The case for an international pandemic treatyBMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n527 (Published 25 February 2021) Cite this as: BMJ 2021;372:n527
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Nikogosian and Kickbusch1 are right in displaying the options for an International Treaty on Pandemics, integrating the perspectives from the current assessments on the COVID-19 pandemic response. There is a need to consider an additional key element: to retake the capacity to exercise the health authority in society. For decades now some governments2, WHO3, and many scholars (including Kickbusch) have advocated for Health in All Policies, with little effectiveness, despite their central role for epidemics, chronic non communicable diseases, and injuries. The Framework Convention on Tobacco Control is timid when having to develop financial, legal, trade, or other intersectoral intervention tools. The International Health Regulations have concentrated their actions on the health care sector, very limited on other public health functions, and not on the All of Government and Society needs and response to be led under the stewardship of Health during a PHEIC. It is true that we need to strengthen the medical and public health capacities inside the health system. But as it demonstrated in the COVID-19 pandemic, other sectors are impacted, have responsibility, and need to be empowered to tackle the pandemic and act aligned to societies and State’s health aims.
The authors mention that “although concerns may arise over WHO’s ability to cover important areas such as finance, trade, supplies, law enforcement, and the broader economic and social disruptions”. It is precisely here where the health authority now needs to be exercised and supported. Public health instruments and institutions must be readied to get out of their comfort zone, consider the broader society’s needs and capacities to collaborate, and advance. To act outside the health sector is demanded for NCDs, injuries, infectious diseases, disasters, in general for most public health concerns, and the treaty could be the turnaround event on achieving this. The current version of the EU treaty4 is an internal health treaty proposal, lacking a vigorous call for a transformative strengthening of the health authority, being this at the WHO or at the national Ministries of Health. At the global level, we have strategic challenges for the health regulatory approval, equitable production, distribution and access of medical supplies, treatments, and vaccines, the certification criteria for healthy and safe work, hospitals, and meeting spaces, as well as vigorous financial mechanisms to support the health and societal response needs. This needs to be considered through a transformed and reinforced stewardship function of WHO, as it must be reflected in a new role of the Health Sector3 within member states. And the call for collaborative action between countries must go beyond the principles of solidarity and fairness included in the European Council proposal, but they should seriously consider the principle of “Sovereign Obligation” originally proposed in international political economy5, that would underlie all other policies. Being this a treaty under the United Nations, or under WHO, the additional decision is the scope of the treaty, either continuing the current limited approach, or advancing to a transformative instrument of health stewardship and leadership.
Nikogosian H, Kickbusch I. The case for an international pandemic treaty. BMJ. 2021 Feb 25;372:n527. doi: 10.1136/bmj.n527
Melkas T. Health in all policies as a priority in Finnish health policy: A case study on national health policy development. Scandinavian Journal of Public Health, 2013; 41(Suppl 11): 3–28. https://journals.sagepub.com/doi/pdf/10.1177/1403494812472296
WHO. Adelaide statement on health in all policies: moving towards a shared governance for health and well-being. Geneva, Switzerland. Accessed on March 30th, 2021. https://www.who.int/social_determinants/publications/isa/hiap_statement_...
European Council. An international treaty on pandemic prevention and preparedness. Accessed on March 30, 2021. https://www.consilium.europa.eu/en/policies/coronavirus/pandemic-treaty/
Hass RN. World Order 2.0. The Case of Sovereing Obligation. Foreign Affairs. January/February 2017. Accessed on March 30, 2021. https://www.foreignaffairs.com/articles/2016-12-12/world-order-20
Competing interests: No competing interests
In their editorial, Nikogosian and Kickbusch propose the development of a global treaty to help prepare us for the next pandemic. [1 ] In making their case, they suggest using the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) as a template for future action. We were all involved in the development of the FCTC; and while we concur that better intergovernmental collaboration is needed, we do not recommend emulating the FCTC in its current form.
Article 19 of the WHO constitution empowers the organization to make treaties. Yet, as Nikogosian and Kickbusch correctly state, the WHO was and is slow to use this authority. One of us (DY) has described the steps taken to overcome that opposition in the context of the FCTC. [2 ] This involved: building on 25 years of WHO resolutions related to tobacco control; developing a strong international NGO movement in support of the FCTC; engaging the World Bank and other parts of the UN family; and collaborating with governments from countries across the world.
In addition to the above, the FCTC succeeded because had a strong intellectual foundation, based on work by Ruth Roemer and supported by Allyn Taylor. Even with this solid grounding, the process was long and complicated, taking five years from conception to adoption. The treaty’s mere existence represents a major international achievement and should be acknowledged as such. Yet, as a tool for actually improving global health, the FCTC leaves much to be desired.
15 years since coming into force, the FCTC has inspired modest progress in some areas of tobacco control, but has been slow to tackle others. For example, the WHO has yet to address taxation measures that could drastically reduce smoking rates; and the FCTC has done little to support cessation and harm reduction among the world’s 1.3 billion current tobacco users. [3, 4] This reminds us that agreements reached in Geneva take time to be felt in communities across the world. The treaty-making process is inevitably slow. As such, we doubt that such a process is fit to address fast-moving pandemics.
