Syrian refugee camp: over 70% of Syrians face hunger and the earthquakes have worsened their plight.

The World Health Organization (WHO) triggered its “no regrets” policy at an emergency meeting on Tuesday in response to the earthquakes that devastated Turkey and Syria this week, while promising long-term aid to the affected regions after the period of emergency response ends.

The policy – which says that in unpredictable crises, WHO should err on the side of caution by over-resourcing disaster response efforts rather than risk under-funding them at a cost later paid in lives – immediately frees up all of the organization’s financial resources and personnel to attack the crisis.

Director General Dr Tedros Adhanom Ghebreyesus announced that WHO had mobilized its network of emergency medical teams – over 20,000 pre-qualified emergency responders, medics and nurses from its member states – to provide essential health care for the injured, with a focus on immediate trauma care.

In addition, three chartered flights carrying surgical trauma kits and other key medical supplies are on route to Turkey and Syria from WHO’s logistics hub in Dubai. The flights are estimated to arrive sometime between Tuesday evening and Wednesday morning.

As aftershocks continued into their third day, the official death toll rose to 5,102, with another 22,000 injured across Turkey and Syria. Over 5,700 buildings were destroyed in Turkey alone, including 15 hospitals. Exact numbers for the destruction of infrastructure in Syria are not known. 

Officials said casualties will continue to rise as rescuers frantically search the rubble for survivors in sub-zero temperatures. The last earthquake of a similar magnitude in Turkey, which shook the north west of the country in 1999, killed over 18,000 people. 

“It’s now a race against time,” Tedros said. “Every minute, every hour that passes the chances of finding survivors alive diminishes.”

Daraa, Syria

A story split by the border

By Tuesday morning, Turkish officials said around 1,000 ambulances, 4,500 health personnel and 240 national emergency medical teams had been deployed to the disaster zones. The arrival of national and international personnel would reinforce this response. Crisis units have also been set up in all affected provinces under the coordination of the national disaster response agency.

In Syria, meanwhile, just 28 ambulances and seven mobile clinics had been dispatched by the government to affected areas in Aleppo and Latakia, just two of the five cities hit by the quakes. 

The stark difference in response illustrates the contrasting realities for survivors on either side of the Turko-Syrian border.

Turkey, despite its recent economic troubles, remains the world’s 19th largest economy, with a vast network of allies across the globe. It has a functional state that is aware the country sits on a dangerous fault-line and is at tremendous earthquake risk, with national plans and designated government agencies to respond to emergencies.

But across the border, a deadly mixture of war, displacement, climate shocks, inflation, economic decay, crumbling infrastructure and a recent cholera outbreak has trapped Syrians in what the WHO calls a “super crisis”. 

Impacts from the earthquake are expected to further compound these crises, making the vulnerable even more vulnerable.

Rebels, poor roads and makeshift houses

The last rebel enclave in northwestern Syria – a place close to three million people who fled the fighting in Syria call home – was the hardest hit by the earthquakes. Rebels govern the region with very few resources, and many people live in temporary housing, tents, or unfinished, poorly built apartment blocks.

Areas of the country under government control do not fare any better. Prior to the quakes, the UN estimated 90% of Syria’s population of 18 million live in poverty, while 70% are in need of humanitarian assistance, the largest number since the conflict began 12 years ago. 

Barely a week before the earthquakes hit, the World Food Programme warned that food insecurity in Syria had reached a 12-year high, with an estimated 2.9 million people at risk of sliding into hunger and a further 12 million do not know where their next meal will come from. This means 70% of the Syrian population may soon be unable to provide food for their families, the UN agency said.  

“If we don’t address this humanitarian crisis in Syria, things are going to get worse than we can possibly imagine,” WFP Director David Beasley said from Damascus on January 27. 

‘Every minute, we lose a life’

As the Syrian conflict reaches its 12th anniversary next month, humanitarian aid has dwindled. In 2022, the United Nations (UN) received less than half of its $4.4 billion target to meet the needs of the people caught in the crossfire of a never-ending stream of crises beyond their control. 

With so many people in need of humanitarian assistance in Syria, the destruction of roads used to deliver aid is another major concern, UN and WHO officials said. 

“The movement of aid through the border into northwest Syria is likely to be or is already disrupted due to the damage caused by the earthquake,” said WHO Senior Emergency Officer Adelheid Marschang. “This, in itself, would be a huge crisis.”

Statements from Médecins Sans Frontiéres (MSF) and the Syrian Civil Defense – an organization better known as the White Helmets – backup Marschang’s concerns in grim detail. 

“Health facilities are impacted and overwhelmed. Medical personnel in northern Syria are working around the clock to respond to the huge numbers of wounded arriving at facilities,” said Sebastien Gay, MSF’s Head of Mission in Syria. 

In a message sent out over WhatsApp, the White Helmets said harsh weather was impeding their rescue efforts, and leaving thousands stranded in the cold. With medical supplies and manpower already stretched thin before the earthquake, the group pleaded for help from the international community. 

“Tens of thousands of civilians are homeless,” the statement said. “The medical situation is abysmal. Tens of thousands of buildings are now cracked. There’s a snowstorm. There’s predictions of flooding in the area. The humanitarian situation is disastrous, with every meaning of the word.

“Every minute, we lose a life. We are now racing with time.” 

 

Image Credits: Engin Akyurt/ Unsplash, Mercy Corps, Mahmoud Sulaiman/ Unsplash.

As the world discusses how language model chatbot ChatGPT is changing the way information is created, the new episode of the “Global Health Matters” podcast addresses the question of how artificial intelligence and other technological tools can improve healthcare.

