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Gavin: Hello and welcome to The Lancet Voice. I'm Gavin Cleaver. I'm here with my co host, Jessamy Bacchanal. It's February 2023. It's a break from our 200th anniversary spotlight this week to bring you a regular episode. I'm doing inverted commas around regular there. And we're going to be talking about the potential for a pandemic treaty.
Dane Barbara Stocking is the chair of the panel for a global public health convention, a body with the aim of preventing future outbreaks from becoming pandemics by negotiating a treaty between countries. But what might such a treaty look like? And how can it change a course of events like COVID 19?
Dane Barbara joins us on this week's episode to discuss.
Dane Barbara Stocking, welcome to the podcast. Thanks so much for joining us to talk about the COVID 19. pandemic treaty. We can start with a little bit of background. I think we often heard before COVID 19 hit that the U. S. and the U. K. were the two best prepared nations in the case of a pandemic. Where do you think this kind of like misplaced confidence in the U.
S. and the U. K. came from in their ability to deal with a pandemic pre 2020?
Barbara: Well, it's right that those countries have very good public health systems. But I think what wasn't recognized is that when you talk about pandemics, you're talking about issues that face the whole of government. And in particular, they face the top leadership, the heads of state, heads of government really have to come in.
And that hadn't been done in the preparedness work in most places, even, even I say the good ones, it was always seen as, it was a public health thing. If there was an epidemic coming, not, not a real government thing. So that was missing. It's quite clear too, that even within the systems, people hadn't done practice simulations, which would have been really helpful in understanding what you might do, and now we know simulations clearly are not the same thing as what's going to happen in real life, but it makes people agile in their thinking about how do we handle this?
And they'll have gone through many of the issues. And in particular, involving people across government in that, I think, you know, would have, obviously would have really happened. But I think another big issue that I see is that there's a psychology in this as well. It's, it's quite difficult to make people understand just how fast pandemics can happen, that it's hours and days.
And for the government, that's very difficult. Mostly the disasters they see, you know, come across, they're quite big disasters and they can see them. So a few cases in an outbreak doesn't mean anything in terms of what sort of response you should make. And it's that understanding that if you're going to stop a pandemic, you really have to act very, very fast to make it happen.
And I think that wasn't understood that. And if we remember February 2020 was a sort of month where we missed it all, you know, governments really did not, you know, go in and operate and really, you know, get their response moving, even if they hadn't got an outbreak in their country. And we missed that. And, you know, by the time people recognize it, you know, the pandemic was in, it, you know, it was happening really.
So there were all those. Sorts of things. I mean, the one thing I'd add into that, of course, is that people, many people who listen to this will know that we have international health regulations and they were set up in 2005. But so often, and in this case too, people did not conform to what they were expected to do under the health regulations.
So all of those things added up to that picture of why this outbreak, you know, did turn into a pandemic. And you, you mentioned it's the rich countries, but of course the poorer countries don't necessarily even have the basic health system in place either. And to, if we're going to have that sorted out, there's going to have to be more money put into low and lower middle income countries to make sure they have got the, the public health surveillance, public health systems that you really need.
Gavin: Were you surprised at how badly the global response to COVID 19 went?
Barbara: Yes. Yes. Very. No, I mean, in one sense, not surprised because. I think a lot of people have been saying for 20 years, we're not ready, we don't know how to do this. But I think the sort of disarray and people, you know, as I said, most senior levels of government not really knowing enough to know what they needed to do was, that was a surprise to me.
And obviously, like everybody, a surprise that we really, it really did take off right across the world. You know, you'd sort of known that that might happen, but, you know, maybe didn't expect that ultimately you know, that would be the case that we'd, that we'd get such a dramatic pandemic and close the world down really.
Jessamy: And I suppose, you know, from that catastrophic handling in many different countries has come a lot of discussion about what the solutions are how we prevent the next one. And obviously that's where a pandemic treaty comes in, which is. Mentor, give us some hope if this happens again, we're going to be better prepared.
