Members of the John Snow Society;

Professor Liam Smeeth, Director of the London School of Hygiene and Tropical Medicine;

Dr. James Hargreaves, Professor of Epidemiology and Evaluation;

Dr. Jimmy Whitworth, Emeritus Professor

Excellencies, ladies and gentlemen. My talk will be on global health equity and the role of trade.

It is an enormous honour to be here to deliver this year's Pumphandle Lecture. I am humbled to follow in the footsteps of previous speakers.

Let me be honest: as I looked at the names of luminaries in the health field such as Dr Anthony Fauci, Sir Jeremy Farrar, who is a friend, Sir David Nabarro, another acquaintance and friend, and my friend Dr John Nkengasong, my first thought was “Why did they invite me?”

I'm Director-General of the World Trade Organization. And while I might know a thing or two about vaccines from my time as chair of the GAVI board, I'm an economist, not a public health specialist.

On further reflection, though, I realized that maybe the John Snow Society's members had a point.

After all, for at least five thousand years — ever since the Sumerians in Mesopotamia would send their surplus grain to what is now Turkey, Iran, and Oman in return for wood, precious stones, and metals — trade has been one of the forces knitting the world closer together.

But when goods, services, ideas, people, and animals moved from one location to another, diseases travelled with them.

As improvements in transport and communications made more trade possible — for good and for ill — they also led to what the French historian Emmanuel Le Roy Ladurie described as the “microbial union of the world.”

The world is still far from flat when it comes to goods and services. But when it comes to bacteria and viruses, we have been getting there for centuries.

The Black Death, the plague pandemic that killed as many as 200 million people in Europe, North Africa, and Asia in the mid-14th century, is widely thought to have spread along land and sea trading routes.

In the 16th century, Europeans brought influenza and smallpox to what we now call the Americas. The viruses decimated local populations throughout the hemisphere and played a major role in the fall of the Aztec, Inca and other pre-Columbian empires.

By 1854, commerce and empire had helped cholera spread far beyond its likely origins on the Indian subcontinent. That was the year the London anaesthesiologist John Snow traced a local outbreak to contaminated water from a pump on Broad Street, becoming a pioneer of epidemiological science — and giving today's lecture its name.

And of course, all of us remember where we were three and a half years ago, when a novel coronavirus travelled around the world at the speed of jet planes. Within the space of weeks, it had gone global, and much of the world was under lockdown, in the grip of a new pandemic.

Globalization has even been linked to the spread of non-communicable diseases. For example, earlier this month, The Guardian had an article about the growing popularity in developing countries of packaged snacks, heavy in salt, sugar, and fat, which was contributing to a rise in diabetes and heart disease.

And yet history tells us that globalization, in terms of the flow of knowledge, goods, and services, has also carried with it the solutions to public health crises. For instance, smallpox spread along the old Silk Roads — but so did awareness of early countermeasures, such as the variolation that inspired the young Edward Jenner to look for a better alternative.

In our own recent experience, trade and cross-border cooperation were vitally important parts of our response to the COVID-19 pandemic.

This may sound surprising if you remember the shortages of masks, gloves, and nasal swabs early in the pandemic, and the export bans some governments introduced in response.

But the fact is that trade and cross-border supply chains quickly became a vital means for ramping up the production of — and access to — desperately needed supplies, from personal protective equipment to pulse oximeters, and within a year, vaccines.

Researchers — like the ones who have just won the Nobel Prize — were able to develop COVID-19 vaccines at record speed because scientists had shared the virus genome online within days of its identification in early 2020. Once COVID-19 vaccines were demonstrated to be safe and effective,  supply chains cutting across as many as 19 countries, and possibly more, allowed billions of doses to be manufactured in relatively short order.

But as we all have a duty to remember; this story had a dark side as well as a positive one.

Yes, keeping medical products and inputs — and food — moving across borders was a key source of resilience for people and countries around the world.

Yes, we saw governments use trade-facilitating policy tools to accelerate access and reduce costs, as they cut red tape and fast-tracked regulatory approvals.

The results were plainly visible in the trade data: even as the value of global merchandise trade shrank by nearly eight percent in 2020, trade in medical products grew by 16 percent. Trade in cloth facemasks nearly quintupled.

At the same time, however, there were stark and cruel inequities in access to COVID-19 vaccines, especially during the first year and a half of mass production.

