To frame discussions at PMAC 2021 Plenary Zero intends to encourage broad discussion of the forces that underpin poor world performance against COVID-19. These could include the following:

• Historic lack of global cooperation on global health
  Organized cooperation on global health dates to the mid 1800s, but it has always been secondary to commercial interests and political rivalries. These are manifested as limitations on health cooperation, such as politicizing and disempowering WHO through budgetary gamesmanship, or the refusal by member states to allow WHO to question national statistics or to exercise supranational authority.
   
• The rise of neoliberalism
  Particularly since the 1980s, donor governments and multilateral organizations have encouraged neoliberal policies in an attempt to make governments more efficient. On the surface, many related concepts such as value for money or impact evaluation are not controversial, and few would argue that state resources should be used inefficiently. However, there are many limitations to market-driven approaches to public health and medicine, as demonstrated by user fees and structural adjustment policies. Overall, neoliberal policies have promoted markets and weakened governments, leaving large vulnerabilities in areas requiring redistribution, coordination, and managing collective action challenges. These challenges are among the core justifications for government, and are critical aspects of pandemic preparation and response, but many governments have been too weak to be effective against COVID-19.
   
• The tragedies of inequalities, climate change, people movements
  The obstacles to controlling COVID-19 are similar to those at the core of many of the most significant global problems, such as climate change, mass migration, and persistent inequality. Limited solidarity, the absence of systematic redistribution, the inability to regulate trade-related health effects, and commercially oriented intellectual property rights regimes are common underpinnings in most global common goods problems.
   
• The economic underpinning of zoonotic risk
  As has been known for decades, and as is the case with COVID-19, many of the infectious human disease risks are zoonotic. A major obstacle to controlling these risks are the economic implications of doing so. At the center of these risks are the commercial production of meat and poultry and consumer demand for these and related foods. The significant implications for zoonoses and climate change have yet to be confronted.
   
• The role of trade (who benefits, who does not)
  Trade and disease are intimately connected by the shared transmission routes of goods and pathogens, and by the health consequences of ultra-processed food, tobacco, alcohol, and other products. The World Trade Organization does not allow trade restrictions on health grounds and few countries have had success protecting their citizens from products widely recognized as deleterious to health. Similarly, the disruption of trade due to the possibility of infectious disease transmission is very difficult. The uneven distribution of costs and benefits in trade-related health issues produces a complex political economy that has been resistant to the efforts of health advocates.