Social distancing squares marked out during the COVID-19 pandemic.

As World Health Organization (WHO) member states get into line-by-line negotiations on a proposed pandemic accord to guide the world’s approach to future pandemics, there are growing calls for independent monitoring to ensure that the terms of such an accord are implemented. Layth Hanbali explains.

Health Policy Watch:  You and other colleagues have noted that the zero draft of the WHO’s Pandemic Accord “contains little on holding countries accountable for the obligations they sign up to” and that it implies that the governing body of the accord would need to “agree to accountability measures after the accord is implemented”. You propose that the accord itself needs to include a mechanism to monitor countries’ compliance, particularly on the legally-binding elements. What should this look like?

Layth Hanbali: An independent monitoring committee should consist of a group of experts from a broad range of disciplines who would assess countries’ compliance with their obligations under the pandemic accord and the timeliness, completeness, and robustness of their reporting on these obligations. They would meet regularly (for example, quarterly) to review the available evidence on countries’ compliance, which would include countries’ own reports, shadow reports by non-state actors, and confidential reports. They would be supported by a dedicated secretariat who would work on behalf of the committee to collect and collate data and prepare analyses and reports.

HPW: Who would this “independent committee of experts” report to, and how would it be financed?

LH: The independent monitoring committee should report to a high-level political body; that means it should consist of, or represent, heads of state. This could, for example, be the proposed Global Health Threats Council or the UN Secretary-General or UN General Assembly.

Financing should be through an international or multilateral mechanism or body, such as the UN Secretary-General’s office or the General Assembly or the Pandemic Fund. The important thing is that the funding enables the committee to operate while firewalled from the influence of any political or commercial actors with a vested interest in pandemic preparedness nnd response (PPR). That also means the funding should be ring-fenced, unconditional, up-front, and sustained.

HPW: Isn’t this the job of the WHO?

LH: The WHO has struggled in the past with calling out countries for failing to fulfil their obligations, such as under the International Health Regulations (IHR). This is partly because it needs to maintain good relations with its members to continue to provide them with the technical support that only WHO can provide. It is therefore not best suited for this kind of function, where it would sometimes be necessary to criticize countries transparently. An independent monitoring mechanism taking on this responsibility would therefore allow the WHO to fulfil its responsibilities and dedicate its resources and expertise to the tasks that it is best placed to do. This will include supporting countries to fill the gaps identified by the independent monitoring committee.

HPW: Some member states fear that the pandemic accord will undermine their sovereignty. How would an implementation mechanism address this?

LH: The pandemic accord can only come into existence if it is agreed upon by member states and there remains a high level of commitment to maintaining state sovereignty in the negotiations of the accord. An accountability mechanism would therefore only assess countries’ compliance with the obligations that they themselves would agree to take on.

HPW: The WHO Director-General has proposed a Global Health Emergency Council, described as a “high-level body on global health emergencies, comprising Heads of State and other international leaders”. Could this council oversee the implementation of the accord, and do you envisage that this could oversee your proposed independent monitoring committee? 

LH: The Director-General’s commitment to secure high-level political commitment to global health emergencies is welcome. There are three main issues with his proposal for such a council to be based at WHO, however. First, the WHO has historically struggled to call out countries for failing to meet obligations, for example under the International Health Regulations. An accountability mechanism should be removed from those dynamics.

Second, his proposal would have the council report to the World Health Assembly, which is traditionally seen as an arena for ministers of health. It is therefore unrealistic to expect heads of state to agree to report to ministers of health.

Third, keeping oversight over the pandemic accord at WHO may undermine the accord’s aim of adopting a whole-of-government approach to pandemic prevention, preparedness, response and recovery while the WHO remains focused on the health sector.

HPW: The Independent Panel for Pandemic Preparedness and Response (IPPPR), co-chaired by Helen Clark and Ellen Sirleaf, has proposed a Global Health Threats Council. Could this be the appropriate body to oversee the accord’s implementation?

LH: The IPPPR’s proposal for a Global Health Threats Council fulfils what we envision as a body that the independent monitoring committee would report to. The proposed council would provide high-level political leadership, monitor actors’ performance, and take on accountability functions. If this comes into existence as it is currently proposed, it would be appropriate for an independent monitoring committee to report its findings to the Global Health Threats Council.

HPW: There is also the Global Preparedness Monitoring Board (GPMB), convened by the WHO and the World Bank. It is described as an “independent monitoring and accountability body to ensure preparedness for global health crises” that is comprised of “globally recognized leaders and experts”, which is “tasked with providing an independent and comprehensive appraisal for policy makers and the world about progress towards increased preparedness and response capacity for disease outbreaks and other emergencies with health consequences”. How does this fit in?

 LH: Our proposal is for an independent committee to monitor each country’s compliance with its individual obligations under the pandemic accord. Meanwhile, the GPMB focuses on global preparedness for pandemics, which it describes as more than the sum of each country’s preparedness. The mandates of these two bodies are therefore related but distinct.

Layth Hanbali is an analyst focusing on global health governance at Spark Street Advisors. His current work tracks developments in the governance of pandemic preparedness and response, and analysing how independent monitoring could promote compliance and accountability in the proposed pandemic accord. He is also an Assistant Researcher in community health at Birzeit University in Palestine, and has worked as a researcher, public health practitioner and doctor; volunteered as a civil society organizer; and taught for several global health programmes. He has a master’s degree in Health Policy, Planning and Financing, a medical degree, and a bachelor’s degree in Global Health. 