Despite the existence of COVAX, which was set up with the aim of ensuring an equitable global distribution of vaccines, rich countries outbid the facility to procure jabs for their own populations, bumping vulnerable and frontline people in poor countries to the back of the queue.

Some countries invoked national security and other imperatives to block the flow of inputs in the vaccine supply chain, causing delays in the manufacture of certain vaccines. Others restricted exports of finished vaccines, in order to shore up domestic availability. Developing economies that lacked money or production capacity were left in the lurch.

Excessive concentration in vaccine production capacity had left the world vulnerable to such surprises: prior to the pandemic, 80% of global vaccine exports, in volume terms, came from only ten countries.

Africa imported 99% of its vaccines, making it particularly exposed and vulnerable to export restrictions.

By October 2021, high-income countries had achieved vaccination rates of 75-80%. Meanwhile,  less than a tenth of people in low-income countries had been vaccinated.⁽¹⁾ Some countries had secured enough doses to vaccinate their populations four times over, while others had coverage of less than 2%.

This vaccine inequity cost 1.3 million lives by the end of 2021, according to the mathematical epidemiologist Sam Moore and his co-authors at the University of Warwick⁽²⁾.

In addition, economic reopening and recovery in poor countries was slower than it could have been, with lasting consequences.

And by the time vaccines finally became available, hesitancy and scepticism had often taken hold. The risk of new variants remains higher than it needed to be.

I had helped set up COVAX when I was still at GAVI. I genuinely believed we had learned from earlier crises, when people in poor countries were kept waiting for HIV/AIDS drugs or H1N1 vaccines. It turned out that we had learned much less than I thought.

That still remains the case even today. One reason I worry that we have not learned the lessons of COVID-19 is the mismatch between the enormous economic costs we just experienced and the pittance we have spent on trying to prevent the next crisis.

How is it that governments which collectively spent $14 trillion on fiscal support to prop up economies and shore up households during the first year of the pandemic seem incapable of pooling together $10 billion in annual funding for the Fund for Pandemic Prevention, Preparedness, and Response housed at the World Bank? How is that possible?

The experience of the past three years makes clear that trade, and international cooperation on trade policy, are indispensable, though insufficient, to achieve global health equity and better pandemic preparedness. 

The interplay between innovation, access, concentration and distribution is complex. A wide range of tools, including manufacturing investment with the necessary human resource skills, regulatory convergence, procurement policies and financing need to be deployed in a coherent manner to achieve equity and build future resilience.

I believe that it is unacceptable for global health that there should be technology available to save lives, but that people should die for lack of access to it.  We cannot accept a world in which you are denied access just because you are poor, or because you happen to live in a poor country.

At the same time, we do not want to inadvertently disincentivize the innovation that the IP system has helped deliver.

The question then becomes “How do we foster innovation and the development of new technologies and at the same time ensure equitable access?”

Trade is part — though only part — of the ecosystem determining whether we meet this challenge. I will devote most of my remaining remarks to looking at what we can do within the trading system to help promote global health equity. I will also share some thoughts on how we could complement those steps with action elsewhere.

But first I want to highlight a separate channel through which trade has contributed to improvements in public health.

The predictable and open global markets underpinned by the World Trade Organization have been a key enabler of faster growth and poverty reduction for developing economies in particular.

Trade-led growth was an important reason why the share of the global population living in extreme poverty fell from nearly 38% in 1990 to just over 8% in 2019, according to the World Bank data.

Though many poor countries, and people within richer countries, did not share adequately in these gains, the progress was real.

Higher incomes for people and more resources for governments were a factor in better health outcomes.

Worldwide deaths of children under five have more than halved, from 12.5 million in 1990 to 5.2 million in 2019, according to the UN. Over the same period, average life expectancy worldwide rose from 64 to nearly 73.

Unfortunately, the COVID-19 pandemic reversed some of these heartening trends. To put poverty reduction back on track, we need to maintain broadly open global trade, while bringing marginalized countries and communities into the global economic mainstream.

But a major risk looms on the horizon: if current geopolitical pressures result in far-reaching fragmentation of the world economy, it would deal a serious blow to growth and development prospects for poor countries. It would make food security and climate action even harder to achieve, which would in turn impact health outcomes. That’s a big part of why efforts to strengthen and reform the WTO are so important — and why the public health community should want them to succeed.

Coming back now to how we can act within and alongside the trading system to promote global health equity, I want to start with a few observations about what the WTO system does and does not do.

