WHO Pressured to Shift Spending from Geneva Headquarters to Countries 31/01/2023 John Heilprin WHO EB 2023 One by one, countries demanded the World Health Organization (WHO) spend more on their countries’ needs while debating a proposal to shore up the U.N. health agency’s finances through a replenishment fund, that would be filled by periodic donor drives. The discussion, which centred around demands to shift spending from WHO’s Geneva headquarters to budget-strapped WHO offices in over 100 low- and middle-income countries dominated Tuesday’s morning session of its Executive Board (EB) meeting. For the first time, more than half of WHO’s 2024-25 budget is earmarked for country offices. Despite an overall budget shortfall, African delegations want this increased to 75%. Historically, the region which bears the world’s biggest burden of many diseases, has also suffered from the biggest lack of resources. “The uneven funding of this biennium seems to be a repeat of the uneven funding from the previous biennium,” said Mahlet Hailu Guadey, Ethiopia’s Deputy United Nations Ambassador in Geneva, representing the African Union. Guadey called for the WHO’s Secretariat to review what she described as uneven funding amongst priorities and regions. The United States, one of WHO’s biggest financial backers, also repeated its conditional approval for increasing WHO’s assessed fees to countries, as long as those increases are accompanied by new processes ensuring more internal controls and accountability. Other nations, however, such as Poland, tried to put the brakes on more spending given the financial drain of global crises and conflicts, ranging from the COVID-19 pandemic to Russia’s war in Ukraine. Flexible funding Tuesday morning’s EB session was dominated by debate over a plan by WHO’s Programme, Budget and Administration Committee (PBAC) to support a ‘replenishment fund’ for urgently needed flexible funding. The fund would be modelled on the successful funds managed by agencies like The Global Fund and Gavi, the Vaccine Alliance, which succeed in raising billions of dollars through high-profile pledging events, staged every three to four years. While expressing support for WHO’s overall goals, EB delegates criticized a system they characterized as a top-heavy bureaucracy that spends too much money on its own divisions and processes instead of in-country programmes. The EB’s chair, Slovenia’s Dr Kerstin Vesna Petrič, noted the prevailing sentiment to support the use of a replenishment fund filled by voluntary donations from both member states and philanthropies at high-profile events. EB’s chair, Slovenia’s Dr Kerstin Vesna Petrič “I can see we all agree that more money should be given to the member states, but by this, we should all bear in mind that more responsibility will be given to the member states,” Petrič told the meeting. Put on the defensive, Raul Thomas, WHO’s Assistant Director-General for Business Operations, told delegates that “every $1 invested in the World Health Organization results in a $35 return on investment” and asserted “this is the most heavily consulted budget ever.” WHO’s Director-General Dr Tedros Adhanom Ghebreyesus tried a bit of diplomacy to bridge the gap between the main funders and those feeling their needs were not getting met. He began by agreeing with the general assertion that countries must be the main focus. “I think if we’re going to raise the capacity of our programs it will depend on the strength of our country offices,” he said. “We have to equip them with everything.” Tedros outlined a funding strategy ranging from an immediate focus for the next 100 days to more mid- and long-term planning, with the ultimate goal of turning country office heads into true leaders. “We cannot use them as messengers, which very often happens,” he said. “Resource allocation is at the center; it’s one of the areas where we said we must make significant progress. And it will be a game changer.” Tedros explained, as he often has in the past, that WHO’s income comes from two principal sources. One is assessed contributions, which comprised only around 14% of the last budget. These are the annual, compulsory dues that 194 member nations pay, using a formula based on each nation’s GDP. Members’ dues provide a stable, predictable source, and the funds can be used as needed for global health priorities. The other 86% of the budget comes from voluntary contributions by member nations, philanthropic foundations and other donors, and usually covers only short-term projects meaning that funding is less flexible because it’s earmarked and is also not guaranteed. “What we’re saying now cannot happen if we’re going to rely on 86% of contributions from voluntary and earmarked where it should be spent,” Tedros told the EB. “This is a very opportune time but it’s also a crossroads.” Only 14% of budget covered by members’ dues The proposed 2024-25 budget being considered by the EB emphasizes the need for sustainable financing. “The pandemic highlighted WHO’s longstanding challenge of sustainable financing. The organization’s ability to make an impact is limited by a funding model in which only 14% of WHO’s funding is fully flexible and predictable (while the remaining funds are dependent on generous donors, heavily earmarked and arrive at unpredictable times),” the budget says. In May 2022, it notes, WHO’s member nations made a landmark decision to increase assessed contributions to represent 50% of the base programme budget by 2030–2031. The draft proposed programme budget for 2024–2025 “benefits from this decision – it has been developed on the expectation of a 20% increase of assessed contributions (from the approved levels of 2022–2023), marking a historic move towards a more empowered and independent WHO,” it says. “This development reflects the increased trust in WHO to serve its member states.” Rather than complaining about WHO’s funding, nations can make recommendations for fixing the system by engaging in efforts to “help us see whether the formula we’re using is wrong or not,” Tedros suggested. “If the formula – the allocation mechanism – is faulty, then definitely the sharing will not be right and you will not have a right to complain.” The EB is expected to discuss the PBAC proposal further this week, before deciding whether to pass the initiative to a vote by the World Health Assembly in May. Currently, member state assessments cover only about 16% of WHO’s budget needs. At last year’s World Health Assembly, nations agreed to cover half of WHO’s core budget through assessed contributions from member states by the year 2030, with an initial stepwise increase of 20% for this budget year. That, however, still leaves a major shortfall in the agency’s annual budget of about $3 billion annually, underlining the need for a replenishment fund, proponents say. Oxford Study: COVID-19 Significant Cause of Death in US Children And Youth 31/01/2023 Megha Kaveri Youth masked up as COVID-19 pandemic hit the world. A new study found COVID-19 has emerged as a leading cause of death in children and young people in the US, ranking eighth overall between August 2021 and July 2022. The Oxford University study determined that COVID-19 was the underlying cause of death for more than 940,000 people in the US, including over 1,300 deaths among children and young people up to 19 years of age. Until now, the study concluded, it had been unclear how the burden of deaths from COVID-19 compared with other leading causes of deaths in this age group. Using data from the US Centers for Disease Control and Prevention (US CDC), researchers found that infants aged less than a year were the most vulnerable with a mortality rate of four per 100,000. Deaths in children and infants were particularly high during the Delta and Omicron waves of COVID-19. Among the studied group of children and young people, COVID-19 ranked first in deaths caused by infectious or respiratory diseases. In the category of disease-related causes of death, COVID-19 ranked fifth overall. Among all causes of death, it ranked eighth. COVID-19 also was the underlying cause for 2% of deaths in children and youth in the US, putting it ahead of influenza and pneumonia as a factor in mortality. “These results demonstrate that while it’s rare for kids and teens to die in the US, COVID-19 is now the leading underlying cause of death from infectious disease for this age group,” said Dr Seth Flaxman, the study’s lead author. “Many of the 82 million American children and young people were infected during the big Delta and Omicron waves,” he said, “and as a result, more than 1,300 children and young people have died from COVID-19 during the pandemic, most in the last two years.” Explaining the seriousness of the issue, Dr Robbie M. Parks, a co-author of the study, said that the deaths in children and youths due to COVID-19 is higher than the deaths caused by a few other diseases before vaccines became available. “If you look at infectious diseases in children in the US historically, in the period before vaccines became available, hepatitis A, rotavirus, rubella, and measles were all major causes of death,” said Parks “But when we compared those diseases to COVID-19, we found that COVID-19 caused substantially more deaths in children and young people than those other diseases did before vaccines became available,” he said. “This demonstrates how seriously we need to take COVID-19 prevention and mitigation measures for the youngest age groups in the US and worldwide.” Image Credits: Photo by Carlynn Alarid on Unsplash. Tedros’ 10-Point Proposal for Reforming Global Emergency Response Gets Mixed Review 30/01/2023 Elaine Ruth Fletcher ‘Cautioning that the Secretariat not to get ahead of member states:’ Loyce Pace, US Assistant Secretary of State for Global Affairs in debate over WHO reform proposal. A new 10-point proposal by the World Health Organization’s Director General Dr Tedros Adhanom Ghebreyesus for improving preparedness and response to health emergencies received mixed reviews from WHO member states in Monday’s opening session of this week’s Executive Board (EB) meeting, the agency’s 34-member governing body. It was the first substantive issue to be tackled in the eight-day long EB meeting packed with an agenda of over 50 draft proposals and resolutions on items ranging from emergency pareparedness and response to non-communicable diseases. Charged management issues, ranging from sustainable finance to the organization’s handline of recent sexual harrassment claims will also be taken up by the EB. The Director General’s 10-point proposal on “strengthening the global architecture for health emergency preparedness, response and resilience” calls for the creation of a new WHO Global Health Emergency Council, which would aim to liaise more efficiently between WHO’s Secretariat and its Member states in health emergencies and outbreaks, and meet during the World Health Assembly. The proposal also calls for massively expanding the size and scope of a WHO Contingency Fund for Emergencies (CFE) to include broad support to member states’ “including deployments through the health emergency workforce and emergency supply chain” of medical products. And the initiative calls for scaling up a system of member state peer reviews of emergency preparedness to increase “transparency”. The WHO proposal synthesizes more than 300 recommendations of several independent panels that reviewed WHO and member state response to the COVID pandemic, the report stated. Initiative raises fears of ‘duplication’, moving ahead of member state negotiations While member states gave positive reviews to the WHO proposal’s overall aims – ensuring more fair, equitable and transparent management of crises – they stressed that concrete reforms are already the focus of two member state fora – and that’s where the discussion should focus. Those include the Intergovernmental Negotiating Board (INB) due to issue a zero draft for a proposed pandemic treaty later this week, as well as another member state working group that will look at more targeted revisions to the circa 2005 International Health Regulations (IHR), the rules currently governing emergency response. Japan joins the UK, USA and China in rare accord that member states should hold reins of emergencies reform wheel at the WHO Executive Board meeting Monday. In a moment of rare agreement between often rival nations – the United Kingdom, China and Japan all expressed hesitations over the creation of a new WHO “Global Health Emergencies Council”, proposed by Tedros, ad meeting during the annual member state World Health Assembly. The UK said it “echoed China’s concerns about being careful about creating new institutions and mechanisms” which might duplicate the work of other bodies. “I think the risk is that there are multiple mechanisms already,” the UK’s EB delegate said, asking. “Do adding new mechanisms add, or do they actually make it more complicated to navigate?” Japan, meanwhile, asked whether it was feasible to create yet another body that convenes during the already packed week-long session of the WHA “unless we have a clear idea of what will be discussed and decided by the council. “Who will be preparing the materials for discussion?” Japan’s EB delegate asked wondering “whether a schedule [of meetings during the WHA] is feasible since we already have Committees A and B?” He was referring to the two main WHA sub-committees in which proposals are debated and decided during the WHA session. Meanwhile, the USA warned against the WHO administration “getting ahead” of member states’ own negotiations over a new Pandemic Treaty, or accord. Those discussions, led by the INB, are already taking up most of the same topics that the WHO Secretariat paper covers, said Loyce Pace, US Assistant Secretary of State for Global Public Affairs. A ‘Zero Draft’ of the pandemic treaty framework is due to be published on Wednesday. “We’re grateful that they have a proposal that draws attention to those negotiations. But we’re still cautioning that the Secretariat not to get ahead of member states in terms of putting forth an architecture that hasn’t yet been agreed, and that would arguably require approval from member states and buy-in from relevant international institutions so they could be operationalized,” Pace said. Ensuring equity as a cross-cutting principle Echoing Brazil Peru says ‘fairness’ needs to be the foundation of reforms. Brazil, likewise, said that the essence of proposals brought forward in document by Tedros and the WHO adminisration is already being debated in the INB and the IHR working groups. “The difference is that this process has been developed in a much more transparent and inclusive way, with clear participation by non-state actors,” said the Brazilian delegate. “Both of these work streams are entering a critical phase this year. Now it’s the time to concentrate our effort to have meaningful debates within those two mechanisms in order to come up with innovative, game changing norms.” He called for the WHO administration proposal to be referred to the IHR and pandemic treaty negotiating bodies “where they can be discussed and fully developed.” Brazil also said that proposals to change the way global emergency response unfolds need to include equitable access to medical countermeasures as a cross-cutting theme, along with “respect and promotion of human rights and racial and gender equity.” Echoing Brazil, Peru added that, “one of the pillars of global architecture when it comes to preparedness and resilience in the face of future health emergencies has to be the principle of fairness.” Revisions to the existing International Health Regulations as well as a new pandemic accord should “allow for a universal universal access to measures such as vaccines, without any privileges or discrimination, and will face challenge questions related to R&D, intellectual property technology transfers, and expanding the manufacturing capacities at the local level …in the context of emergencies,” added the Peruvian EB delegate. African Group – more WHO and donor support to countries Equitable access to health products and more support for WHO country offices – Ethiopia speaks on behalf of the African group of 47 countries at the 152nd session of the WHO Executive Board Meanwhile, Ethiopia, speaking on behalf of the African group of 47 states stressed that in a time when many countries in the region are facing a complex array of climate-related and infectious disease health emergencies, “less than 10% of African countries have adequate human resources with technical emergency know how to prepare, detect and respond to emergencies.” There is also a “large reliance on international funding due to limited capacity to mobilize sustainable and predictable resources domestically.” She called for “stronger support of the WHO country offices in strengthening the IHR capacities,” as part of the solution as well as underlining the importance of “greater coordination across the funding landscape to ensure that existing funding flows are ….targeted to the most critical gaps at the global regional and national level. And that this role should be augmented by additional catalytic gap funding. She also called for a greater role for African representation in the new World Bank -managed pandemic fund, and other governance mechanisms. “We would also appreciate a greater focus on equitable access to health products, technologies and know-how, and as such, funding and capacity incentives for states to report information to the international community to be further explored. Conflicts and Health Emergencies Overshadow WHO Successes as Executive Board Gets Underway 30/01/2023 Kerry Cullinan Dr Tedros opens the WHO executive board meeting. Supporting 100 million tobacco users to quit, increasing exclusive breastfeeding for babies under six months to 48% globally, and helping 63 countries to build climate-resilient health systems are some of the recent successes of the World Health Organization (WHO), said Director General Dr Tedros Adhanom Ghebreyesus. Addressing the opening of the WHO’s executive board (EB) meeting on Monday, Tedros said that the global body was focused on “promoting, providing, protecting, powering and performing for health”. The 152nd session of the Executive Board, which runs until 7 February, has a very heavy agenda – ranging from a series of initiatives to improve global emergency response to an updated menu of WHO-recommended “best buys” to fight non-communicable diseases. The EB’s approval of draft resolutions and decisions is a prerequisite to bringing most proposals before the World Health Assembly (WHA) in May. The EB also plays a watchdog role, vis a vis the 9000-member WHO’s finance and budet planning, advising on strategic directions for the global body’s work. Protecting health during conflicts and humanitarian crises constituted a huge part of the WHO’s work in 2022 as it responded to 72 graded emergencies last year, “including three public health emergencies of international concern, outbreaks of Ebola and cholera, conflicts in Ethiopia, Syria, Ukraine and Yemen, and humanitarian crises in the greater Horn of Africa, the Sahel and much more”, said Tedros. “Thanks to the generosity of donors to the Contingency Fund for Emergencies, we were able to release more than $87 million immediately to support rapid response, and we delivered essential health supplies to 90 countries from our Dubai logistics hub in the United Arab Emirates,” said Tedros. Africa demands an increase in country allocations However, in reaction to the speech, Botswana for African Union called on the WHO to strengthen the African region, and particularly strengthen the region’s WHO country offices, which are historically under-resourced and staffed, so that they can better support national ministries responding to health crises. “We call on the WHO to enhance capacity at the regional and national levels in order to accelerate progress. Currently, the regional office needs both technical and financial support in order to effectively address and support country needs,” said Botswana. While for the first time, over one-half of WHO’s 2024-25 budget has been earmarked for country offices, Botswana called for this to be increased to 75% to “address the budget and funding imbalances”, declaring that this was “a precondition for the increase in assessed contributions” from member states. For many member states’ reacting to Tedros’s speech, Russia’s war in Ukraine loomed large as a huge impediment to global well-being. Demark condemns Russia’s aggression in Ukraine. Russia’s war in Ukraine Denmark, representing the 27 European Union member states and seven aligned countries, said that “nearly 750 attacks on health care have been verified in Ukraine” while the Office of the UN High Commissioner for Human Rights has reported a total of 17,023 casualties in Ukraine”. “Russia’s military aggression has triggered energy and food supply challenges, exacerbating existing food system vulnerabilities that have already been weakened by the effect of climate change and the COVID-19 pandemic. The huge impact of conflict on health and well being of people and societies is the case in all ongoing conflicts across the world.” Canada, the US, the UK and Japan also condemned Russian aggression and its impact on the people of Ukraine and food security. However, in response, Russia warned that “the politicisation of the WHO agenda is unacceptable and this will simply lead to increased inequality and a