vaccinations to meet “as necessary” the 40 per cent and 60 per cent targets, (Actually, they cited a 70 per cent target for mid-2022.) The declaration is replete with language supporting private sector engagement, including through “technology transfer hubs” in various regions and through “joint production and processing arrangements”. In another place, the declaration urges “voluntary technology transfer on mutually agreed terms”. And there is, of course, a reference to the WTO’s ministerial conference (MC12), supporting work for “enhancing timely, equitable and global access to vaccines”.
In addition, the G20 seems to have recognized the importance of the special session of the World Health Assembly, scheduled for 29 November to 2 December 2021, to consider developing a global pandemic treaty – but without necessarily endorsing the merits of a treaty. The special session has been mandated by WHO members to “consider developing a WHO convention, agreement or other international instrument on pandemic preparedness and response”. The WHO has opted to convene this as a “hybrid” session of in-person and off-site participation. So it is not affected by the growing crisis around the omicron variant – in contrast to the last-minute decision at the WTO to postpone its own MC12, which did not have a hybrid component to it but was to be entirely “in person” in Geneva in the same week starting 29 November!
Science versus Politics? or Science with Politics?
Anyway, I do sense that there is a new kind of distinction between science and politics that is gaining support, whether this means something that is more intergovernmental or more multi-stakeholder. In the early stages of the pandemic, there were strong advocates of the argument that a global response to pandemics should be based on deference to supposedly apolitical scientific evidence. I have not been convinced about this myself because I still believe that consensus on policy needs to be driven by political engagement. But I do recognize that political divisions, especially in the United States, have wreaked havoc with scientific credibility.,
In this respect, I think it is useful here to paraphrase a response by Dr. Fauci to a question by one of my fellow White House Fellows. He was asked what he had learned about how science should inform policy and stay independent of political divisions, There is no place in science, he said, for biased political opinion. Nonetheless, what he has learned in this pandemic is three lessons:: 1. Make sure you know what your message is. 2. Know your audience. and 3. Communicate your message to get people to understand what you are talking about rather than to show off your scientific prowess. My impression of his remarks is that he is both a scientist and a politician! And we need both.
We may all be lamenting the deterioration of the world order these days, but I do think this is an area where creative new institutional efforts may be on the upswing. The immediate crisis of a dangerous new variant may mobilize global leaders to act more quickly on the urgency of redirecting available vaccine doses quickly. If so, we might ultimately see that 2 billion dose target for 40% global coverage achieved by the end of the year after all. Looking beyond this immediate crisis, though, my own preoccupation with the global response to the pandemic has been motivated by an interest in new global mechanisms for multi-stakeholder collaboration, and I am “re-inspired” by what I see on the horizon here.
I am hopeful that this will happen in other areas, too – like climate change or Internet governance or gender equality. I was intrigued by the decision of the UK Government to make health one of the three UK priority areas for the Glasgow summit on climate change (COP26). There was in fact a specially convened Global Conference on Health and Climate Change during the first week of COP26, where the focus was on “climate-smart” health care. Numerous commitments were announced – from climate-resilient health systems to low-carbon health systems. The record number of health professionals at COP26 pointed to the growing awareness of the relationship between health and climate – and to the importance of global collaboration, greater financing and more equitable sharing of solutions. This is a subject for a separate commentary, to be sure, but I close here with renewed optimism for collaborative global action on the pandemic.
