The International Pandemic Preparedness Treaty and an Emerging Digital Divide

Public health measures, including travel restrictions and social distancing, have been re-imposed in many parts of the world to curb the growing incidence of the highly transmissible SARS-CoV-2 variant Omicron, putting a damper on celebrations to usher in 2022. Since the World Health Organization (WHO) declared the outbreak of Covid-19 a global pandemic on 11 March 2020, almost 5.5 million deaths across the globe have been attributed to it. Apart from its high degree of infectivity, little is known about the Omicron variant, first reported to the WHO by South Africa on 24 November 2021.

The grim persistence of the pandemic may well have turned initial ambivalence towards a proposal for a new international treaty on pandemic preparedness and response (PPR Treaty) into a decision on 1 December 2021 by the WHO’s 194 member states to set up an intergovernmental body to begin work on a draft accord. Under its constitution, the WHO (through the World Health Assembly) has the power to adopt conventions or agreements on matters that fall within its purview. This rarely invoked power successfully established an international convention on tobacco control, which remains binding on 182 countries. It is still too early to say if the proposed PPR Treaty would garner sufficiently wide support but there are many challenges ahead.

There is clearly a need to address the inequities that the pandemic has made manifest, whether in terms of access to crucial supplies such as vaccines and ventilators or gross inequalities in income or gender, among others. These and related concerns are perhaps redolent of the inequities that were already apparent in a succession of recent epidemics, notably SARS, H1N1, Ebola and Zika.

What is different with this pandemic is the application of digital technologies either as or in support of public health countermeasures, as well as to sustain a variety of day-to-day work and social interactions. Not surprisingly, these digital modalities are similarly tainted by inequities reflected in the generic term “digital divide”.

At a practical level, the proposed PPR Treaty is expected to include measures that will seek to prevent, or at least mitigate, the many and deep inequities laid bare by the pandemic. At a more fundamental level, the treaty will have an even more challenging task of fostering multilateralism in the global health architecture.

We highlight here the need for the proposed PPR Treaty to address emerging digital inequalities that arise from the different capabilities of health systems to harness the benefits and/or address the pitfalls of digitalization. In considering the experiences of a number of health systems in Asia with the digitalization of contact tracing, we hope to show that the capability to support public health intervention through digital means should be a component of pandemic preparedness, and should not itself become another source of inequality, particularly between health systems that are digitally enabled and those that are not.

Digitally supported countermeasures

Social distancing measures, including drastic shelter-in-place orders in some cities, were quickly introduced across China in the early phase of the Covid-19 outbreak in January 2020. Other East Asian health systems followed suit. But, unlike during the SARS outbreak of 2003, many public health measures for infection control and surveillance of at-risk individuals have been enhanced by digital technologies. Public health agencies use digital platforms, including social media, news outlets and dedicated websites to disseminate public health interventions, rules and information. Digital tools, including artificial intelligence (AI)-powered chatbots, have been deployed to shift part of healthcare provision away from hospitals and to support the self-management of chronic disease in the community. With the closure of schools and adults working from home, digital technologies have sustained many aspects of professional and social life at a pace and scale not seen in previous outbreaks.

Digital tools that are used to monitor health conditions were previously applied primarily in limited and controlled settings such as health-related research. With the intensive use of digital technologies and the resulting data amassed during the pandemic, in some already increasingly digitalized societies, these technologies will have a fundamental role in shaping post-pandemic public health and healthcare landscapes, as well as other aspects of social life. By “digitalized” and “digitalization”, we refer to the added value of applying digital technologies such as data analytics, AI and robotics to interventions directed at meeting healthcare, public health and, more broadly, social goals.

Digital tracking technologies for contact tracing vary in purpose, features and complexity, but commonly involve the use of devices such as smartphones and wearable gadgets to enforce isolation or quarantine measures by establishing virtual boundaries (or geofences) and to track users through internet access, satellite navigation systems or cell tower triangulation, or otherwise, pick up signals (such as Bluetooth) from devices in close proximity and maintain a record of them. This allows other users who have been in close contact with an infected user to be notified and to take precautionary measures including undergoing testing and self-isolation. Data collected by these devices may also support epidemiological modelling – public health research aimed at controlling transmission of the disease or in preventing its resurgence.

However, the collection of such data to identify with whom a user has been in frequent contact, places they frequent and their social activities have raised privacy concerns. If detailed information on individuals is collected over an extended duration, collated into a centralized repository and processed for purposes unrelated to public health, this could become an insidious form of population surveillance. Where digital proximity tracking technologies are being developed and used by private companies, there is the added concern of commercial exploitation, not only of individuals but also of public health infrastructure that lack regulation or suffer from weak governance.