 * Kerry Cullinan asked the questions.

 

Image Credits: Shahin Khalaji/ Unsplash.

Chinese Foreign Ministry Spokesperson Mao Ning

A US intelligence chief has claimed that COVID-19 most likely originated in a laboratory in China, a claim that was promptly dismissed by the Chinese government. 

“The FBI has for quite some time now assessed that the origins of the pandemic are most likely a potential lab incident in Wuhan,” Christopher Wray, the head of the US Federal Bureau of Investigation (FBI) told Fox News on Monday.

He said that the FBI had teams of experts spanning across topics that assess the threats posed by various actors. “…and here we’re talking about a potential leak from a Chinese- government-controlled lab that killed millions of Americans”.

However, on Tuesday China dismissed his comments as “political manipulation”, and urged the US to respect “science and facts”

“The origins-tracing of SARS-CoV-2 is about science and should not be politicised,” said Chinese Foreign Ministry Spokesperson Mao Ning.

“China has always supported and participated in global science-based origins-tracing,” she stressed, adding that a laboratory origin of the pandemic was considered to be “extremely unlikely” according to the “science-based, authoritative conclusion reached by the experts of the WHO-China joint mission after field trips to the lab in Wuhan and in-depth communication with researchers”.

Certain parties should stop rehashing the “lab leak” narrative, stop smearing China and stop politicizing origins-tracing, she added.

“Based on the poor track record of fraud and deception of the US intelligence community, the conclusions they draw have no credibility whatsoever,” added Mao.

‘Low confidence’ assessment 

The FBI chief’s statement comes close on the heels of the US Department of Energy’s (DoE) “low confidence” assessment that the pandemic was the result of an unintended laboratory leak in China, as reported in the Wall Street Journal (WSJ) over the weekend. 

The WSJ report stated that the DoE’s claim is a result of new classified intelligence in its possession, which has been submitted to the US Congress. This is reportedly an update to its 2021 document which said that the department was “undecided” on the origins of the pandemic. 

Apart from the FBI and DoE, other members of the US Intelligence community have attributed the origins of the pandemic to various other causes, such as zoonotic spillover. Two of the agencies are undecided. 

According to a US National Intelligence Overview document published by the Office of the Director of National Intelligence (ODNI), a low confidence level indicates that “the information used in the analysis is scant, questionable, fragmented, or that solid analytical conclusions cannot be inferred from the information, or that the Intelligence Community has significant concerns or problems with the information sources”. 

Lack of concrete evidence 

The claims from the FBI and the DoE have evoked a barrage of responses from the scientific communit

Pointing out that the latest statements from the FBI and the DoE are based on classified information, Dr Angela Rassmussen, a virologist and a research scientist at the Vaccine and Infectious Disease Organization (VIDO) at the University of Saskatchewan, tweeted that there is still no publicly available evidence to suggest that the COVID-19 pandemic was caused by a lab accident.

She emphasized that the “low confidence” level attributed to the latest statement by the DoE raises doubts about the strength of the evidence in its possession. 

“However, given the “low confidence” rating and the DOE’s failure to persuade any other IC, I’m extremely sceptical that this intel comprises any such evidence,” she tweeted. 

Dr Stephen Griffin, a virologist and associate professor at the University of Leeds, too echoed Dr Rasmussen’s thoughts on the lab leak theory. 

“If there’s something that’s changed in the evidence base, let’s hear it. Otherwise, there remains not a shred of meaningful evidence that SARS2 was engineered or leaked. End of,” he tweeted. 

WHO demands more Chinese cooperation

However, the origins of the pandemic are far from conclusive and the World Health Organization (WHO) has been at the forefront of investigations, demanding more cooperation from China to help the world better understand how the pandemic originated. 

In January 2023, Dr Maria Van Kerkhove, the COVID-19 Technical lead at the WHO, said that the agency was working with China to fill some “very important information gaps”. 

“We have requested further information to have those sequences be shared publicly so that a deeper analysis and more phylogenetic analysis can be done so that we could look mutation by mutation to really assess what is circulating there,” she added. 

In February 2020, as the SARS-CoV-2 started spreading across the world, the WHO set up a team of 25 national and international experts to visit China to understand the origins of the COVID-19 pandemic. The report released by the WHO after the mission stated that the possibility of the pandemic originating from a lab accident in China is low. 

“Prior to December 2019, there is no evidence of circulation of SARS-CoV-2 amongst people globally and the surveillance programme in place was limited regarding the number of samples processed and therefore the risk of accidental culturing SARS-CoV-2 in the laboratory is extremely low,” the report said. 

However, the independent team that visited China had limited access to various sites and patient medical records, leading to the WHO repeatedly demanding more cooperation from China to enable better understanding of the origins of the pandemic. 

The WHO’s Intergovernmental Negotiating Body’s fourth meeting is underway in Geneva.

Although the drafting of the proposed global pandemic accord will happen behind closed doors, civil society organisations want a say as they’re often on the ground dealing with health emergencies.

This emerged during the second day of the meeting of the World Organization’s (WHO) intergovernmental negotiating board (INB), which is just starting to discuss the zero draft of the accord.