The WTO promotes predictable and open trade, but it does not promote untrammelled trade. In fact, it consciously preserves governments’ right to regulate, with extra policy space for measures necessary to protect human, animal and plant health.

Similarly, the WTO Agreement on Trade-Related Aspects of Intellectual Property Rights, or TRIPS, sets out a multilateral baseline for how intellectual property is protected and enforced. But the agreement makes clear that intellectual property is not protected as an end in itself, but as a means for better social and economic welfare.

To that end, patent rights are not absolute, and the TRIPS Agreement offers governments wide latitude to implement a range of entirely legitimate options to override patent rights when the public interest demands it — including, but not limited to, public health emergencies. 

A big issue here then is that domestic legal frameworks and choices are critical. The TRIPS Agreement merely defines some bedrock standards: it is up to governments to take action.

Developing countries need to put in place domestic laws that make full use of TRIPS flexibilities for innovation and access.

Meanwhile, developed countries, which have demonstrated they would not hesitate to use emergency powers within their own intellectual property systems, could be more supportive of developing countries seeking to use their legitimate entitlement to do the same thing.

On both of these fronts — that is, with respect to open and regulated trade as well as the use of TRIPS flexibilities, the WTO has evolved considerably since 1995.

The right to regulate has become more firmly entrenched over time. Recent examples include Chile's “traffic light” food labelling system warning consumers about sugar, fat or salt content; and Australia's plain packaging rule for tobacco. The latter was upheld when challenged in the WTO dispute settlement system. Both have been emulated in other countries.

WTO members have taken some useful steps to help keep trade flowing smoothly — which as we have seen is an important means for enabling medicines and vaccines to reach people around the world.

The WTO Agreement on Trade Facilitation, which cuts red tape at borders, reducing delays and costs, has proven to be more than an economic tool since its entry into force in 2017 — it has been a powerful mechanism for access to medicines by lowering trade-related costs, paperwork and delays.

At our Twelfth Ministerial Conference in June last year, Members adopted a consensus declaration on the WTO’s response to the COVID-19 pandemic and preparedness for future pandemics. In it, Ministers addressed a panoply of trade measures relevant for meeting global health challenges, from export restrictions to regulatory cooperation, trade facilitation, and food security.

In particular, they pledged that any emergency trade measures should be targeted, proportionate, transparent, and temporary, and should not create unnecessary barriers to trade or disruptions in supply chains. They also underscored the role that trade in health services could play in fighting future pandemics.

Together with the World Bank, the WTO Secretariat last year published a small book called Trade Therapy, which sets out the full range of ways trade can contribute to pandemic response and preparedness.

Approaches to the TRIPS Agreement and its flexibilities have also come a long way from painful beginnings that many of us here remember all too well.

The TRIPS Agreement started to enter into force in the mid-1990s. This coincided with the moment when breakthroughs in the development of anti-retroviral therapies meant HIV/AIDS was no longer a death sentence — for people who had access to them.

The inequities in access, however, were staggering. Africa had become the epicentre of the HIV/AIDS crisis. At the turn of the millennium, over 20 million people in sub-Saharan Africa were HIV-positive, with double-digit infection rates in many countries. Nearly one-and-a-half million people were dying every year, and the number was rising.

At market prices, treatment was prohibitively expensive — annual costs of a course of antiretroviral treatment exceeded the per capita incomes of most African countries.

Many in the health community saw the TRIPS Agreement very much as the problem, pointing to major cost savings from the threat of compulsory licensing in places like Brazil.

At around the same time, 39 international drug companies sued the South African government and President Nelson Mandela to overturn pro-access legislation enabling the import of lower cost and generic HIV/AIDS drugs. The claim wasn’t just catastrophically bad PR in a country that was losing 250,000 people a year to the epidemic; it was rooted in poor legal reasoning, and eventually had to be dropped.

What became lost in the debate at that time is that the TRIPS Agreement included flexibilities that legitimized the measures Brazil was successfully using, and that South Africa wanted to use. These flexibilities were in fact modelled on existing practice in major developed countries.

In 2001, African governments brought the HIV/AIDS crisis to the negotiating table at the WTO, and demanded action to ensure the TRIPS Agreement wasn’t an obstacle to access to lifesaving medicines.

This debate yielded the 2001 Doha Declaration on TRIPS and Public Health, which reaffirmed the clear entitlement of governments to override patent rights when necessary to protect public health.

