In late 2021, as the world reeled from the arrival of the highly contagious omicron variant of the coronavirus, representatives of almost 200 countries met – some online, some in person in Geneva – hoping to forestall a future worldwide outbreak by developing the first-ever global pandemic accord.

The deadline for a deal? May 2024.

The costs of not reaching one? Incalculable, experts say. An unknown future pathogen could have far more devastating consequences than SARS-CoV-2, which cost some 7 million lives and trillions of dollars in economic losses.

But even as negotiators pack in extra hours, the goal of clinching a legally binding pact by next month is far from certain – despite a new draft document being delivered in recent days. The main sticking point involves access to vital information about new threats that may emerge – and to the vaccines and medicines that could contain that threat.

“It’s the most momentous time in global health security since 1948,” when the World Health Organization was established, said Lawrence O. Gostin, director of the WHO Collaborating Center for National and Global Health Law at Georgetown University.

The backdrop to today’s negotiations is starkly different from the years after World War II when countries united around principles guaranteeing universal human rights and protecting public health. The unifying fear of COVID has been replaced by worries about repeating the injustices that tainted the response to the pandemic, deepening rifts between the Global North and the Global South.

“The trauma of the COVID-19 pandemic has seeped into the negotiations,” said Ellen ‘t Hoen, a lawyer and public health advocate who specializes in intellectual property policies. Representatives of the WHO’s 194 member countries, she said, are looking backward rather than forward.

The reasons are clear. A paper published in October 2022 in the journal Nature showed that by the end of 2021, nearly 50% of the global population had received two doses of coronavirus vaccine but that huge disparities existed between high-income countries, where coverage was close to 75%, and many low-income countries, where less than 2% of the population had received two doses. At the same time, South Africa, where the omicron variant was identified, felt punished by travel bans instead of being praised for its scientists’ epidemiological acumen and openness.

“We felt like we were beggars when it came to vaccine availability,” South African President Cyril Ramaphosa recalled at a global financial summit in 2023. “We felt like life in the Northern Hemisphere is much more important than life in the Global South.”

The United States has signaled its support for a legally binding agreement, including leveraging its purchasing power to expand access to medicines around the world. But the United States, like many European Union countries, is the object of mistrust because it is the seat of the powerful pharmaceutical industry, which is reluctant to relax control over manufacturing know-how.

The chief point of contention involves pathogen access and benefit sharing. In many ways, the story of the fraught pandemic accord negotiations is the story of Henrietta Lacks – the African American patient whose cancer cells were used in research for years without her family’s knowledge – retold on a global stage. Who gets to use – and profit from – samples and scientific information, which often come from disadvantaged groups?

High-income countries want guarantees that samples and genetic data about any new pathogen will be quickly shared to allow for the development of tests, vaccines and treatments. Developing nations, where pathogens such as AIDS, Ebola and MERS emerged in recent decades, want guarantees of benefits, such as equal access to vaccines and collaboration with local scientists.

Almost 20 years ago, the Indonesian government forced those contrasting priorities to the forefront by refusing to share bird flu samples. WHO member states responded by creating the Pandemic Influenza Preparedness Framework, or PIP, under which key manufacturers agree to supply 10% of flu vaccines they make to the WHO for distribution.

No such agreement exists for other pathogens with pandemic potential.

“The PIP Framework provides us with good guidance for what an access and benefits sharing instrument could look like, but there are areas where the pandemic agreement could improve,” said Alexandra L. Phelan, senior scholar at the Johns Hopkins Center for Health Security, who co-authored a piece in the journal Nature in February calling for a “science-for-science mechanism” to ensure vaccine equity in the next pandemic.

A new agreement, Phelan said, could include an obligation to share genetic sequence data and factor in public health risks when determining how medical products are shared during an emergency. Unlike in earlier outbreaks, no need exists today to wait for a pathogen sample to arrive by mail in a test tube; work on vaccines and treatments can begin based on genetic sequencing attached to an email.

Even as negotiators wrestle over those points, the venture is being roiled by misinformation on social media, including hostility toward the WHO and assertions that any international agreement would threaten the sovereignty of nations – claims that WHO Director General Tedros Adhanom Ghebreyesus has condemned as “utterly, completely, categorically false.” The final agreement, Tedros said in early April, won’t give the WHO power to impose lockdowns or mask mandates in individual countries.