Health Action International stressed “the legitimacy of public interest civil society to participate in this and other international processes, not only as providers of expertise and knowledge but as recipients of a mandate to transmit the voice and grievances of communities, individuals and parties too often overlooked, persecuted or taken for granted by far too many governments and organisations”.

The Office of the United Nations High Commissioner for Human Rights (OHCHR) urged the INB to include civil society in the drafting of the pandemic, saying that “we have a successful example of that sort of participation in the development of the Convention on the Rights of Persons with Disabilities”. 

The OHCHR emphasised the important role of civil society organisations played in “resolving difficult questions and identifying priorities”, particularly during pandemics and other crises.

Transparency

Key access to medicines advocates including Medecins sans Frontieres, Knowledge Ecology International (KEI), and Medicines Law & Policy called for the accord to give attention to transparency, particularly in regard to research and development (R&D) and public funding.

“Transparency will be essential for addressing future pandemic risks and implementing the agreement including monitoring compliance,” added Medicines Law & Policy’s Ellen ‘t Hoen

She added that the sharing of intellectual property (IP), know-how and technology could be mandatory during a pandemic, and that new legal obligations “can be created in compliance with existing international law including the World Trade Organization TRIPS Agreement”. 

Ellen t’Hoen

KEI described article 7.4 B of the zero draft as “the most important intellectual property proposal in the text”.

This clause states that, in the event of a pandemic, member states “will apply the full use of the flexibilities provided in the TRIPS Agreement, including those recognized in the Doha Declaration”.

However, KEI warned that the clause “should avoid a closed list of exceptions or specific references to the TRIPS agreement” as, in the event of a pandemic, “the mandatory obligations to use exceptions” were often needed in country’s domestic IP laws.

“Parties should also be required to review and modify domestic laws to ensure that there are sufficient exceptions to exclusive rights and intellectual property in order to respond to a pandemic,” KEI added.

Vision is limited

Meanwhile, the Independent Panel for Pandemic Preparedness and Response (IPPPR)’s co-chair, Helen Clark, said that the draft’s vision was lacking as it assumed pandemics would take place – yet the political decisions taken by member states “can avert devastating pandemics”.

“The International Health Regulations and the pandemic instrument should together set the rules that ensure an outbreak does not result in a devastating pandemic,” said Clark in a statement.

Clark added that “accountability must include independent monitoring, which should be explicitly built into this draft. We would welcome an independent expert group for continuous monitoring, which could, for example, be modelled on the IPCC, associated with the climate convention”.

Closed sessions

The afternoon session of the INB was closed for member states to be guided through a reading of the draft to ensure that all parties had the same understanding of the clauses, said co-chair Roland Driece.

Much of the rest of the week is also likely to be closed as the drafting of clauses will follow. However, the INB co-chairs have promised to hold open information sessions from time to time.

Image Credits: WHO.

INB co-chair Precious Matsoso and Dr Tedros at the opening of INB4.

Concerns about equity and financing dominated day one of the negotiations on a global pandemic accord’s zero draft at the World Health Organization’s (WHO) Geneva head office on Monday.

Opening the fourth meeting of the intergovernmental negotiating body (INB) that is steering the process, WHO Director-General Dr Tedros Adhanom Ghebreyusus noted that various people had remarked about emerging “divisions between North and South” during negotiations. He then appealed to member states “not to repeat the same mistakes” made during the COVID-19 pandemic.

Tedros also notified the INB that the two United Nations ambassadors from Morocco and Israel, who are facilitating the UN summit on pandemic prevention, preparedness and response in New York in September, were observing the proceedings to “listen to all the stakeholders”.

“They believe in an inclusive and transparent process, which is very, very crucial,” added Tedros.

The meeting moved into a closed session for the rest of the morning to discuss the modalities of negotiations for this meeting and the next, being held from 3 to 5 April.

Equity concerns

During the afternoon session, a number of member states including India, Namibia and Indonesia raised concerns about how equity was not mainstreamed throughout the document.

According to Namibia, it appeared as though equity was “voluntary”, while Indonesia appeals for equity to be considered both between and within countries.

Mexico, speaking for Latin America, was concerned about the lack of “binding language” and incentives to encourage equity.

Meanwhile, for the US “commitment to equity must address inequities not only between countries but also within them, not just protecting populations from pandemics but also from illness, death and disrupted access to essential health care services during pandemics, including sexual and reproductive health services”. 

The US, Japan and India expressed disquiet about the accord prescribing “specific allocations of domestic budgets or GDP” to pandemic preparedness and response.

“We would like to know from the Bureau the basis of determining 5% of member states current expenditure on health to be dedicated for pandemic preparedness, response and health system recoveries as this tool seems unnecessarily prescriptive,” said India.

Japan said that it could not be a party to an instrument “with a percentage GDP financial commitment”, adding that intellectual property issues should be addressed at the World Trade Organization and the World Intellectual Property Organization.

China at INB4

Climate change inclusion

Fiji on behalf of the Western Pacific, asked for consideration of the “multi-dimensional vulnerabilities such as geographical remoteness and the particular context of small island developing states that may be an impediment in pandemic response” and “specific recommendations in recognition of the impacts of climate change”. 