The TRIPS Agreement was subsequently amended to create an additional legal avenue for Members without manufacturing capacity at home to procure medicines produced under compulsory license in other countries. This tool has formally been used only once, but it has added to governments’ leverage in access and pricing negotiations with pharmaceutical firms.

In the early years of this century, prices for HIV drugs fell precipitously. Combination therapies that had cost as much as $15,000 per year fell to $350.   Lower prices made it possible to dramatically scale up treatment programmes. Prices today for a year-long course of certain combinations are closer to $60.

Despite fairly frequent use of TRIPS flexibilities for public health purposes in the intervening years, when the COVID-19 pandemic hit, there were echoes of earlier debates, amplified by the inequities in access to vaccines. Many developing countries called for waiving TRIPS protections for COVID-19 vaccines, therapeutics, and diagnostics. A number of developed countries objected, arguing that the obstacles were elsewhere.

After long and tough negotiations, WTO members reached a compromise at our Twelfth Ministerial Conference with respect to vaccines.  The decision reaffirmed the full range of legitimate options for overriding patents in the public interest, and addressed the key obstacles developing countries had identified. 

It smoothed the path for governments to meet urgent demand in other countries by overriding patents to produce vaccines for export, doing away with prior notification requirements and allowing such exports to go directly to humanitarian vaccination programmes without waiting for a formal government request. And it made clear that countries could limit the protection of clinical trial data if necessary to avoid impeding the government-authorised production of COVID-19 vaccines.

This hard-fought compromise raised hackles all around: NGOs said it did too little, while big pharma said it did too much. A decision on whether to extend this to therapeutics and diagnostics is still pending at the WTO

Looking ahead, new challenges will require new solutions, so there will always be scope for all actors — the public and private sectors, and civil society — to do more to find an optimal balance among intellectual property protections, innovation, and access.

Avoiding hyperbole would be a good start. To take the recent example, some pharma industry voices had warned that the mere prospect of softened intellectual property protections would halt innovation. This assertion is hard to square with what the WHO counts to be around 400 COVID-19 vaccine candidates from a diverse array of research programs on six continents.

At the same time, the fact that core technologies behind key COVID-19 vaccines were not patented in many developing and least developed countries does not seem to have given those countries an edge in vaccine production. Civil society groups have also been guilty of hyperbole at times: merely saying that it is important not to disincentivize research and innovation can lead to accusations of support for big profits for big pharma.

And as I said earlier, what really matters for taking advantage of TRIPS flexibilities is domestic legal frameworks. Developing countries need to modify their laws accordingly — and developed countries should support, not discourage, their efforts, as they sometimes do.

Voluntary licenses and mechanisms like the Medicines Patent Pool have done a great deal to expand access within countries that routinely find themselves at the back of the queue. The MPP has licensed important treatments for HIV, viral hepatitis, and for key antivirals to treat COVID-19. Oxford and AstraZeneca became the new canonical example for licensing vaccine technology and transferring knowledge, with production rapidly scaled up across 25 manufacturing sites around the world.

These examples stand as a reminder that the economy of ideas can be a positive-sum game. Humanitarian licensing need not be at odds with commercial interests.

In a similar vein, calls to link public funding for research and development to ‘access clauses’ make a lot of sense. Such clauses would seek to ensure that the resulting products reach low- and middle-income countries, as well as less privileged sections of society within richer countries.

I have spoken at length about intellectual property because TRIPS has been at the centre of these debates for years, and I thought I would pre-empt this in any of your questions. I hope I have done that.

But ensuring that trade contributes as fully as possible to global health equity goes beyond intellectual property issues and ensuring that goods keep moving around. It also requires attention to procurement policies and the geographic diversification of production capacity — and, of course, it requires financing.

Procurement is the bridge between production and the large number of people who cannot afford to buy medicines on the open market.

And as we saw with vaccines, when medical manufacturing capacity is overly concentrated in a small number of countries, it makes global supplies vulnerable to localized disruptions, whether it's a public health crisis, an extreme weather event, or even an airport shutdown.

Procurement systems need to be up to the task of delivering quality medicines for everyone, providing value for money, and responding to emergencies.

Regional pooled procurement can offer economies of scale, especially when national health systems are small. I am proud to say that African governments showed the way on this during the COVID-19 pandemic. They quickly set up a continent-wide platform for procuring and distributing medical supplies, and established an African Vaccine Acquisition Task Team (AVATT) to procure and distribute vaccines.

