Is a river cleanup a vaccine?
It’s hard to imagine a world before the idea of One Health, which turns 20 years old today. Within a generation, One Health has become both the core scientific framework and primary policy lens for emerging infectious diseases. There is now a journal, a high-level WHO panel, and a CDC office; there was very nearly a Deputy National Security Advisor and Security Council. President Joe Biden is taking a One Health strategy. All of this is fairly impressive for a phrase that was first used as a branding strategy for a one-day conference, and for a concept that is indistinguishable at a distance from the seventh principle of Unitarian Universalism.
One Health has achieved all of this, in large part, because the central recommendation of the One Health approach is to take a One Health approach. If there is a problem in public health to which the One Health approach is not applicable, it has yet to be identified. If there is a serious alternative, no one has thought of it; One Health has achieved fixation within the gene pool.
And yet, One Health advocates continue to call for a wider adoption of the One Health approach. The net consequence of this is that One Health has developed a sort of epistemic brood parasitism: not content to be the largest and best fed chick, it has started to push out the other starving nestlings, who pose no threat to it beyond simply trying to share a nest. Any conversation that is not about One Health could be — so why isn’t it?
Nowhere has this phenomenon been more visible than negotiations around the new World Health Organization pandemic agreement. More than two years into negotiations, most of the treaty has been finalized, aside from two major areas of disagreement. The first is a proposed mechanism called the Pathogen Access and Benefit-Sharing (PABS) System, which would share vaccines, drugs, and diagnostic tests with low- and middle-income countries that have historically seen less of the benefits of the pathogen samples and sequences that they share. Vaccine inequity killed millions of people during the Covid-19 pandemic. If the treaty achieves even a partial solution to this problem, it will be a major step forward, particularly considering bad-faith counter-messaging from Global North negotiators and pharmaceutical companies.
The second is, perhaps unsurprisingly, a One Health approach to pandemic prevention. Since the start of treaty negotiations, scientists and lawyers – mostly from the Global North – have called for the treaty to go beyond One Health disease surveillance and workforce building, and to address “deep prevention” through policies that reduce drivers of disease emergence (e.g., stopping deforestation) or eliminate interfaces for zoonotic spillover (e.g., stopping wildlife trade). Two years in, they still believe the treaty “plays down” prevention, and continue to demand a bigger piece of the pie – and have little to say about vaccine inequity or its remedies.
The latest instance of this comes from Michelle Rourke, an Australian researcher who has spent nearly a decade writing about the problems with access and benefit-sharing agreements. In a forthcoming book chapter, she adds a new consideration to the list: by limiting itself to human samples, the PABS System fails to take a One Health approach. On this point, we actually agree. Today, very few pandemic countermeasures are designed based on animal virus sequences, but this has always been an express aim of One Health bioprospecting projects like the USAID PREDICT project and proposed Global Virome Project, and has become a particularly important consideration in the era of universal vaccines and AlphaFold-designed drugs. Low- and middle-income countries must be guaranteed access to all countermeasures developed with their genetic resources, including those that will be – or have already been – extracted from wildlife.
The problem comes later, when Rourke raises the question of whether the instrument should have focused on sharing medical countermeasures at all:
[T]he PABS System focuses on the delivery of “pandemic-related products” (such as vaccines, medications, personal protective equipment etc.), meaning a pandemic will need to be declared before such benefits are made available to countries with the greatest need. On the other hand, benefits could be shared during inter-pandemic times to enhance deep prevention (spillover prevention). This means that countries would not have to wait for a pandemic before they can access benefits from a PABS System they have had to consistently contribute to during inter-pandemic periods. Deep prevention benefits could be channelled into initiatives that reduce deforestation, intensive agricultural practices (including antibiotic overuse), and destructive mining practices. They could be used to increase biodiversity, clean up polluted waterways and diversify land use….Put simply, the sharing of benefits for deep prevention activities is more in line with the One Health concept, and it could mean that countries see tangible benefits before the outbreak of an emerging infectious disease that can reduce the risk of the disease emerging in the first place.