Along with countries including Australia and the UK, Fiji also supported the “integration of a One Health approach.. working collaboratively across the human, animal, environment and food sectors”.

Both China and Russia were concerned that a pandemic accord should not undermine their sovereignty.

China called for a “more flexible and effective dialogue mechanism so as to fully and widely consult and incorporate the opinions and needs of different parties in whole process and reflect the principles of respecting national sovereignty, respecting diversity and differences, equity, solidarity, coordination and inclusion”.

Various European states and the EU used the meeting to condemn Russia’s invasion of Ukraine, with Russia retaliating that they were attempting to “politicize” the INB process.

The meeting continues until Friday, although most of the sessions will be for member states only.

The antiviral of Merck’s key competitor, Pfizer’s Paxlovid, received full approval in January 2022. Now the company is fighting to catch up.

Merck will appeal the recommendation by the Europe Union’s (EU) Committee for Medicinal Products for Human Use (CHMP) that the European Medicines Agency (EMA) rejects its COVID-19 antiviral, Lagevrio (molnupiravir).

The decision comes after months of deliberation by European regulators, who began looking at Lagevrio, in November 2021. The CHMP said there was a lack of evidence to support its efficacy in patients. There have also been previous concerns that the benefits of Merck’s drug do not outweigh its cost.

In its response to European regulators, Merck highlighted that more than 25 countries have authorized the use of the antiviral, including the US and the United Kingdom, which was the first country to authorize the drug in November 2021, the same month the CHMP started its review process.

Deaths from COVID-19 applied pressure on regulators to get Lagevrio and its competitor, Paxlovid (Pfizer), available as fast as possible.

But doubts about the side effects of the pill have been present from the start, and even countries that approve Lagevrio place restrictions on its use. The US Food and Drug Administration (FDA) advises that it should only be used “for whom alternative COVID-19 treatment options authorized by the FDA are not accessible or clinically appropriate.” It also cannot be given to patients under the age of 18, or to pregnant women due to the potential for birth defects.

“More than four million patients worldwide have been treated with Lagevrio,” Dr Dean Li, president of Merck Research Laboratories said. “We remain confident that Lagevrio has an important role to play in the COVID-10 treatment landscape.”

Merck provided the CHMP with data from a trial of 1,400 unvaccinated adults, which the company said provided “compelling evidence” from real-world use, and demonstrates the “positive impact that Lagevrio can provide for patients by reducing the risk of hospitalisation and death among adults at increased risk for severe disease.”

But the CHMP was unimpressed, and its decision unambiguous: “The clinical benefit of Lagevrio could not be demonstrated.”

“Based on the totality of data, it was not possible to conclude that Lagevrio can reduce the risk of hospitalisation or death or shorten the duration of illness or time to recovery in adults at risk of severe disease,” the agency said. “Furthermore, it was not possible to identify a specific group of patients in whom a clinically relevant benefit of Lagevrio could be demonstrated.”

Lagevrio made Merck over $5.7 billion in sales last year. Merck and its development partner Ridgeback Therapeutics said they expect to make around $1 billion from the antiviral in 2023.

Image Credits: Creative Commons.

The working group on amending the IHR met in Geneva last week (20-24 Februar 2023).

After five days of discussions last week on how to amend the World Health Organization’s (WHO) International Health Regulations to make them more able to combat future pandemics, the international working group has “agreed on a way forward”, according to the WHO.

WHO member states have proposed 307 amendments, and much of last week’s meeting was taken up by explanations of these.

While the regulations set out common approaches and obligations for countries to prepare for, and respond to, disease outbreaks, the COVID-19 pandemic exposed many weaknesses.

Behind closed doors

Much of last week’s meeting, the second of the working group, was behind closed doors, but agreement was reached on “next steps to tackle more in-depth negotiations on the proposed amendments, and plans for its next meeting running from 17-20 April”, according to WHO.

Co-Chair of the IHR Working Group, Dr Ashley Bloomfield, said in discussing amendments to the Regulations, governments focused on making their countries, and the international community, better prepared for future emergencies.

“COVID-19 showed us that having a good, strong set of International Health Regulations is essential, and showed where the current regulations need to be improved,” said Dr Bloomfield, former Director-General of Health in New Zealand, and working group co-chair. 

“The tone of the discussions and progress made during this week’s meeting clearly show that countries understand the responsibility they have to ensure this process is successful.”

Better detection

Co-chair Dr Abdullah Assiri, Saudi Arabia’s deputy health minister, said that updated regulations “will enable the world to better detect outbreaks early, and prevent them from developing into public health emergencies of international concern”. 

“Countries are in the driving seat of this process as they need to implement the IHR, deliver on the obligations, and make the key decisions needed to respond to public health threats,” said Assiri. 

“During the pandemic, the world faced the urgent need for functioning international instruments, and placed increasing importance in international organizations, such as WHO. Alongside the IHR amendments discussions, member states are also negotiating the drafting of a pandemic accord to address prevention, preparedness and response, and the fourth meeting of the inter-governmental board to consider the zero draft of the accord began on Monday and will run until 3 March.

Bloomfield described the two processes as complementary: “The efforts to update the IHR and draft a pandemic accord share a number of common themes, including the importance of equity in access to health, collaboration and capacity building,” he said. “It is important that there is consistency and alignment across the two processes.”

