Why global governance failed during COVID-19.

I joined this panel discussion today on the failures of global governance during the COVID-19 pandemic. These were my short remarks at the start of the discussion.

We should acknowledge that more than a year into the pandemic, many of the systems that had been designed for just this moment — surveillance systems, track and trace systems, and even our political systems, have not functioned as they were intended to.

However, I would argue that the pharmaceutical system we have is working exactly as it is intended to — or how it has been designed.

This was a broken system when we entered the pandemic, and it is likely to remain a broken system when we exit — but collectively we have long tolerated this system as ‘good enough’. It’s a pharmaceutical system which has always rationed access to low and middle income countries — whether we mean access to scientific resources, financial resources, or end products.

Two million people die every year of tuberculosis, almost all of them in low and middle income countries, and yet no new vaccine has been developed for a century, and the preferred drug regimens for people with drug resistant TB are expensive, lengthy, and are not highly effective.

But all of this, at least to the general public, has been mostly invisible.

The COVID pandemic is making us question the pharmaceutical system, or at least how we behave within it, because the inequity is too obvious to ignore, or perhaps too easy to describe.

But again, I would argue the system is performing as intended and as it has in the past — in four ways.

First, public investments of funds — over 100 billion dollars — and publicly funded technology have been privatised with no benefit or rights back to the public sector and public interest.

Second, all of the products have been claimed by a narrow set of high income countries and wealthy populations, while everyone else has to wait at the back of the line.

Third, drug companies have earned outsized profits and will continue to do so for the duration of the pandemic — Pfizer expects 30 billion dollars in revenues just this year.

And fourth, when everything falls apart, as it has, we scramble to put in place inadequate voluntary measures to compensate for our failures — and create what I would call a new ‘charitable equilibrium’.

The problem with global governance is not that it has created this failure, but people at the controls never seriously believed that we would end up in this place. I would even argue that many of their decisions have made the situation worse.

Global health agencies have not been transparent. Drug companies are feted as equal partners and even saviours instead of arms-length entities that have a different set of short and long term interests. And too much trust was placed in the main government funders of R&D — who ultimately were more focused on securing their own supplies and needs instead of pushing for worldwide sharing of knowledge and mass production. And in spite of all the rhetoric, these behaviours are accelerating — the European Union has already booked nearly two billion doses of vaccines for the next two years, and the UK has reserved an additional 60 million doses this year to provide its population with a third dose, even as most people will not have had their first.

This failure in global governance is also built on many bad decisions from the last two decades, and the lessons that were learned and then unlearned after the initial catastrophe of the AIDS pandemic. In the early part of this century, there was a momentum towards accountability — red lines that neither governments nor companies could cross — and a sense that overcoming AIDS in a fair and equitable manner was to be determined by all governments collectively and by those living with or at high risk of HIV. Yet as the sense of ‘never again’ waned away, and as we forgot what produced success, we moved towards an approach to HIV more grounded in voluntarism, of philanthropy and charity, and of the drug industry as partners in the response. This ‘win-win’ approach largely worked because there was no real pain or trade off for the winners — namely pharmaceutical companies and wealthy countries.

By that I mean drug companies got their profits and repaired their reputations, wealthy countries could afford to support the response and improve their standing, and low and middle income countries got access to low cost medicines on terms set by drug companies. Yet ‘win-win’ solutions only work when those with power do not have their power or profits challenged, and when the disease itself only affects people living elsewhere. If the more powerful side has to make a sacrifice or may actually lose something — the win-win solution becomes a win-lose ‘free for all’, and we all know who ends up having to suffer.

And finally, if there is one major difference between the early response in 2000 to HIV and the situation we are in today, it is the role of the Gates Foundation. The Gates Foundation designed much of the international response to the pandemic. It championed drug companies as partners and saviours. It refused to acknowledge intellectual property rights as a barrier to access and placed a large bet on capacity reservations and advance purchase commitments — both of which have largely failed — whether one looks at the distribution of diagnostics, monoclonal antibodies, and of course vaccines. Bill Gates now speaks out against the TRIPS waiver — even after 100 governments, Members of Congress, and former Heads of State and Nobel Prize winners, support it. To state the obvious, the whole purpose of the Gates Foundation’s approach, and of course of any philanthropy, is to make the current system work, no matter how badly it is performing.

It’s a relief the Gates Foundation was not involved in the early AIDS response. What would have happened if, like Bill Gates states today with respect to vaccines, and much as drug companies did in 2000, that companies and public producers in low and middle income countries were not capable of producing AIDS medicines without grants, technical assistance, and permission from the Gates Foundation and the pharmaceutical industry. How much more of a catastrophe would we have had?

And so we have a choice — either we have an approach to pandemic preparedness and response that is based on the messy, but collective will of governments and societies and based on evidence of what works, or we allow a single individual, leading an unaccountable, opaque and unelected foundation, to make these decisions on behalf of everyone. We cannot have both.

We also must be honest about whether we can continue to tolerate a system that works for so few and that is broken for so many. If we do continue to tolerate the way things are, at least we know we are doing so with our eyes wide open.