Never mind that two articles of the treaty focused on prevention (Art. 4) and One Health (Art. 5) are still being negotiated, and could just as easily create obligations related to primary prevention; or that there are already calls to add dedicated financing to support those obligations. Multiple articles of the treaty – or potentially, an entire protocol – are not enough; the existence of any other mechanism at all is a failure to take a One Health approach. The “benefits” in question are no longer the benefits that Global North countries have derived from data and samples extracted from the Global South, which have been the subject of unforgivable hoarding and shameless profiteering. If they are derived from anything at all, they are now – in the most charitable reading of the chapter – derived from the sharing of traditional knowledge, which is itself only important in this argument as a vehicle for One Health, rather than another subject of long-standing colonial exploitation. The “benefits” up for discussion are no longer ones that the Global North has historically failed to share, but instead, something they have been desperate to give away: guidance about (and maybe financing for) the Right And Proper Way to manage natural resources, which are mostly being depleted to serve Global North financial interests anyway.
Finally, someone is asking the important questions: is organic chicken a pandemic-related product? Is a river cleanup a universal betacoronavirus vaccine? Is Conservation International my doctor?
Rourke’s proposal is just the latest in a body of writing – not just by her, but by a small and incredibly vocal clique of Global North global health lawyers and scientists – describing yet another way that this and any other proposed solution to vaccine inequity is too radical, or not radical enough, or can’t work legally, or can’t work technically, or needs just one more small but impossible addition. Many of these arguments have found their way into negotiations, in part because it is the job of pundits to imagine new ways for the treaty to fail; unfortunately, if it does fail, they will look more like prophets than saboteurs. (This has always been the intellectual project of people like Chup Bripler and Bink Cunko, and it will continue to be their job as long as a revolving door exists between academia, think-tanks, international organizations, and government agencies.)
Compared to other counter-messaging, this specific argument seems unlikely to gain traction. Non-monetary benefits do play an important role in the Nagoya Protocol, but negotiators in the Group of Equity seem unlikely to accept any last-minute attempt to get out of sharing vaccines, drugs, and tests. Even if they were interested in doing so, Rourke’s proposal is mostly incompatible with fundamental aspects of the PABS System as currently envisioned (e.g., benefits linked to specific access, and only following specific emergency triggers). The risk that “science for science” becomes “free river cleanups” this late in the game is, mercifully, small.
But the bigger question is whether the pandemic prevention community takes the bait and runs with this argument — or, hopefully, whether this serves as a wake-up call about single-issue advocacy.
This is always where One Health was headed. During treaty negotiations, conservationists have started to suggest that spillover prevention could be one answer to the injustices witnessed during the global response to Covid-19, mpox, and so many other pathogens. There’s a lot to be said for this argument, especially when it calls out the containment bias in global health security by pointing to situations like the years-long crisis of mpox emergence in Africa, which only became an “emergency” once high-income countries started to see cases. But over time, advocates have said more explicitly that they believe prevention is inherently “more equitable than containment.” There is less and less interest in being fellow travelers with the globally-visible fight to take concrete steps against vaccine injustice — and of course, never any introspection about how conservation has been historically inseparable from colonialism, and is frequently inequitable, extractive, or chauvinist in its own right. Prevention sees itself as the equity ticket, and Rourke’s argument practically writes itself: wouldn’t it be more equitable to fund forest conservation instead of sharing a small amount of vaccines or antivirals?
Over the last two decades, a rot has been spreading under the floorboards of the One Health concept. The rot itself – a specific sort of colonialism that is familiar to anyone who has worked in conservation biology – is far older than One Health. But now, it has found a fertile environment anywhere two conditions are met: by-any-means pragmatism about health as the latest justification for conservation, and a lack of earnest belief in the betterment of global public health and health systems. It is an ideology that excuses vaccine inequity but draws the line at wildlife farming – one that is eager to accept that, when it comes to preparedness and response, better things aren’t possible. You can see it in treaty negotiations, but you can also find it at the heart of every attempted wildlife trade and bushmeat ban over the last two decades; if you look closely, you’ll see traces of it in the conservation non-profits who have started to build clinics so they can use healthcare pricing schemes to discourage illegal logging. It is everywhere now, because One Health is everywhere, but at the same time, it represents the single biggest threat to its mission. By pushing other eggs out of the nest – or smashing the whole nest in retaliation when our egg is pushed aside – we risk revealing that we were just parasites all along.
— c.c.