deterioration of the situation in developing states”. US warning on sexual and reproductive rights US assistant secretary of state for global public affairs Loyce Pace Meanwhile, both the US and Brazil indicated that they would oppose any attacks on sexual and reproductive health and rights. Loyce Pace, US assistant secretary of state for global public affairs, said that the US “prioritises efforts to promote universal health coverage through strengthening primary health care and protecting people from catastrophic spending”. In addition, said Pace, US is focused on “ensuring the health and rights of lesbian, gay, bisexual, transgender, queer and intersex individuals and communities because we will not accept intolerance or discrimination of any people. We look forward to the EB’s discussions in this area”. Last year’s World Health Assembly stalled for hours over the inclusion of phrases such as men who have sex with men in a technical document on HIV, facing significant opposition from countries form the Mediterranean and North Africa (MENA) region of WHO. Brazil backed the US, saying that it too will “work with all the partners to improve the respect for human rights, in particular when it comes to gender and racial equality, sexual and reproductive health and rights”. “We will fight discrimination based on sexual orientation and gender identity and promote the rights of people with disabilities and indigenous peoples. In this regard, I would like to announce our intention to put forward the resolution on the health of indigenous peoples a topic never addressed directly before by the World Health Assembly with the objective of ensuring the right to health according to their own requirements and under their own administration,” said Brazil’s representative. Bringing Neglected Tropical Diseases out of the Silo 30/01/2023 Simon Bland A man with symptoms of the deadly NTD African trypanosomiasis (sleeping sickness), is examined by Dr Victor Kande in the Democratic Republic of Congo (DRC). The number of people requiring treatment for Neglected Tropical Diseases (NTDs) decreased from 2.19 to 1.65 billion between 2010 and 2021 – an impressive 25 percent decline. However, interlinked challenges, including the COVID pandemic and, now, accelerating patterns of climate change are putting this progress at risk. On World NTD Day, we need to recognise these emerging challenges and look to more integrated approaches. The impressive 25 percent decrease in the number of people requiring treatment for NTDs and the mounting number of countries that have eliminated at least one NTD are testimony to the progress being made to stamp out some of the world’s most deadly and debilitating diseases – which strike mostly at communities in developing countries and at people living in poverty. According to the World Health Organization (WHO), 47 countries have eliminated at least one NTD since 2010, and NTD programmes have performed better in the past year than in 2021. But while this progress is admirable, it is too slow for millions of people still living with, or at risk of infection from these 20 viral, parasitic and bacterial diseases considered NTDs which range from river blindness to leprosy, rabies and more, and continue to defy national and global elimination plans in many parts of the world today. Storm clouds on the horizon Moreover, new challenges like the COVID-19 pandemic and climate change are putting recent progress at risk, threatening to reverse the tremendous gains that have been made over the last few years. During the pandemic, services for NTDs were the second most frequently disrupted set of health systems services. Looking ahead, changing temperature and rainfall patterns will exacerbate poverty and displace people, and climate change will influence the emergence and re-emergence of multiple NTDs in higher latitudes and altitudes and pose a major risk for communities. This year’s World NTD Day is an opportunity to revitalise the way we tackle NTDs to not only maintain the progress we achieved so far, but to catalyse better, more efficient, bolder strategies for elimination in the future – harnessing the power of collective action. The climate threat Water shortage in Ethiopia. Population exposure to heat is increasing due to climate change. Globally, extreme temperature events are observed to be increasing in their frequency, duration, and magnitude. This is especially crucial in addressing the added challenges that climate change poses. NTDs are highly influenced by temperature, rainfall, humidity, and other climatic changes, and even small fluctuations can greatly increase transmission and spread, with potentially devastating effects. Climate change is thus threatening the re-emergence of NTDs in many parts of the world and will likely result in negative health outcomes and disruptions to healthcare systems. The threat to progress expands beyond NTDs to other infectious diseases. For malaria alone, studies show that climate change could lead to an additional 60,000 malaria deaths per year between 2030 and 2050. Despite the risks, the world is paying little attention to the climate-health nexus and the impact it could have on the resurgence of NTDs and their transmission. Up until now, approaches to address health and climate emergencies have remained largely separate, perhaps partly due to the lack of knowledge and guidance surrounding the health impact of climate change. The current literature on the intersection between climate and health also is insufficient to guide policy development. This is why countries, world leaders, and all stakeholders involved should prioritise research in this area. By exploring new and under-explored areas of the interface between climate and infectious disease, we can start to tackle the challenge and protect the gains and accelerate progress towards elimination. Removing NTDs from the disease control silo Fulfilling the goal of elimination begins by taking NTDs prevention and control out of isolation and adopting a more integrated approach. At the Global Institute for Disease Elimination (GLIDE) we see the intrinsic value of promoting and adopting cross-disease, cross-border, multi-stakeholder and multi-sector, approaches to innovatively and effectively control, eliminate, and eradicate NTDs. For this to work in global health, we must make way for more integrated healthcare systems that address preventable infectious diseases of poverty. The COVID-19 pandemic has exposed the pre-existing cracks in our healthcare systems, spotlighting the dangerous link between NTDs, other communicable diseases, and health emergencies. It has also reinforced the need to address health issues in a more holistic manner. A stronger, more systems-wide approach to health will strengthen surveillance, early warning, and pandemic preparedness. Mainstreaming NTDs within health systems and primary health care services, and promoting country ownership and accountability is an effective jumping off point, according to WHO’s NTD road map 2021-2023. In fact, this will contribute to sustainable and efficient NTD prevention and control, yielding better health outcomes and program management, and cost-effective solutions. But we must understand the economics of neglected diseases and elimination better in order to develop and refine investment cases in a more holistic way, using the health system and packages of essential health care as an important entry point to this mainstreaming. Water, sanitation and hygiene as a starting point Africa and Asia have the least access to basic sanitation facilities in the whole world Another starting point is to consider cross-sector coordination such as with water, sanitation, and hygiene (WASH) for disease prevention. WHO’s roadmap lays out a plan for effective elimination efforts, citing WASH as one of the key interventions in tackling 18 of the 20 NTDs. Improved access to clean water and sanitation can reduce the transmission of many NTDs, such as schistosomiasis, trachoma and guinea worm which, according to the Centers for DIsease Control and Prevention (CDC), is caused by the parasite Dracunculus medinensis and contracted when people do not have access to safe water for drinking. There is no vaccine or medicine available against guinea worm. However, eradication is being achieved by implementing WASH-related preventive measures. These include filtering drinking water to remove the water fleas that carry the parasite, providing improved water sources and preventing infected individuals from wading or swimming in drinking-water sources. The measures – supplemented by active surveillance and case containment, vector control and provision of improved water sources – have led to great progress toward eliminating guinea worm, with the number of human cases annually falling from 3.5 million in the mid-1980s to just 13 cases in 2022, poising it to become the second disease in human history that could be eradicated altogether, according to a report last week by the Carter Center. Breaking down silos The elimination of NTDs is feasible, but we need new approaches. The upcoming 28th Conference of the Parties (COP28) to the United Nations Framework Convention on Climate Change (UNFCCC), hosted by the United Arab Emirates (UAE) between 30 November and 12 December 2023, will be an opportunity for world leaders to both recognise and commit to addressing the health impacts of climate change. The World Health Assembly’s NTD road map 2021-2030, meanwhile, emphasizes the importance of integrating NTD programs and establishing links with other sectors such as education, nutrition, WASH, animal, and environmental health. We also must increase spending on NTD control and elimination, strengthening the case for investment. There is an intimate connection between the health of individuals and the interlinked, cross-boundary events across the globe. Recognizing this, we need an approach that engages all sectors and geographies in ways that facilitate collaboration, stimulate innovation and continued investment and, finally, by staying committed to delivering a world free of NTDs. ____________________________________ Simon Bland is the CEO of the Global Institute for Disease Elimination (GLIDE), based in the United Arab Emirates (UAE) and focused on accelerating the elimination of four preventable infectious diseases – malaria, polio, lymphatic filariasis, and river blindness – by 2030 and beyond. Founded in 2019 as the result of a collaboration between UAE President, His Highness Sheikh Mohamed bin Zayed Al Nahyan, and the Bill & Melinda Gates Foundation, GLIDE works to elevate awareness and engagement, advance elimination strategies, and foster and scale innovation for disease elimination and eradication. Image Credits: DNDi, Oxfam East Africa, Deep Knowledge Group. Influential WHO Committee Greenlights Initiative for ‘Replenishment Fund’ to Bolster Finance 30/01/2023 Kerry Cullinan Last year’s World Health Assembly mandated the secretariat to look into a replenishment fund. An influential sub-committee of the World Health Organisation (WHO)’s Executive Board (EB) has greenlighted a proposal by the cash-strapped global body’s Secretariat to seek additional funds via a replenishment fund, that would be filled by voluntary donations from both member states and philanthropies recruited at high-profile events. In its report published on Monday just as the WHO’s Executive Board’s began a week-long meeting, the Programme, Budget and Administration Committee (PBAC), accepted that a replenishment fund could provide an avenue for flexible funding that the WHO so desperately needs. “The committee acknowledged WHO’s need for more flexible, predictable and sustainable financing and considered that a replenishment mechanism provided a possible solution, especially for chronically underfunded areas of the organization’s programme budget,” according to the report, which concluded the deliberations of the three-day meeting of the PBAC last week. The Global Fund to fight AIDS, Tuberculosis and Malaria raised $15.7 billion in its ‘replenishment drive’ last year, while Gavi, The Vaccine Alliance as well as the World Bank and other UN-backed global organisations also run replenishment fundraising drives to attract additional funds from donors. Last year’s World Health Assembly mandated the WHO Secretariat to explore a replenishment fund based on six principles, including that it is driven by member states, allows flexibility in allocation, covers the base budget, and aligns with the WHO’s resolutions. Funding crisis The Executive Board is now expected to consider the proposal further this week in a series of discussions on improving WHO’s financial sustainability. A nod by the EB would pave the way for a full-fledged vote by the World Health Assembly in May. At the EB’s opening session on Monday, Director General Dr Tedros Adhanom Ghebreyesus confirmed that he expected that the proposal for a replenishment process would be submitted to member states for consideration. “We recognize that with increased flexibility and sustainability come increased expectations for transparency, efficiency, compliance and accountability. All of this leading to results,” said Tedros. Only around one-fifth of the WHO’s budget comes from members’ countries’ “assessed contributors” (calculated on their GDP), with the rest being made up from donations. But the donations are usually tied to particular programmes, inflexible and can be withdrawn at any time. At last year’s World Health Assembly, member states agreed to increase their contributions to cover half of the WHO’s budget. This year, members’ annual contributions are slated to be increased by around 20%. However, even when member states increase their contributions, there will still be a gaping shortfall, obviously undesirable given disease outbreaks and other demands. Developing the replenishment option Recommending that the executive board accepts the replenishment mechanism, the PBAC has advised the secretariat to develop the proposal further by examining “replenishment mechanisms established by other global health organizations and [analysing] the advantages and disadvantages of the various systems”. It also recommended that the “funding envelope for a replenishment mechanism should be based on the base segment of the programme budget, minus approved assessed contributions”. Still up for discussion is whether the fund will be based on the budget over one (two-year) budget cycle or two (four-year). More money for country offices PBAC has also recommended that the WHO secretariat consider further increases to its country operations rather than head office and regional structures. However, while the secretariat confirmed its commitment to strengthen country offices, it said that this would only be possible “gradually over time”. The WHO secretariat told PBAC that the main reason for the uneven financing of its programmes was “the extremely tight earmarking of the funds it received”. Director-General Dr Tedros Adhanom Ghebreyesus told the committee that member states’ agreement to an increase in assessed contributions would “make all the difference”. In response, the committee proposed that the Secretariat should “improve the persistent uneven financing across programmes, major offices and levels of the organization, including by distributing undistributed funds”. As far as the 2024/25 WHO budget is concerned, PBAC has recommended that member states should have until 10 February “to study and provide feedback on the programme budget digital platform” to allow proper consideration of the proposed budget ahead of the World Health Assembly in May. It’s Still a Pandemic: WHO Advisers and Chief Concur 30/01/2023 John Heilprin A healthcare worker wearing PPE disinfecting a street in the early days of the COVID-19 pandemic. The World Health Organization’s Emergency Committee on the COVID-19 pandemic and Director General Dr Tedros Adhanom Ghebreyesus both agree: the event continues to constitute a public health emergency of international concern (PHEIC). The UN health agency agreed on Monday that ending the state of international public health emergency over the coronavirus would be premature even after three long years since its appearance upended the world of normality as we knew it three years ago. Tedros said in a statement that he concurs with the advice offered by committee in its report based on a closed videoconference on Friday. He acknowledged the committee’s views that the COVID-19 pandemic is “probably at a transition point” that must be navigated carefully while ensuring the world is able to mitigate the potential negative consequences. “Achieving higher levels of population immunity globally, either through infection and/or vaccination, may limit the impact of SARS-CoV-2 on morbidity and mortality, but there is little doubt that this virus will remain a permanently established pathogen in humans and animals for the foreseeable future,” the committee reported. “As such, long-term public health action is critically needed,” it said. “While eliminating this virus from human and animal reservoirs is highly unlikely, mitigation of its devastating impact on morbidity and mortality is achievable and should continue to be a prioritized goal.” Personal protective equipment was essential to protect healthcare workers during the pandemic Seven pandemic recommendations As a result of his decision, Tedros advised nations to: Maintain momentum for COVID-19 vaccination to achieve 100% coverage of high-priority groups. Improve reporting of SARS-CoV-2 surveillance data to WHO Increase uptake and ensure long-term availability of medical countermeasures. Maintain strong national response capacity and prepare for future events Continue working with communities and their leaders to address the infodemic Continue to adjust any remaining international travel-related measures and do not require proof of vaccination for international travel Continue to support research for improved vaccines that reduce transmission and have broad applicability The committee said moving forward past the PHEIC will require a focused commitment by WHO and its 194 member nations, along with other international organizations, put in place “systematic, long-term prevention, surveillance, and control action plans.” The committee members, whose statement comes on the three-year anniversary of the determination of the COVID-19 PHEIC in January 2020, said it agreed the world is in a better position than it was during the peak of the Omicron transmission a year ago, yet more than 170,000 COVID-19-related deaths have been reported globally in the past eight weeks. It agreed surveillance and genetic sequencing declined globally, making it more harder to track known variants and detect new ones, while health systems are struggling with COVID-19 and caring for patients with influenza and respiratory syncytial virus (RSV), health workforce shortages, and fatigued health workers. Investment in strong health systems is key to pandemic=proofing the world. WHO asked to study impact of ending pandemic Vaccines, therapeutics, and diagnostics have been and remain critical in preventing severe disease, saving lives and taking the pressure off health systems and health workers globally, it said, but “the COVID-19 response remains hobbled in too many countries unable to provide these tools to the populations most in need, older people and health workers.” Some 13.1 billion doses of COVID-19 vaccines have been administered, with 89% of health workers and 81% of adults older than 60 years completing the primary series, WHO said. “COVID-19 remains a dangerous infectious disease with the capacity to cause substantial damage to health and health systems,” the committee said, adding that has asked the WHO Secretariat to provide an assessment of the regulatory implications for developing and authorizing vaccines, diagnostics, and therapeutics if the PHEIC were ended sometime “in the coming months.” Image Credits: Photo by Maksym Kaharlytskyi on Unsplash, Tehran Heart Centre . WHO Experts Confer on Possible End to COVID International Health Emergency 27/01/2023 Elaine Ruth Fletcher WHO Director General Dr Tedros Adhanom Gehebreyesus (left) and Didier Houssin, chair of the WHO Emergency Committee. on 30 January 2020, when the COVID International Health Emergency was first declared. The World Health Organization’s Emergency Committee on the COVID-19 pandemic was meeting Friday evening – with mixed signals emerging about whether the expert advisory group would recommend that the global health agency end the state of international public health emergency over the virus whose emergence stunned the world a little more than three years ago. At a press conference in December 2022, WHO’s Director General Dr Tedros Adhanom Ghebreyesus expressed hopes that the emergency that he first declared on 30 January, 2020, under WHO’s International Health Regulations, could finally be concluded sometime in 2023. But in his remarks to the Emergency Committee’s 14th meeting, the WHO Director General hinted for a second time this week that the time may not yet be ripe – as cases of new infection increased again worldwide only recently and a new wave of the virus continues to rip through China shortly after strict lockdown policies were finally relaxed. “As we enter the fourth year of the pandemic, we are certainly in a much better position now than we were a year ago, when the Omicron wave was at its peak, and more than 70,000 deaths were being reported to WHO each week,” said