The IHR are legally binding on member states and create rights and obligations for countries, including the requirement to report public health events with risk of international spread to the WHO. 

They also outline the criteria for a public health emergency of international concern, WHO’s highest level of alarm under the IHR, which in turn triggers specific response actions for countries to prevent the further spread of the epidemics.

Image Credits: WHO.

Avian flu
The death of an 11-year-old girl in Cambodia has sparked new worries about the potential for human transmission of deadly avian influenza (H5N1).

World Health Organization (WHO) officials have sounded alarm bells following the death of an 11-year-old girl in Cambodia from the deadly H5N1 strain of avian influenza, the first such death in the country in nearly 10 years. 

At least 12 people in Cambodia have now been tested for infection with H5N1 following the girl’s death, WHO officials said at a press briefing on Friday. 

WHO officials said the organization was in direct contact with Cambodian public health authorities at the time of the briefing. Cambodia is closely watching the girl’s father, who was also infected, as well as her other contacts, in an effort to determine if person-to person transmission of the deadly virus may have occurred.

The H5N1 strain of Avian influenza has only occasionally infected humans, and mostly as a result of animal-to-human contact. 

But public health officials have long been concerned that a new strain of the virus, harbored by poultry and other birds around the world, could eventualy emerge that is more easily transmissible between people.   

‘Worrying’ says WHO official

“The situation is worrying,” said Dr Sylvie Briand, WHO’s director of epidemic and pandemic preparedness and prevention. The press conference was supposed to provide an update on the composition of seasonal flu vaccines, but was largely taken over by concerns about the more deadly and unpredictable H5N1 pathogen.

The virus has had a fatality rate of over 53% among the 868 cases recorded worldwide between 2003 and November 2022. 

But so far documented cases of human-to-human transmission have been exceedingly rare, and there is no evidence of sustained human transmission of the virus, according to WHO officials.   

“So far, it is too early to know if it’s human-to-human transmission or exposure to the same environmental conditions,” Briand said.

Case in Cambodia follows one in China last year  

The case in Cambodia follows a similar case of H5N1 in China in September 2022, also in an infected girl who ultimately succumbed to the virus.  It was the first case of avian influenza to be recorded in China since 2015.  

The disease is spreading rapidly among bird populations. Since the start of last year, over 200 million birds worldwide were culled or died as a result of the disease, according to the World Organisation for Animal Health.

Genomic sequence not yet known, but vaccines are on hand

The genomic sequence of the exact strain that infected the girl is still unknown. But it is most likely one of two clades, said Dr Richard Webby, Director of WHO’s Collaborating Centre for Studies on the Ecology of Influenza in Animals. 

The two dominant clades of the virus reported by Cambodian authorities in recent years include Clade 2344B, which has ravaged bird flocks across Europe, Africa and the Americas, and Clade 2321C, circulating in Cambodia and the surrounding South Asia region.  

Many of the tools needed to respond to the H5N1 threat already exist, including multiple vaccines and antivirals, said Dr Wenqing Zhang, Head of WHO’s Global Influenza Programme at the briefing. He said that in addition to five vaccines, nearly 20 products are licensed for pandemic use.

WHO has recommended an update the existing reference vaccine, which will begin production in the coming weeks. While it will take some time before the newest vaccine is deployed, Zhang said the vaccines contained in pre-existing international stockpiles built up after an H5N1 outbreak in 2003 stoked fears of a pandemic, have also produced promising clinical trial results against circulating strains. 

If an outbreak occurs, “there is going to be a period of time when the perfectly matching vaccine won’t be available,” Webby said. “That’s when the stockpiled vaccines could perhaps come into play and probably offer offer protection from more severe disease.”

But Webby noted that the trials were not definitive proof of real world efficacy.

“We need to separate in vitro reactivity of people’s antibodies from vaccine effectiveness,” he said.

Image Credits: Roee Shpernik.

Two residents stand in the ruins of residential apartments in Borodianka in the Kyiv region

On the first anniversary of Russia’s invasion of Ukraine, the international community is grappling with how to hold Russia accountable for war crimes, while many Ukrainians are struggling mentally and physically. 

“Ukraine is a crime scene,” Karim Khan, Prosecutor of the International Criminal Court (ICC), told a United Nations (UN) session on the war in Ukraine on Wednesday.

ICC Prosecutor Karim Khan addressing the UN this week.

The ICC had been asked to investigate Russia’s invasion of Ukraine, which started a year ago on 24 February 2022, and Khan visited various Ukrainian cities last May. There he saw civilians being bombed and body bags, and heard testimony from girls and women who had been raped and ex-prisoners of war who had been tortured by Russian soldiers.

Khan said that there were “reasonable grounds” for prosecution under the Rome Statute – the treaty that established the ICC to investigate genocide, crimes against humanity, war crimes, and the crime of aggression.

Late Thursday, the United Nations General Assembly adopted a resolution reiterating its demand that Russia “immediately, completely and unconditionally withdraw all of its military forces from the territory of Ukraine and called for a cessation of hostilities”. Only seven member states – Belarus, North Korea, Eritrea, Mali, Nicaragua, Russia and Syria – voted against the resolution, with 141 states in favour and 32 abstentions including China, India, Pakistan and large parts of Africa.

