• Ethics

The World Health Organization (WHO) is currently in advanced stages of developing a ‘WHO convention, agreement, or other international instrument on pandemic prevention, preparedness and response’ (also known as WHO CA+, referred to below as: Pandemic Agreement).1 Rightly, the instrument places equity at the centre. Yet, it currently also omits reference to an impactful tool to promote equity that has been adopted in an unprecedented manner during COVID-19—a set of measures known as disadvantage indices. Embedding disadvantage indices would provide concrete constructive guidance; align the Pandemic Agreement with the use of indices by other United Nations (UN) agencies; help realise the Agreement’s goal of addressing social and other determinants of health within countries, and furthermore offer feasible ways improving equity in allocation across countries.

WHO member states began work on a Pandemic Agreement in December 2021. The current timeline envisages a final version to be considered by the May 2024 World Health Assembly.1 The publicly available version of the Pandemic Agreement at the time of writing comprises 36 articles under three separate chapters (Bureau’s Text, A/INB/7/3, 30 Oct 2023).1

Chapter 1 provides general scene setting describes objectives, and highlights key terms. While the concept of equity is still somewhat implicit and would benefit from further articulation,2 overall, there seems to be a latent understanding that inequity obtains when there are unfair differences in health outcomes and opportunities within and across countries. Correspondingly, ‘[e]quity is at the centre of pandemic prevention, preparedness, response, both at the national level within States and at the international level between States. It requires, inter alia, specific measures to protect persons in vulnerable situations’.1 Chapter 3 addresses procedural issues, such as the establishment and rules of interactions of different types of advisory committees. Chapter 2 is titled ‘The world together equitably: Achieving equity in, for and through pandemic prevention, preparedness and response’1 and comprises 17 Articles.

True to the nature of the type of document, the majority of articles—but not all—are somewhat general. For example, without providing further details on any ‘how-to’ aspects, Article 8 would establish periodic multicountry or regional multisectoral tabletop exercises; Article 9 asks states to increase clinical trial capacity and strengthen clinical trial policy frameworks; and Article 15 urges the development of national strategies for managing liability risks. In some cases, more concrete guidance is offered. In an overarching way, the Pandemic Agreement highlights the conceptual One Health approach, ruling out overly myopic anthropocentric angles. To facilitate benefit sharing, Article 12 would establish a new WHO Pathogen Access and Benefit-Sharing System, and Article 13 might create a WHO Global Pandemic Supply Chain and Logistics Network.

Article 17 on whole-of-government and whole-of-society approaches at the national level emphasizes that states need to “strengthen national public health and social policies to facilitate a rapid, resilient response to pandemics, especially for persons in vulnerable situations” i.e. “individuals, groups or communities with a disproportionate increased risk of infection, severity, disease or mortality in the context of a pandemic, including vulnerability due to discrimination on the basis of race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth or other status”. This characterization of vulnerability that recognizes the intersectionality and often cumulative and compounding nature of disadvantage is critical, and rightly, central in the Agreement’s understanding of equity—but how should states operationalize vulnerability in practice?

The US pandemic response certainly had scope for improvement in many dimensions. But it is also noteworthy in this regard as it saw the innovative and widespread uptake of a set of measures known as disadvantage indices.

Disadvantage indices are typically based on census data and integrate around 15–20 variables to characterise and rank particular geographic areas by their relative level of advantage or disadvantage. For example, the US Centers for Disease Control and Prevention’s Social Vulnerability Index (SVI) focuses on the census tract (between 1200 and 8000 people) and comprises 16 equally weighed variables under four domains: socioeconomic status (capturing share of the population below 150% of poverty threshold, unemployed, with housing cost burden, no high school diploma, no health insurance); household characteristics (aged 65 and older, aged 17 and younger, disability, single-parent household, limited English language proficiency); racial and ethnic minority status (relative share of racial and ethnic groups); and housing type and transportation (multiunit structures, mobile homes, crowding, no vehicle, group quarters). Other indices differ in factors such as the number, type and weighing of variables. For example, the Area Deprivation Index focuses on a smaller geographic area (block group level: 600–3000 people) and comprises 17 variables (but not race/ethnicity).3 At an even smaller level, the Multidimensional Poverty Index (MPI) can be used at the level of individual people, and, in its global version, for comparing relative levels of disadvantage across countries.4 5

In the US context, an analysis of four types of major indices, including the SVI, showed a strong association with COVID-19 incidence and mortality,6 aligning directly with the Pandemic Agreement’s conceptualisation of vulnerable populations.