Tedros in his remarks at the closed meeting, reported by WHO in a press release. “When you last met in October, the number of weekly reported deaths was near the lowest since the pandemic began – less than 10,000 a week,” he added. “However, since the beginning of December, the number of weekly reported deaths globally has been rising.” China trends create a second level of concerns Following a massive wave of protests in autumn 2022, China lifted most of its COVID restrictions – which had been among the strictest in the world. In addition, Tedros noted, the lifting of COVID restrictions in China has led to a spike in deaths in the world’s most populous nation, whose citizens were poorly protected by vaccinations as well as having low natural immunity thanks to months of social isolation. “Last week, almost 40 thousand deaths were reported to WHO, more than half of them from China,” Tedros said. “In total, over the past eight weeks, more than 170,000 deaths have been reported. The actual number is certainly much higher.” Earlier this week, Tedros also expressed his mixed feelings about declaring an end to the pandemic even more bluntly, saying: “While I will not preempt the advice of the emergency committee, I remain very concerned by the situation in many countries and the rising number of deaths,” he said, speaking at WHO’s weekly press briefing. “While we’re clearly in better shape than three years ago when this pandemic first hit, the global collective response is once again under strain.” In fact, after reaching a peak in mid-December, the wave of new cases in China and worldwide have been declining for the past month – both according to WHO data and other data monitoring platforms. However, in light of the reduced amount of COVID testing worldwide, the confirmed case count is an increasingly unreliable measure of true cases. “Surveillance and genetic sequencing have declined dramatically around the world, making it more difficult to track known variants and detect new ones,” Tedros told the committee at the outset of Friday’s meeting. Revolution in vaccines, treatments and diagnostics has not reached everyone Related to that, the global response to COVID remains “hobbled” because “powerful, life-saving tools are still not getting to the population that need them most – especially older people and health workers, Tedros said. “Many health systems around the world are struggling to cope with COVID-19, on top of caring for patients with other diseases including influenza and RSV, and with work shortages and fatigued health workers. “And public trust in the safe and effective tools for controlling COVID-19 is being undermined by a continuous torrent of mis- and disinformation.” It was unclear as to whether the committee’s deliberations would continue into the weekend, or when their conclusions will finally be announced. However, there was speculation that their report might only be published on Monday, when the WHO Executive Board, WHO’s governing body, begins its first annual round of meetings for 2023. Among the nearly 50 items on the week-long agenda are a raft of reports and recommendations on strengthening global preparedness and response to health emergencies. The WHO Public Health Emergency of International Concern (PHEIC) was declared in the framework of the 2005 International Health Regulations, which constitute a legally binding agreement between WHO member states regarding emergency outbreak and response. In March 2020, Tedros also declared that the emergency also constituted a “pandemic” – although there is in fact no legal provision for a pandemic declaration in the IHR. However, the weaknesses in the IHR system of outbreak alerts, notification and resonses, highlighted by the faltering and inconsistent reponse to the COVID pandemic, have paved the way for major reconsideration of global pandemic response frameworks, with debates over a new pandemic treaty, as well as IHR revisions, set to continue throughout 2023 and into 2024. See related story here: Governing Pandemics Snapshot Image Credits: Twitter: @WHO. WHO Provides New Medicines List, Policy Recommendations for Nuclear Emergency 27/01/2023 Maayan Hoffman A Nuclear powerplant in Belgium. The World Health Organization (WHO) on Friday released an updated list of medicines that should be stockpiled in the event of a radiological and nuclear emergency, along with new policy advice in the event of such an incident. “Preparedness for radiation emergencies is consistently reported as the weakest area of preparedness in many countries,” the 66-page report said. This newest report updates the one released over 15 years ago, in 2007, and thus includes a host of new pharmaceutical developments. “In radiation emergencies, people may be exposed to radiation at doses ranging from negligible to life-threatening. Governments need to make treatments available for those in need – fast,” said Dr Maria Neira, WHO Acting Assistant Director-General of the Healthier Populations Division. “It is essential that governments are prepared to protect the health of populations and respond immediately to emergencies. This includes having ready supplies of lifesaving medicines that will reduce risks and treat injuries from radiation.” Added Dr Mike Ryan, Executive Director of WHO’s Health Emergencies Programme: “This updated critical medicines list will be a vital preparedness and readiness tool for our partners to identify, procure, stockpile and deliver effective countermeasures in a timely fashion to those at risk or exposed in these events.” Radiological or nuclear emergencies could occur at nuclear power plants, medical or research facilities or be the result of accidents during transport of radioactive materials, WHO explained. In addition, these emergencies could be the result of a malicious event, such as a nuclear bombing. To date, there were two massive nuclear incidents: The 1945 atomic bombings of Hiroshima and Nagasaki by the United States, the consequences of which have been continually studied. There was also the 1986 accident at the Chernobyl nuclear plant in Ukraine – the largest uncontrolled radioactive release in history. Former Russian President Dmitry Medvedev warned this month in yet another Telegram post that a defeat of Russia in Ukraine could trigger a nuclear war. “The defeat of a nuclear power in a conventional war may trigger a nuclear war,” Medvedev wrote. Exposure to high doses of radiation can have severe consequences on a person’s long-term health or lead to immediate or early death. As such, aside from generic supplies and materials used for any type of emergencies, stockpiles should include medicines that either prevent or reduce exposure to radiation, WHO explained. Only a handful of recommended medicines There are only a handful of specific drugs that have been proven effective in the treatment of over-exposure to radiation and these are included in the report. They include: stable iodine; chelating sand (decorporating agents); cytokines used for mitigation of damage to the bone marrow; and medicines to treat vomiting, diarrhea and infections. “One of the most serious outcomes of over-exposure to radiation is acute radiation syndrome (ARS), which manifests as a haematopoietic syndrome”. The latter, also called bone marrow syndrome, impacts blood cell production and in cases of acute poisoning, can lead to death through infection or hemorrhage. “Depending on the severity of the exposure may further progress as gastrointestinal, cardiovascular and neurological syndromes,” the report states. However, the WHO recommendations only include treatments of haematopoietic and gastrointestinal syndromes, “as cardiovascular and neurological syndromes are considered non-salvageable and require only palliative care.” Blocking agents such as stable iodine, could be used to block the uptake of radionuclides in the body, the WHO report added. Other agents like Prussian blue are applied to remove radioactive ceasium from the body. Calcium or zinc diethylenetriaminepentaacetic acid can treat internal contamination with transuranium radionuclides. “These and other elements of such stockpiles should be made rapidly available in case of radiation emergencies,” wrote WHO. Bone marrow syndrome – emerging treatments In the case of haematopoietic, or bone marrow syndrome, radiation attacks all three blood lineages – white and red blood cells and platelets. Low white blood cell count weakens the immune system, making an individual vulnerable to infection. Red blood cells carry oxygen to the body and platelets are responsible for coagulation, which prevents bleeding, explained Yaky Yanay, CEO and president of Pluri – an Israeli-based biotech firm developing an injection of placenta cells for the treatment of ARS. The treatment has been approved by the United States Food and Drug Administration as an “Investigational New Drug” (IND) for use in the event of a nuclear incident – although it is not yet mature enough to be considered for the WHO list of recommended medicines. The WHO report notes, however, that researchers are making progress on developing novel treatments, although none of them have been approved by the global health agency for use in a nuclear emergency. WHO: Stockpile based on population size WHO stressed that a country’s nuclear medicines stockpile should be based on reliable data for national risk profiles, the size of the population and available resources and capabilities of their health system. Finally, WHO called on national health authorities, health-care facilities, pharmaceutical suppliers and logistics, civil defense and emergency services to be leveraged in the event of an emergency. These teams should be coordinated in advance to be able to function effectively in the event of a nuclear incident. Image Credits: Photo by Frédéric Paulussen on Unsplash. Governing Pandemics Snapshot 27/01/2023 Gian Luca Burci, Suerie Moon, Daniela Morich, Adam Strobeyko & Seyed-Moeen Hosseinalipour Standing ovation at the close of the special World Health Assembly session 1 December 2021, in which member states agreed to negotiate a new pandemic accord. A briefing series on the status of moves to reform the global system of pandemic preparedness and response launches today, just ahead of the WHO Executive Board review of progress next week. Looking back at 2022 and forward into 2023, this series by the Global Health Center of the Geneva Graduate Institute, published in collaboration with Health Policy Watch, provides an update on the progress so far in the WHO-led negotiations over a new pandemic treaty. It also looks at the progress in revisions to the existing emergency rules of the International Health Regulations (IHR) – while considering what could happen next. The complete “Governing Pandemics Snapshot”, also includes briefings on reforms being considered in the financing of pandemics as well as the rules around pathogen access and benefit-sharing. Pandemic treaty: tough political negotiations ahead By Daniela Morich Following a milestone World Health Assembly decision in late 2021, WHO Member States have been negotiating an international agreement on pandemic prevention, preparedness and response to strengthen global capacities and resilience for future pandemics. The year 2022 was the year for the advance of these pandemic treaty talks with the establishment of a formal process, a strict timeline, and initial discussions on principles. In 2023, negotiations will shift from broad consultations to tough politics. The Covid-19 pandemic brought to the surface the shortcomings of global health governance for emergencies and accelerated discussions to reform it. At a special WHA session in late 2021, the second-ever convened by the World Health Assembly, WHO Member States agreed to establish an intergovernmental negotiating body (INB) to negotiate a new “instrument” to strengthen pandemic prevention, preparedness and response – or, a pandemic treaty. The INB initiated its work in early 2022 and is to present the outcome of the negotiations to the 77th World Health Assembly (WHA) in May 2024. This is an ambitious timeline for a complex international rule-making process, especially as it will run in parallel to the process to revise the International Health Regulations (IHR), a pre-existing WHO instrument that governs the cross-border spread of infectious disease. Nonetheless, the INB is moving forward and achieved two mid-term milestones in 2022. In July, at the second INB meeting, Member States agreed that the instrument should be legally binding, which suggests countries are ready to accept new international obligations to improve pandemic prevention and response. In addition, the INB engaged in intensive intersessional consultations to seek input not only from governments or well-established experts – the traditional protagonists of international rulemaking – but also from civil society organizations and the public. Despite these efforts, commentators have argued that the process is still not as inclusive as it should be. As work on the instrument progresses, negotiators should expect more demands to expand meaningful participation of stakeholders beyond governments. The INB’s Bureau (six countries elected to lead the process) released the ‘conceptual zero draft’ (CZD) ahead of the third meeting of the INB, which took place in December 2022. The CZD –which can be seen as the first rough draft of the accord – brought to the negotiating table a broad set of issues and highlighted a collective willingness to ensure a more equitable response to future threats. It also reflected tough divisions on several issues, in particular, intellectual property (IP), pathogen- and benefit- sharing, One Health, financing and accountability, which will likely become more visible and contentious as negotiations move to the next phase. At the conclusion of the gathering, Member States directed the INB Bureau to develop the ‘zero draft’. Delegates strongly encouraged the Bureau to move away from the vague and aspirational language of the CZD and to present clear legal provisions and definitions, including one for ‘pandemic’, for Member States to negotiate in earnest. The INB Bureau is expected to circulate the zero draft in early February 2023. At this stage, the negotiation process will likely shift from a consultation and information gathering process to become a more politicized, polarized and consequential debate. The time available to negotiators is constrained. The 2023-2024 agenda includes 6 additional INB meetings scheduled over 14 months in addition to meetings of the drafting groups, with the IHR revision process unfolding in parallel. Considering the complexity of the issues on the table, the existing divisions between Member States, and the limited time available to negotiators, achieving meaningful progress in this new highly-political phase is the tall order for 2023. An existential moment for the International Health Regulations Dr Hiroki Nakatani, chairman of the May World Health Assembly, applauds the WHA decision to revise the International Health Regulations. By Gian Luca Burci While negotiations on a new pandemic instrument continue in 2023-24, the International Health Regulations (IHR) remain the sole global legally-binding instrument devoted to the prevention and control of the international spread of disease – and revisions to those are already underway. Can the two parallel processes complement each other or will they add new layers of confusion? That is the challenge negotiators and member states will face. Although considered an essential component of the global health security toolbox, the IHR attracted severe criticism and allegedly low compliance during the COVID-19 pandemic. The momentum towards a new “pandemic treaty”, beginning in late 2020, was in part a reaction to the perceived weaknesses and limitations of the IHR. The difficult and sometimes confusing discussions in the Working Group on strengthening WHO preparedness and response to health emergencies created by the 74th World Health Assembly in 2021 to discuss reforms, ultimately led to a WHA decision in December 2021 to launch negotiations on a new legal instrument (“pandemic treaty”) to be adopted by 2024. Then, in 2022, attention turned back to the IHR as member states sought faster solutions for the most burning issues that had surfaced during the pandemic – particularly around outbreak reporting and IHR compliance. As a result, a complex IHR amendment process is also now underway. The two processes (IHR revisions and pandemic accord) are thus now proceeding in parallel, with hard decisions still to be made on the issues that the revised IHR will tackle – as compared to the new pandemic accord. Negotiations to amend the IHR in 2023/2024 raise an existential question about their raison d’etre: should they retain their technical, operational character, or expand significantly to address highly political questions such as those on international assistance, equity and access to technologies for disease outbreaks? The US broke the ice by proposing its own substantial set of amendments in January 2022, and successfully winning agreement at the 75th WHA in May 2022, to both adopt a set of limited technical IHR amendments and to open up a broader process for further amendments. The WHA thus launched negotiations towards “targeted amendments” of the IHR with the same 2024 deadline for WHA adoption as the new pandemic accord. Member States submitted their proposed amendments by 30 September 2022 and an expert “review committee” analyzed them and presented its recommendations to the Director-General in January 2023. A Working Group open to all Member States will work from February 2023 towards a negotiated package. The process is unusual compared to other intergovernmental negotiations, in that states hardly ever place on the table all their proposed amendments at the outset; the initial US disclosure of all its amendments, however, required a similar treatment for other states and made that approach inevitable. Wildly diverse amendments but a few trends emerge A patchwork of national rules around international travel, vaccines and border controls were a feature of the COVID pandemic, highlighting the inconsistent application of key IHR provisions aimed at ensuring international trade and travel during health emergencies. The outcome of the first phase of this process is a massive aggregation of wildly diverse amendments (available here) proposed or supported by almost 100 states. They range from focused technical amendments to far-reaching changes. Despite their diversity, a few trends emerge dividing Global South and Global North countries. The most political proposals, coming in particular from the African Region, Bangladesh and India, aim at ensuring equitable access to vaccines, distributed manufacturing capacities, technology transfer, limitations on patenting and sustainable financing of national capacities. These proposals reflect the North-South divide that we have been witnessing in the recent treaty conferences on climate change and biodiversity and are clearly also a consequence of the inequities in access to life-saving medical countermeasures displayed during the COVID-19 pandemic. Other proposals, in particular from the European Union, the Eurasian Economic Union (submitted by the Russian Federation) and the United States, aim at strengthening the IHR within their current approach, e.g. by tightening compliance and accountability for information sharing, encouraging the sharing of genetic sequence data and through the use of digital technologies. Two negotiating processes unfolding at the same time The challenge in reaching an agreed package in time for the 2024 WHA is increased by the unprecedented parallel unfolding of two negotiating processes with the same timeline, where countries will probably submit the same types of proposals for both instruments to secure an overall favorable outcome. An important point in this respect that is often overlooked is that amendments to the IHR will in principle enter into force at the same time for all its 196 parties, whereas the pandemic instrument – since it will likely be an international treaty – will enter into force once a critical mass of countries has ratified it and only for them, with new countries joining once they ratify. The broad range of proposals for the pandemic instrument and the likelihood that the US will eventually not ratify it may actually lead Global South countries to prioritize the IHR for some of the most ambitious proposals. This possibility raises one final issue. Currently, the IHR is essentially an operational instrument to coordinate outbreak prevention and control and depoliticize WHO’s role in managing them. There is no emphasis on equity, assistance or international cooperation. Amendments proposed by Global South countries would transform it into a regulatory and transactional instrument with a more political role for WHO and differential treatment for developing countries to improve equity in the availability of health technologies. Fundamentally, negotiators will have to decide what they want the IHR to be – and if the IHR is expanded to encompass the issues of health equity then what role would the new pandemic instrument play? For essays on financing pandemics and pathogen and benefit sharing, see the full Governing Pandemics Snapshot here. This is the first in a periodic series of updates to be published during the year. About the authors Daniela Morich is Manager and Adviser of the Governing Pandemics initiative at the Global Health Centre, and a lawyer with experience in multilateral negotiations. Dr Gian Luca Burci is Adjunct Professor of International Law at the Geneva Graduate Institute. He was a member of the IHR Review Committee that completed its expert analysis of the proposed IHR amendments in January 2023. He co-leads the Governing Pandemics initiative. Dr Suerie Moon is Professor of Practice and Co-Director of the Global Health Centre, and co-leads the Governing Pandemics initiative. Adam Strobeyko is a Hauser Global Fellow at NYU Law and was a Doctoral Researcher for the Governing Pandemics initiative. Moeen Hosseinalipour is a master’s student in global health and international affairs at the University of Geneva and Geneva Graduate Institute, and a research assistant for the Governing Pandemics initiative. Image Credits: Geneva Graduate Institute. Posts navigation Older postsNewer posts This site uses cookies to help give you the best experience on our website. Cookies enable us to collect information that helps us personalise your experience and improve the functionality and performance of our site. 