The Quad’s Cancer Moonshot Initiative

Commentary by Erin L. Murphy, Katherine E. Bliss, andJ. Stephen Morrison

Published October 22, 2024

The Quad heads of state from Australia, the United States, Japan, and India committed-to the surprise of many observers-to the Quad Cancer Moonshot Initiative during their summit in Wilmington, Delaware, on September 21. The collective goal of this ambitious effort is to advance the elimination of cervical cancer, caused by the human papillomavirus (HPV), in collaboration with low- and middle-income Indo-Pacific partners, through expanded access to vaccines, screening, and treatment.

The Quad Cancer Moonshot Initiative builds on the work in healthcare the grouping has accomplished and holds out the promise of scalability and careful measurement of impacts in addressing a leading cause of death among women in the Pacific Islands. Cervical cancer is one of the only cancers considered possible to eliminate through vaccination and recent advances in testing for HPV infection-these have raised the promise of early detection, leading to effective treatment and lives saved. In 2020, the World Health Assembly adopted a Global Strategy for Cervical Cancer Elimination, with the March 2024 Global Forum on Cervical Cancer Elimination in Colombia aiming to advance public-private partnerships to strengthen prevention, testing, and treatment efforts. If successful, the moonshot initiative will build on this global momentum to integrate the respective strengths and assets of the individual Quad members (in screening, treatment, technology, research, and education), create enduring capabilities across its many partners, and potentially save hundreds of thousands of lives. The initiative can also serve as a foundation to target other types of cancer of increasing concern in the region.

The moonshot initiative has a wide reach. It leverages multilateral development banks, the private sector, foundations, and nonprofits. The World Bank is increasing its funding to further support the work it is already doing on HPV vaccination, cervical cancer screening, and treatment in Bangladesh, Cambodia, Indonesia, Laos, the Philippines, and Vietnam. The Serum Institute of India and the Gates Foundation will promote the provision of HPV vaccines and organizations such as Jhpiego and the Women's Health and Economic Empowerment Network will provide education, public awareness, and access to screening. Several other companies and organizations are also providing further investments into prevention, screening, and treatments, and building oncological expertise and capacity throughout the region.

How Did the Quad Get to This Point?

The Quad has come a long way since its initial efforts to band together to provide disaster assistance and humanitarian aid following the 2004 Boxing Day Tsunami. After being elevated to regular exchanges at the foreign minister level during the Trump administration and to the executive leadership level during the Biden administration, since 2021, the Quad has sought to establish its leadership in climate change, maritime security, telecommunications and cybersecurity, and infrastructure. The Covid-19 pandemic sharpened the group's focus, providing an opportunity for each member state to use its respective financing and development tools to not only address the effects of the pandemic in Indo-Pacific economies but also compete more effectively against Chinese vaccine diplomacy.

In March 2021, the Quad leaders announced its Covid-19 vaccine project and the advent of the Vaccine Experts Group. The project resulted in the newly created U.S. International Development Finance Corporation (DFC) announcing its financial support to increase vaccine manufacturing capacity for the Indian private sector biotechnology and biopharmaceutical company, Biological E. This would contribute to the goal of producing 1 billion doses of vaccines by the end of 2022 to be exported to developing countries in the region and to COVAX, the initiative to provide vaccines to low-income countries. The Japan Bank for International Cooperation provided a capital injection to Biological E to support its day-to-day activities. Australia, as part of the Quad Covid-19 project, contributed 77 million USD for the provision of vaccines and "last-mile" delivery support with a focus on Southeast Asia, adding to its 407 million USD commitment to regional vaccine access and health security to the Pacific Islands.

The group in 2023 announced the Quad Health Security Partnership to strengthen coordination and collaboration on health security in the region. The partners committed funding toward detecting and responding to outbreaks of diseases with epidemic or pandemic potential, supporting field epidemiology and outbreak responder training, disease surveillance, improving data systems, and strengthening public health laboratories. This collaboration and training have continued through 2024 and have extended to the current Mpox outbreak.

The Quad has at critical moments stumbled. Coordination is challenging among four countries with domestic priorities and national security concerns testing the allure and oftentimes, necessity, of cross-country collaboration.