How did you get involved in that process and what's your sort of specific role there? Right. Well I personally got
Barbara: involved because a study was done at the University of Miami with about 35 experts in public health and, and governance of it really, across the world before COVID. And we all said quite a lot of the things that I've just said now about why we weren't ready and that people were not adhering to IHR and that there was very little accountability.
We all said the same things. And in fact, there was an article published in The Lancet about that in May 2020. But I was asked out of that if I would chair an independent panel. This was at the time out of the University of Miami where the president is. A renowned public health leader, Julio Frenk, and I was asked to, to set up an independent panel.
And the reason for that was that great though lancet articles are, and we do believe that at the same time, you really need advocacy with people to, to make something happen. And that's what this panel is. And it's a small group, a dozen of us, of people a range, some people have expertise in particular public health matters like Larry Gostin and.
Others have been ministers of health, but we have some two ex presidents as well. So you've got a good look at governance in this system. And we've been working to really try and put pressure at the highest level, really influencing member states and the influentials on member states is the way we've been working.
And so. We're bobbing along and following the treaty structure very closely.
Jessamy: And I suppose, you know, within that, there's also, there are other panels, there are the committee, you know, we had our own COVID 19 commission, you know, been near the independent panel on pandemic preparedness and their reports.
There's so much knowledge out there, there's so much discussion about what's happened. Within this process, do you feel that that's being translated? And can it even be translated into a treaty? Well, not
Barbara: everything can be translated. Clearly, people have got, you know, interests and issues that go well beyond.
And in the end, it can't be everything to everybody. But the key elements of it, I think, are going into the treaty or being considered for the treaty because we're still not into the negotiation phase. But there's a lot of work to do in all the aspects of persuading people. And perhaps the biggest one is this issue about persuading countries that they really are willing to do things and be accountable for it.
That's the one element that's, it's in the principles that people are putting out for this treaty. But we haven't got a practical way forward, which I can, let's talk about a bit later. But it's, it's something that has to be pressed all the time in this, and not lost in too many of all the issues that may be, may be arising.
And I think that one of the issues at the moment, of course, is the issue that the international health regulations are now being looked at as well, which is in one sense good, but in another sense, it's reopening things. And there's a big question about how the IHR must fit in. As a sort of subsidiarity to this treaty, if it's all going to work together.
So there's, there's still quite a lot of work for people to do, I think.
Jessamy: And maybe just for our listeners, you could kind of just give us a big picture overview. When, when did this sort of process start? Where are we now? What are we looking at?
Barbara: Well, it was quite a slow start, I think. There was talk about having a pandemic treaty, but it took another six months following the World Health Assembly, where it was expected to be agreed that there would be one, before it even got going.
So the negotiations, or the even start to thinking, didn't happen until the beginning of 2022. And now, It's got to the point where all the issues are on the table. But the negotiations directly have to start on each of this with a view to this being agreed in May, 2024 at the world health assembly.
And I think we have to keep our feet on the pedal on that because with that and the IHR, people are beginning to say, Oh, can we do it all? But frankly, the world can't keep waiting for this treaty to come into effect because it will need ratifying by governments. It will take time anyway, and we need it now because we know we could be facing very, very quickly another outbreak that could turn itself into a pandemic.
Because as we know, the absolute essence of this is not at this moment being able to stop all outbreaks. That is really not possible with the you know, the number of viruses in animals and birds that may actually transmit eventually to humans and human to human. So we will undoubtedly get some outbreaks, but the key thing is, can we control those?
Can we stop the going to pandemics? And for that, we need real commitment right across the world.
Jessamy: And it's that commitment, which is often so challenging, isn't it? With these sort of trying to get, you know, lots of different countries with competing interests, politicians who are people and got their own agenda.
You know, trying to get that all together is extraordinarily difficult.