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Oxford Study: COVID-19 Significant Cause of Death in US Children And Youth 31/01/2023 Megha Kaveri Youth masked up as COVID-19 pandemic hit the world. A new study found COVID-19 has emerged as a leading cause of death in children and young people in the US, ranking eighth overall between August 2021 and July 2022. The Oxford University study determined that COVID-19 was the underlying cause of death for more than 940,000 people in the US, including over 1,300 deaths among children and young people up to 19 years of age. Until now, the study concluded, it had been unclear how the burden of deaths from COVID-19 compared with other leading causes of deaths in this age group. Using data from the US Centers for Disease Control and Prevention (US CDC), researchers found that infants aged less than a year were the most vulnerable with a mortality rate of four per 100,000. Deaths in children and infants were particularly high during the Delta and Omicron waves of COVID-19. Among the studied group of children and young people, COVID-19 ranked first in deaths caused by infectious or respiratory diseases. In the category of disease-related causes of death, COVID-19 ranked fifth overall. Among all causes of death, it ranked eighth. COVID-19 also was the underlying cause for 2% of deaths in children and youth in the US, putting it ahead of influenza and pneumonia as a factor in mortality. “These results demonstrate that while it’s rare for kids and teens to die in the US, COVID-19 is now the leading underlying cause of death from infectious disease for this age group,” said Dr Seth Flaxman, the study’s lead author. “Many of the 82 million American children and young people were infected during the big Delta and Omicron waves,” he said, “and as a result, more than 1,300 children and young people have died from COVID-19 during the pandemic, most in the last two years.” Explaining the seriousness of the issue, Dr Robbie M. Parks, a co-author of the study, said that the deaths in children and youths due to COVID-19 is higher than the deaths caused by a few other diseases before vaccines became available. “If you look at infectious diseases in children in the US historically, in the period before vaccines became available, hepatitis A, rotavirus, rubella, and measles were all major causes of death,” said Parks “But when we compared those diseases to COVID-19, we found that COVID-19 caused substantially more deaths in children and young people than those other diseases did before vaccines became available,” he said. “This demonstrates how seriously we need to take COVID-19 prevention and mitigation measures for the youngest age groups in the US and worldwide.” Image Credits: Photo by Carlynn Alarid on Unsplash. Tedros’ 10-Point Proposal for Reforming Global Emergency Response Gets Mixed Review 30/01/2023 Elaine Ruth Fletcher ‘Cautioning that the Secretariat not to get ahead of member states:’ Loyce Pace, US Assistant Secretary of State for Global Affairs in debate over WHO reform proposal. A new 10-point proposal by the World Health Organization’s Director General Dr Tedros Adhanom Ghebreyesus for improving preparedness and response to health emergencies received mixed reviews from WHO member states in Monday’s opening session of this week’s Executive Board (EB) meeting, the agency’s 34-member governing body. It was the first substantive issue to be tackled in the eight-day long EB meeting packed with an agenda of over 50 draft proposals and resolutions on items ranging from emergency pareparedness and response to non-communicable diseases. Charged management issues, ranging from sustainable finance to the organization’s handline of recent sexual harrassment claims will also be taken up by the EB. The Director General’s 10-point proposal on “strengthening the global architecture for health emergency preparedness, response and resilience” calls for the creation of a new WHO Global Health Emergency Council, which would aim to liaise more efficiently between WHO’s Secretariat and its Member states in health emergencies and outbreaks, and meet during the World Health Assembly. The proposal also calls for massively expanding the size and scope of a WHO Contingency Fund for Emergencies (CFE) to include broad support to member states’ “including deployments through the health emergency workforce and emergency supply chain” of medical products. And the initiative calls for scaling up a system of member state peer reviews of emergency preparedness to increase “transparency”. The WHO proposal synthesizes more than 300 recommendations of several independent panels that reviewed WHO and member state response to the COVID pandemic, the report stated. Initiative raises fears of ‘duplication’, moving ahead of member state negotiations While member states gave positive reviews to the WHO proposal’s overall aims – ensuring more fair, equitable and transparent management of crises – they stressed that concrete reforms are already the focus of two member state fora – and that’s where the discussion should focus. Those include the Intergovernmental Negotiating Board (INB) due to issue a zero draft for a proposed pandemic treaty later this week, as well as another member state working group that will look at more targeted revisions to the circa 2005 International Health Regulations (IHR), the rules currently governing emergency response. Japan joins the UK, USA and China in rare accord that member states should hold reins of emergencies reform wheel at the WHO Executive Board meeting Monday. In a moment of rare agreement between often rival nations – the United Kingdom, China and Japan all expressed hesitations over the creation of a new WHO “Global Health Emergencies Council”, proposed by Tedros, ad meeting during the annual member state World Health Assembly. The UK said it “echoed China’s concerns about being careful about creating new institutions and mechanisms” which might duplicate the work of other bodies. “I think the risk is that there are multiple mechanisms already,” the UK’s EB delegate said, asking. “Do adding new mechanisms add, or do they actually make it more complicated to navigate?” Japan, meanwhile, asked whether it was feasible to create yet another body that convenes during the already packed week-long session of the WHA “unless we have a clear idea of what will be discussed and decided by the council. “Who will be preparing the materials for discussion?” Japan’s EB delegate asked wondering “whether a schedule [of meetings during the WHA] is feasible since we already have Committees A and B?” He was referring to the two main WHA sub-committees in which proposals are debated and decided during the WHA session. Meanwhile, the USA warned against the WHO administration “getting ahead” of member states’ own negotiations over a new Pandemic Treaty, or accord. Those discussions, led by the INB, are already taking up most of the same topics that the WHO Secretariat paper covers, said Loyce Pace, US Assistant Secretary of State for Global Public Affairs. A ‘Zero Draft’ of the pandemic treaty framework is due to be published on Wednesday. “We’re grateful that they have a proposal that draws attention to those negotiations. But we’re still cautioning that the Secretariat not to get ahead of member states in terms of putting forth an architecture that hasn’t yet been agreed, and that would arguably require approval from member states and buy-in from relevant international institutions so they could be operationalized,” Pace said. Ensuring equity as a cross-cutting principle Echoing Brazil Peru says ‘fairness’ needs to be the foundation of reforms. Brazil, likewise, said that the essence of proposals brought forward in document by Tedros and the WHO adminisration is already being debated in the INB and the IHR working groups. “The difference is that this process has been developed in a much more transparent and inclusive way, with clear participation by non-state actors,” said the Brazilian delegate. “Both of these work streams are entering a critical phase this year. Now it’s the time to concentrate our effort to have meaningful debates within those two mechanisms in order to come up with innovative, game changing norms.” He called for the WHO administration proposal to be referred to the IHR and pandemic treaty negotiating bodies “where they can be discussed and fully developed.” Brazil also said that proposals to change the way global emergency response unfolds need to include equitable access to medical countermeasures as a cross-cutting theme, along with “respect and promotion of human rights and racial and gender equity.” Echoing Brazil, Peru added that, “one of the pillars of global architecture when it comes to preparedness and resilience in the face of future health emergencies has to be the principle of fairness.” Revisions to the existing International Health Regulations as well as a new pandemic accord should “allow for a universal universal access to measures such as vaccines, without any privileges or discrimination, and will face challenge questions related to R&D, intellectual property technology transfers, and expanding the manufacturing capacities at the local level …in the context of emergencies,” added the Peruvian EB delegate. African Group – more WHO and donor support to countries Equitable access to health products and more support for WHO country offices – Ethiopia speaks on behalf of the African group of 47 countries at the 152nd session of the WHO Executive Board Meanwhile, Ethiopia, speaking on behalf of the African group of 47 states stressed that in a time when many countries in the region are facing a complex array of climate-related and infectious disease health emergencies, “less than 10% of African countries have adequate human resources with technical emergency know how to prepare, detect and respond to emergencies.” There is also a “large reliance on international funding due to limited capacity to mobilize sustainable and predictable resources domestically.” She called for “stronger support of the WHO country offices in strengthening the IHR capacities,” as part of the solution as well as underlining the importance of “greater coordination across the funding landscape to ensure that existing funding flows are ….targeted to the most critical gaps at the global regional and national level. And that this role should be augmented by additional catalytic gap funding. She also called for a greater role for African representation in the new World Bank -managed pandemic fund, and other governance mechanisms. “We would also appreciate a greater focus on equitable access to health products, technologies and know-how, and as such, funding and capacity incentives for states to report information to the international community to be further explored. Conflicts and Health Emergencies Overshadow WHO Successes as Executive Board Gets Underway 30/01/2023 Kerry Cullinan Dr Tedros opens the WHO executive board meeting. Supporting 100 million tobacco users to quit, increasing exclusive breastfeeding for babies under six months to 48% globally, and helping 63 countries to build climate-resilient health systems are some of the recent successes of the World Health Organization (WHO), said Director General Dr Tedros Adhanom Ghebreyesus. Addressing the opening of the WHO’s executive board (EB) meeting on Monday, Tedros said that the global body was focused on “promoting, providing, protecting, powering and performing for health”. The 152nd session of the Executive Board, which runs until 7 February, has a very heavy agenda – ranging from a series of initiatives to improve global emergency response to an updated menu of WHO-recommended “best buys” to fight non-communicable diseases. The EB’s approval of draft resolutions and decisions is a prerequisite to bringing most proposals before the World Health Assembly (WHA) in May. The EB also plays a watchdog role, vis a vis the 9000-member WHO’s finance and budet planning, advising on strategic directions for the global body’s work. Protecting health during conflicts and humanitarian crises constituted a huge part of the WHO’s work in 2022 as it responded to 72 graded emergencies last year, “including three public health emergencies of international concern, outbreaks of Ebola and cholera, conflicts in Ethiopia, Syria, Ukraine and Yemen, and humanitarian crises in the greater Horn of Africa, the Sahel and much more”, said Tedros. “Thanks to the generosity of donors to the Contingency Fund for Emergencies, we were able to release more than $87 million immediately to support rapid response, and we delivered essential health supplies to 90 countries from our Dubai logistics hub in the United Arab Emirates,” said Tedros. Africa demands an increase in country allocations However, in reaction to the speech, Botswana for African Union called on the WHO to strengthen the African region, and particularly strengthen the region’s WHO country offices, which are historically under-resourced and staffed, so that they can better support national ministries responding to health crises. “We call on the WHO to enhance capacity at the regional and national levels in order to accelerate progress. Currently, the regional office needs both technical and financial support in order to effectively address and support country needs,” said Botswana. While for the first time, over one-half of WHO’s 2024-25 budget has been earmarked for country offices, Botswana called for this to be increased to 75% to “address the budget and funding imbalances”, declaring that this was “a precondition for the increase in assessed contributions” from member states. For many member states’ reacting to Tedros’s speech, Russia’s war in Ukraine loomed large as a huge impediment to global well-being. Demark condemns Russia’s aggression in Ukraine. Russia’s war in Ukraine Denmark, representing the 27 European Union member states and seven aligned countries, said that “nearly 750 attacks on health care have been verified in Ukraine” while the Office of the UN High Commissioner for Human Rights has reported a total of 17,023 casualties in Ukraine”. “Russia’s military aggression has triggered energy and food supply challenges, exacerbating existing food system vulnerabilities that have already been weakened by the effect of climate change and the COVID-19 pandemic. The huge impact of conflict on health and well being of people and societies is the case in all ongoing conflicts across the world.” Canada, the US, the UK and Japan also condemned Russian aggression and its impact on the people of Ukraine and food security. However, in response, Russia warned that “the politicisation of the WHO agenda is unacceptable and this will simply lead to increased inequality and a deterioration of the situation in developing states”. US warning on sexual and reproductive rights US assistant secretary of state for global public affairs Loyce Pace Meanwhile, both the US and Brazil indicated that they would oppose any attacks on sexual and reproductive health and rights. Loyce Pace, US assistant secretary of state for global public affairs, said that the US “prioritises efforts to promote universal health coverage through strengthening primary health care and protecting people from catastrophic spending”. In addition, said Pace, US is focused on “ensuring the health and rights of lesbian, gay, bisexual, transgender, queer and intersex individuals and communities because we will not accept intolerance or discrimination of any people. We look forward to the EB’s discussions in this area”. Last year’s World Health Assembly stalled for hours over the inclusion of phrases such as men who have sex with men in a technical document on HIV, facing significant opposition from countries form the Mediterranean and North Africa (MENA) region of WHO. Brazil backed the US, saying that it too will “work with all the partners to improve the respect for human rights, in particular when it comes to gender and racial equality, sexual and reproductive health and rights”. “We will fight discrimination based on sexual orientation and gender identity and promote the rights of people with disabilities and indigenous peoples. In this regard, I would like to announce our intention to put forward the resolution on the health of indigenous peoples a topic never addressed directly before by the World Health Assembly with the objective of ensuring the right to health according to their own requirements and under their own administration,” said Brazil’s representative. Bringing Neglected Tropical Diseases out of the Silo 30/01/2023 Simon Bland A man with symptoms of the deadly NTD African trypanosomiasis (sleeping sickness), is examined by Dr Victor Kande in the Democratic Republic of Congo (DRC). The number of people requiring treatment for Neglected Tropical Diseases (NTDs) decreased from 2.19 to 1.65 billion between 2010 and 2021 – an impressive 25 percent decline. However, interlinked challenges, including the COVID pandemic and, now, accelerating patterns of climate change are putting this progress at risk. On World NTD Day, we need to recognise these emerging challenges and look to more integrated approaches. The impressive 25 percent decrease in the number of people requiring treatment for NTDs and the mounting number of countries that have eliminated at least one NTD are testimony to the progress being made to stamp out some of the world’s most deadly and debilitating diseases – which strike mostly at communities in developing countries and at people living in poverty. According to the World Health Organization (WHO), 47 countries have eliminated at least one NTD since 2010, and NTD programmes have performed better in the past year than in 2021. But while this progress is admirable, it is too slow for millions of people still living with, or at risk of infection from these 20 viral, parasitic and bacterial diseases considered NTDs which range from river blindness to leprosy, rabies and more, and continue to defy national and global elimination plans in many parts of the world today. Storm clouds on the horizon Moreover, new challenges like the COVID-19 pandemic and climate change are putting recent progress at risk, threatening to reverse the tremendous gains that have been made over the last few years. During the pandemic, services for NTDs were the second most frequently disrupted set of health systems services. Looking ahead, changing temperature and rainfall patterns will exacerbate poverty and displace people, and climate change will influence the emergence and re-emergence of multiple NTDs in higher latitudes and altitudes and pose a major risk for communities. This year’s World NTD Day is an opportunity to revitalise the way we tackle NTDs to not only maintain the progress we achieved so far, but to catalyse better, more efficient, bolder strategies for elimination in the future – harnessing the power of collective action. The climate threat Water shortage in Ethiopia. Population exposure to heat is increasing due to climate change. Globally, extreme temperature events are observed to be increasing in their frequency, duration, and magnitude. This is especially crucial in addressing the added challenges that climate change poses. NTDs are highly influenced by temperature, rainfall, humidity, and other climatic changes, and even small fluctuations can greatly increase transmission and spread, with potentially devastating effects. Climate change is thus threatening the re-emergence of NTDs in many parts of the world and will likely result in negative health outcomes and disruptions to healthcare systems. The threat to progress expands beyond NTDs to other infectious diseases. For malaria alone, studies show that climate change could lead to an additional 60,000 malaria deaths per year between 2030 and 2050. Despite the risks, the world is paying little attention to the climate-health nexus and the impact it could have on the resurgence of NTDs and their transmission. Up until now, approaches to address health and climate emergencies have remained largely separate, perhaps partly due to the lack of knowledge and guidance surrounding the health impact of climate change. The current literature on the intersection between climate and health also is insufficient to guide policy development. This is why countries, world leaders, and all stakeholders involved should prioritise research in this