The Quad Vaccine Partnership did not fulfill its 1 billion vaccines pledge and the timeline for export was slower than expected. The inaugural delivery of Covid-19 vaccines under the Quad's flagship Vaccine Partnership was made in Cambodia in April 2022, 13 months after the announcement. In all, the Quad delivered nearly 800 million Covid-19 vaccine doses globally, 400 million of which went to Indo-Pacific countries. This outcome was due to a few issues, most importantly the export restrictions on vaccines India imposed as the Delta variant of Covid-19 hit India and ignited a massive surge of infection and death-and fueled a popular, urgent demand for vaccines.

What Explains the Surprise Moonshot Initiative?

A moonshot initiative focused on cervical cancer would appear, at least on the surface, improbable. The announcement on September 21 took many close observers by surprise. An unusual convergence of factors, most importantly high-level leadership, is what has made the moonshot initiative possible.

The lead element is Australia. The moonshot initiative grew out of the Australian leadership's commitment, through a national strategy, to eliminate cervical cancer from Australia by 2035-the first country in the world to set such an ambitious target. That goal has been combined with its commitment to invest in HPV control partnerships through its Elimination Partnership in the Indo-Pacific for Cervical Cancer (EPICC) consortium with eight Pacific neighbors, where the burden of cervical cancer is seven times that of Australia. Under the new moonshot program, total funding commitments to EPICC will expand to 29.6 million AUD.

A second key factor was U.S. high-level decisions. U.S. ambassador to Australia Caroline Kennedy enlisted President Joe Biden and First Lady Jill Biden, beginning in 2022, behind the idea that a Quad initiative could be erected on the Australian foundation and branded with President Biden's signature Cancer Moonshot (which historically ties back to the early 1960s original moonshot program conceived by her father, President John F. Kennedy.) That success in turn mobilized the National Cancer Institute and the active support of staff for the Cancer Moonshot at the White House Office of Science and Technology Policy. It also aligned with evolving U.S. foreign policy, as the geopolitical significance of Pacific Island nations rose steadily in recent years, as competition for influence with China intensified.

A third critical factor was changes in outlook, approach, and financing for global cervical cancer elimination programs, including vitally important new U.S. financial pledges. Beginning in 2022, there was a conspicuous resurgence of international interest in eliminating cervical cancer, following the severe disruptions of the Covid-19 pandemic. The Global HPV Consortium was launched in the fall of 2023. The Asia-Pacific Economic Cooperation (APEC) Health Working Group issued in 2023 its report, Cervical Cancer Elimination in the APEC Region.

In 2022, the Board of Gavi, the vaccine alliance that managed the COVAX initiative that brought billions of doses of Covid-19 vaccine to low- and middle-income countries, committed to relaunching the alliance's HPV program, with an emphasis on supporting Gavi-eligible countries in purchasing HPV vaccines and strengthening health systems. The same year, the World Health Organization (WHO) Strategic Advisory Group of Experts on Immunization recommended a single-dose HPV vaccination regimen (versus two doses), which dramatically reduced costs and streamlined the administration of vaccines. The Gavi program calls for an investment of 600 million USD, vaccinating 86 million adolescent girls by 2025, saving an estimated 1.4 million lives.

Pledging for Gavi's five-year replenishment is scheduled for early 2025. Well ahead of that, First Lady Jill Biden announced an unprecedented five-year U.S. pledge of 1.58 billion USD at the launch of Gavi's replenishment campaign in Paris in June of 2024.

The Quad Moonshot Initiative was successful in mobilizing over 70 private sector pledges, most notably the commitment by the Australian magnate, Andrew Forrest, through his Minderoo foundation, of $8.8 million towards the EPICC program, enabling the expansion of partner countries from 8 to 11. Important also, the DFC pledged to support future private sector investment, in line with its ongoing work through its Global Health and Prosperity initiative.

Japan and India were less forward-leaning on cervical cancer as a potential Quad priority but ultimately were persuaded to come on board in support of the moonshot initiative.

Cervical cancer remains a highly sensitive matter in Japan. In 2013, the Japanese government withdrew the requirement for adolescents to be vaccinated against HPV, after several adolescent girls, recently vaccinated, experienced chronic pain, motor impairment, and headaches after immunization. It was only a decade later that a national requirement was finally reintroduced after extensive additional review of the safety and efficacy of the vaccines. Japan agreed to the moonshot initiative on the basis that its 27 million USD initial investment, through the Japan International Cooperation Agency, will be in medical infrastructure and technology that has broad application to cancers of many forms.