Gavin: Especially as well. It must be such a political hotspot of COVID 19. You know, we're there, which is, I think you, you kind of touched on it at the start. It's actually become a very political arena, COVID 19. So it must be difficult to kind of direct all these, all these differing interests.
Barbara: I guess it's not a good time in history anyway for multilateralism. That's another problem. Interestingly, it, it feels like sometimes when I've been in meetings with people that the pandemic, because it is a public health thing, it is about people's health. It's a good issue that people can come together on more.
And I've been surprised at some of the countries that have been prepared to go along with this treaty. Because it's something that they can actually come to that isn't quite such a dramatic issue as some of the other things that we've got going on, including, you know, climate change and so on. So there's been more general support, but that doesn't solve the problem because these particular issues, particularly about accountability.
You know, are still there and not everybody agrees with that. That's going to be the struggle for this year, no doubt about it.
Gavin: Yeah. So perhaps you could talk us through some of the mechanisms that you've kind of realistically put in place for enforcement and accountability and things like, because I think that's a very interesting aspect of this treaty, obviously, isn't it?
This kind of multilateralism that you talk about, but making it work when these problems actually arise.
Barbara: Yeah. Well, if I do it, I mean, obviously there'll be a lot of the things in the treaty, but the, for us, the absolute essence is preparedness and response. That's fundamentally what's needed. Now on preparedness, there's been work already done to help countries peer review each other in some different schemes.
And that is being worked on further so that all countries can know what sort of preparedness they should be, you know putting in place in their countries. Now, the important thing about that for us as a panel is. That although peer review is really good, it's a great thing to do, that is not enough.
You have to have independent assessment of what governments are doing. And I think there's quite a lot of agreement from member states about that because we're big, well partly because of comparisons with things like the Human Rights Council and the difficulties that ensued from that with some of the prepare the peer reviews.
But so there's an issue about you need, you need independent assessment. Now who does that assessment? And what we're proposing is that there should be an independent assessment body within the treaty structure, not actually directly in WHO, because WHO has to be a friend to the country and a supporter and it's very difficult often for them to actually say publicly.
you know, what they think is happening in that country, report on it and so on. But it, but the, but the treaty will sit, it will be hosted in WHO. So you're at arm's length from WHO, though somewhat, you know, removed from that really. That's the preparedness bit, but the preparedness bit is, is in a way more straightforward because you'll be doing that on a rotating basis.
For example, looking at each country every three or four years or something. So you can do that. The more difficult part is the response. But again, what you really do need is independent assessment at the time of response to see what particular countries are doing, and also to have that, you know, I mean with authority put in the public domain because we do need to know at that time what countries are doing, and in particular, WHO will still be having to set the standards for what people should be doing.
So it's really important that, you know, this independent body looks at what WHO has said. that governments should do. In fact, they will say they shall require those things to be done. And that needs to be looked at by this, we think, by this independent body. Now, I mean, there are some, there are lots of issues in all this.
One of them, of course, is for the low income countries, because they're not going to make it to the same levels at the same speed. And again, we've been talking about, well, it may be that for poorer countries, they will have to set their own objectives for what, so they can achieve with where they start from and what finance they're going to get to be able to do that you know, as a way through this.
response is in a way more tricky because if you think about the stages, you have an outbreak in one country, you have outbreak in other countries, they're developing as you go. And some of the advice that will be given by WHO will have to vary according to where we are in stages right through to the full pandemic and the management of that.
But also taking into account you know, the cultures of countries as well. What can they really do from their, their histories? And what's the right advice, you know, to give to them? So, but having an independent body really look at that seems to be an absolutely vital part if we're going to be able to say that countries are accountable.
I mean, there are issues about how we persuade countries to do that. One of them, the main fundamental, but may not actually make it happen is that we all know now that every country is affected by every other's behavior. And that's got to be the essence of why you would be prepared to be accountable, that you would do your transparency of data going into WHO, all those sorts of things.