area. By exploring new and under-explored areas of the interface between climate and infectious disease, we can start to tackle the challenge and protect the gains and accelerate progress towards elimination. Removing NTDs from the disease control silo Fulfilling the goal of elimination begins by taking NTDs prevention and control out of isolation and adopting a more integrated approach. At the Global Institute for Disease Elimination (GLIDE) we see the intrinsic value of promoting and adopting cross-disease, cross-border, multi-stakeholder and multi-sector, approaches to innovatively and effectively control, eliminate, and eradicate NTDs. For this to work in global health, we must make way for more integrated healthcare systems that address preventable infectious diseases of poverty. The COVID-19 pandemic has exposed the pre-existing cracks in our healthcare systems, spotlighting the dangerous link between NTDs, other communicable diseases, and health emergencies. It has also reinforced the need to address health issues in a more holistic manner. A stronger, more systems-wide approach to health will strengthen surveillance, early warning, and pandemic preparedness. Mainstreaming NTDs within health systems and primary health care services, and promoting country ownership and accountability is an effective jumping off point, according to WHO’s NTD road map 2021-2023. In fact, this will contribute to sustainable and efficient NTD prevention and control, yielding better health outcomes and program management, and cost-effective solutions. But we must understand the economics of neglected diseases and elimination better in order to develop and refine investment cases in a more holistic way, using the health system and packages of essential health care as an important entry point to this mainstreaming. Water, sanitation and hygiene as a starting point Africa and Asia have the least access to basic sanitation facilities in the whole world Another starting point is to consider cross-sector coordination such as with water, sanitation, and hygiene (WASH) for disease prevention. WHO’s roadmap lays out a plan for effective elimination efforts, citing WASH as one of the key interventions in tackling 18 of the 20 NTDs. Improved access to clean water and sanitation can reduce the transmission of many NTDs, such as schistosomiasis, trachoma and guinea worm which, according to the Centers for DIsease Control and Prevention (CDC), is caused by the parasite Dracunculus medinensis and contracted when people do not have access to safe water for drinking. There is no vaccine or medicine available against guinea worm. However, eradication is being achieved by implementing WASH-related preventive measures. These include filtering drinking water to remove the water fleas that carry the parasite, providing improved water sources and preventing infected individuals from wading or swimming in drinking-water sources. The measures – supplemented by active surveillance and case containment, vector control and provision of improved water sources – have led to great progress toward eliminating guinea worm, with the number of human cases annually falling from 3.5 million in the mid-1980s to just 13 cases in 2022, poising it to become the second disease in human history that could be eradicated altogether, according to a report last week by the Carter Center. Breaking down silos The elimination of NTDs is feasible, but we need new approaches. The upcoming 28th Conference of the Parties (COP28) to the United Nations Framework Convention on Climate Change (UNFCCC), hosted by the United Arab Emirates (UAE) between 30 November and 12 December 2023, will be an opportunity for world leaders to both recognise and commit to addressing the health impacts of climate change. The World Health Assembly’s NTD road map 2021-2030, meanwhile, emphasizes the importance of integrating NTD programs and establishing links with other sectors such as education, nutrition, WASH, animal, and environmental health. We also must increase spending on NTD control and elimination, strengthening the case for investment. There is an intimate connection between the health of individuals and the interlinked, cross-boundary events across the globe. Recognizing this, we need an approach that engages all sectors and geographies in ways that facilitate collaboration, stimulate innovation and continued investment and, finally, by staying committed to delivering a world free of NTDs. ____________________________________ Simon Bland is the CEO of the Global Institute for Disease Elimination (GLIDE), based in the United Arab Emirates (UAE) and focused on accelerating the elimination of four preventable infectious diseases – malaria, polio, lymphatic filariasis, and river blindness – by 2030 and beyond. Founded in 2019 as the result of a collaboration between UAE President, His Highness Sheikh Mohamed bin Zayed Al Nahyan, and the Bill & Melinda Gates Foundation, GLIDE works to elevate awareness and engagement, advance elimination strategies, and foster and scale innovation for disease elimination and eradication. Image Credits: DNDi, Oxfam East Africa, Deep Knowledge Group. Influential WHO Committee Greenlights Initiative for ‘Replenishment Fund’ to Bolster Finance 30/01/2023 Kerry Cullinan Last year’s World Health Assembly mandated the secretariat to look into a replenishment fund. An influential sub-committee of the World Health Organisation (WHO)’s Executive Board (EB) has greenlighted a proposal by the cash-strapped global body’s Secretariat to seek additional funds via a replenishment fund, that would be filled by voluntary donations from both member states and philanthropies recruited at high-profile events. In its report published on Monday just as the WHO’s Executive Board’s began a week-long meeting, the Programme, Budget and Administration Committee (PBAC), accepted that a replenishment fund could provide an avenue for flexible funding that the WHO so desperately needs. “The committee acknowledged WHO’s need for more flexible, predictable and sustainable financing and considered that a replenishment mechanism provided a possible solution, especially for chronically underfunded areas of the organization’s programme budget,” according to the report, which concluded the deliberations of the three-day meeting of the PBAC last week. The Global Fund to fight AIDS, Tuberculosis and Malaria raised $15.7 billion in its ‘replenishment drive’ last year, while Gavi, The Vaccine Alliance as well as the World Bank and other UN-backed global organisations also run replenishment fundraising drives to attract additional funds from donors. Last year’s World Health Assembly mandated the WHO Secretariat to explore a replenishment fund based on six principles, including that it is driven by member states, allows flexibility in allocation, covers the base budget, and aligns with the WHO’s resolutions. Funding crisis The Executive Board is now expected to consider the proposal further this week in a series of discussions on improving WHO’s financial sustainability. A nod by the EB would pave the way for a full-fledged vote by the World Health Assembly in May. At the EB’s opening session on Monday, Director General Dr Tedros Adhanom Ghebreyesus confirmed that he expected that the proposal for a replenishment process would be submitted to member states for consideration. “We recognize that with increased flexibility and sustainability come increased expectations for transparency, efficiency, compliance and accountability. All of this leading to results,” said Tedros. Only around one-fifth of the WHO’s budget comes from members’ countries’ “assessed contributors” (calculated on their GDP), with the rest being made up from donations. But the donations are usually tied to particular programmes, inflexible and can be withdrawn at any time. At last year’s World Health Assembly, member states agreed to increase their contributions to cover half of the WHO’s budget. This year, members’ annual contributions are slated to be increased by around 20%. However, even when member states increase their contributions, there will still be a gaping shortfall, obviously undesirable given disease outbreaks and other demands. Developing the replenishment option Recommending that the executive board accepts the replenishment mechanism, the PBAC has advised the secretariat to develop the proposal further by examining “replenishment mechanisms established by other global health organizations and [analysing] the advantages and disadvantages of the various systems”. It also recommended that the “funding envelope for a replenishment mechanism should be based on the base segment of the programme budget, minus approved assessed contributions”. Still up for discussion is whether the fund will be based on the budget over one (two-year) budget cycle or two (four-year). More money for country offices PBAC has also recommended that the WHO secretariat consider further increases to its country operations rather than head office and regional structures. However, while the secretariat confirmed its commitment to strengthen country offices, it said that this would only be possible “gradually over time”. The WHO secretariat told PBAC that the main reason for the uneven financing of its programmes was “the extremely tight earmarking of the funds it received”. Director-General Dr Tedros Adhanom Ghebreyesus told the committee that member states’ agreement to an increase in assessed contributions would “make all the difference”. In response, the committee proposed that the Secretariat should “improve the persistent uneven financing across programmes, major offices and levels of the organization, including by distributing undistributed funds”. As far as the 2024/25 WHO budget is concerned, PBAC has recommended that member states should have until 10 February “to study and provide feedback on the programme budget digital platform” to allow proper consideration of the proposed budget ahead of the World Health Assembly in May. It’s Still a Pandemic: WHO Advisers and Chief Concur 30/01/2023 John Heilprin A healthcare worker wearing PPE disinfecting a street in the early days of the COVID-19 pandemic. The World Health Organization’s Emergency Committee on the COVID-19 pandemic and Director General Dr Tedros Adhanom Ghebreyesus both agree: the event continues to constitute a public health emergency of international concern (PHEIC). The UN health agency agreed on Monday that ending the state of international public health emergency over the coronavirus would be premature even after three long years since its appearance upended the world of normality as we knew it three years ago. Tedros said in a statement that he concurs with the advice offered by committee in its report based on a closed videoconference on Friday. He acknowledged the committee’s views that the COVID-19 pandemic is “probably at a transition point” that must be navigated carefully while ensuring the world is able to mitigate the potential negative consequences. “Achieving higher levels of population immunity globally, either through infection and/or vaccination, may limit the impact of SARS-CoV-2 on morbidity and mortality, but there is little doubt that this virus will remain a permanently established pathogen in humans and animals for the foreseeable future,” the committee reported. “As such, long-term public health action is critically needed,” it said. “While eliminating this virus from human and animal reservoirs is highly unlikely, mitigation of its devastating impact on morbidity and mortality is achievable and should continue to be a prioritized goal.” Personal protective equipment was essential to protect healthcare workers during the pandemic Seven pandemic recommendations As a result of his decision, Tedros advised nations to: Maintain momentum for COVID-19 vaccination to achieve 100% coverage of high-priority groups. Improve reporting of SARS-CoV-2 surveillance data to WHO Increase uptake and ensure long-term availability of medical countermeasures. Maintain strong national response capacity and prepare for future events Continue working with communities and their leaders to address the infodemic Continue to adjust any remaining international travel-related measures and do not require proof of vaccination for international travel Continue to support research for improved vaccines that reduce transmission and have broad applicability The committee said moving forward past the PHEIC will require a focused commitment by WHO and its 194 member nations, along with other international organizations, put in place “systematic, long-term prevention, surveillance, and control action plans.” The committee members, whose statement comes on the three-year anniversary of the determination of the COVID-19 PHEIC in January 2020, said it agreed the world is in a better position than it was during the peak of the Omicron transmission a year ago, yet more than 170,000 COVID-19-related deaths have been reported globally in the past eight weeks. It agreed surveillance and genetic sequencing declined globally, making it more harder to track known variants and detect new ones, while health systems are struggling with COVID-19 and caring for patients with influenza and respiratory syncytial virus (RSV), health workforce shortages, and fatigued health workers. Investment in strong health systems is key to pandemic=proofing the world. WHO asked to study impact of ending pandemic Vaccines, therapeutics, and diagnostics have been and remain critical in preventing severe disease, saving lives and taking the pressure off health systems and health workers globally, it said, but “the COVID-19 response remains hobbled in too many countries unable to provide these tools to the populations most in need, older people and health workers.” Some 13.1 billion doses of COVID-19 vaccines have been administered, with 89% of health workers and 81% of adults older than 60 years completing the primary series, WHO said. “COVID-19 remains a dangerous infectious disease with the capacity to cause substantial damage to health and health systems,” the committee said, adding that has asked the WHO Secretariat to provide an assessment of the regulatory implications for developing and authorizing vaccines, diagnostics, and therapeutics if the PHEIC were ended sometime “in the coming months.” Image Credits: Photo by Maksym Kaharlytskyi on Unsplash, Tehran Heart Centre . WHO Experts Confer on Possible End to COVID International Health Emergency 27/01/2023 Elaine Ruth Fletcher WHO Director General Dr Tedros Adhanom Gehebreyesus (left) and Didier Houssin, chair of the WHO Emergency Committee. on 30 January 2020, when the COVID International Health Emergency was first declared. The World Health Organization’s Emergency Committee on the COVID-19 pandemic was meeting Friday evening – with mixed signals emerging about whether the expert advisory group would recommend that the global health agency end the state of international public health emergency over the virus whose emergence stunned the world a little more than three years ago. At a press conference in December 2022, WHO’s Director General Dr Tedros Adhanom Ghebreyesus expressed hopes that the emergency that he first declared on 30 January, 2020, under WHO’s International Health Regulations, could finally be concluded sometime in 2023. But in his remarks to the Emergency Committee’s 14th meeting, the WHO Director General hinted for a second time this week that the time may not yet be ripe – as cases of new infection increased again worldwide only recently and a new wave of the virus continues to rip through China shortly after strict lockdown policies were finally relaxed. “As we enter the fourth year of the pandemic, we are certainly in a much better position now than we were a year ago, when the Omicron wave was at its peak, and more than 70,000 deaths were being reported to WHO each week,” said Tedros in his remarks at the closed meeting, reported by WHO in a press release. “When you last met in October, the number of weekly reported deaths was near the lowest since the pandemic began – less than 10,000 a week,” he added. “However, since the beginning of December, the number of weekly reported deaths globally has been rising.” China trends create a second level of concerns Following a massive wave of protests in autumn 2022, China lifted most of its COVID restrictions – which had been among the strictest in the world. In addition, Tedros noted, the lifting of COVID restrictions in China has led to a spike in deaths in the world’s most populous nation, whose citizens were poorly protected by vaccinations as well as having low natural immunity thanks to months of social isolation. “Last week, almost 40 thousand deaths were reported to WHO, more than half of them from China,” Tedros said. “In total, over the past eight weeks, more than 170,000 deaths have been reported. The actual number is certainly much higher.” Earlier this week, Tedros also expressed his mixed feelings about declaring an end to the pandemic even more bluntly, saying: “While I will not preempt the advice of the emergency committee, I remain very concerned by the situation in many countries and the rising number of deaths,” he said, speaking at WHO’s weekly press briefing. “While we’re clearly in better shape than three years ago when this pandemic first hit, the global collective response is once again under strain.” In fact, after reaching a peak in mid-December, the wave of new cases in China and worldwide have been declining for the past month – both according to WHO data and other data monitoring platforms. However, in light of the reduced amount of COVID testing worldwide, the confirmed case count is an increasingly unreliable measure of true cases. “Surveillance and genetic sequencing have declined dramatically around the world, making it more difficult to track known variants and detect new ones,” Tedros told the committee at the outset of Friday’s meeting. Revolution in vaccines, treatments and diagnostics has not reached everyone Related to that, the global response to COVID remains “hobbled” because “powerful, life-saving tools are still not getting to the population that need them most – especially older people and health workers, Tedros said. “Many health systems around the world are struggling to cope with COVID-19, on top of caring for patients with other diseases including influenza and RSV, and with work shortages and fatigued health workers. “And public trust in the safe and effective tools for controlling COVID-19 is being undermined by a continuous torrent of mis- and disinformation.” It was unclear as to whether the committee’s deliberations would continue into the weekend, or when their conclusions will finally be announced. However, there was speculation that their report might only be published on Monday, when the WHO Executive Board, WHO’s governing body, begins its first annual round of meetings for 2023. Among the nearly 50 items on the week-long agenda are a raft of reports and recommendations on strengthening global preparedness and response to health emergencies. The WHO Public Health Emergency of International Concern (PHEIC) was declared in the framework of the 2005 International Health Regulations, which constitute a legally binding agreement between WHO member states regarding emergency outbreak and response. In March 2020, Tedros also declared that the emergency also constituted a “pandemic” – although there is in fact no legal provision for a pandemic declaration in the IHR. However, the weaknesses in the IHR system of outbreak alerts, notification and resonses, highlighted by the faltering and inconsistent reponse to the COVID pandemic, have paved the way for major reconsideration of global pandemic response frameworks, with debates over a new pandemic treaty, as well as IHR revisions, set to continue throughout 2023 and into 2024. See related story here: Governing Pandemics Snapshot Image Credits: Twitter: @WHO. WHO Provides New Medicines List, Policy Recommendations for Nuclear Emergency 27/01/2023 Maayan Hoffman A Nuclear powerplant in Belgium. The World Health Organization (WHO) on Friday released an updated list of medicines that should be stockpiled in the event of a radiological and nuclear emergency, along with new policy advice in the event of such an incident. “Preparedness for radiation emergencies is consistently reported as the weakest area of preparedness in many countries,” the 66-page report said. This newest report updates the one released over 15 years ago, in 2007, and thus includes a host of new pharmaceutical developments. “In radiation emergencies, people may be exposed to radiation at doses ranging from negligible to life-threatening. Governments need to make treatments available for those in need – fast,” said Dr Maria Neira, WHO Acting Assistant Director-General of the Healthier Populations Division. “It is essential that governments are prepared to protect the health of populations and respond immediately to emergencies. This includes having ready supplies of lifesaving medicines that will reduce risks and treat injuries from radiation.” Added Dr Mike Ryan, Executive Director of WHO’s Health Emergencies Programme: “This updated critical medicines list will be a vital preparedness and readiness tool for our partners to identify, procure, stockpile and deliver effective countermeasures in a timely fashion to those at risk or exposed in these events.” Radiological or nuclear emergencies could occur at nuclear power plants, medical or research