Moreover, disadvantage indices have not only been used descriptively but also in very concrete ways to promote equity in pandemic response. In vaccine allocation, the majority of US states embedded indices to promote health equity.7 Planners prioritised millions of more disadvantaged people by using indices to, for example, allocate larger shares of vaccines to more disadvantaged areas; conduct targeted communication and outreach; plan the locations of testing or vaccine dispensing sites; and monitor, and course-correct, allocations to achieve equity targets.7 Similarly, at federal and state levels, disadvantage indices were used for rationing other scarce resources such as ventilators, treatments or tests.

Internationally, the global MPI has been used for more than a decade by the United Nations Development Programme to recognise that economic measures such as living below $2 per day are meaningful, but also limited.4 5 More recently, WHO explored the use of multidimensional poverty and vulnerability indices to inform equitable policies and interventions in health emergencies.8

It would hence be desirable to add some reference to the potential of using disadvantage indices within the Pandemic Agreement. Doing so would directly respond to the current Agreement’s understanding of vulnerable populations and offer more concrete (yet still sufficiently general) guidance how parties can ‘identify and prioritize populations for access to pandemic-related products and health services… [and] take the necessary steps to address the social, environmental and economic determinants of health, and the vulnerability conditions that contribute to the emergence and spread of pandemics’.1 One option would to add, after the last quoted section above wording along the following lines: ‘…each party shall consider, and deploy, where feasible and appropriate, available statistical and other measures that recognize the intersectionality and compounding nature of disadvantage for the purpose of monitoring the spread of infections, as well as for devising equitable response strategies.’ Since the Agreement is also very clear that "States are accountable to provide specific measures to protect persons in vulnerable situations1" disavantage indices hold major potential in this regard, too (especially absent alternative suggestions that would enable assessing the degree to which states's measures succeed in protecting vulnerable people).

Importantly, indices such as the global MPI also offer a tool to address equity in allocation and other dimensions across countries.4 5 The predominant allocation formula envisaged by the COVID-19 Vaccines Global Access initiative was to initially allocate vaccines proportionate to population. Critics rightly pointed out that this strategy ignored major differences in development between countries,9 and instead proposed adjusting quotas by drawing on country-specific life expectancy.10 While going in the right direction, life tables alone do not recognise the intersectionality of disadvantage. Article 13 in the current Agreement suggests that WHO in partnership with other relevant UN agencies should ‘be guided by equity and public health needs, paying particular attention to the needs of developing country Parties’.1 Here, too, and index such as the MPI holds major promise to devise allocation formulas that capture the intricate ways in which those who are worse off in multiple dimensions of disadvantage are typically also far more likely to get and spread infections and die from them.4–7 Embedding a disadvantage index in global allocation formulars can mitigate the risk that allocations insufficiently protect particularly vulnerable populations,11 12 or worse, replicate and continue the very structures that underlie the major differences in health and well-being across countries outside of pandemic contexts.

Clearly, far more detail is required to establish in what ways exactly disadvantage indices can meaningfully promote equity within and across countries, and key aspects would need to be unfolded in complementary guidance typically issued in parallel, or subsequent to documents such as the Pandemic Agreement. But providing high-level orientation in the Agreement itself can, at a minimum, serve as a checklist for policy makers. This seems all the more important as the current draft emphasises equity in key sections, yet does not include an expert committee that would guide equity efforts (Chapter 3 lists only committees focused on implementation and compliance; scientific advice; pandemic Pathogen Access and Benefit-Sharing-).

The Pandemic Agreement offers a major opportunity to learn from mistakes during the COVID-19 pandemic and to build on innovative new approaches. The current central role that equity plays in the Agreement is to be welcomed—yet also needs further spelling out, including considering the use of disadvantage indices that have been demonstrated to be both feasible and impactful in working towards more equitable allocations pandemic response.