“Investigators have already been testing the applicability of artificial intelligence to healthcare,” says host Garry Aslanyan. “A recent study in PLoS Digital Health has shown these kinds of AI algorithms to have huge potential in the early diagnostics of dementia.”

Highlighting the potential of new technologies but also their limits, during the episode Aslanyan entertains a conversation with Florence, a freely accessible AI health worker developed by the World Health Organization in partnership with the Ministry of Health of Qatar.

“Florence was engaging, but I must admit I didn’t get the responses that I needed to hear,” remarks Aslanyan.

According to Yara Aboelwaffa, an independent Digital Health Consultant and co-founder of Health 2.0 Egypt, eventually Florence will become a game-changer.

“The future versions of Florence, or generally AI powered chatbots, have many possible uses like debunking medicine myths or responding to simple medical questions,” she tells Aslanyan. “There are a lot of possibilities for the future of Florence. Mostly that it can become the first line of primary care that would initially relieve some of the pressure on the medical professionals.”

Can chatbots become culturally acceptable?

For Tim Mackey, an associate professor at the University of San Diego and the co-founder of healthcare big data startup S-3 Research, the key question is whether chatbots will become culturally acceptable for people.

“I think the thing that’s important for public health people to understand is that we can’t just depend on technology to solve all our problems,” he says. “We have to give it time to develop and we have to invest more in it.”

Funding research and implementation of new technologies is one of the key challenges of the field, both experts point out.

“Most of the digital health projects are focused on market needs that are highly profitable and scalable,” Aboelwaffa highlights. “That’s because innovations that do not have a proven financial return on investment are still extremely limited because they don’t get funded.”

Mackey and Aboelwaffa also emphasise the significant positive impact that new technologies are already having in many fields of healthcare, a trend that has been accelerated by the COVID-19 pandemic.

“There’s a lot of innovation coming forward in the future and also being developed right now, and a lot of it is focused on a suite of digital health tools that can be used to enhance public health,” remarks Mackey.

“The thing I’m most excited about is data,” says the consultant, sharing what she is witnessing in the Middle East. “Data is the bedrock for providing evidence for informed interventions within the health system. Many different health systems within the region have been implementing national-level systems to collect, aggregate and report on data.”

Asked about how she sees the healthcare of the future, Aboelwaffa says that she thinks it is going to be “participatory, preventative, personalised, democratised and destigmatised.”

“It basically means that health systems will empower people to take charge of their own health, shift to more preventative approaches to keep the population in this magic circle of wellness, and provide tailored health services that address specific needs of the individual regardless of their age, sex, gender, and income,” she concludes.

Image Credits: TDR.

Daraa, Syria, is devastated by war.

As a second earthquake hit Turkey and Syria on Monday morning, the World Health Organization’s (WHO) member states offered their solidarity during an Executive Board (EB) session that presciently focused on refugees and migrants.

The two earthquakes struck within 12 hours, and by Monday evening over 2,600 deaths had been reported, while thousands of people had been displaced as their homes were destroyed.

Syria’s representative appealed to the EB for support from member states, saying that many people were still under ruins.

“The emergency services are working flat out at all levels. They’re doing their utmost, but it’s a terrible disaster,” she said. “We’re facing a lot of problems today, and that’s also because of the blockade on our country. We call on the conscience of the world to wake up and support us. We hope that WHO and all of its member states will help us as we seek to grapple with this disaster.”

WHO Director-General Dr Tedros Adhanom Ghebreyesus told the EB that the WHO’s network of emergency medical teams had been activated “to provide essential health care for the injured and most vulnerable affected by the earthquake that hit Turkey and Syria”. 

Extension of WHO action plan on refugees and migrants

Meanwhile, the EB resolved to extend the WHO’s action plan on refugee and migrant health through to 2030. 

It is estimated that there are more than one billion people on the move globally, about one in eight of the global population, according to a report prepared by Tedros for the EB.

“In 2020, there were 281 million international migrants and by June 2022, the number of forcibly displaced people had reached more than 100 million,” the report added. 

“Migration and displacement are key determinants of health and well-being. Refugees and migrants remain among the most vulnerable members of society faced often with: xenophobia; discrimination; poor living and working conditions; and inadequate access to health services, despite frequently occurring physical and mental health problems.”

The WHO action plan was focused on five priorities, including “promoting the health of refugees and migrants through a mix of short-term and long-term public health interventions” and ensuring the “continuity and quality of essential health care, while developing, reinforcing and implementing occupational health and safety measures”, according to the Secretariat report.

“The need is now to shift the operational paradigm from immediate issues to a longer-term vision for refugee and migrant health,” it added.

Poland’s lessons from Ukraine

Poland told the EB that the war in Ukraine had forced it to update its approach to refugees, and it was ready to “share our experience in order to contribute to global response to the health needs of refugees”

“Last year, we encountered a new, unexpected situation which has caused the biggest wave of migration in Europe since World War Two,” said Poland. “Since 24 February last year, almost 10 million of our neighbours from Ukraine have crossed the Polish border.”

Poland had enabled Ukrainians to get free access to universal health services, set up hotlines to facilitate understanding of how to access services and an innovative digital application that “enables smooth communication between a doctor and patient not speaking the same language”. 

“We ensured the continuation of long-term TB and HIV/AIDS treatment according to the Ukrainian scheme and with the same medicines they were taking at home”, while Ukrainian children were included in the Polish system of vaccinations. 

Ukrainian refugees

Morocco told the EB that “60% of refugees throughout the world are in our region [the Eastern Mediterranean].” 

“Yemen is one country that is particularly severely affected by war. There’s been a war raging there for seven years and this has triggered a very serious crisis, one of the worst in the world, and 70% of people living there need humanitarian assistance just to survive,” said Morocco.