facilities or be the result of accidents during transport of radioactive materials, WHO explained. In addition, these emergencies could be the result of a malicious event, such as a nuclear bombing. To date, there were two massive nuclear incidents: The 1945 atomic bombings of Hiroshima and Nagasaki by the United States, the consequences of which have been continually studied. There was also the 1986 accident at the Chernobyl nuclear plant in Ukraine – the largest uncontrolled radioactive release in history. Former Russian President Dmitry Medvedev warned this month in yet another Telegram post that a defeat of Russia in Ukraine could trigger a nuclear war. “The defeat of a nuclear power in a conventional war may trigger a nuclear war,” Medvedev wrote. Exposure to high doses of radiation can have severe consequences on a person’s long-term health or lead to immediate or early death. As such, aside from generic supplies and materials used for any type of emergencies, stockpiles should include medicines that either prevent or reduce exposure to radiation, WHO explained. Only a handful of recommended medicines There are only a handful of specific drugs that have been proven effective in the treatment of over-exposure to radiation and these are included in the report. They include: stable iodine; chelating sand (decorporating agents); cytokines used for mitigation of damage to the bone marrow; and medicines to treat vomiting, diarrhea and infections. “One of the most serious outcomes of over-exposure to radiation is acute radiation syndrome (ARS), which manifests as a haematopoietic syndrome”. The latter, also called bone marrow syndrome, impacts blood cell production and in cases of acute poisoning, can lead to death through infection or hemorrhage. “Depending on the severity of the exposure may further progress as gastrointestinal, cardiovascular and neurological syndromes,” the report states. However, the WHO recommendations only include treatments of haematopoietic and gastrointestinal syndromes, “as cardiovascular and neurological syndromes are considered non-salvageable and require only palliative care.” Blocking agents such as stable iodine, could be used to block the uptake of radionuclides in the body, the WHO report added. Other agents like Prussian blue are applied to remove radioactive ceasium from the body. Calcium or zinc diethylenetriaminepentaacetic acid can treat internal contamination with transuranium radionuclides. “These and other elements of such stockpiles should be made rapidly available in case of radiation emergencies,” wrote WHO. Bone marrow syndrome – emerging treatments In the case of haematopoietic, or bone marrow syndrome, radiation attacks all three blood lineages – white and red blood cells and platelets. Low white blood cell count weakens the immune system, making an individual vulnerable to infection. Red blood cells carry oxygen to the body and platelets are responsible for coagulation, which prevents bleeding, explained Yaky Yanay, CEO and president of Pluri – an Israeli-based biotech firm developing an injection of placenta cells for the treatment of ARS. The treatment has been approved by the United States Food and Drug Administration as an “Investigational New Drug” (IND) for use in the event of a nuclear incident – although it is not yet mature enough to be considered for the WHO list of recommended medicines. The WHO report notes, however, that researchers are making progress on developing novel treatments, although none of them have been approved by the global health agency for use in a nuclear emergency. WHO: Stockpile based on population size WHO stressed that a country’s nuclear medicines stockpile should be based on reliable data for national risk profiles, the size of the population and available resources and capabilities of their health system. Finally, WHO called on national health authorities, health-care facilities, pharmaceutical suppliers and logistics, civil defense and emergency services to be leveraged in the event of an emergency. These teams should be coordinated in advance to be able to function effectively in the event of a nuclear incident. Image Credits: Photo by Frédéric Paulussen on Unsplash. Governing Pandemics Snapshot 27/01/2023 Gian Luca Burci, Suerie Moon, Daniela Morich, Adam Strobeyko & Seyed-Moeen Hosseinalipour Standing ovation at the close of the special World Health Assembly session 1 December 2021, in which member states agreed to negotiate a new pandemic accord. A briefing series on the status of moves to reform the global system of pandemic preparedness and response launches today, just ahead of the WHO Executive Board review of progress next week. Looking back at 2022 and forward into 2023, this series by the Global Health Center of the Geneva Graduate Institute, published in collaboration with Health Policy Watch, provides an update on the progress so far in the WHO-led negotiations over a new pandemic treaty. It also looks at the progress in revisions to the existing emergency rules of the International Health Regulations (IHR) – while considering what could happen next. The complete “Governing Pandemics Snapshot”, also includes briefings on reforms being considered in the financing of pandemics as well as the rules around pathogen access and benefit-sharing. Pandemic treaty: tough political negotiations ahead By Daniela Morich Following a milestone World Health Assembly decision in late 2021, WHO Member States have been negotiating an international agreement on pandemic prevention, preparedness and response to strengthen global capacities and resilience for future pandemics. The year 2022 was the year for the advance of these pandemic treaty talks with the establishment of a formal process, a strict timeline, and initial discussions on principles. In 2023, negotiations will shift from broad consultations to tough politics. The Covid-19 pandemic brought to the surface the shortcomings of global health governance for emergencies and accelerated discussions to reform it. At a special WHA session in late 2021, the second-ever convened by the World Health Assembly, WHO Member States agreed to establish an intergovernmental negotiating body (INB) to negotiate a new “instrument” to strengthen pandemic prevention, preparedness and response – or, a pandemic treaty. The INB initiated its work in early 2022 and is to present the outcome of the negotiations to the 77th World Health Assembly (WHA) in May 2024. This is an ambitious timeline for a complex international rule-making process, especially as it will run in parallel to the process to revise the International Health Regulations (IHR), a pre-existing WHO instrument that governs the cross-border spread of infectious disease. Nonetheless, the INB is moving forward and achieved two mid-term milestones in 2022. In July, at the second INB meeting, Member States agreed that the instrument should be legally binding, which suggests countries are ready to accept new international obligations to improve pandemic prevention and response. In addition, the INB engaged in intensive intersessional consultations to seek input not only from governments or well-established experts – the traditional protagonists of international rulemaking – but also from civil society organizations and the public. Despite these efforts, commentators have argued that the process is still not as inclusive as it should be. As work on the instrument progresses, negotiators should expect more demands to expand meaningful participation of stakeholders beyond governments. The INB’s Bureau (six countries elected to lead the process) released the ‘conceptual zero draft’ (CZD) ahead of the third meeting of the INB, which took place in December 2022. The CZD –which can be seen as the first rough draft of the accord – brought to the negotiating table a broad set of issues and highlighted a collective willingness to ensure a more equitable response to future threats. It also reflected tough divisions on several issues, in particular, intellectual property (IP), pathogen- and benefit- sharing, One Health, financing and accountability, which will likely become more visible and contentious as negotiations move to the next phase. At the conclusion of the gathering, Member States directed the INB Bureau to develop the ‘zero draft’. Delegates strongly encouraged the Bureau to move away from the vague and aspirational language of the CZD and to present clear legal provisions and definitions, including one for ‘pandemic’, for Member States to negotiate in earnest. The INB Bureau is expected to circulate the zero draft in early February 2023. At this stage, the negotiation process will likely shift from a consultation and information gathering process to become a more politicized, polarized and consequential debate. The time available to negotiators is constrained. The 2023-2024 agenda includes 6 additional INB meetings scheduled over 14 months in addition to meetings of the drafting groups, with the IHR revision process unfolding in parallel. Considering the complexity of the issues on the table, the existing divisions between Member States, and the limited time available to negotiators, achieving meaningful progress in this new highly-political phase is the tall order for 2023. An existential moment for the International Health Regulations Dr Hiroki Nakatani, chairman of the May World Health Assembly, applauds the WHA decision to revise the International Health Regulations. By Gian Luca Burci While negotiations on a new pandemic instrument continue in 2023-24, the International Health Regulations (IHR) remain the sole global legally-binding instrument devoted to the prevention and control of the international spread of disease – and revisions to those are already underway. Can the two parallel processes complement each other or will they add new layers of confusion? That is the challenge negotiators and member states will face. Although considered an essential component of the global health security toolbox, the IHR attracted severe criticism and allegedly low compliance during the COVID-19 pandemic. The momentum towards a new “pandemic treaty”, beginning in late 2020, was in part a reaction to the perceived weaknesses and limitations of the IHR. The difficult and sometimes confusing discussions in the Working Group on strengthening WHO preparedness and response to health emergencies created by the 74th World Health Assembly in 2021 to discuss reforms, ultimately led to a WHA decision in December 2021 to launch negotiations on a new legal instrument (“pandemic treaty”) to be adopted by 2024. Then, in 2022, attention turned back to the IHR as member states sought faster solutions for the most burning issues that had surfaced during the pandemic – particularly around outbreak reporting and IHR compliance. As a result, a complex IHR amendment process is also now underway. The two processes (IHR revisions and pandemic accord) are thus now proceeding in parallel, with hard decisions still to be made on the issues that the revised IHR will tackle – as compared to the new pandemic accord. Negotiations to amend the IHR in 2023/2024 raise an existential question about their raison d’etre: should they retain their technical, operational character, or expand significantly to address highly political questions such as those on international assistance, equity and access to technologies for disease outbreaks? The US broke the ice by proposing its own substantial set of amendments in January 2022, and successfully winning agreement at the 75th WHA in May 2022, to both adopt a set of limited technical IHR amendments and to open up a broader process for further amendments. The WHA thus launched negotiations towards “targeted amendments” of the IHR with the same 2024 deadline for WHA adoption as the new pandemic accord. Member States submitted their proposed amendments by 30 September 2022 and an expert “review committee” analyzed them and presented its recommendations to the Director-General in January 2023. A Working Group open to all Member States will work from February 2023 towards a negotiated package. The process is unusual compared to other intergovernmental negotiations, in that states hardly ever place on the table all their proposed amendments at the outset; the initial US disclosure of all its amendments, however, required a similar treatment for other states and made that approach inevitable. Wildly diverse amendments but a few trends emerge A patchwork of national rules around international travel, vaccines and border controls were a feature of the COVID pandemic, highlighting the inconsistent application of key IHR provisions aimed at ensuring international trade and travel during health emergencies. The outcome of the first phase of this process is a massive aggregation of wildly diverse amendments (available here) proposed or supported by almost 100 states. They range from focused technical amendments to far-reaching changes. Despite their diversity, a few trends emerge dividing Global South and Global North countries. The most political proposals, coming in particular from the African Region, Bangladesh and India, aim at ensuring equitable access to vaccines, distributed manufacturing capacities, technology transfer, limitations on patenting and sustainable financing of national capacities. These proposals reflect the North-South divide that we have been witnessing in the recent treaty conferences on climate change and biodiversity and are clearly also a consequence of the inequities in access to life-saving medical countermeasures displayed during the COVID-19 pandemic. Other proposals, in particular from the European Union, the Eurasian Economic Union (submitted by the Russian Federation) and the United States, aim at strengthening the IHR within their current approach, e.g. by tightening compliance and accountability for information sharing, encouraging the sharing of genetic sequence data and through the use of digital technologies. Two negotiating processes unfolding at the same time The challenge in reaching an agreed package in time for the 2024 WHA is increased by the unprecedented parallel unfolding of two negotiating processes with the same timeline, where countries will probably submit the same types of proposals for both instruments to secure an overall favorable outcome. An important point in this respect that is often overlooked is that amendments to the IHR will in principle enter into force at the same time for all its 196 parties, whereas the pandemic instrument – since it will likely be an international treaty – will enter into force once a critical mass of countries has ratified it and only for them, with new countries joining once they ratify. The broad range of proposals for the pandemic instrument and the likelihood that the US will eventually not ratify it may actually lead Global South countries to prioritize the IHR for some of the most ambitious proposals. This possibility raises one final issue. Currently, the IHR is essentially an operational instrument to coordinate outbreak prevention and control and depoliticize WHO’s role in managing them. There is no emphasis on equity, assistance or international cooperation. Amendments proposed by Global South countries would transform it into a regulatory and transactional instrument with a more political role for WHO and differential treatment for developing countries to improve equity in the availability of health technologies. Fundamentally, negotiators will have to decide what they want the IHR to be – and if the IHR is expanded to encompass the issues of health equity then what role would the new pandemic instrument play? For essays on financing pandemics and pathogen and benefit sharing, see the full Governing Pandemics Snapshot here. This is the first in a periodic series of updates to be published during the year. About the authors Daniela Morich is Manager and Adviser of the Governing Pandemics initiative at the Global Health Centre, and a lawyer with experience in multilateral negotiations. Dr Gian Luca Burci is Adjunct Professor of International Law at the Geneva Graduate Institute. He was a member of the IHR Review Committee that completed its expert analysis of the proposed IHR amendments in January 2023. He co-leads the Governing Pandemics initiative. Dr Suerie Moon is Professor of Practice and Co-Director of the Global Health Centre, and co-leads the Governing Pandemics initiative. Adam Strobeyko is a Hauser Global Fellow at NYU Law and was a Doctoral Researcher for the Governing Pandemics initiative. Moeen Hosseinalipour is a master’s student in global health and international affairs at the University of Geneva and Geneva Graduate Institute, and a research assistant for the Governing Pandemics initiative. Image Credits: Geneva Graduate Institute. Posts navigation Older postsNewer posts This site uses cookies to help give you the best experience on our website. Cookies enable us to collect information that helps us personalise your experience and improve the functionality and performance of our site. 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Tedros’ 10-Point Proposal for Reforming Global Emergency Response Gets Mixed Review 30/01/2023 Elaine Ruth Fletcher ‘Cautioning that the Secretariat not to get ahead of member states:’ Loyce Pace, US Assistant Secretary of State for Global Affairs in debate over WHO reform proposal. A new 10-point proposal by the World Health Organization’s Director General Dr Tedros Adhanom Ghebreyesus for improving preparedness and response to health emergencies received mixed reviews from WHO member states in Monday’s opening session of this week’s Executive Board (EB) meeting, the agency’s 34-member governing body. It was the first substantive issue to be tackled in the eight-day long EB meeting packed with an agenda of over 50 draft proposals and resolutions on items ranging from emergency pareparedness and response to non-communicable diseases. Charged management issues, ranging from sustainable finance to the organization’s handline of recent sexual harrassment claims will also be taken up by the EB. The Director General’s 10-point proposal on “strengthening the global architecture for health emergency preparedness, response and resilience” calls for the creation of a new WHO Global Health Emergency Council, which would aim to liaise more efficiently between WHO’s Secretariat and its Member states in health emergencies and outbreaks, and meet during the World Health Assembly. The proposal also calls for massively expanding the size and scope of a WHO Contingency Fund for Emergencies (CFE) to include broad support to member states’ “including deployments through the health emergency workforce and emergency supply chain” of medical products. And the initiative calls for scaling up a system of member state peer reviews of emergency preparedness to increase “transparency”. The WHO proposal synthesizes more than 300 recommendations of several independent panels that reviewed WHO and member state response to the COVID pandemic, the report stated. Initiative raises fears of ‘duplication’, moving ahead of member state negotiations While member states gave positive reviews to the WHO proposal’s overall aims – ensuring more fair, equitable and transparent management of crises – they stressed that concrete reforms are already the focus of two member state fora – and that’s where the discussion should focus. Those include the Intergovernmental Negotiating Board (INB) due to issue a zero draft for a proposed pandemic treaty later this week, as well as another member state working group that will look at more targeted revisions to the circa 2005 International Health Regulations (IHR), the rules currently governing emergency response. Japan joins the UK, USA and China in rare accord that member states should hold reins of emergencies reform wheel at the WHO Executive Board meeting Monday. In a moment of rare agreement between often rival nations – the United Kingdom, China and Japan all expressed hesitations over the creation of a new WHO “Global Health Emergencies Council”, proposed by Tedros, ad meeting during the annual member state World Health Assembly. The UK said it “echoed China’s concerns about being careful about creating new institutions and mechanisms” which might duplicate the work of other bodies. “I think the risk is that there are multiple mechanisms already,” the UK’s EB delegate said, asking. “Do adding new mechanisms add, or do they actually make it more complicated to navigate?” Japan, meanwhile, asked whether it was feasible to create yet another body that convenes during the already packed week-long session of the WHA “unless we have a clear idea of what will be discussed and decided by the council. “Who will be preparing the materials for discussion?” Japan’s EB delegate asked wondering “whether a schedule [of meetings during the WHA] is feasible since we already have Committees A and B?” He was referring to the two main WHA sub-committees in which proposals are debated and decided during the WHA session. Meanwhile, the USA warned against the WHO administration “getting ahead” of member states’ own negotiations over a new Pandemic Treaty, or accord. Those discussions, led by the INB, are already taking up most of the same topics that the WHO Secretariat paper covers, said Loyce Pace, US Assistant Secretary of State for Global Public Affairs. A ‘Zero Draft’ of the pandemic treaty framework is due to be published on Wednesday. “We’re grateful that they have a proposal that draws attention to those negotiations. But