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Sustainability in the pandemic accord
  1. G Owen Schaefer1,
  2. Ezekiel Emanuel2,
  3. Govind Persad3,
  4. Maxwell J Smith4
  1. 1Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
  2. 2Medical Ethics and Health Policy, University of Pennsylvania, Philadelphia, Pennsylvania, USA
  3. 3University of Denver, Denver, Colorado, USA
  4. 4Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada
  1. Correspondence to Dr G Owen Schaefer; owen_schaefer{at}

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Careful consideration of ethical principles and their ramifications continues to be central to pandemic prevention, preparedness and response, as reflected in the latest iteration of the pandemic accord. This latest version of the proposal was prepared for the ninth meeting of the International Negotiating Body (April and May 2024) for further deliberation and refinement.1 It contains a number of important revisions, including the winnowing down of divergent ‘options’ in the earlier ‘Bureau’s Text’ to a more coherent single set of provisions,2 as well as centralising most governance arrangements through broad powers held by a ‘Conference of Parties’.

Here, we will focus on one observation: the absence of explicit acknowledgement of the central importance of sustainability. Sustainability is mentioned more times in the treaty text than any other principle except for equity, yet it is given no official definition or status. The treaty exhorts sustainability in health systems, production of pandemic-related products, research and development investments, financing of pandemic prevention, preparedness and response, as well as funding of the accord itself.

We agree that sustainability is key to the accord. However, the parties must be more explicit in identifying it as a guiding principle, defining it and demonstrating how it is used to inform and/or justify certain provisions. In 1987, the United Nations’ World Commission on Environment and Development usefully defined sustainable development in terms of ‘meet(ing) the needs of the present without compromising the ability of future generations to meet their own needs’. The UN recognises that sustainability is a core value and requires balancing both near-term and long-term outcomes.3 The pandemic accord would benefit from a definition that is more contextualised to pandemics. Thus, we have offered a more tailored definition of sustainability: ‘Ensure that emergency responses that are appealing for the immediate problem do not imperil future responses, preparation for the next pandemic, or responding with research, development and manufacturing to subsequent pandemics.’4

This addition to the accord would accomplish two things. First, it would help validate the relevance of ethical principles—not merely as a throat-clearing exercise or hand-waving at ethics, but as a core feature of the accord that necessarily informs the content and application of its provisions. While the current proposal explicitly identifies six guiding principles and approaches, it is mostly unclear exactly how these guiding principles and approaches are reflected in the provisions of the main document. Specifically, it is unclear whether and how delineated principles such as solidarity actually inform the justification or application of actual treaty provisions. Sustainability is already much more clearly integrated into the rest of the text than most of the delineated principles, and so its explicit inclusion would underscore all the principles’ relevance.4 Similar integration into the main text of any other principle truly considered central to the accord’s provisions would also be appropriate.

Second, sustainability is fundamental to responsible pandemic preparedness. The Accord is itself premised on the supposition that pandemics will foreseeably and periodically recur, even if the precise timeframe is not easily determined. Consequently, the Accord’s provisions must be designed to last beyond the next pandemic. Because the Accord is concerned with multiple future pandemics, attention must be paid to potential trade-offs between the near-term and long-term effects of policies.

Humans naturally discount the future.5 The innate tendency is to sacrifice tomorrow for today. But in the face of multiple pandemics, sustainability requires proper planning for the pandemic that will follow the next one. For instance, intellectual property reforms that might enable wider production of already-developed interventions today could affect financial incentives for research and development of interventions in the future. While sustainability requires considering the long-term consequences of these reforms, it need not proscribe them. Rather, it counsels considering reforms as part of the broader ecosystem of innovation incentives and coupling IP reforms, for instance, with alternative pathways to incentivise innovation in pandemic response. Such pathways could include cash prizes for successful pandemic response innovations, grants for pandemic-focused innovation, or other forms of rewards, such as the priority review voucher programme used in the USA to encourage innovations to treat neglected tropical diseases.

Similarly, the brief text in the latest draft of the accord on liability could be enriched by considerations of sustainability: the need to ensure fair and just compensation for any harms caused by pandemic interventions like vaccines while not imperilling companies’ incentives to develop and distribute highly beneficial products. An emphasis on sustainability can then provide a more robust ethical grounding for some of the approaches only mentioned in passing, such as no-fault compensation systems funded by private contributions.

Adding sustainability to the current list of principles and approaches would further lengthen the list of core ethical principles. Consequently, adding sustainability to the list of guiding principles should be accompanied by a critical review of the role of the other principles. Like sustainability, they should either be directly integrated into the pandemic text to clarify their role and relevance or excluded from the list if, on reflection, the principle does not play a guiding role meriting such placement. Such an exercise is advisable in any case to promote parsimony and highlight the principles that should actually influence policy recommendations.

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  • Handling editor Helen J Surana

  • X @G_Owen_Schaefer, @zekeemanuel, @GovindPersad, @maxwellsmith

  • Contributors All authors jointly conceived, drafted and edited the commentary.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests GOS and MJS have no competing interests or funding to declare. GP has a grant from the Greenwall Foundation and posts at the WCG IRB and ASCO. EE is Special Advisor to the Director General of WHO and also serves as an Expert Advisory Member on the WHO COVID-19 Ethics & Governance Working Group. EE reports non-financial support from Global Innovation Forum AAHC Travel, non-financial support from Macalester College Travel, non-financial support from Oak CEO Summit Travel, personal fees from Advocate Aurora Health Summit, non-financial support from DPharm Conference Travel, non-financial support from University of Pittsburgh Medical Ctr Shadyside, non-financial support from University of California San Francisco Travel, non-financial support from Cain Brothers Conference Travel, personal fees from Bowdoin College Travel, non-financial support from Galien Foundation Travel, non-financial support from HLTH 2022 Travel, non-financial support from Hawaii Medical Service Association Travel, non-financial support from Tel Aviv University Travel, non-financial support from The Suntory Foundation Travel, personal fees from Ontario Hospital Association Travel, non-financial support from University of Oklahoma Travel, non-financial support from The Quadrangle Travel, non-financial support from Lazard HC Leadership Summit Lodging, non-financial support from HLTH 2023 Travel, personal fees from Sanford Health Travel, personal fees from Health Plan Alliance Travel, personal fees from Emory HC Leaders Retreat Travel, personal fees from Employer Direct HC Travel, non-financial support from University of Virginia Travel, non-financial support from New York Historical Society Travel, and non-financial support from Amangiri Executive Retreat Lodging. EE serves on the following: Board of Advisors Cellares Corp.; Advisor Notable Health; Advisory Board Member JSL Health Capital; Advisory Board Member Peterson Center on Health Care; Advisor Clarify Health Solutions; Consultant Health Care Foundry Inc.; Advisory Board Member Feel Better Ltd.; Consultant Korro/Coach AI Ltd.; Consultant Aberdeen Inc.; Board of Advisors Alto Pharmacy Holdings; Advisor Link Health Technologies; Advisor Nuna; Expert Advisory Member WHO COVID 19 Ethics & Governance Working Group; Advisory Board Member HIEX Health Innovation Exchange partnership sponsored by UN Geneva; Advisory Board Member Biden's Transition COVID-19 Committee; Special Advisor to the Director General WHO.

  • Provenance and peer review Not commissioned; externally peer reviewed.