In June, Morocco will be hosting a third round of global consultations on the health of refugees and migrants to provide guidance for decision-makers to strengthen healthcare for refugees and migrants throughout the world.

US Assistant Secretary of State for Global Public Affairs Loyce Pace said that her country was a co-sponsor of the resolution, stating that “we must strengthen our commitment to address the needs of health needs of refugees and migrants in all their diversity, especially as countries chart their path towards achieving universal health coverage”. 

“Reaching women and girls in conflict-affected fragile settings is essential to promoting gender equality, and empowering all women as well as achieving key targets,” said Pace.

“We expect WHO to lead by example and show member states that refugees and migrants should play a central role in the implementation phase.”

This sentiment was echoed by the International Committee of the Red Cross, which called for refugees to be included in the development and implementation of any health plans aimed at them.

Meanwhile, Rwanda, speaking for the 47 African member states, appealed for the integration of migrant and refugee health into regional and international initiatives “in a way that lessens the burden on host countries, enhancing coordination and partnership, capacity strengthening and support, strategic health information and multi-sectoral approaches to health”. 

Traditional medicine policy 

The EB also adopted a draft decision calling for a global policy on traditional medicine that was tabled by Bangladesh, China, Eswatini, India, Indonesia, Japan, Malaysia, Nicaragua, Republic of Korea, Singapore, South Africa, Thailand and Turkey.

The WHO and India are establishing a Global Centre for Traditional Medicine in Jamnagar in Gujarat in India, and 170 of the 194 member states report that their citizens use traditional medicine.

Thailand, on behalf of the WHO Southeast Asia region, expressed its support for the global centre, noting that it would “harness the potential of traditional medicine from across the world through knowledge sharing, evidence generation and incorporating modern science and technology to improve the health of people and the planet”.

Meanwhile, the US’s Pace stressed the importance of “scientific rigour in studying the safety and efficacy of traditional medicines” and “evaluating traditional medicine”.

“Member states must also adhere to their obligations under the Convention on International Trade in Endangered Species of Wild Fauna and Flora and take meaningful action to protect endangered species from exploitation,” she added.

Image Credits: Mahmoud Sulaiman/ Unsplash, Maria Teneva/ Unsplash, Kevin Buckert/ Unsplash.

US representative Loyce Pace (left) and Denmark’s Erik Brøgger Rasmussen

A major overhaul of the World Health Organization’s (WHO) finances is chugging ahead after member states at Monday’s Executive Board meeting agreed that the reform proposals – including the mooted replenishment fund to bolster the global body’s core finances – will be taken to the World Health Assembly in May.

However, some member states expressed concern about the body’s financial priorities, accountability and reporting.

Madagascar, on behalf of the 47 African member states, once again called for a greater budget allocation for regions and country offices, while Russia called on the WHO to pay more attention to corruption and fraud as these were “more common than sexual misconduct”.

Meanwhile, Denmark’s Erik Brøgger Rasmussen, speaking on behalf of his country, Estonia, Finland, Iceland, Norway and Sweden, supported the decision to increase assessed contributions to the WHO.

The proposals to improve governance strike “the right balance between the respective roles and responsibilities of member states and the secretariat”, added Rasmussen, but added that the countries looked forward to “improvements in transparency, efficiency and accountability”. 

He added that while the replenishment mechanism “has potential”, this should be “further explored” including through in-depth consultations between the Secretariat and member states in the run-up to the World Health Assembly.

The UK and US supported the idea of a replenishment fund but stressed this should be voluntary, while China stressed that it should ensure that the WHO had access to flexible funding.

Germany commended the Secretariat for its “substantial progress” in resolutions, adding that the current programme budget “shows the weaknesses of how WHO was financed”. 

It added that “the replenishment mechanism, as an additional voluntary pillar of WHO funding, will lead to a more sustainable, transparent and above all, predictable financing”.

WHO Director-General Dr Tedros Adhanom Ghebreyesus and Raul Thomas, WHO Assistant Director-General for Business Operations.

Increase in members’ fees

“The gradual increase in assessed contributions will be an important step to further strengthen WHO.”
Australia expressed commitment to “working with fellow member states and the Secretariat to implement reforms that are tangible, cost-effective and have measurable impact to achieve more efficient use of resources”, and also supported “sustainably financing the organisation, particularly through increased assessed contributions”.

Japan, however, cautioned that all economies had been affected by the COVID-19 pandemic, and that it would need to be able to justify any increases in assessed contributions to its citizens.

In response to member states’ concerns, the WHO’s Secretariat reported that more budgetary information would be loaded onto the member states’ password-protected portal once certain security issues had been resolved.

Raul Thomas, Assistant Director-General for Business Operations, said that there would also be reportbacks to the Programme, Budget and Administration Committee (PBAC), the EB and the World Health Assembly – but that with 59 proposed reforms on the table, “the major challenge is going to be resources”.

In response to Africa’s ask, Thomas said that country allocation had increased from 39% in the 2018/19 biennium to 50% in the proposed 2024/ 25 biennium – with a 4% increase since  the last biennium. 

“We are making strides in this respect. What we really need to also focus on is the financing of the budget,” stressed Thomas. “Increasing a ceiling alone will not address our problems.”

Shortly before the EB, the influential PBAC proposed that the WHO Secretariat should explore details about a replenishment mechanism for continued consideration by Member States, consulting members about the timeframe, and base segment of the programme budget to be used in a replenishment mechanism.

Dr Bruce Aylward, the Director-General’s special advisor, said that the Secretariat had “heard loud and clear” member states’ suggestions on the replenishment mechanism.