Back in September, the Independent International Commission of Enquiry on Ukraine, established by the UN Office of the High Commissioner of Human Rights (OHCHR), also reported that there were “reasonable grounds to conclude that an array of war crimes, violations of human rights and international humanitarian law have been committed in Ukraine”. 

The Commission reported “summary executions, unlawful confinement, torture, ill-treatment, rape and other sexual violence committed in areas occupied by Russian armed forces across the four regions on which it focused”. 

Given the gravity of the identified violations, there is an “undeniable need for accountability”, the commission added.

While Russian soldiers are responsible for the “vast majority of the violations identified, including war crimes”, Ukrainian forces had also violated international humanitarian law in some cases, including two incidents that qualify as war crimes, the commission reported.

The UN resolution on Ukraine also calls for “accountability for the most serious crimes under international law committed on the territory of Ukraine through appropriate, fair and independent investigations and prosecutions at the national or international level”.

Collecting evidence of war crimes

However, ensuring accountability is not going to be easy. The ICC has been assisted by forensic investigators from the Netherlands who are helping to “collect evidence to the highest international standards”, said Khan.

The ICC is also working with the European Union (EU) Agency for Criminal Justice Cooperation (Eurojust), which has set up a joint investigative team to investigate war crimes in Ukraine, as well as the Genocide Network, a European network of jurists specialising in international crimes.

“There is no space for spectators in this battle of conscience… It is imperative that the law is rendered effective in this critical moment of world affairs,” said Khan.

However, ensuring that Russian war criminals are tried and convicted will be almost impossible unless there is a regime change. Russia withdrew from the Rome Statute in 2016 after the ICC ruled that its activity in Crimea amounted to an “ongoing occupation”. Travel bans on key leaders make it unlikely that the culprits will leave Russia.

Access to abortion for refugees in Poland

A year into the war, the physical and mental suffering of Ukrainians is immense. By the end of 2022, 18 million Ukrainians needed humanitarian help, with 14.5 million people needing health assistance.

About eight million Ukrainians are refugees, dependent primarily on neighbouring countries for their survival.

This week, a number of Members of the European Parliament expressed concern for Ukranian women who had fled to Poland, which does not allow abortion except if a woman’s life is in danger, or in cases of rape or incest.   

“According to the UN, more than one and a half million Ukrainians have fled to Poland. Ukrainian women and girls who have been raped by Russian soldiers are among the millions of people who have fled to Poland. Now they find themselves in a country that harshly restricts access to reproductive healthcare, including abortion,” the MEPs noted.

They asked the European Commission how it would “ensure that Ukrainian women and girls who have become pregnant as a result of rape have access to reproductive healthcare, including abortion, in accordance with Polish law”.

Kyiv residents queue for water in the street after water infrastructure was destroyed by Russian bombings.

Health, power and water facilities bombed

By the end of 2022, 763 healthcare facilities had been attacked, and half of the health facilities in Donetska, Zaporizka, Mykolaivska and Kharkivska oblasts are either partially or completely non-functional, according to the WHO Surveillance System, 

The continual bombing has destroyed power and water supplies, making it difficult for hospitals to function as well as undermining people’s health.

Approximately 9.6 million people in Ukraine may have a mental health condition, according to the WHO. This is based on previous research on those caught in war and conflict, which shows that almost a quarter (22%) develop depression, anxiety, post-traumatic stress disorder, bipolar disorder or schizophrenia. 

“From overcoming war trauma, to social isolation, to daily struggles without power and heating, to displacement-related challenges and more, the consequences of the war are expected to cause mental health problems for at least five years after the war ends,” says the global health body.

Retreating Russian forces have also mined land, and Ukraine estimates that 30% of the country’s land is contaminated by mines. 

Future geopolitical relations

The war has caused a global realignment, with an isolated Russia working hard to win new allies. India’s trade with Russia has increased by 400%, largely fueled by the sales of discounted crude oil while many African countries are being courted by Russia, including South Africa which has hosted Russian warships in the past few months in violation of US-imposed sanctions.

Ukraine is actively seeking membership of the European Union and has to satisfy an EU seven-point checklist of anti-corruption and judicial reforms – which explains the recent government investigations and dismissals.

Meanwhile, Europeans are increasingly anxious about the war, according to a recent Eurobarometer survey Some 85% of Germans and 82% of French are “very concerned” about the situation in Ukraine, while almost 80% of Poles believe that the war threatens their security.

However, US President Joe Biden’s visit to Kyiv this week to show solidarity with Ukraine, Europe’s discussion of joint arms procurement for the country, and Russian President Vladimir Putin’s decision to pull out of a nuclear pact with the US, point to a hardening of attitudes, and the likelihood that the war will drag on.

Image Credits: Oleksandr Ratushniak/ UNOCHA, Matteo Minasi/ UNOCHA.

In 2020, a woman died every two minutes from pregnancy or childbirth.

By the time you finish reading this article, at least two women will have died from complications in pregnancy or childbirth. In the next 24 hours, another 798 will lose their lives. Nearly all of these women will be from low-and lower middle-income countries, and nearly all of their deaths will have been preventable. 

These are the jarring findings of a new multi-agency UN report tracking deaths related to pregnancy and childbirth from 2000 to 2020 published on Thursday.

The report paints a vivid picture of the dangers faced by women who lack access to the basic but life-saving health services for preventing maternal deaths that most of the world has benefited from for decades. 