But that may not be enough to persuade people. You're, that's partly why having the, the data out about, having from an independent assessment, at least you've got some public view of that, which may be reputational. That's another part of this. It's very hard though, to think of anything that could be called sanctions on this, because almost anything you would put in that was a sanction would immediately affect all the people of the country concerned, and you don't want to do that.
So we've been looking at different means to try and you know, encourage people to take part. For the, for the, again, for the lower income countries, there is a lot of benefit in signing up because of course they, they do need financing. They do need much more technical support, you know, to happen. For the rich countries, one thing that we're exploring that has come onto the table from a number of people is Article 4 of the IMF, which actually is the financial stability of a country.
And if you put some of the measures of preparedness and response into that to look at, it might be that that influenced countries to really do their, you know, to do the, this accountability that we're expecting from them. Because even rich countries really care about the IMF's measurement of financial stability.
But that's just a. You know, a sort of an idea at this stage, as I say, it's, we can't, the essence of why we should do it is there and so important, but you can't just work with goodwill. What will really help make this happen?
Jessamy: And I suppose the people discussing the treaty, they're going to meet at the end of February.
Is that sort of next? Correct. Yes. That's the next big thing. That's when countries are going to really begin official negotiations or, or to continue them. Correct. Yes. What, what do you see as, you know, some of the key things that are being left out right now?
Barbara: Well, as I say, one is actually real mention of accountability and the measures, but beyond that, it is actually, in fact, the governance of the treaty and, and how that will happen.
And, you know, for instance, whether You may have what, you know, this head body, the conference of parties. It may be relatively small for a while because that will only cover people who have ratified. So there are talks about, well, maybe we need to have something with that, which actually brings all member states and perhaps other stakeholders into that too, and at head of state level.
So the issues about governance are there. Of course, the absolutely central, central one that is really, really difficult is equity. It's written into the principles now that in this new zero draft, and there's a lot of suggestion in it about what would make this treaty equitable. And as you know, well, it's issues about vaccines, drugs, testing, equipment, and all those things, and making those available to all people.
Because that, of course, has been one of the great failures of the response to COVID 19. And I think there's got to be some resolution of that, because I don't think the developing countries we'll really sign up to, you know, the rest of the treaty, the being accountable for other things.
Jessamy: Yeah.
Barbara: If actually we can't resolve that issue and that's probably the most fundamentally difficult really.
Jessamy: Yeah. And again, we have these sort of parallels with, you know, climate change and any sort of movement on there where we're now in the era of what, you know, what they call loss and damage, you know, also, which is about equity and about justice. Yes. I mean, do we have good examples? Where we've able, been able to build in equity and this sort of interglobal processes.
Barbara: Yeah, I think this one is the one that's hitting it the most, frankly. Okay, well that's, I'll tell you the reason why. It's because for the first time, say, say in terms of giving money, because money is a central part of the country. In, normally when, when rich countries give to poor countries, they think they're sort of, you know, doing good, doing the right thing by them.
This time, they're not just doing the right thing by them. They're actually protecting themselves. And that's a slightly different position
Jessamy: that's, that's going on here. And it's different to climate change also, because their countries tend not to be as impacted at the moment by climate change. Yes, that's
Barbara: right.
And I, so I think there is some reasons why it can be done differently. And I'm very interested in the World Bank's Pandemic Fund. Which, with a lot of pressure from civil society, has come up with a view that you will need equal members on the board of the, of that fund, for those countries who are the implementing countries, and those who have actually put the money in to do it.
And it's stopped being called donors and recipients. It is about implementing countries. And that's a big change from the way the World Bank normally sets things out and certainly not with equal voice and so on, and with civil society on.
Jessamy: Yeah.
Barbara: No, it's, it's taking a bit from the model of the Global Fund, because the Global Fund for HIV, AIDS, TB and Malaria has been one that has worked much more on that more even footing basis.
Yeah. And in both civil society and so on as well. So that's a sort of small good sign.