“We’re delighted to do this in consultation with the member states. It’s a big new direction for the organisation, and we are committed to having intercessional sessions with you to work out some of the detail,” he added.

“We’ve heard the importance of ensuring those [funds] are unearmarked contributions, that they are directed in the right manner, etc and we look forward to further discussing those with you.”

Russia
The World Health Organization’s Executive Board meeting

The Russian delegation to the World Health Organization (WHO) Executive Board (EB) called the report on the work of the UN health agency’s response to the Ukraine war “politicised,” prompting a spirited defense from the agency chief.

Russia pressured the UN health agency to revise a report related to its emergency response in Ukraine, prompting a tense exchange with WHO Director-General Dr Tedros Adhanom Ghebreyesus on Saturday while also clashing with the United States and its European allies over descriptions of the humanitarian crisis sparked by Russia’s war on the country. 

Russia’s delegation to the EB accused the WHO Secretariat of preparing a one-sided report on its emergency response in the embattled country, which it said politicised references to Ukraine, describing the Russian military action as an “invasion”.  Russia said that the single-word description was evidence that WHO’s leaders were under political pressure.

The report on WHO’s response to the Ukraine emergency was filed as a follow-up to a May World Health Assembly resolution condemning Russia’s war on Ukraine, which was approved in May. The report was considered in Saturday’s session along with a broader WHO report, which referred to Ukraine as one of eight acute global health emergencies among the 50 emergencies to which WHO was responding.

Unusual move at EB meetings

Despite the EB chair’s attempts at mediation, the decision was made to merely “note” the report – in contrast to the norm at EB meetings to reach decisions by consensus.

The EB’s Chair Dr Kerstin Vesna Petrič of Slovenia asked EB delegations, which include both Russia and the US, to agree that the Secretariat will continue to work on the report “with a view to presenting, comprehensive, balanced validated data. It’s understanding that all relevant aspects will be included.”

US Ambassador Bathsheba Nell Crocker also urged the Secretariat to include language in the report stating that Russia’s latest attacks that have caused “unspeakable harm to civilians and critical infrastructure in Ukraine.”

Russia
Ukraine operating theatre destroyed

A testy vote in showdown with Russia

Despite Petrič’s attempt to compromise, Russia insisted upon a roll-call over the EB report – documents that are typically approved by consensus. Petrič then led delegations in a vote to “note” its report on WHO’s humanitarian and emergency health response to the war in Ukraine.

Among the 34 EB delegations with the right to vote, only 22 delegates were in the room at the time of the vote and participated; the motion passed by a vote of 18-4 with six abstentions.

The US and Denmark delegations, among others, accused Russia of undermining the work of the Secretariat.

Russia

WHO Director-General Dr Tedros Adhanom Ghebreyesus responds to Russia’s charges of politicisation.

The last word

Defending himself and his office against charges of politicisation, Tedros fired back that “it would not be right that we conclude this without me saying something.”

He assured the assembly that “this report was written truthfully and in good faith,” and urged any member nation to come to the Secretariat with any concerns if they feel there are specific issues or facts that are wrong.

Tedros vehemently defended his use of the word “invasion” in the humanitarian and emergency health response report to describe what happened in Ukraine.

“I used the same word in a speech last year,” he noted. “I couldn’t find any other word that would represent it because it’s the truth. What could I say?”

“The report is truthful and was written in good faith, and it’s my report and I take full responsibility,” he said, adding the report was written a while ago and would be updated. “We didn’t try to politicize anything. … There was no pressure.”

Last year’s, WHA resolution condemning Russia’s invasion of Ukraine passed by 88 votes to 12 – but the 53 abstentions reflected the discomfort of many members, particularly in low- and middle-income countries, with the debate that they perceived as polarising the global health body.

Image Credits: WHO.

Cancer
Dr Tlotlo Ralefala, on oncologist at Princess Marina Hospital in Botswana, examines a patient.

Successful intervention is urgently needed – and entirely possible. 

Cancer kills nearly 10 million people a year, but the risk of dying from cancer varies greatly depending on where in the world you live. About 70%  of these deaths are in low- and middle-income countries – and the disparity is worsening.

A Lancet Oncology Commission report, published in May 2022, highlights that, in Africa, cancer deaths are expected to more than double, reaching roughly 1.4 million deaths annually by 2040. Meanwhile, in the U.S., the latest American Cancer Society statistics point to a 28-year, 32% decline in cancer deaths.

With President Joe Biden’s reignited Cancer Moonshot initiative, the US is doubling down on its commitment to save lives. The initiative aims to reduce the cancer death rate by at least 50% over the next 25 years. 

Although the immediate goals are domestic, the ambitions of the Cancer Moonshot extend globally, recognizing the disparities in death rates and the value of international collaborations. During the US-Africa Leaders Summit in December, the White House announced $200 million in new and renewed commitments to fighting cancer in Africa.

This is a step in the right direction, but far more is urgently needed. This week, the World Health Organization’s Executive Board reviewed and approved updated recommendations on “best buys” for noncommunicable diseases, with cancer high on the list. This, and World Cancer Day, observed today, 4 February, makes it a good time to turn our focus to the rapidly escalating crisis of cancer in Africa and what must be done about it.

Sub-Saharan Africa particularly alarming

Deaths from cervical cancer by age in 2018

In the region of sub-Saharan Africa, the situation is particularly alarming. The Lancet Commission found the cancer incidence rate to be higher there than in other world regions of comparable social and economic development, as measured by the Human Development Index (HDI).