we’re still cautioning that the Secretariat not to get ahead of member states in terms of putting forth an architecture that hasn’t yet been agreed, and that would arguably require approval from member states and buy-in from relevant international institutions so they could be operationalized,” Pace said. Ensuring equity as a cross-cutting principle Echoing Brazil Peru says ‘fairness’ needs to be the foundation of reforms. Brazil, likewise, said that the essence of proposals brought forward in document by Tedros and the WHO adminisration is already being debated in the INB and the IHR working groups. “The difference is that this process has been developed in a much more transparent and inclusive way, with clear participation by non-state actors,” said the Brazilian delegate. “Both of these work streams are entering a critical phase this year. Now it’s the time to concentrate our effort to have meaningful debates within those two mechanisms in order to come up with innovative, game changing norms.” He called for the WHO administration proposal to be referred to the IHR and pandemic treaty negotiating bodies “where they can be discussed and fully developed.” Brazil also said that proposals to change the way global emergency response unfolds need to include equitable access to medical countermeasures as a cross-cutting theme, along with “respect and promotion of human rights and racial and gender equity.” Echoing Brazil, Peru added that, “one of the pillars of global architecture when it comes to preparedness and resilience in the face of future health emergencies has to be the principle of fairness.” Revisions to the existing International Health Regulations as well as a new pandemic accord should “allow for a universal universal access to measures such as vaccines, without any privileges or discrimination, and will face challenge questions related to R&D, intellectual property technology transfers, and expanding the manufacturing capacities at the local level …in the context of emergencies,” added the Peruvian EB delegate. African Group – more WHO and donor support to countries Equitable access to health products and more support for WHO country offices – Ethiopia speaks on behalf of the African group of 47 countries at the 152nd session of the WHO Executive Board Meanwhile, Ethiopia, speaking on behalf of the African group of 47 states stressed that in a time when many countries in the region are facing a complex array of climate-related and infectious disease health emergencies, “less than 10% of African countries have adequate human resources with technical emergency know how to prepare, detect and respond to emergencies.” There is also a “large reliance on international funding due to limited capacity to mobilize sustainable and predictable resources domestically.” She called for “stronger support of the WHO country offices in strengthening the IHR capacities,” as part of the solution as well as underlining the importance of “greater coordination across the funding landscape to ensure that existing funding flows are ….targeted to the most critical gaps at the global regional and national level. And that this role should be augmented by additional catalytic gap funding. She also called for a greater role for African representation in the new World Bank -managed pandemic fund, and other governance mechanisms. “We would also appreciate a greater focus on equitable access to health products, technologies and know-how, and as such, funding and capacity incentives for states to report information to the international community to be further explored. Conflicts and Health Emergencies Overshadow WHO Successes as Executive Board Gets Underway 30/01/2023 Kerry Cullinan Dr Tedros opens the WHO executive board meeting. Supporting 100 million tobacco users to quit, increasing exclusive breastfeeding for babies under six months to 48% globally, and helping 63 countries to build climate-resilient health systems are some of the recent successes of the World Health Organization (WHO), said Director General Dr Tedros Adhanom Ghebreyesus. Addressing the opening of the WHO’s executive board (EB) meeting on Monday, Tedros said that the global body was focused on “promoting, providing, protecting, powering and performing for health”. The 152nd session of the Executive Board, which runs until 7 February, has a very heavy agenda – ranging from a series of initiatives to improve global emergency response to an updated menu of WHO-recommended “best buys” to fight non-communicable diseases. The EB’s approval of draft resolutions and decisions is a prerequisite to bringing most proposals before the World Health Assembly (WHA) in May. The EB also plays a watchdog role, vis a vis the 9000-member WHO’s finance and budet planning, advising on strategic directions for the global body’s work. Protecting health during conflicts and humanitarian crises constituted a huge part of the WHO’s work in 2022 as it responded to 72 graded emergencies last year, “including three public health emergencies of international concern, outbreaks of Ebola and cholera, conflicts in Ethiopia, Syria, Ukraine and Yemen, and humanitarian crises in the greater Horn of Africa, the Sahel and much more”, said Tedros. “Thanks to the generosity of donors to the Contingency Fund for Emergencies, we were able to release more than $87 million immediately to support rapid response, and we delivered essential health supplies to 90 countries from our Dubai logistics hub in the United Arab Emirates,” said Tedros. Africa demands an increase in country allocations However, in reaction to the speech, Botswana for African Union called on the WHO to strengthen the African region, and particularly strengthen the region’s WHO country offices, which are historically under-resourced and staffed, so that they can better support national ministries responding to health crises. “We call on the WHO to enhance capacity at the regional and national levels in order to accelerate progress. Currently, the regional office needs both technical and financial support in order to effectively address and support country needs,” said Botswana. While for the first time, over one-half of WHO’s 2024-25 budget has been earmarked for country offices, Botswana called for this to be increased to 75% to “address the budget and funding imbalances”, declaring that this was “a precondition for the increase in assessed contributions” from member states. For many member states’ reacting to Tedros’s speech, Russia’s war in Ukraine loomed large as a huge impediment to global well-being. Demark condemns Russia’s aggression in Ukraine. Russia’s war in Ukraine Denmark, representing the 27 European Union member states and seven aligned countries, said that “nearly 750 attacks on health care have been verified in Ukraine” while the Office of the UN High Commissioner for Human Rights has reported a total of 17,023 casualties in Ukraine”. “Russia’s military aggression has triggered energy and food supply challenges, exacerbating existing food system vulnerabilities that have already been weakened by the effect of climate change and the COVID-19 pandemic. The huge impact of conflict on health and well being of people and societies is the case in all ongoing conflicts across the world.” Canada, the US, the UK and Japan also condemned Russian aggression and its impact on the people of Ukraine and food security. However, in response, Russia warned that “the politicisation of the WHO agenda is unacceptable and this will simply lead to increased inequality and a deterioration of the situation in developing states”. US warning on sexual and reproductive rights US assistant secretary of state for global public affairs Loyce Pace Meanwhile, both the US and Brazil indicated that they would oppose any attacks on sexual and reproductive health and rights. Loyce Pace, US assistant secretary of state for global public affairs, said that the US “prioritises efforts to promote universal health coverage through strengthening primary health care and protecting people from catastrophic spending”. In addition, said Pace, US is focused on “ensuring the health and rights of lesbian, gay, bisexual, transgender, queer and intersex individuals and communities because we will not accept intolerance or discrimination of any people. We look forward to the EB’s discussions in this area”. Last year’s World Health Assembly stalled for hours over the inclusion of phrases such as men who have sex with men in a technical document on HIV, facing significant opposition from countries form the Mediterranean and North Africa (MENA) region of WHO. Brazil backed the US, saying that it too will “work with all the partners to improve the respect for human rights, in particular when it comes to gender and racial equality, sexual and reproductive health and rights”. “We will fight discrimination based on sexual orientation and gender identity and promote the rights of people with disabilities and indigenous peoples. In this regard, I would like to announce our intention to put forward the resolution on the health of indigenous peoples a topic never addressed directly before by the World Health Assembly with the objective of ensuring the right to health according to their own requirements and under their own administration,” said Brazil’s representative. Bringing Neglected Tropical Diseases out of the Silo 30/01/2023 Simon Bland A man with symptoms of the deadly NTD African trypanosomiasis (sleeping sickness), is examined by Dr Victor Kande in the Democratic Republic of Congo (DRC). The number of people requiring treatment for Neglected Tropical Diseases (NTDs) decreased from 2.19 to 1.65 billion between 2010 and 2021 – an impressive 25 percent decline. However, interlinked challenges, including the COVID pandemic and, now, accelerating patterns of climate change are putting this progress at risk. On World NTD Day, we need to recognise these emerging challenges and look to more integrated approaches. The impressive 25 percent decrease in the number of people requiring treatment for NTDs and the mounting number of countries that have eliminated at least one NTD are testimony to the progress being made to stamp out some of the world’s most deadly and debilitating diseases – which strike mostly at communities in developing countries and at people living in poverty. According to the World Health Organization (WHO), 47 countries have eliminated at least one NTD since 2010, and NTD programmes have performed better in the past year than in 2021. But while this progress is admirable, it is too slow for millions of people still living with, or at risk of infection from these 20 viral, parasitic and bacterial diseases considered NTDs which range from river blindness to leprosy, rabies and more, and continue to defy national and global elimination plans in many parts of the world today. Storm clouds on the horizon Moreover, new challenges like the COVID-19 pandemic and climate change are putting recent progress at risk, threatening to reverse the tremendous gains that have been made over the last few years. During the pandemic, services for NTDs were the second most frequently disrupted set of health systems services. Looking ahead, changing temperature and rainfall patterns will exacerbate poverty and displace people, and climate change will influence the emergence and re-emergence of multiple NTDs in higher latitudes and altitudes and pose a major risk for communities. This year’s World NTD Day is an opportunity to revitalise the way we tackle NTDs to not only maintain the progress we achieved so far, but to catalyse better, more efficient, bolder strategies for elimination in the future – harnessing the power of collective action. The climate threat Water shortage in Ethiopia. Population exposure to heat is increasing due to climate change. Globally, extreme temperature events are observed to be increasing in their frequency, duration, and magnitude. This is especially crucial in addressing the added challenges that climate change poses. NTDs are highly influenced by temperature, rainfall, humidity, and other climatic changes, and even small fluctuations can greatly increase transmission and spread, with potentially devastating effects. Climate change is thus threatening the re-emergence of NTDs in many parts of the world and will likely result in negative health outcomes and disruptions to healthcare systems. The threat to progress expands beyond NTDs to other infectious diseases. For malaria alone, studies show that climate change could lead to an additional 60,000 malaria deaths per year between 2030 and 2050. Despite the risks, the world is paying little attention to the climate-health nexus and the impact it could have on the resurgence of NTDs and their transmission. Up until now, approaches to address health and climate emergencies have remained largely separate, perhaps partly due to the lack of knowledge and guidance surrounding the health impact of climate change. The current literature on the intersection between climate and health also is insufficient to guide policy development. This is why countries, world leaders, and all stakeholders involved should prioritise research in this area. By exploring new and under-explored areas of the interface between climate and infectious disease, we can start to tackle the challenge and protect the gains and accelerate progress towards elimination. Removing NTDs from the disease control silo Fulfilling the goal of elimination begins by taking NTDs prevention and control out of isolation and adopting a more integrated approach. At the Global Institute for Disease Elimination (GLIDE) we see the intrinsic value of promoting and adopting cross-disease, cross-border, multi-stakeholder and multi-sector, approaches to innovatively and effectively control, eliminate, and eradicate NTDs. For this to work in global health, we must make way for more integrated healthcare systems that address preventable infectious diseases of poverty. The COVID-19 pandemic has exposed the pre-existing cracks in our healthcare systems, spotlighting the dangerous link between NTDs, other communicable diseases, and health emergencies. It has also reinforced the need to address health issues in a more holistic manner. A stronger, more systems-wide approach to health will strengthen surveillance, early warning, and pandemic preparedness. Mainstreaming NTDs within health systems and primary health care services, and promoting country ownership and accountability is an effective jumping off point, according to WHO’s NTD road map 2021-2023. In fact, this will contribute to sustainable and efficient NTD prevention and control, yielding better health outcomes and program management, and cost-effective solutions. But we must understand the economics of neglected diseases and elimination better in order to develop and refine investment cases in a more holistic way, using the health system and packages of essential health care as an important entry point to this mainstreaming. Water, sanitation and hygiene as a starting point Africa and Asia have the least access to basic sanitation facilities in the whole world Another starting point is to consider cross-sector coordination such as with water, sanitation, and hygiene (WASH) for disease prevention. WHO’s roadmap lays out a plan for effective elimination efforts, citing WASH as one of the key interventions in tackling 18 of the 20 NTDs. Improved access to clean water and sanitation can reduce the transmission of many NTDs, such as schistosomiasis, trachoma and guinea worm which, according to the Centers for DIsease Control and Prevention (CDC), is caused by the parasite Dracunculus medinensis and contracted when people do not have access to safe water for drinking. There is no vaccine or medicine available against guinea worm. However, eradication is being achieved by implementing WASH-related preventive measures. These include filtering drinking water to remove the water fleas that carry the parasite, providing improved water sources and preventing infected individuals from wading or swimming in drinking-water sources. The measures – supplemented by active surveillance and case containment, vector control and provision of improved water sources – have led to great progress toward eliminating guinea worm, with the number of human cases annually falling from 3.5 million in the mid-1980s to just 13 cases in 2022, poising it to become the second disease in human history that could be eradicated altogether, according to a report last week by the Carter Center. Breaking down silos The elimination of NTDs is feasible, but we need new approaches. The upcoming 28th Conference of the Parties (COP28) to the United Nations Framework Convention on Climate Change (UNFCCC), hosted by the United Arab Emirates (UAE) between 30 November and 12 December 2023, will be an opportunity for world leaders to both recognise and commit to addressing the health impacts of climate change. The World Health Assembly’s NTD road map 2021-2030, meanwhile, emphasizes the importance of integrating NTD programs and establishing links with other sectors such as education, nutrition, WASH, animal, and environmental health. We also must increase spending on NTD control and elimination, strengthening the case for investment. There is an intimate connection between the health of individuals and the interlinked, cross-boundary events across the globe. Recognizing this, we need an approach that engages all sectors and geographies in ways that facilitate collaboration, stimulate innovation and continued investment and, finally, by staying committed to delivering a world free of NTDs. ____________________________________ Simon Bland is the CEO of the Global Institute for Disease Elimination (GLIDE), based in the United Arab Emirates (UAE) and focused on accelerating the elimination of four preventable infectious diseases – malaria, polio, lymphatic filariasis, and river blindness – by 2030 and beyond. Founded in 2019 as the result of a collaboration between UAE President, His Highness Sheikh Mohamed bin Zayed Al Nahyan, and the Bill & Melinda Gates Foundation, GLIDE works to elevate awareness and engagement, advance elimination strategies, and foster and scale innovation for disease elimination and eradication. Image Credits: DNDi, Oxfam East Africa, Deep Knowledge Group. Influential WHO Committee Greenlights Initiative for ‘Replenishment Fund’ to Bolster Finance 30/01/2023 Kerry Cullinan Last year’s World Health Assembly mandated the secretariat to look into a replenishment fund. An influential sub-committee of the World Health Organisation (WHO)’s Executive Board (EB) has greenlighted a proposal by the cash-strapped global body’s Secretariat to seek additional funds via a replenishment fund, that would be filled by voluntary donations from both member states and philanthropies recruited at high-profile events. In its report published on Monday just as the WHO’s Executive Board’s began a week-long meeting, the Programme, Budget and Administration Committee (PBAC), accepted that a replenishment fund could provide an avenue for flexible funding that the WHO so desperately needs. “The committee acknowledged WHO’s need for more flexible, predictable and sustainable financing and considered that a replenishment mechanism provided a possible solution, especially for chronically underfunded areas of the organization’s programme budget,” according to the report, which concluded the deliberations of the three-day meeting of the PBAC last week. The Global Fund to fight AIDS, Tuberculosis and Malaria raised $15.7 billion in its ‘replenishment drive’ last year, while Gavi, The Vaccine Alliance as well as the World Bank and other UN-backed global organisations also run replenishment fundraising drives to attract additional funds from donors. Last year’s World Health Assembly mandated the WHO Secretariat to explore a replenishment fund based on six principles, including that it is driven by member states, allows flexibility in allocation, covers the base budget, and aligns with the WHO’s resolutions. Funding crisis The Executive Board is now expected to consider the proposal further this week in a series of discussions on improving WHO’s financial sustainability. A nod by the EB would pave the way for a full-fledged vote by the World Health Assembly in May. At the EB’s opening session on Monday, Director General Dr Tedros Adhanom Ghebreyesus confirmed that he expected that the proposal for a replenishment process would be submitted to member states for consideration. “We recognize that with increased flexibility and sustainability come increased expectations for transparency, efficiency, compliance and accountability. All of this leading to results,” said Tedros. Only around one-fifth of the WHO’s budget comes from members’ countries’ “assessed contributors” (calculated on their GDP), with the rest being made up from donations. But the donations are usually tied to particular programmes, inflexible and can be withdrawn at any time. At last year’s World Health Assembly, member states agreed to increase their contributions to cover half of the WHO’s budget. This year, members’ annual contributions are slated to be increased by around 20%. However, even when member states increase their contributions, there will still be a gaping shortfall, obviously undesirable given disease outbreaks and other demands. Developing the replenishment option Recommending that the executive board accepts the replenishment mechanism, the PBAC has advised the secretariat to develop the