Jessamy: Yes. Yeah. And sort of that power is being slightly redistributed. Yes. Yes. You know, along the general lines of it, of decolonizing agenda. Yeah. When it comes to kind of actually getting people to sign up to it and to say that they'll do this, even if they think that they might be protecting themselves.
Do we see the types of political cycles to, to allow that right now? You know, we've seen so much short termism and it's been discussed so much, you know, we need some kind of process that allows nation states that are working in multilateral bodies to be able to have some sort of long term vision. Yeah.
Barbara: It quietly goes on at the moment, you know, in a way, it's not on the big global agenda. Now, in, in one sense, that's, that's bad because we certainly don't want to lose momentum on the pandemic treaty, but equally it's not in the flames of things, you know, of things that are being challenged all the time and we need to keep up the momentum enough to get the treaty through, but in, you know, sort of a positive order really.
And I think that is possible with this one because people can genuinely want to do something good on health and recognise it's in their own interest. And it's not the first time in even the, you know, sort of in history, I mean, you know, for climate change and for nuclear weapons. I mean, there have been treaties that come together that do recognize that this is so big, it's going to affect the whole world and people will do it.
So I think we could be moderately optimistic. We'll get a treaty. We just want one that's firm enough.
Gavin: We've, we've been talking a lot about shared sovereignty. You know, you, you've kind of explained reasons why this might not be the case, but do you think with all the kind of economic problems the setting lots of countries at the moment in the kind of post pandemic high inflation landscape.
Have you found this become a struggle to make countries kind of look past themselves and looking after their own citizens first?
Barbara: No, and to some extent you wouldn't expect them not to be looking after their own citizens first. And that, and that is, that is a difficulty. And I think it comes particularly into the into those, you know, the vaccines, drugs sort of debates, really.
Because that is, you know, are you doing your country first, or, you know, and your own people, or where are you going? So that does bring in dilemmas there. But I'm really interested because there is a bit of a campaign in some places against the shared sovereignty idea. And I always respond to that by actually going back to the Charter of the United Nations about sovereignty.
And if I can just read a couple of bits from this. In the charter, it states that sovereign rights to manage their approach to public health is part of their sovereignty. But it goes on to say, provided that activities within their jurisdiction or control do not cause damage to other states and their peoples.
And I'd rather like to hang on to that, because that's exactly what this one is all about. And when you know, some of the campaigners have gone on saying, Oh, that all means shared sovereignty. You can certainly say, well, we've already had shared sovereignty. And sometimes in other areas, but in particular in this one, that's what the charter says and means for us to, how it means us to behave.
And of course, You're right about, you know, looking after your own country. I mean, there are things that countries will do in order to, you know, to protect their own. But it's just how we can get enough to make, of the sharedness, to make this, the whole thing work, whether it's preparedness and response or on the, you know, the drugs vaccine side as well.
And I think, I mean, there are a lot, there are signs that, that that's all possible. I was thinking about the MRNA work that's going on in South Africa, and that isn't just about building a factory, it is actually passing on the know how as well. And that's absolutely central if we're going to, you know, deal with the equity questions, to actually share the know how in this.
But it is a balance clearly for some countries in, you know, in their pharmaceutical industries versus, and, and even, as you say, you know, sometimes making, putting your own country first as compared to making sure we do this right on the, on a global scale. No, yes, it's a balance, no doubt about it.
Gavin: Well, I was just wondering how you kind of square this optimism with how rich countries acted in regards to vaccine distribution.
Barbara: Well, I think it's very bad. That's why they need pressure on them from the developing countries. And that's pressure is coming through the treaty, very loud and strong. In fact, there's some argument coming from developing countries about why this has to be done, which is first of all, it's a good thing, but it's, it's, it's actually that they're not going to be prepared to commit themselves in various ways if they don't get some of that moving.
And it's just about trying to work out what is, what, what the way through this is, which I certainly can't say that. I mean, I've seen the WTO council issues and it's very, very difficult, but we have to make some way through that with this treaty.