Compared with people in the world’s most developed regions (identified as “very high HDI regions” in the report), the Lancet commission found that people in sub-Saharan Africa seem to face a lower risk of getting cancer but a much higher risk of dying from it. The mortality-to-incidence ratios were seven in 10 for sub-Saharan Africa and three in 10 for very high HDI regions.

How do we explain this?

First, there are crucial differences in detection, diagnosis and treatment. Wealthy countries have many resources at their disposal; sub-Saharan African countries don’t. Shortages are widespread: not enough healthcare providers trained in oncology, inadequate diagnostic equipment and limited access to treatments such as radiotherapy and chemotherapy are among the barriers. This means that cancer takes a long time to be diagnosed, let alone treated. Many patients die, needlessly, from cancers that have high survival rates in wealthy, well-equipped regions of the world.

Second, it is likely that cancer cases are vastly underreported in sub-Saharan Africa, where population-based cancer registries – the gold standard of information on cancer incidence in a population – are scarce. Also, cancer is underdiagnosed in sub-Saharan Africa, partly because of severely limited diagnostic capacity and societal barriers in seeking health care.

Highest rates of cervical cancer in the world

Cervical cancer awareness

Even with limited data, sub-Saharan Africa has the highest rates of cervical cancer in the world, and cervical cancer is the leading cause of cancer deaths in the region, followed by breast cancer. In sub-Saharan African men, prostate cancer leads in both incidence and mortality. There are various reasons why these kinds of cancers are common in sub-Saharan Africa, including rising rates of obesity, higher rates of HIV infection, and genetics. While these root causes have no simple solutions, all three cancer types have highly effective preventive care and early detection protocols that, if implemented, would save many lives.

We live in a world that has made remarkable scientific and medical advancements in cancer detection, diagnosis and treatment, but a person’s chances of surviving cancer hinge arbitrarily on where they were born. This is unacceptable.

The Lancet Commission, in its May 2022 report, recommended several urgent actions. Among them are: the creation of early detection and prevention programmes; building and supporting national cancer registries, establishing workforce training, raising community awareness and – a lesson from covid – investing in telehealth.

Begin in one country and prove change is possible

Botswana-Rutgers Partnership for Health; begin in one country and prove change is possible.

If the prospect of introducing changes in so many areas throughout sub-Saharan Africa seems insurmountable, begin in one country and prove change is possible there. This is the aim of the Botswana-Rutgers Partnership for Health, through which Rutgers University and Rutgers Health are collaborating with Botswana’s government to implement needed cancer care and prevention strategies.

Recently, the partnership launched Cancer Kitso, an education and training initiative that responds to urgent specialty workforce needs in oncology. Using both on-site and virtual training components, Cancer Kitso aims to improve cancer care and prevention knowledge and skills among healthcare professionals in Botswana. 

To close the breast cancer screening gap, the partnership also is piloting a rapid “screen and treat” clinical approach for early breast cancer detection and treatment. This effort includes evaluating evidence-based interventions in primary care clinics, as well as training nurses to administer clinical breast examinations and to provide breast self-care education to women.

Universities, companies and philanthropies all can take more active roles in collaborating with African governments to confront cancer. Hearts, minds and funding will follow – at a level that could move mountains.

Precedent exists: In the late 1990’s and early 2000s, the sub-Saharan African country of Botswana faced the most severe HIV epidemic in the world. Botswana’s government partnered with outside universities, pharmaceutical companies and private foundations to launch an aggressive and highly successful national HIV/AIDS prevention, treatment and care initiative. Based largely on Botswana’s success, President George W. Bush in 2003 allocated billions of dollars to establish a global HIV/AIDS response that has gone on to save more than 25 million lives in many countries worldwide.

HIV/AIDS once seemed like too big a problem to fight in Africa, and no one believed it would work – until it did, and attitudes and priorities changed.

Cancer is threatening sub-Saharan African populations to a degree that demands a large-scale response. There are many interventions that we know will work and we have no time to wait. Millions of lives hang in the balance. 

____________________________________________________

Wilfred Ngwa is a professor of global health at Rutgers Global Health Institute and chair of the Lancet Oncology Commission for sub-Saharan Africa.
Richard Marlink is the director of Rutgers Global Health Institute and one of the creators of the Botswana-Rutgers Partnership for Health.

Image Credits: The Lancet, Shutterstock , Rutgers University.

Nutrition
Diets rich in fresh fruits and vegetables combat obesity – but these are being overtaken by fast and processed foods in developing as well as developed countries. Portrayed here a market in Tamil Nadu, India

A new report on global nutrition from the head of the World Health Organization (WHO) reveals just how much the COVID-19 pandemic hurt the world’s efforts to improve healthy eating and reduce diet-related noncommunicable diseases.

Despite declaring 2016-2025 as the “United Nations Decade of Action on Nutrition,” the UN General Assembly’s efforts to bolster nutrition within the 17 Sustainable Development Goals by 2030 have largely been crushed by the devastating impacts of the pandemic.

The nutrition goals, in line with World Health Assembly resolutions from a decade ago, target issues such as child wasting, stunting and being overweight; anaemia in women aged 15 to 49; low birth weight; the rise in diabetes and obesity; and excessive intake of salt/sodium.

“The effects of the COVID-19 pandemic, other health emergencies – together with the disruption of the food supply caused by intensified conflicts and climate change – impede progress towards ending hunger and malnutrition in all its forms and achieving the health-related targets of the Sustainable Development Goals,” according to the report from WHO Director-General Dr Tedros Adhanom Ghebreyesus, which was approved by the body’s Executive Board (EB) on Friday.

“Adult obesity continues to rise worldwide. More than 1.9 billion adults are affected by overweight or obesity,” the report notes. “Nearly 3.1 billion people could not afford a healthy diet in 2020. At the same time, up to 222 million people in 53 countries or territories are expected to face acute food insecurity or worse conditions, with malnutrition remaining at critical levels.”