Yet instead of showing progress, the report reveals an alarming new development: nearly all regions of the world have witnessed an increase or stagnation in maternal deaths since 2016. 

The consequences for women’s health if this global backsliding continues, the report’s authors warned, will be severe. 

“We need to reverse the declines that we’re seeing in maternal mortality reductions,” said Dr Jenny Cresswell, lead author of the report. “This is a very important issue with very substantial inequities by country and within countries, which is unacceptable given that the majority of maternal deaths are due to preventable causes.”

In 2020, an estimated 287,000 women died of complications during pregnancy or childbirth – one every two minutes. For every woman who died, between 15 to 30 more paid for their survival with life-altering disabilities. And for every mother who does not make it past childbirth, a newborn is left at higher risk of dying as well. 

“The persistent gender norms that deprioritize the health of women and girls must be addressed,” said Dr Tedros Adhanom Ghebreyesus, WHO’s Director-General at a media briefing on Tuesday. 

“While pregnancy should be a time of immense hope and a positive experience for all women, it is tragically still a shockingly dangerous experience for millions around the world who lack access to high quality, respectful health care,” he added.

“Childbirth should be a time of life, not death.” 

A story of inequality

Maternal mortality ratio estimates by country 2020.

Maternal death rates tell a story of deep global inequalities. An astonishing 70% of global maternal deaths in 2020 — over 200,000 — occurred in sub-Saharan Africa, where girls aged 15 face a one in 40 chance of dying from pregnancy-related complications. Central and Southern Asia arrive in a distant second, accounting for 17% of the global death toll. 

Globally, nearly 95% of all maternal deaths occur in low- and lower middle-income countries. Meanwhile, 73 countries, mostly in Europe, Latin America and the Caribbean, recorded less than 20 maternal deaths in 2020. 

The sub-Saharan death rate is 136 times higher than in Australia and New Zealand, the region with the lowest maternal mortality rate documented in the report. 

Between countries on the statistical extremes, inequalities are staggering. 

In Chad, the country with the highest rate of maternal mortality, a 15-year-old girl has a one in 15 chance of dying of maternal causes in her lifetime. If that same girl lived in Belarus, the highest performing country analyzed in the report, she would be 4,000 times less likely to succumb to pregnancy related causes. 

The stark contrast between the world’s best and worst performing countries highlight deep divisions within countries and regions that get lost in the averages of global statistics. 

While regional disparities are heavily influenced by relative development levels and the impacts of prolonged conflict and climate change, national disparities run along the rural-urban divide that defines health access in developing countries, where limited health workforces and facilities are concentrated in cities due to their relative wealth and high population densities. 

Remote populations out of reach of their country’s central power grid also suffer from reduced levels of care in the facilities at their disposal due to a lack of access to electricity. Paired with overstretched health systems lacking in critical medicines and essential medical supplies, the absence of electricity to power even barebones medical setups limits doctors’ abilities to provide life-saving care during childbirth, or operate incubators if a child is successfully delivered. 

One billion people in low- and middle-income countries do not have access to health facilities with reliable electricity, and South Asia and sub-Saharan Africa – the two regions with the highest maternal death rates – also have the lowest rates of healthcare facilities with reliable electricity. 

“No mother should have to fear for her life while bringing a baby into the world,” said UNICEF Executive Director Cathering Russell. “Equity in healthcare gives every mother, no matter who they are or where they are, a fair chance at a safe delivery and a healthy future with their family.” 

Progress is possible, but the world is backsliding 

Global reductions in maternal mortality rate by five-year time period, 2000-2020.

The 287,000 maternal deaths seen in 2020 is more than a third lower than the 446,000 documented at the turn of the millennium. From 2020 to 2015, all global regions achieved significant reductions in maternal mortality. 

But since 2016, the year the UN’s Sustainable Development Goals (SDGs) came into effect, this era of progress has flatlined.

The SDG target for maternal mortality is to reduce deaths to 70 per 100,000 live births by 2030. The report found that for the world to reach this goal, an unprecedented reduction of 11.6% per year will be needed from 2021 to 2030. 

From 2000 to 2020, the average annual drop in maternal mortality was just 2.1% – a fifth of the rate needed to hit the SDG. 

Based on available data, the optimistic scenario outlined in the report projects the world will miss the SDG by more than double. The business-as-usual scenario, meanwhile, has the world arriving at a rate over three times the SDG target. 

Africa faces an even taller task: the continent needs to reduce maternal deaths by a staggering 86% to reach the rate set out in the SDG target. 

Australia and New Zealand, and Central and South Asia were the only two regions to make significant progress since 2016, reducing maternal mortality by 34.6% and 15.7% respectively. 

Half of global pregnancies are unplanned

Distributions of contraceptive users by method and region, 2019. / UNFPA

Nearly half of all pregnancies around the world, totalling 121 million annually, are unintended. According to the UN Population Fund (UNFPA), an estimated 257 million women wishing to avoid pregnancy lack access to safe, modern family planning methods like contraception and abortion.

In a report published in March 2022, UNFPA found that in 47 countries, about 40% of sexually active women were not using any contraceptive methods to avoid pregnancy, while nearly a quarter of all women are not able to say no to sex. 