Jessamy: I just wanted to ask I know that you're quite keen to discuss this to a sort of broader audience.
Yes. What you feel, you know, our responsibility is either as physicians and, and healthcare workers, or as just people who are interested, involved citizens, you know, you've already spoken about sort of the role of civil society that that has had in, in other areas that have been beneficial. In this one, what do you think people can do?
What, what should we be doing? How can we get a pandemic treaty through? Well, it
Barbara: does depend on the different bodies, of course. I mean, the civil society, I think we all need to keep working with to say, just keep on the ball, keep mentioning this, keep explaining where the pandemic has got to. And obviously on some of it, we've got the people's vaccine working, for example.
That's, you know, quite clear. But for a lot of other civil society, it's only one bit of their picture. But just completely reminding them over and over again to keep mentioning what's happening. and telling people who are, you know, sort of engaged with them. The big group that we're really interested in now is parliamentarians, partly because we need to get them to understand what this is all about, or to help them understand what it's all about, because they will be the people who ratify the treaty in the end.
And also, as the argument we make to them, it's not only that you ratify the treaty, by having a treaty that's ratified, you'll be able to hold your government to account for delivery. So, in all countries, it's, it's got to be looking out to, well, it's people in the country, often through civil society, clearly, and parliamentarians, who are going to hold their own governments to account.
Now, for so many people, there's not a lot of knowledge about what a pandemic is, why, you know, why it happened, all those sorts of things. So we're trying to push at the moment to try and get some very basic information around because I keep hearing, like from parliamentarians, could you write a quick booklet, a really simple booklet on, you know, what these things mean and and what the options are.
Ten bullet points, if you could. Yeah, I think they could go for a bit more than that. You know, a paragraph on 20 items, might be, but a sort of Q& A. But a simple, a simple thing that they can really understand what it's all about, what, for some of it, what they should be arguing for, but some of it will be, has to be more neutral.
It's not necessarily what our panel are saying. It's got to be something, you know, that shows the pros and cons of the issues as well to them. But I think they're a, they're a very important group. But of course, you're right too. The medical profession itself or health workers themselves, we really need to help them remember that how horrible it truly was and that we need to just keep up the action through, I mean, through a lot of the, the groups that are, you know, around in, in the health scene.
And I said, particularly the, the, you know, the professional workers, you know, making sure that they I'll at least know that this is going on and they keep thinking, yes, it's a good thing. We need to make this happen. Really. I
Gavin: thought we could kind of end with a little bit of a little bit of a thortics though.
I was interested to, to ask if the COVID 19 pandemic happens again, but we have a treaty like this in place. What would you hope would go differently?
Barbara: Really a nice list, really. But well, first of all that you have to have a whole lot of government involved right from the start, so that your planning was done, you know, really properly, thoroughly.
and that they really understood the precautionary principle about really moving immediately, you know, things are happening. You need to have systems in place with all actually good preparedness. And as I say, they are ready to act. They know that they have, when they have to move very fast, that they would have they would be good at passing on all information.
And I don't mean just right at the beginning, but information about numbers of cases, what's happening, the genomic sequencing, all of those things that they're, they're all prepared to, you know, to do that again you know, at speed and that they're prepared to listen to WHO when it gives advice. And sometimes they may not take it because they can explain why they, they can't, or that doesn't fit or whatever, but you know, really to take WHO standards setting really seriously.
And perhaps this last one, and make sure this is done equitably. That will also help stop the spread any further, and be fair to all people. And if we could do all that, then that would be a sort of miracle, I think. That would be good.
Gavin: Thanks so much for joining us for this episode of The Lancet Voice. This podcast will be marking The Lancet's 200th anniversary throughout 2023. by focusing on the spotlights with lots of different guest hosts from across the Lancet group. Remember to subscribe if you haven't already, and we'll see you back here soon.
Thanks so much for listening.