Yet the report also notes that “in the face of existing setbacks, there is very positive momentum and urgency for accelerated efforts towards the global nutrition targets.”

Nutrition
Between 1975 and 2016, southern Africa saw the world’s highest proportional increase in child and adolescent #obesity – an alarming 400% per decade. Ultra-processed foods and sugary drinks contribute to rising rates of #diet-related diseases.

Acute need to improve nutrition in Africa

Globally, some 193 million experienced a food crisis in 2021, up from 155 million people a year earlier, according to the Global Report on Food Crises 2022.

Among the 10 countries with the most people in crisis, more than half were in Africa: the Democratic Republic of the Congo, Ethiopia, Yemen, Nigeria, Sudan and South Sudan. The others were Afghanistan, Syria, Pakistan and Haiti.

Unsurprisingly, the African Union (AU) declared last year as the Year of Nutrition in the face of widespread hunger from COVID-19, conflict and climate change.

And last June, WHO announced it was setting up a hub in Kenya to help fight the “major physical and mental health repercussions” of the food crisis in the Eastern Africa region.

“Malnutrition remained at critical levels in countries affected by food crises, driven by a complex interplay of factors, including low quality food due to acute food insecurity and poor child-feeding practices, a high prevalence of childhood illnesses, and poor access to sanitation, drinking water and health care,” the World Food Program’s report says.

Despite limited data, the report shows almost 26 million children under 5 years old were suffering from wasting and in need of urgent treatment in 23 of the 35 major food crises and more than 5 million children were at an increased risk of death due to severe wasting.

In the 10 countries with the highest number of people in crisis, 17.5 million children were wasted – a term that refers to when a child is too thin for his or her height and results from recent rapid weight loss or the failure to gain weight.

Friction over corporate nutrition

Before the report’s passage, Tedros said he had “two prayers” for the world –  one for more food on the table for everyone, the other for less unhealthy food.

“So the issue now is addressing both both obesity and malnutrition. And I think the key is to implement the action plan in its totality,” he told the EB, adding that another important issue is the UN healthy agency’s carrot-and-stick approach to corporate engagement on nutrition.

“I would like to assure you that we collaborate on issues we can collaborate. On issues we can’t and we don’t, then we continue the dialogue, but we use the regulatory function to enforce,” said Tedros. “WHO has not been working with the food industry. It’s mainly – to us – confrontational. I don’t think that approach really helps.”

Tedros said WHO can enforce regulations when needed, but he obviously prefers to gain corporate cooperation whenever possible, which is what happened in 2019 when the food industry agreed to eliminate industrial trans fats by 2023.

“Many of them are doing it already. So we collaborate on that. While on salt and sugar, we still have a problem and on breastfeeding we have a problem,” he added.

Nutrition
The UN Decade of Action on Nutrition, Explained

Image Credits: @veerajayanth03, Dr Alexey Kulikov/Twitter, United Nations.

WHO independent evaluation
The Executive Board considers a new initiative on falsified and substandard medical products.

World Health Organization’s Executive Board (EB) has gotten behind the rollout of an independent evaluation of the agency’s member state mechanism addressing  falsified and substandard medical products in order to see how surveillance and enforcement of production standards could be improved. 

The initiative, which now needs to go to the World Health Assembly in May, follows in the wake of a raft of recent reports on  illnesses and deaths from contaminated medicines – that have been implicated in the deaths of dozens of children in Asia and Africa. 

Those include high-profile reports of the recent deaths of at least 66 children in The Gambia and 18 children in Uzbekistan, all linked to consumption of tainted cough syrups produced in India.   

In the EB discussion on Thursday, countries also asked WHO to facilitate the more effective sharing of information on fake and substandard medicines and the necessary expertise to address the problem. 

However, member states like Brazil and Thailand, as well as  several  civil society  actors,  also stressed that tightening regulations around medicines manufacture should not be designed in a way that exacerbates already existing shortages and restrictions in medicines access in low- and middle-income countries. 

“The evaluation should include recommendations aimed at addressing the lack of equitable access to medicines, high drug pricing, supply and demand issues, and regulatory failures, which enable the circulation of quality-compromised medicine,”  said Medicus Mundi International and the People’s Health Movement in a statement to the EB.

Other countries, such as Colombia, stressed that their national authorities are just now setting up a medicines surveillance system to regulate drugs. So reports of the presence of tainted or fake medicines problems doesn’t necessarily mean that overall standards are low – but that enforcement is weak. . 

“Many countries are only just starting to implement their certification systems, and therefore if they have problems that doesn’t necessarily mean they have low standards that facilitate the proliferation of substandard and falsified medical products. It just means that they’re at an early stage of developing systems to cope with it,” Colombia’s delegate, Sr. Jaime Hernán Urrego Rodríguez, Vice Minister of Public Health, pointed out. 

WHO EB
Sr. Jaime Hernán Urrego Rodríguez, the vice-minister for public health, Colombia.

Sharing is caring

Several member states also called on the WHO to facilitate more sharing of information and the development of technical expertise to detect and take timely action on fake and substandard medicines. 

“When we have substandard or falsified medical products, we’re talking about an issue that varies considerably from one country to another depending on the regulatory authorities capacity to act in different countries and depending on the environment in which it finds itself,” the EB delegate from Senegal stated, on behalf of 47 member states from Africa. 

“We therefore would encourage the Secretariat to facilitate the exchange of information, the sharing and pooling of information among states, and also between the global network, with the focal points and other mechanisms and platforms that may exist.” 