India was similarly ambivalent. Its burden of cervical cancer among women is huge, with India contributing to 24 percent of global HPV incidence in 2020. Plans to launch a major national program floundered in August 2024, owing to budgetary barriers. India does, however, have an effective vaccine for HPV, one-third of the cost of Western vaccines. Once the new Indian vaccine is prequalified by the WHO, India has pledged 40 million doses to the moonshot program along with HPV sampling kits and detection tools totaling 7.5 million USD.

What's Next for the Moonshot Initiative?

While the Quad Cancer Moonshot Initiative is highly promising, timely, and critical to decreasing the burden of HPV in the Indo-Pacific, future success is far from assured and will ultimately rest on multiple factors. It is a long-term enterprise, not a short-term pandemic emergency, which begs for a long-term plan of action.

There will soon be calls for concrete proof that the effort is being scaled successfully and generating quantifiable impacts. A monitoring mechanism will be needed.

No less critical will be the continuity of leadership and commitment by the four Quad member states. They will each need to navigate their respective leadership transitions and evolving budgetary realities. The Quad has undergone one leadership change in Australia, which put a short pause on working-level action until officials were in place. Japan just recently appointed its new prime minister, and soon the United States will undergo its own leadership changes. Political proofing the Quad will be a challenge to ensure the Quad itself remains a strongly shared priority, with an enduring focus on the moonshot program. India has already committed to hosting the next summit in 2025, signaling it is committed to future Quad work with new leaders.

For the moonshot initiative, a successful Gavi replenishment in 2025 remains essential, as is follow-through on the early DFC pledge to support innovative private-sector efforts to advance cervical cancer prevention, screening, and care. The Quad partners have committed to working with the United Nations to lower the prices of new HPV diagnostic tests and to enhance countries' access to radiation therapy tools for cancer treatment. The same is true of timely prequalification by the WHO of the new Indian vaccine, follow-through by India on its pledged 40 million doses, and renewed action by India to put in place a strong national program of control of cervical cancer. Over time, Japan will hopefully commit to enlarging its investments in medical infrastructure technology for the detection, screening, and treatment of cancers.

A Closing Thought

The Quad has laid a strong foundation for healthcare cooperation in the Indo-Pacific region, through its work on Covid-19 vaccines and the Health Security Partnership, and now through its multilayered commitments organized under the Cancer Moonshot Initiative. It could further strengthen its impact by elevating to a guiding priority the one dimension that lies at the very core of all of the Quad's health work and ties all of the Quad's head endeavors together. That dimension is laboratory strengthening across the region-pathogen agnostic, supported by harmonized, rigorous standards and a skilled and ample workforce. The Quad, if it were to embrace this approach, would create a powerful through-line to its health work, laying the foundation for long-term strategies.

India remains an especially promising place for scaling up and innovating for the region, but other countries with already impressive work in diagnostics and pharmaceuticals, medical equipment, and vaccine manufacturing could become the spokes in an Indo-Pacific healthcare hub. Vietnam, the Philippines, and Indonesia could be strong partners and would benefit from building up their national lab and surveillance systems.

Close coordination and close attention to upgrading standards and quality will be critical for the Quad Moonshot Initiative. Educational and financial resources from the Quad partners' government agencies, along with their engagement and partnerships with private sector actors and foundation and research organizations, could help bring standardization and a sense of rigor and process to companies in these target countries, so that they become viable, credible players. Though each country has its own domestic standards, these often fall short of the global standards set out by the WHO or other global medical organizations.

Erin Murphy is a deputy director and senior fellow with the Chair on India and Emerging Asia Economics at the Center for Strategic and International Studies in Washington, D.C. Katherine E. Bliss is a senior fellow and director of Immunizations and Health Systems Resilience with the Global Health Policy Center at CSIS. J. Stephen Morrison is senior vice president and director of the Global Health Policy Center at CSIS.

The authors wish to offer special thanks to Sophia Hirshfield, research associate at the CSIS Global Health Policy Center, for her extensive support in the production of the commentary.

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