The 77th World Health Assembly (WHA)—the annual meeting of member states of the World Health Organization (WHO)—concluded on the 1st of June 2024. At this high-level meeting, after four days of intense negotiations (and many years of back-and-forth discussions preceding it) the Assembly made two major decisions. First, to adopt several amendments to the International Health Regulations (IHR), that is, the international legal rules governing the rights and responsibilities of states with respect to disease outbreaks. Secondly, to extend the mandate of the Intergovernmental Negotiating Body (INB) for a further year to finalise its work of developing a new Pandemic Agreement (sometimes referred to as the ‘Pandemic Treaty’). The IHR amendments have been heralded as a success of multilateralism, while the extension of the INB at least avoided an embarrassing collapse after multiple years of fraught and contentious debates over the content of the Pandemic Agreement.

Both these processes, aimed at developing and augmenting rules and norms of cooperation to address disease outbreaks—prompted by the devastating global impact of the COVID-19 pandemic—are couched (at least rhetorically) in terms of various ethical commitments and imperatives that we want to explore in this article, as a lens into the wider ethics of global health governance. When we speak of the ethics of global health governance, we mean the moral principles on which the idea that health issues require some form of collective action are based, and the consequences of these principles on questions of rights, responsibilities, distribution of resources, justice, and so forth. We look at some of the key amendments proposed (and, in the case of the IHR, adopted) in these two side-running processes of international law and the ethical principles that underpin them. Through this exploration of key ethical questions at the heart of the IHR and Pandemic Agreement negotiations, we demonstrate that there are ethical limits to these state-based processes. We do so by drawing attention to the gaps between the rhetoric of global health cooperation and solidarity and its practice, as well as the systemic dimensions of global ill-health that are left unaddressed by these rule- and norm-setting exercises which take place in an international order shot through with extreme hierarchies of power and resources.

Ideas of solidarity in the Pandemic Agreement & amended International Health Regulations

The COVID-19 pandemic clearly demonstrated the challenges to solidarity and cooperation in global health governance. Distrust and scapegoating of international organizations like the WHO by Jair Bolsonaro and Donald Trump (among others), the failure to implement a waiver on intellectual property rules to ensure that health technologies could be shared, global vaccine inequity (partly a result of the lack of a waiver), hoarding and commandeering of other biomedical products, and more, all suggest a breakdown in cooperation and flouting of ideals of solidarity.

Yet, these failures also catalysed attempts to create more binding and rigid instruments to increase international cooperation for when the next pandemic inevitably occurs. Following a special session of the WHA in November 2021, WHO member states formally began negotiating the terms of the Pandemic Agreement and simultaneously proposed revisions to the IHRs. These negotiations stemmed from the recognised shortcomings of the IHRs (which were last updated in 2005) and member state dissatisfaction with their adequacy during the COVID-19 pandemic. With these dissatisfactions in mind, the proposed Pandemic Agreement would be a legally binding instrument to strengthen the global response to future disease outbreaks, while working alongside new IHR amendments aimed at fostering scientific data sharing and equitable access to medical countermeasures.

In the several drafts of the Pandemic Agreement that have so far been published, the IHR amendments, as well as the speeches and statements around them, there is a notable and new commitment to ethical principles such as ‘solidarity, fairness, transparency, inclusiveness and equity’. Indeed, principles of equity and solidarity feature prominently, such as in the guiding principles of the draft Pandemic Agreement text, which asserts ‘equity as the goal and outcome of pandemic prevention, preparedness and response, ensuring the absence of unfair, avoidable or remediable difference among groups of people’, and aims for ‘solidarity, transparency and accountability’ in the work to achieve that equity.

The inclusion of these principles speak to the widespread anger—especially from the majority world—at the inequities of information sharing, the restrictions of intellectual property rights, and vaccine development and distribution during COVID-19. Indeed, many of the draft Treaty articles are particularly aimed at bringing these ethical commitments to fruition, particularly with respect to technology and know-how transfer. Under Article 11, states are reminded of their rights to use flexibilities in the Trade-Related Aspects of Intellectual Property (TRIPS) agreement and encouraged to implement intellectual property waivers. Meanwhile, Article 12 contains a critical cornerstone of the draft agreement, namely the creation of a new Pathogen Access and Benefit Sharing (PABS) system aimed at enhancing the sharing of pathogen data but with reciprocal commitments to ensure, ‘on an equal footing, equitable,........

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