Contaminated cough syrups responsible for at dozens of deaths

Contaminated cough syrups have been implicated in the reported deaths of hundreds of deaths of children in Asia and Africa over the past decade, including dozens of children in the past year. 

At the EB session, delegates from the USA and Botswana highlighted the severity of the fake drugs problem, as evidenced by the proliferation of recent incidents, calling for coordinated action to “address this critical and preventable issue”. 

On January 25, the US Food and Drug Administration (FDA) announced that it will join hands with the WHO and other organizations in a joint investigation into the source of these contaminated cough syrups. 

In October 2022, the WHO issued a product alert concerning four cough syrup products, contaminated with diethylene glycol (DEG) and ethylene glycol (EG).

“Laboratory analysis of samples of each of the four products confirms that they contain unacceptable amounts of diethylene glycol and ethylene glycol as contaminants,” the alert pointed out. The samples were tested in laboratories in Switzerland and Ghana. 

WHO added that the manufacturer of all the four syrups was an Indian company, Maiden Pharmaceuticals Private Limited. These cough syrups were sold in the Gambia. At least 66 children died after consuming the tainted cough syrups, WHO stated, although an investigation into the precise cause of deaths is still going on. 

While India said it found no manufacturing malfunction at Maiden Pharmaceuticals, the WHO has not retracted its report.

Cough syrup
The products from Maiden Pharmaceuticals, flagged by the WHO, after tests in both Switzerland and Ghana showed evidence of chemical contamination.

The WHO also flagged another Indian pharmaceutical manufacturer, Marion Biotech Private Limited, for exporting substandard products laced with DEG and EG to Uzbekistan in central Asia. In a product alert issued in January 2023, the agency said, “Laboratory analysis of samples of both products, undertaken by national quality control laboratories of the Ministry of Health of the Republic of Uzbekistan found both products contained unacceptable amounts of diethylene glycol and /or ethylene glycol as contaminants.” Use of these products has been linked to the recent deaths of 19 children in Uzbekistan. 

India, the EB member whose manufacturers have been the focus of many of the complaints, did not present a statement at Thursday’s session. 

Don’t set manufacturing standards so high that they impede access

Brazil and Thailand called for the WHO to ensure that the work to advance safe medicines does not inadvertedly impact access to medicines, by setting the bar too high for the production of medicines by low- and middle-income countries.  

“Brazil supports initiatives that promote access to affordable, safe, and quality medical products, including through actions aiming at preventing detecting and responding to substandard and falsified medical products. Actions in this area nevertheless should not hamper the critical work to enable access to medicines through the provision of generic drugs,” Brazil said. 

“The requirement to meet manufacturing standards should not become a barrier to access or an excuse to protect the interest of patent holding producers,” added Medicus Mundi International and the People’s Health Movement in their EB statement. 

There is a risk that raising manufacturing standards too high – to the levels of the United States or European regulators could boomerang, impinging on the production of generic  medicines in Africa and Asia, explained civil society actors at an EB side event on Tuesday evening, sponsored by Knowledge Ecology International. 

Rather, WHO Good Manufacturing Practices (GMP), and low- and middle income countries, such as Morocco, with a good track record of implementing good quality control standards, should be considered as models for emulation, they argued. The WHO GMP is used as the basis for WHO’s Prequalification scheme for medicines and vaccines that are approved by the global health agency for procurement by other UN and UN-Supported agencies.

Image Credits: Megha Kaveri, World Health Organization.

Noma
Umar, an eight-year-old noma patient from Kano Sstate, Nigeria, and Adamu, a 15-year-old noma patient from Kebbi State, stand at the entrance of the post-operative ward at the Sokoto Noma Hospital. The two boys are looking forward to going outside.

Twenty years ago, 16-year-old Mulikat Okanlawan embarked on a 1000-kilometer journey from her home in the Nigerian capital of Lagos to the Northwestern city of Sokoto in a bid to change her life.

She is a survivor of noma, a little-known bacterial disease that attacks cells in facial tissue and bones. On paper, Okanlawan had been lucky. Noma is fatal in 90% of cases, often taking the life of those infected within mere days.

Mulikat, a 33-year-old former patient originally from the south of Nigeria, moved to Sokoto 17 years ago to undergo facial reconstructive surgery. She now works in the hospital.

But survivors, mostly children between the ages of 2 and 6 at the time of infection, are left with severe facial deformities that follow them long after the acute phase of noma subsides. These can make it hard to eat, speak, see or breathe, and often lead to discrimination against survivors in their own communities.

“It left a deadly mark on my face that hindered me from associating with people in the community,” Okanlawan said. “Imagine a life where people are running away from you because of your condition. I used to cry every day. I was alone.”

Noma results from deadly synergy between bacterial pathogens that causes ulcers to develop in the mouth, followed by the destruction of cells in the tissues and bones of the face. Often referred to as “the face of poverty,” its key risk factors include malnutrition, lack of basic hygiene, contaminated drinking water, immunodeficiencies, and recent illness, especially from malaria or measles.

Okanlawan has since received several reconstructive facial surgeries at the Sokoto Noma Children’s Hospital, the only specialised noma hospital in Nigeria since its founding in 1999. Little by little, Okanlawan found a new lease on life.

“I began to admire myself,” she said. “I began to relate with people in the community.”

After returning to school to complete her education, Okinlawan returned to Sokoto, where she now works as a hygiene officer and helps patients recover from the trauma of disfiguration.

WHO decision due in 2023

Despite years of campaigning from medical organizations and national governments, noma has yet to be included in the World Health Organization’s neglected tropical diseases list, an omission Médecins Sans Frontières (MSF) health advisor for Nigeria Mark Sherlock says makes noma “the most neglected of the neglected diseases.”