Underlying it all is “a lack of trust,” said ‘t Hoen, who, like Phelan, is one of the outside experts approved by member states to provide input to the negotiations although they do not take part in the closed-door talks. Some describe lingering in the cafeteria, waiting for the opportunity to glean information or offer counsel to country representatives when they emerge in need of refreshment.

“This is a pretty nontransparent process,” said Phelan, with “a lot of grumpy and unhappy people.”

The stymied talks prompted former British prime minister Gordon Brown, who serves as WHO ambassador for global health financing, to write a letter in March to the 194 WHO member states urging them to collaborate for the common good. The letter was signed by many former presidents and prime ministers, along with experts in global health and finance.

But signing on is less politically palatable for current political leaders now that so many people have moved on from the pandemic, choosing to ignore the not-if-but-when warnings that public health officials are airing again today, just as they did before the novel coronavirus was identified more than four years ago in China.

“The global leadership is absent,” said Nina Schwalbe, principal of the global health think tank Spark Street Advisors, another expert approved to provide input to the negotiations.

And in many ways, the coronavirus has left the world more vulnerable, Schwalbe and others argue, amid increased resistance to vaccination and other preventive measures and the weariness of public health officials. In some U.S. states, officials’ powers have been curtailed by legislatures.

Meanwhile, climate change and increased interactions between human and animal populations are increasing the possibility of spillover events spawning zoonotic diseases that are all but impossible to contain given the speed of modern travel.

Efforts to study pathogens present their own risk, with laboratories around the world engaged in medical and military research aimed at increasing the virulence of existing bacteria and viruses through “gain-of-function” research, posing a threat of accidental or deliberate release.

And in March, the National Academies of Sciences, Engineering, and Medicine released a paper outlining a new peril: Advances in gene editing and synthetic biology make it possible to revive pathogens including the virus that causes deadly and disfiguring smallpox – the only human disease declared to have been eradicated following a vaccine campaign by epidemiologists nearly half a century ago.

“New technologies could enable nefarious actors to genetically engineer the smallpox virus from scratch or make it even more lethal,” said Gostin, who chaired the committee that produced the National Academies report. “The potential for a laboratory leak or intentional release of smallpox or other pox viruses is real.”

Nature is also making a show of strength.

Since the beginning of 2023, the Democratic Republic of Congo has reported more than 12,000 cases of mpox resulting in 581 deaths, according to the Centers for Disease Control and Prevention, and there have been more than 700 cases this year in the United States. Bird flu has been identified in dairy cows in several U.S. states, with one dairy worker being treated for symptoms. A new JN.1 strain of the coronavirus is circulating.

When the ninth and supposedly final round of talks on the global pandemic accord closed in late March with no agreement, Tedros declared overtime, setting a date in late April for negotiations to resume. The WHO director general has portrayed the pandemic agreement as an urgent generational opportunity, only the second such global health accord, following the 2003 Framework Convention on Tobacco Control, which used new taxation and labeling and advertising rules to target smoking.

Asked in early April whether a deal could still be struck, Tedros sounded cautious. “I believe it can happen,” he said. In mid-April, the policy nonprofit Health Policy Watch published a new bare-bones draft agreement that is being sent to member states. It maintains support for equity, while leaving key details to be hashed out during the next two years, by which time the leadership of many instrumental countries, including the United States, may have changed. Meetings are set to resume April 29.

Some experts have speculated that the original timeline was too short to unite 194 countries around such a divisive and complex topic, pointing out that many treaties take years to finalize and that this process has been complicated by concurrent negotiations over the International Health Regulations, which aim to prevent the spread of disease. The Biden administration also just announced its own Global Health Security Strategy, with a goal of combating health emergencies by using U.S. leadership to drive investment in prevention and response among partner countries.

But past crises have shown that complex global negotiations can move quickly.

“After Chernobyl, a legally binding treaty was negotiated within six months,” Schwalbe said, referring to the 1986 nuclear power plant disaster. “COVID-19 is a calamity of equal importance.”

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