Normative determinants of digital capability

Ethical guidance issued by the WHO on the use of digital proximity tracking technologies for Covid-19 contact tracing explicitly acknowledges that their effectiveness remains unknown and that an enabling environment must be present. More recently, additional guidance was provided for the design and implementation of digital proximity tracing and for the digital documentation of Covid-19 vaccinations. These guides build on foundational ethical principles on public health surveillance that were articulated by the WHO in response to the Ebola outbreak in West Africa.

An environment that enables the responsible use of digital tracking technologies for contact tracing will require considerations that include:

• a rigorous review of digital contact tracing necessary to build public confidence and sustain trust,
• means to assess the effectiveness of such technologies, which could themselves be dependent on the technological infrastructure and users’ uptake and digital literacy (such as widespread smartphone use),
• a robust legal regime on personal data protection,
• an inclusive communication strategy, and
• policies to monitor and reduce social inequities aggravated by the outbreak.

Read holistically, these guidelines remind us that digital tracking technologies have limitations and none are currently able to explain how a user got infected or replace conventional contact tracing that is done by a public health worker in person. To be effective, digital capabilities that enhance contact tracing must also be part of a wider pandemic response strategy and remain fully integrated in the public health system.

The digitalization of contact tracing as a public health countermeasure against the Covid-19 pandemic has been at best reactive and, hence, largely lacking in consistency or coherence when considered in relation to the overall and long-term pandemic response. Digitalization has also reached into other aspects of public health practice including quarantine monitoring, self-testing of symptoms through online symptoms checkers, providing public health information, and accessing public health interventions such as checking the availability of vaccines and booking a vaccination appointment.

In Hong Kong and Singapore, for instance, digital tools were initially introduced to support contact tracing. Since then, additional functions have been added for other public health purposes, such as health and vaccination certification. In mainland China, screening systems that apply AI have been used in some localities to screen for Covid-19 among individuals who are suspected to have contracted the disease. Particularly in urban areas, a wide variety of digital applications have been used for health certification during the initial stages of the pandemic. However, the degree of penetration and the extent of uptake of these apps remain unclear.

A system of digital health certification has since been developed for overseas travel. In India, at least 50 smartphone applications have been developed in relation to Covid-19. The functions of these applications vary significantly, although many are used for contact tracing. Perhaps owing to their novelty, digital tools did not appear to be well integrated into the pandemic response plans of these health systems in the first year of the pandemic. Additionally, the relationship between the public health response plan (in terms of its policies, laws and regulations) and digital health or mobile health policies is unclear. While in some health systems, public health agencies may have led or collaborated in the development of these digital tools, it is unclear how prepared the health and public health workforce is for the broad use of these tools, particularly in view of the recommendations of the WHO on contact tracing, including via digital modalities.

A related concern that is shared across many jurisdictions is the extent to which the use of digital public health tools should be mandated, for instance, to access certain places or services, or for certain types of work or work settings. Where digital tools have been used for health certification purposes, there are interoperability concerns. In China, for instance, various digital tools were required for inter-state travel as a particular software application used in one province was often not recognized by others. National guidelines were subsequently issued to harmonize standards and requirements.

Globally, there is a need to indicate what digital health capability every health system should have as a matter of pandemic preparedness, possibly building on the global strategy that was devised prior to the outbreak of Covid-19. The International Health Regulations do not indicate whether or to what extent WHO member states should digitalize their disease surveillance and response capabilities, or to limit restrictions on trade and travel through digital means. A multistakeholder initiative such as the Access to COVID-19 Tools Accelerator (ACT-A) is unlikely to be able to meet this need, given that its vaccine manufacturing and distribution mechanism (COVAX) has not been successful in reducing global inequalities in access to vaccines and may itself lack transparency and accountability.

The proposed PPR Treaty will need to serve as a pragmatic and neutral geopolitical platform to enable all WHO member states to develop a coherent pandemic preparedness plan, as well as the capability to implement some aspects of it through digital means. As the strength of the entire global health infrastructure is likely to be defined by its weakest link, there should be a high degree of consistency in the capabilities of all WHO member states to address public health and global health needs and goals.

Arguably, the fragmentation in the world order underscores the importance of empowering the WHO as the sole global health agency for coping with future pandemics. Current experience with the ACT-A indicates that a dispersed and loosely coordinated pandemic response will only deepen global inequalities. A progress report on the PPR Treaty will be issued at the World Health Assembly in 2023. Our message is that pandemic preparedness should include a range of digital health capabilities, with a view to minimizing the digital divide across multiple scales.