“For the women affected, the most life-altering reproductive choice – whether or not to become pregnant – is no choice at all,” UNFPA Executive Director Dr Natalia Kanem said. “The staggering number of unintended pregnancies represents a global failure to uphold women and girls’ basic human rights.”

At a press conference with reporters on Tuesday, WHO officials said the ability to make autonomous decisions regarding reproductive health, including the choice of having children and the timing of childbirth, is crucial for women to plan and space their pregnancies and safeguard their well-being. 

A lack of access to the necessary care and medical resources leads many women to turn to unsafe abortions, which account for 45% of all abortions performed every year. These hospitalize about 7 million women a year globally and cause 5 to 13 percent of all maternal deaths – one of its leading causes.

Pregnant women from marginalized communities with limited access to essential maternity care are at increased risk due to inequalities related to income, education, race or ethnicity, the report added.

Nearly a third of women do not even have half of the recommended eight antenatal checks during their pregnancy, or receive any postnatal care. 

“We have the tools, knowledge and resources to end preventable maternal deaths,” Kanem said. “What we need now is the political will.”

Crisis and instability drive maternal deaths 

Pakistan
When disaster strikes, contraception and maternal health are often treated as secondary concerns.

Women and children are the first to suffer security and health consequences from war, conflict and instability. Amid the chaos, maternal health services are no longer considered essential, with dire consequences for women living in conflict zones. 

In the world’s nine most unstable countries on the Fragile States Index – Chad, Yemen, South Sudan, Somalia, Syria, Democratic Republic of Congo, Central African Republic, and Afghanistan – women die from pregnancy or childbirth at a rate more than double the world average. 

“It is telling and discouraging that the five countries with the highest maternal mortality (Afghanistan, Central African Republic, Chad, Somalia, and South Sudan) are all experiencing or recovering from conflict,” WHO said. 

This has knock on effects on the health outcomes of their potential children, too. Of the 54 countries on track to miss the SDG for child mortality, half are considered fragile or in conflict. 

Humanitarian crises push contraception down the priority list due to the increased urgency of finding food, shelter, safety, water, and other life or death necessities made scarce in times of crisis. 

International aid also prioritizes these essentials, meaning maternal health assistance is often an afterthought. Experts say changing this paradigm could save thousands of lives. 

“Delivery doesn’t wait. Whether it’s an earthquake or whether it’s COVID,” said Dr Anshu Banerjee, Assistant Director General for Universal Health Coverage at WHO. “[Maternal health services] need to be part of the core package for any intervention in a humanitarian setting.”

If the world continues on its current trajectory, an estimated one million women will die preventable deaths by 2030.

Image Credits: UN, UN, UNFPA, UNDP.

masks
Dr Maria van Kerkhove, WHO’s Covid-19 technical lead.

The World Health Organization (WHO) has reiterated its firm recommendation that wearing masks is an effective method to prevent the spread of COVID-19 in a media briefing on Wednesday.

Dr Maria Van Kerkhove, WHO’s technical lead for COVID-19, said that coronavirus is still in circulation and wearing appropriate face masks is one of the ways to prevent the spread of the virus. 

“I reiterate that the use of masks continues to be part of our strategy to reduce the spread. We have a strategy that is based on vaccinations, on distancing as much as possible as we go about our lives, wearing of well-fitting masks when we’re around others, and particularly on public transportation and certainly among health workers.”

In January 2023, Cochrane published a comprehensive analysis of 78 randomized controlled trials (RCTs) conducted in several countries over a period of time, including six RCTs conducted during COVID-19 pandemic, concluded that wearing face masks “makes little or no difference to the outcome of influenza‐like illness (ILI)/COVID-19 like illness compared to not wearing masks”. 

The study said that there is uncertainty about the effects of face masks. “The pooled results of RCTs did not show a clear reduction in respiratory viral infection with the use of medical/surgical masks. There were no clear differences between the use of medical/surgical masks compared with N95/P2 respirators in healthcare workers when used in routine care to reduce respiratory viral infection.”

“There was a systematic review that was published that was looking at randomized controlled trials,” Van Kerkhove said, adding that as an organization, the WHO looks at all available evidence on the issue. 

“We continue to look at all available evidence that is provided to us, that is published through this pandemic as well as looking at other studies of other respiratory diseases, including flu, influenza-like illness, acute respiratory infections and severe acute respiratory infections,” she added.

“Masks remain one of the recommendations that we have because we know that they are effective at preventing some of the transmission. They’re not perfect and that’s why we have a comprehensive strategy, a layered approach of many different types of interventions,” stressed Van Kerkhove.

Working around sanctions on Syria

The WHO also told the media briefing that it is making the best possible use of the pause in sanctions against Syria to ensure that aid reaches the people who have been affected by the earthquake. 

Around 47,100 people were killed in the devastating earthquake that struck Syria and parts of Turkiyë on 6 February. Several countries including the US have imposed sanctions on Syria in an attempt to pressurise the regime of Bashar al-Assad to stop killing civilians.

However, sanctions have been relaxed to enable aid to reach those affected by the earthquake. 

Explaining that the WHO is working with other UN partners to procure and mobilize medical equipment and supplies, Dr Abdi Rahaman Mahamud said that the relief work is moving in the right direction. 

In response to the global mobilization of help to Syria and Turkiyë, the US government released a compliance document on Tuesday for those willing to mobilize aid.