The International Health Regulations (IHR), negotiated under Article 21 of the WHO Constitution, were designed for infectious disease outbreaks and have their roots in the earliest of international agreements. [ 5,6 ] Yet, the success of new regulation depends on strong and courageous leadership that can withstand pressures from powerful Member States. Directors General Halfdan Mahler and Gro Harlem Brundtland exemplified this kind of leadership. [7 ,8] Unfortunately, the current international political landscape does not lend itself to bold decision making at the WHO. Further, even the development of firm resolutions does not guarantee results. Unlike national law, international treaties hold no mechanism for assured implementation. Their success depends on moral persuasion, global consensus, and extraordinary diplomacy.
Moreover, the FCTC holds inherent weaknesses that should preclude it from forming the basis of a pandemic treaty. Careful reading of its text will reveal that “trade” only appears in the context of “illicit trade” and that the term “intellectual property” does not appear at all. There were reasons for this. At the time, intellectual property debates (e.g., related to HIV/AIDS, drugs, and other pharmaceuticals) required deep engagement with trade ministers and the world trade organization (WTO). Recognizing the complexity of such debates, the FCTC leadership opted to keep trade issues out of negotiations. As a gesture of compromise, the WTO issued a statement in support of the FCTC, with the implication that it might play a role in future trade disputes. 
The decisions regarding trade arose, in part, from the state of tobacco science, technology, and industry at the time. FCTC leadership did not consider the possibility that patents might be important for tobacco control because, at the time, tobacco companies were not seriously investing in reduced risk products worthy of patent protection. 20 years later, things have changed. Today, tobacco and e-cigarette companies lead innovation, patent filing, and technology development aimed at harm reduction. 
As such, the FCTC should be updated to address the role of intellectual property, as well as public-private partnership (PPP). Likewise, a pandemic treaty would require serious consideration regarding the role of industry, patents, and trade. Improving global pandemic readiness requires investment in better diagnostics, vaccines, treatments, and digital surveillance systems; and the private sector leads innovation in these areas. Any treaty in this area should thus emerge not just from the WHO, but from science, commerce, trade, and industry sectors of government. Indeed, comments from the incoming WTO Director General indicate that she views future pandemic response as falling within her brief. 
Before it can be used as a model for other treaties, the FCTC itself must be amended to better define the role of industry. For instance, Article 5.3 should be adapted to encourage PPP in ways that protect the WHO from conflicts of interest.  Further, this article should not be interpreted (as has been done in in the past) as justification to ban, boycott and exclude the private sector and affiliated scientists from engagement. The latest Edelman Trust Barometer shows that corporations are now far more trusted than governments in 18 of 27 countries surveyed.  These sentiments, combined with innovations coming from the private sector, suggest that industry will play a critical role in the future of both tobacco control and pandemic readiness.
Given ongoing geopolitical instability, an intergovernmental solution alone does not seem the most prudent way forward. Rather, we should strengthen mechanisms of the WHO’s existing IHR, with the goal of addressing technical aspects of pandemic preparedness. Simultaneously, we should build more robust PPP that leverages private sector innovation to equitably improve global health. [14 ] In the area of vaccinations, GAVI already uses this approach and now leads in delivering COVID-19 vaccines to low- and middle-income countries. [15 ]
When asked a few years ago whether more treaties were needed, Director General Brundtland suggested that the era of treaties was closing. [16 ] Though she led the development of several major international environmental treaties and protocols in the 1980s, Brundtland acknowledges that such treaties depended on strong support for multilateralism—something that does not exist today.  Like Nikogosian and Kickbusch, we believe that the mitigation of future pandemics requires serious attention. However, we also believe that these efforts should reflect current political realities and incorporate fresh, multisectoral approaches to global health.
1 Nikogosian H, Kickbusch I. The case for an international pandemic treaty. BMJ 2021;372:n527.
2 Yach D. The origins, development, effects, and future of the WHO Framework Convention on Tobacco Control: a personal perspective. Lancet 2014;383:1771–9.
3 WHO. WHO report on the global tobacco epidemic 2019: offer help to quit tobacco use. https://www.who.int/teams/health-promotion/tobacco-control/who-report-on... (accessed 28 Feb 2021)
4 Yach D. Accelerating an end to smoking: a call to action on the eve of the FCTC’s COP9. Drugs and Alcohol Today 2020;20:173–89.
5 WHO. Constitution of The World Health Organization.
https://www.who.int/governance/eb/who_constitution_en.pdf (accessed 28 Feb 2021).
6 Gostin LO. International infectious disease law: revision of the World Health Organization’s International Health Regulations. JAMA 2004;291:2623–7.
7 WHO. Dr. Halfdan Mahler. Published Online First: 20 November 2017.https://www.who.int/medicines/areas/nextgen_essentialmeds/next_mahler/en/ (accessed 28 Feb 2021).
