On 12 October the UN General Assembly adopted a political declaration on pandemic prevention, preparedness and response by 153 votes to three, after the United States and a few others blocked the usual consensus. The declaration is non-binding. The binding instrument, the WHO Pandemic Agreement, cannot open for signature until its Pathogen Access and Benefit-Sharing (PABS) annex is agreed, and that annex missed its May deadline; Member States now have until May 2027. A central sticking point is whether manufacturers that use shared pathogens must sign legally binding contracts to share the resulting benefits. At the World Health Assembly, Pakistan warned against a deal that “preserves the commercial privileges of a handful of manufacturers”.
In a recent BMJ Analysis, Daniel Bernal-Serrano, Nurul Maretia Rahmayanti and I set out to explain why equity keeps being deferred. As modelling in The Lancet projects that USAID’s defunding could cause over 14 million additional deaths by 2030, the push for reform has gathered pace. The Lusaka Agenda seeks to align the major global health initiatives behind country-led priorities, and Ghana’s President John Mahama, launching an Accra Reset report in September, insisted there can be “no ownership without control”. Both deserve credit, as does the Pandemic Agreement. None of them; however, binds anyone to change the rules underneath. A health ministry can own its national plan and still have little control over the price of a patented medicine or the interest it pays to bondholders.
If global health inequity is a governance problem, better-designed organisations can fix it. If it is a structural feature of how a capitalist world economy allocates the means of life, organisations redesigned under the same rules will reach the same limits. We argue the latter, drawing on two older ideas. In 1845 Friedrich Engels called it social murder when a society knowingly keeps people in conditions that will kill them early; Kamran Abbasi applied the term to the pandemic’s avoidable deaths in The BMJ in 2021. Immanuel Wallerstein’s world-systems theory explains why such outcomes recur: the capitalist world economy concentrates wealth and productive capacity in core states, while the periphery supplies labour and raw materials on unequal terms. Hickel and colleagues estimate that unequal exchange drained $62 trillion (in 2011 dollars) from the global South between 1960 and 2018, or $152 trillion counting lost growth. Structural violence describes these conditions; these two lenses add how they are reproduced and who sustains them.
COVID-19 showed the mechanism at work. When India and South Africa proposed a WTO waiver of intellectual property rules on COVID-19 products in October 2020, the European Union, the UK and Switzerland were its most prominent opponents; the decision adopted twenty months later covered only vaccine patents. Pfizer’s revenues nearly doubled to $81.3 billion in 2021, largely on a vaccine built on decades of public research funding. Governments defend such monopolies for their export earnings too: in 2025 the EU ran a record €221 billion surplus in pharmaceutical trade. The same interests now sit at the PABS table. At this month’s World Health Summit, as Antoine de Bengy Puyvallée reported in these pages, industry asked donors to back a “strong, predictable IP regime”.
We propose three structural changes, each with accountable actors. First, make publicly funded innovation a public good, with open licensing and technology transfer as default conditions of research grants, which funders can already impose. Jonas Salk did not patent the polio vaccine; the choice remains available. Second, restructure the debt architecture. UNCTAD reported this month that 3.7 billion people live in countries that spend more on interest than on either health or education. Official bilateral creditors paused debt service for the poorest countries during the pandemic, which shows it can be done. What is missing is a working sovereign debt workout mechanism, and reparative finance from progressive taxes on wealth and corporate profits, for which the UN tax convention, due in 2027, could lay the ground. Third, delink essential health functions from profit through public financing and firm regulation of private providers. England offers the cautionary tale: outsourcing NHS services to for-profit providers has been associated with higher treatable mortality.
Our paper ends, deliberately, without the customary call for political will. Social murder theory locates responsibility in actors making rational, self-interested choices, and goodwill rarely changes those. Accountability and organised pressure can: treatment activists and a coalition of developing countries won the 2001 Doha Declaration on TRIPS and public health over the resistance of far more powerful states. Whether the architecture’s foundations move will depend less on technical design than on the organised power behind the demand. Most of us who read this newsletter work somewhere inside that architecture. The question is which side of the balance our own work adds weight to.