Ten countries, backed by the United Nations Economic Commission for Africa, have set up a pooled procurement mechanism to purchase essential medicines at more competitive prices.  Another such example is the Revolving Fund of the Pan American Health Organization, which has been delivering vaccines to the Americas and the Caribbean for more than 40 years.

For regional procurement to be effective, countries need to avoid costly duplication in regulatory requirements. The pandemic brought to light how fragmented even neighbouring countries’ health regulatory systems can be. International standards, reference to WHO emergency use listings and mutual recognition can help reduce regulatory fragmentation and thus lower costs for governments and patients. Regional institutions like the new African Medicines Agency were set up to solve problems like these.

Regional cooperation on regulations and procurement would also help support diversification by creating bigger, more unified markets that enhance incentives for investment. This would amplify the market-expanding impact of regional economic integration initiatives like the African Continental Free Trade Area.

The challenges of deconcentrating and diversifying the global pharmaceutical manufacturing base are substantial. There are reasons why the high degree of concentration came about. We are talking about complex supply chains, typically spanning multiple jurisdictions, and requiring trained workers and sound regulatory systems and quality safeguards.

As new pharmaceutical production facilities come online in Africa, Latin America and elsewhere, there will be short-term trade-offs between higher costs and longer-term diversification goals.

Public procurement programmes are running into very concrete dilemmas: do you pay more to procure vaccines or medicines from the new regional production facility so that it has some guaranteed business and can scale up investment? Or do you buy them from the lowest-cost source and put the savings to another good use?

A reasonable case can be made for either. In my view, we should think of deconcentration as an insurance policy that is worth paying for greater resilience in the face of future crises. Just as we pay insurance premiums in case the worst happens, some up-front costs are worth shouldering until new producers become globally competitive. There is an important role here for international and regional donors in stepping up to share some of the burden.

The pandemic treaty currently being negotiated at the World Health Organization offers an avenue for harnessing the necessary resources. It could also become a platform for global cooperation on shared health challenges.  As I discussed recently with my WHO counterpart Dr Tedros, we can work together to ensure that trade and the WTO fulfil their potential as force multipliers for the efforts underway at the WHO.

Ladies and gentlemen, friends, let me now conclude. The pandemic has shown how trade has an essential role to play in advancing global health equity. Trade policy choices helped governments improve access to vital medical products despite the backdrop of the pandemic and the war in Ukraine.

But while trade was on balance a force for resilience, the disruptions we experienced stand as a reminder that supply networks were not resilient enough. And while attempting to manufacture vaccines, therapeutics, and PPE within individual countries would have left us all worse off, too many people, in too many countries, were left behind even though we had multi-country supply chains at our disposal.

We need to do better. Another crisis is inevitable, whether it comes from a known threat like anti-microbial resistance, or something unexpected. We would be better positioned to meet these challenges in a world where pharmaceutical capacity is more widely diversified, and anchored in open global markets that allow inputs and finished products to circulate more freely.

A world in which more countries have the means or the external support to build stronger health systems. A world in which scientists share information across borders, and expanding access to medical innovations is a shared global priority.

Meaningful global cooperation in the service of shared interests may seem like a great deal to hope for in today's fractious world.

And yet, we have come together before under even less promising circumstances. In the 1970s, a much poorer world, divided by the Cold War, managed to eradicate smallpox.

Many of you in this room and online are following in John Snow's footsteps. Tracking health crises and finding solutions is — or will be — your life’s work.

The late Dr Paul Farmer, a champion of global health equity, used to say, and I quote, “any time there’s a new tool developed — whether they are vaccines or therapeutics — there must also be a delivery plan.” I hope I have convinced you that trade, and institutions like the WTO, are part of the delivery plan: key mechanisms for getting the solutions you come up with to everyone who needs them, wherever in the world they live.

In our interconnected world, diseases may travel faster than ever — but so can solutions, provided we cooperate. As my favourite Igbo proverb puts it “Aka nni Kwo aka ekpe, aka ekepe akwo akanni wancha adi ocha” — “if the right hand washes the left hand, and the left hand washes the right hand, then both become clean.” It is a call for collective action to get the job done.

Back in 1854, to put the Broad Street pump out of commission, John Snow only needed to persuade the local authorities.  To successfully remove today's pumphandles — and tomorrow's — we will need to work together.

Thank you ladies and gentlemen.