8 WHO. Dr Gro Harlem Brundtland, Director-General. Published Online First: 2 August 2011.https://www.who.int/dg/brundtland/bruntland/en/ (accessed 28 Feb 2021).
9 WTO Tobacco Agreement. https://www.wto.org/english/news_e/news03_e/sp_who_tobacco_agr_3march03_... (accessed 28 Feb 2021).
10 Understanding Nicotine. https://www.understandingnicotine.org/ (accessed 28 Feb 2021).
11 Zarocostas J. New WTO leader faces COVID-19 challenges. Lancet 2021;397:782.
12 WHO. Article 5.3 of the WHO Framework Convention on Tobacco Control. Published Online First: 20 April 2012.https://www.who.int/tobacco/wntd/2012/article_5_3_fctc/en/ (accessed 28 Feb 2021).
13 2021 Edelman Trust Barometer. https://www.edelman.com/trust/2021-trust-barometer (accessed 28 Feb 2021).
14 Gostin LO, Katz R. The International Health Regulations: The Governing Framework for Global Health Security. Milbank Q 2016;94:264–313.
15 Gavi, the Vaccine Alliance. https://www.gavi.org/ (accessed 28 Feb 2021).
16 Yach D, von Schirnding Y. Public health lives: Gro Harlem Brundtland. Public Health 2014;128:148–50.
17 UN World Commission on Environment and Development, ed. Report of the World Commission on Environment and Development: Our Common Future. Oxford: Oxford University Press, 1987.
Competing interests: Disclosure Statement: Derek Yach is President of the Foundation for a Smoke-Free World (FSFW); Ehsan Latif is Vice President of Grant Management and Stakeholder Engagement at FSFW; and Chitra Subramaniam is an FSFW consultant. The Foundation is an independent, US nonprofit 501(c)(3) private foundation whose mission it is to end smoking in this generation. The Foundation accepts charitable gifts from PMI Global Services Inc. (PMI); pursuant to the Foundation’s Bylaws and Pledge Agreement with PMI, the Foundation is independent from PMI and the tobacco industry.
Let this not be a case for inaction, but in our deliberations over a future international pandemic treaty, we must grapple with a question requiring social and political foresight, a sense of historical contingency, and rigorous self-honesty: would an international legal instrument backed by the contemporary global governance system really have made the difference in pandemic prevention, and realization, over a year ago?
And, as part of our answer, we should consider at least these seven questions:
-How plausible would it have been to have the data transparency the UK and US governments currently call for in 2019?
-How likely would it have been to deploy UN fact-finding missions to Wuhan in the early days of the pandemic?
-What would that real-time data sharing look like?
-What would an agreed upon compromise of Chinese state sovereignty in favor of timely international investigation, and potential intervention, look like?
-How would it have changed the politics of speculation and conspiracy theories amidst the current internet governance dilemma?
-What would the adjudication of blame—on a country where a pandemic virus originated—ultimately look like?
-And collectively, considering the answers to and assumptions of the above questions, how might we predict the likely behavior of governments to cooperate and respond to the discovery of a disease with pandemic potential?
Let these queries become thought experiments and these thought experiments to be the beginning of the future of pandemic preparedness, and so too the making of a less rigid and more cooperative world order conscious of the threats that face it. Indeed, there is one answer we know already: this is a task for everyone.
All views are personal and do not reflect the views of the author's institution.
Competing interests: No competing interests
I congratulate the authors for a very timely proposition that must have serious and prompt consideration of all member countries both in the UN and WHO. The devastation in terms of the suffering of over 28 million people and over 2.5 million deaths surely calls for a global solution.
Hence, concurring fully with the authors and having worked for about two decades for effective tobacco control in India through the implementation of the FCTC since 2004, I consider that it is time that our World thinks differently abot the "tobacco pandemic" in view of about 9 million deaths annually. It is disappointing that, despite a stronger tobacco control movement, in the past two decades the number of deaths have increased by over 3 million annually, which in terms of share numbers could easily average around 50 million additional preventable deaths.
Maybe it should consider on the lines similar to what authors have suggested to tackle pandemics, i.e. having a specific treaty #tobaccofreeworld2030 in view of the ever increasing number of tobacco-related deaths as well as challenges, barriers and threats envisaged under the FCTC.
But, such mechanisms should extend beyond both the UN and WHO to include other stakeholding world bodies such as the IMF, WTO, ILO, etc., for a quicker, stronger and more effective response. I consider that their combined collaborative strength can overcome the weaknesses of the FCTC. And, therefore, the earlier it is worked out, the better it will be for the entire world in which constituent countries haven't realised that the existence of tobacco cultivation and industry is in direct conflict with the health of people.
To conclude, tobacco-related disease and deaths too, many more than those due to the current pandemic (these too are huge), require thinking beyond the FCTC. The treaty has lived its life! Now is the time to move to what should become writing on the wall, i.e. bring the endgame on tobacco howsoever by 2030 through another treaty - #tobacco-freeworld2030.
Competing interests: No competing interests