But this may be about to change. In late January, the Federal Ministry of Health of Nigeria, supported by 30 member states from five WHO regions, submitted a dossier on noma requesting the formal recognition of noma as a neglected tropical disease (NTD).

The request is a follow-up to the resolution on oral health passed by WHO at the 74th World Health Assembly in 2021, which recommended that “noma should be considered for inclusion in the NTD portfolio as soon as the list is reviewed in 2023.”

The latest WHO statistics – updated in 1998 – estimate 140,000 people are affected by noma every year. No systematic study of its disease burden has been conducted in the intervening 25 years.

The WHO’s Strategic and Technical Advisory Group for Neglected Tropical Diseases is supposed to make a final decision on whether to add noma to its list of neglected tropical diseases this year, but a date for the meeting has not yet been published.

Not a “silver bullet”, but noma belongs on the list

Amina, an 18-year-old noma patient from Yobe state, visited the Sokoto Noma Hospital for the first time in November 2016 with her mother. She has been disfigured since early childhood, and has a habit, like many noma survivors, of hiding her scars behind a veil. (MSF, Sokoto, Nigeria.) 
18 October, 2017.

Despite its omission from the official WHO list, Noma is the quintessential neglected disease.

It disproportionately affects people living in extreme poverty, is generally neglected by research, affects populations in tropical and sub-tropical areas of Africa, Asia, and Latin America, and incurs significant socio-economic costs on the communities it affects.

Its high mortality rate can also be attributed to neglect and lack of awareness education among the public and medical communities due to the highly treatable and preventable nature of the disease.

“Due to extreme poverty and lack of awareness, unfortunately, a lot of children die at home without even making it to the hospital,” said Dr Shafiu Isah, Chief Medical Director at the Sokoto Noma Children’s Hospital. “This disease is still not very well known in our communities, including among health care workers, who often mistake it for cancer or other illnesses.”

Doctors, researchers and activists recognize that the inclusion of noma on the WHO list would not change the situation of patients on the ground overnight, but say recognition of its neglected status would shine a much needed spotlight on a disease in dire need of renewed resources and attention.

“Whilst not a silver bullet, noma’s inclusion on the WHO list will draw attention to the disease and those at risk of or experiencing it, attract funding for research, prevention, and treatment, and integrate noma in existing protocols of disease-monitoring,” said Dr Ioana Cismas, co-lead of the research collective The Noma Project.

“Those who have lived experience of this disease are calling for national and international action.”

Read more: Noma Survivors Demand that WHO List the Disease as a Neglected Tropical Disease

Image Credits: Claire Jeantet – Fabrice Catérini / Inediz’.

Assistant Director-General Dr Tereza Kasaeva, WHO’s interim head of NCDs

Higher taxes and warning labels on unhealthy food, cigarettes and alcohol, and better screening for cancers, are on the World Health Organization’s (WHO) updated list of “best buys” to address non-communicable diseases (NCD) discussed by member states at the body’s Executive Board meeting on Thursday.

The list was updated in response to the lack of progress to reduce NCDs, with not a single country on track to achieve the 2025 global targets set by the World Health Assembly back in 2013, and the declaration by the UN General Assembly High-Level Meeting on NCDs in 2018.

The new list now recommends 112 interventions and enabling actions – up from 88 when it was last updated in 2017, and the global body has also worked out which are the most cost-effective.

There was wide support for the new list from member states. However, civil society representatives criticised its silence on kidney disease, dementia, obesity co-morbidities, as well as a lack of attention to older people more likely to have NCDs.

Lack of progress

In his report on progress made to address NCDs, WHO Director-General Dr Tedros Adhanom Ghebreyesus noted that health systems were failing to prevent and control these diseases.

“The [COVID-19 pandemic] has highlighted the urgent need to strengthen health systems through a radical reorientation towards primary health care as the foundation for progress towards universal health coverage, as well as to ensure health security and achieve health and well-being for all,” said Tedros. 

“The prevention and control of NCDs and the promotion, protection and care of mental health are integral to this reorientation.”

The cost of implementing the interventions in 76 low and lower-middle-income countries is less than US$ 1 per person per year, and together these actions could save seven million lives per country, according to the WHO.

However, Botswana, on behalf of the Africa region, requested that more affordable treatments are developed to assist lower-income countries.

Mental health remains neglected

“Between now and 2030, the economic gains from implementing the cost-effective NCD interventions could amount to more than $230 billion in lower-middle income countries when individual, economic and social benefits are factored in,” according to Tedros, who noted that almost three-quarters of deaths were caused by NCDs.

Almost a billion people globally lived with a mental disorder. A massive 283 million people had alcohol use disorders in 2016 and 36 million with drug use disorders in 2019, yet less than a third of member states had mental health policies and plans and only 2% of health budgets go to mental health. 

Denmark, on behalf of the European Union, called on the WHO to “strengthen the efforts for mental health and have a greater focus on information sharing and de-stigmatization efforts”.

Deputy Director-General Dr Zsuzsanna Jakab told the EB at a session on Thursday night that the best buys would “invigorate implementation of both the global action plan and relevant regional frameworks”.

‘We know these approaches work. In Southeast Asia for example, we have seen a rapid decline in tobacco use. Smoking prevalence among men in the region declined from 50% in 2000 to 25% in 2020,” said Jakab.

Assistant Director-General Dr Tereza Kasaeva, WHO’s interim head of NCDs, recommended that member states “define the list of priorities that are considered good value for money according to their national context”, and WHO would support them to implement these.

The list will continue to be updated as more evidence became available, added Kasaeva.