proposal further by examining “replenishment mechanisms established by other global health organizations and [analysing] the advantages and disadvantages of the various systems”. It also recommended that the “funding envelope for a replenishment mechanism should be based on the base segment of the programme budget, minus approved assessed contributions”. Still up for discussion is whether the fund will be based on the budget over one (two-year) budget cycle or two (four-year). More money for country offices PBAC has also recommended that the WHO secretariat consider further increases to its country operations rather than head office and regional structures. However, while the secretariat confirmed its commitment to strengthen country offices, it said that this would only be possible “gradually over time”. The WHO secretariat told PBAC that the main reason for the uneven financing of its programmes was “the extremely tight earmarking of the funds it received”. Director-General Dr Tedros Adhanom Ghebreyesus told the committee that member states’ agreement to an increase in assessed contributions would “make all the difference”. In response, the committee proposed that the Secretariat should “improve the persistent uneven financing across programmes, major offices and levels of the organization, including by distributing undistributed funds”. As far as the 2024/25 WHO budget is concerned, PBAC has recommended that member states should have until 10 February “to study and provide feedback on the programme budget digital platform” to allow proper consideration of the proposed budget ahead of the World Health Assembly in May. It’s Still a Pandemic: WHO Advisers and Chief Concur 30/01/2023 John Heilprin A healthcare worker wearing PPE disinfecting a street in the early days of the COVID-19 pandemic. The World Health Organization’s Emergency Committee on the COVID-19 pandemic and Director General Dr Tedros Adhanom Ghebreyesus both agree: the event continues to constitute a public health emergency of international concern (PHEIC). The UN health agency agreed on Monday that ending the state of international public health emergency over the coronavirus would be premature even after three long years since its appearance upended the world of normality as we knew it three years ago. Tedros said in a statement that he concurs with the advice offered by committee in its report based on a closed videoconference on Friday. He acknowledged the committee’s views that the COVID-19 pandemic is “probably at a transition point” that must be navigated carefully while ensuring the world is able to mitigate the potential negative consequences. “Achieving higher levels of population immunity globally, either through infection and/or vaccination, may limit the impact of SARS-CoV-2 on morbidity and mortality, but there is little doubt that this virus will remain a permanently established pathogen in humans and animals for the foreseeable future,” the committee reported. “As such, long-term public health action is critically needed,” it said. “While eliminating this virus from human and animal reservoirs is highly unlikely, mitigation of its devastating impact on morbidity and mortality is achievable and should continue to be a prioritized goal.” Personal protective equipment was essential to protect healthcare workers during the pandemic Seven pandemic recommendations As a result of his decision, Tedros advised nations to: Maintain momentum for COVID-19 vaccination to achieve 100% coverage of high-priority groups. Improve reporting of SARS-CoV-2 surveillance data to WHO Increase uptake and ensure long-term availability of medical countermeasures. Maintain strong national response capacity and prepare for future events Continue working with communities and their leaders to address the infodemic Continue to adjust any remaining international travel-related measures and do not require proof of vaccination for international travel Continue to support research for improved vaccines that reduce transmission and have broad applicability The committee said moving forward past the PHEIC will require a focused commitment by WHO and its 194 member nations, along with other international organizations, put in place “systematic, long-term prevention, surveillance, and control action plans.” The committee members, whose statement comes on the three-year anniversary of the determination of the COVID-19 PHEIC in January 2020, said it agreed the world is in a better position than it was during the peak of the Omicron transmission a year ago, yet more than 170,000 COVID-19-related deaths have been reported globally in the past eight weeks. It agreed surveillance and genetic sequencing declined globally, making it more harder to track known variants and detect new ones, while health systems are struggling with COVID-19 and caring for patients with influenza and respiratory syncytial virus (RSV), health workforce shortages, and fatigued health workers. Investment in strong health systems is key to pandemic=proofing the world. WHO asked to study impact of ending pandemic Vaccines, therapeutics, and diagnostics have been and remain critical in preventing severe disease, saving lives and taking the pressure off health systems and health workers globally, it said, but “the COVID-19 response remains hobbled in too many countries unable to provide these tools to the populations most in need, older people and health workers.” Some 13.1 billion doses of COVID-19 vaccines have been administered, with 89% of health workers and 81% of adults older than 60 years completing the primary series, WHO said. “COVID-19 remains a dangerous infectious disease with the capacity to cause substantial damage to health and health systems,” the committee said, adding that has asked the WHO Secretariat to provide an assessment of the regulatory implications for developing and authorizing vaccines, diagnostics, and therapeutics if the PHEIC were ended sometime “in the coming months.” Image Credits: Photo by Maksym Kaharlytskyi on Unsplash, Tehran Heart Centre . WHO Experts Confer on Possible End to COVID International Health Emergency 27/01/2023 Elaine Ruth Fletcher WHO Director General Dr Tedros Adhanom Gehebreyesus (left) and Didier Houssin, chair of the WHO Emergency Committee. on 30 January 2020, when the COVID International Health Emergency was first declared. The World Health Organization’s Emergency Committee on the COVID-19 pandemic was meeting Friday evening – with mixed signals emerging about whether the expert advisory group would recommend that the global health agency end the state of international public health emergency over the virus whose emergence stunned the world a little more than three years ago. At a press conference in December 2022, WHO’s Director General Dr Tedros Adhanom Ghebreyesus expressed hopes that the emergency that he first declared on 30 January, 2020, under WHO’s International Health Regulations, could finally be concluded sometime in 2023. But in his remarks to the Emergency Committee’s 14th meeting, the WHO Director General hinted for a second time this week that the time may not yet be ripe – as cases of new infection increased again worldwide only recently and a new wave of the virus continues to rip through China shortly after strict lockdown policies were finally relaxed. “As we enter the fourth year of the pandemic, we are certainly in a much better position now than we were a year ago, when the Omicron wave was at its peak, and more than 70,000 deaths were being reported to WHO each week,” said Tedros in his remarks at the closed meeting, reported by WHO in a press release. “When you last met in October, the number of weekly reported deaths was near the lowest since the pandemic began – less than 10,000 a week,” he added. “However, since the beginning of December, the number of weekly reported deaths globally has been rising.” China trends create a second level of concerns Following a massive wave of protests in autumn 2022, China lifted most of its COVID restrictions – which had been among the strictest in the world. In addition, Tedros noted, the lifting of COVID restrictions in China has led to a spike in deaths in the world’s most populous nation, whose citizens were poorly protected by vaccinations as well as having low natural immunity thanks to months of social isolation. “Last week, almost 40 thousand deaths were reported to WHO, more than half of them from China,” Tedros said. “In total, over the past eight weeks, more than 170,000 deaths have been reported. The actual number is certainly much higher.” Earlier this week, Tedros also expressed his mixed feelings about declaring an end to the pandemic even more bluntly, saying: “While I will not preempt the advice of the emergency committee, I remain very concerned by the situation in many countries and the rising number of deaths,” he said, speaking at WHO’s weekly press briefing. “While we’re clearly in better shape than three years ago when this pandemic first hit, the global collective response is once again under strain.” In fact, after reaching a peak in mid-December, the wave of new cases in China and worldwide have been declining for the past month – both according to WHO data and other data monitoring platforms. However, in light of the reduced amount of COVID testing worldwide, the confirmed case count is an increasingly unreliable measure of true cases. “Surveillance and genetic sequencing have declined dramatically around the world, making it more difficult to track known variants and detect new ones,” Tedros told the committee at the outset of Friday’s meeting. Revolution in vaccines, treatments and diagnostics has not reached everyone Related to that, the global response to COVID remains “hobbled” because “powerful, life-saving tools are still not getting to the population that need them most – especially older people and health workers, Tedros said. “Many health systems around the world are struggling to cope with COVID-19, on top of caring for patients with other diseases including influenza and RSV, and with work shortages and fatigued health workers. “And public trust in the safe and effective tools for controlling COVID-19 is being undermined by a continuous torrent of mis- and disinformation.” It was unclear as to whether the committee’s deliberations would continue into the weekend, or when their conclusions will finally be announced. However, there was speculation that their report might only be published on Monday, when the WHO Executive Board, WHO’s governing body, begins its first annual round of meetings for 2023. Among the nearly 50 items on the week-long agenda are a raft of reports and recommendations on strengthening global preparedness and response to health emergencies. The WHO Public Health Emergency of International Concern (PHEIC) was declared in the framework of the 2005 International Health Regulations, which constitute a legally binding agreement between WHO member states regarding emergency outbreak and response. In March 2020, Tedros also declared that the emergency also constituted a “pandemic” – although there is in fact no legal provision for a pandemic declaration in the IHR. However, the weaknesses in the IHR system of outbreak alerts, notification and resonses, highlighted by the faltering and inconsistent reponse to the COVID pandemic, have paved the way for major reconsideration of global pandemic response frameworks, with debates over a new pandemic treaty, as well as IHR revisions, set to continue throughout 2023 and into 2024. See related story here: Governing Pandemics Snapshot Image Credits: Twitter: @WHO. WHO Provides New Medicines List, Policy Recommendations for Nuclear Emergency 27/01/2023 Maayan Hoffman A Nuclear powerplant in Belgium. The World Health Organization (WHO) on Friday released an updated list of medicines that should be stockpiled in the event of a radiological and nuclear emergency, along with new policy advice in the event of such an incident. “Preparedness for radiation emergencies is consistently reported as the weakest area of preparedness in many countries,” the 66-page report said. This newest report updates the one released over 15 years ago, in 2007, and thus includes a host of new pharmaceutical developments. “In radiation emergencies, people may be exposed to radiation at doses ranging from negligible to life-threatening. Governments need to make treatments available for those in need – fast,” said Dr Maria Neira, WHO Acting Assistant Director-General of the Healthier Populations Division. “It is essential that governments are prepared to protect the health of populations and respond immediately to emergencies. This includes having ready supplies of lifesaving medicines that will reduce risks and treat injuries from radiation.” Added Dr Mike Ryan, Executive Director of WHO’s Health Emergencies Programme: “This updated critical medicines list will be a vital preparedness and readiness tool for our partners to identify, procure, stockpile and deliver effective countermeasures in a timely fashion to those at risk or exposed in these events.” Radiological or nuclear emergencies could occur at nuclear power plants, medical or research facilities or be the result of accidents during transport of radioactive materials, WHO explained. In addition, these emergencies could be the result of a malicious event, such as a nuclear bombing. To date, there were two massive nuclear incidents: The 1945 atomic bombings of Hiroshima and Nagasaki by the United States, the consequences of which have been continually studied. There was also the 1986 accident at the Chernobyl nuclear plant in Ukraine – the largest uncontrolled radioactive release in history. Former Russian President Dmitry Medvedev warned this month in yet another Telegram post that a defeat of Russia in Ukraine could trigger a nuclear war. “The defeat of a nuclear power in a conventional war may trigger a nuclear war,” Medvedev wrote. Exposure to high doses of radiation can have severe consequences on a person’s long-term health or lead to immediate or early death. As such, aside from generic supplies and materials used for any type of emergencies, stockpiles should include medicines that either prevent or reduce exposure to radiation, WHO explained. Only a handful of recommended medicines There are only a handful of specific drugs that have been proven effective in the treatment of over-exposure to radiation and these are included in the report. They include: stable iodine; chelating sand (decorporating agents); cytokines used for mitigation of damage to the bone marrow; and medicines to treat vomiting, diarrhea and infections. “One of the most serious outcomes of over-exposure to radiation is acute radiation syndrome (ARS), which manifests as a haematopoietic syndrome”. The latter, also called bone marrow syndrome, impacts blood cell production and in cases of acute poisoning, can lead to death through infection or hemorrhage. “Depending on the severity of the exposure may further progress as gastrointestinal, cardiovascular and neurological syndromes,” the report states. However, the WHO recommendations only include treatments of haematopoietic and gastrointestinal syndromes, “as cardiovascular and neurological syndromes are considered non-salvageable and require only palliative care.” Blocking agents such as stable iodine, could be used to block the uptake of radionuclides in the body, the WHO report added. Other agents like Prussian blue are applied to remove radioactive ceasium from the body. Calcium or zinc diethylenetriaminepentaacetic acid can treat internal contamination with transuranium radionuclides. “These and other elements of such stockpiles should be made rapidly available in case of radiation emergencies,” wrote WHO. Bone marrow syndrome – emerging treatments In the case of haematopoietic, or bone marrow syndrome, radiation attacks all three blood lineages – white and red blood cells and platelets. Low white blood cell count weakens the immune system, making an individual vulnerable to infection. Red blood cells carry oxygen to the body and platelets are responsible for coagulation, which prevents bleeding, explained Yaky Yanay, CEO and president of Pluri – an Israeli-based biotech firm developing an injection of placenta cells for the treatment of ARS. The treatment has been approved by the United States Food and Drug Administration as an “Investigational New Drug” (IND) for use in the event of a nuclear incident – although it is not yet mature enough to be considered for the WHO list of recommended medicines. The WHO report notes, however, that researchers are making progress on developing novel treatments, although none of them have been approved by the global health agency for use in a nuclear emergency. WHO: Stockpile based on population size WHO stressed that a country’s nuclear medicines stockpile should be based on reliable data for national risk profiles, the size of the population and available resources and capabilities of their health system. Finally, WHO called on national health authorities, health-care facilities, pharmaceutical suppliers and logistics, civil defense and emergency services to be leveraged in the event of an emergency. These teams should be coordinated in advance to be able to function effectively in the event of a nuclear incident. Image Credits: Photo by Frédéric Paulussen on Unsplash. Governing Pandemics Snapshot 27/01/2023 Gian Luca Burci, Suerie Moon, Daniela Morich, Adam Strobeyko & Seyed-Moeen Hosseinalipour Standing ovation at the close of the special World Health Assembly session 1 December 2021, in which member states agreed to negotiate a new pandemic accord. A briefing series on the status of moves to reform the global system of pandemic preparedness and response launches today, just ahead of the WHO Executive Board review of progress next week. Looking back at 2022 and forward into 2023, this series by the Global Health Center of the Geneva Graduate Institute, published in collaboration with Health Policy Watch, provides an update on the progress so far in the WHO-led negotiations over a new pandemic treaty. It also looks at the progress in revisions to the existing emergency rules of the International Health Regulations (IHR) – while considering what could happen next. The complete “Governing Pandemics Snapshot”, also includes briefings on reforms being considered in the financing of pandemics as well as the rules around pathogen access and benefit-sharing. Pandemic treaty: tough political negotiations ahead By Daniela Morich Following a milestone World Health Assembly decision in late 2021, WHO Member States have been negotiating an international agreement on pandemic prevention, preparedness and response to strengthen global capacities and resilience for future pandemics. The year 2022 was the year for the advance of these pandemic treaty talks with the establishment of a formal process, a strict timeline, and initial discussions on principles. In 2023, negotiations will shift from broad consultations to tough politics. The Covid-19 pandemic brought to the surface the shortcomings of global health governance for emergencies and accelerated discussions to reform it. At a special WHA session in late 2021, the second-ever convened by the World Health Assembly, WHO Member States agreed to establish an intergovernmental negotiating body (INB) to negotiate a new “instrument” to strengthen pandemic prevention, preparedness and response – or, a pandemic treaty. The INB initiated its work in early 2022 and is to present the outcome of the negotiations to the 77th World Health Assembly (WHA) in May 2024. This is an ambitious timeline for a complex international rule-making process, especially as it will run in parallel to the process to revise the International Health Regulations (IHR), a pre-existing WHO instrument that governs the cross-border spread of infectious disease. Nonetheless, the INB is moving forward and achieved two mid-term milestones in 2022. In July, at the second INB meeting, Member States agreed that the instrument should be legally binding, which suggests countries are ready to accept new international obligations to improve pandemic prevention and response. In addition, the INB engaged in intensive intersessional consultations to seek input not only from governments or well-established experts – the traditional protagonists of international rulemaking – but also from civil society organizations and the public. Despite these efforts, commentators have argued that the process is still not as inclusive as it should be. As work on the instrument progresses, negotiators should expect more demands to expand meaningful participation of stakeholders beyond governments. The INB’s Bureau (six countries elected to lead the process) released the ‘conceptual zero draft’ (CZD) ahead of the third meeting of the INB, which took place in December 2022. The CZD –which can be seen as the first rough draft of the accord – brought to the negotiating table a broad set of issues and highlighted a collective willingness to ensure a more equitable response to future threats. It also reflected tough divisions on several issues, in particular, intellectual property (IP), pathogen- and benefit- sharing, One Health, financing and accountability, which will likely become more visible and contentious as negotiations move to the next phase. At the conclusion of the gathering, Member States directed the INB Bureau to develop the ‘zero draft’. Delegates strongly encouraged the Bureau to move away from the vague and aspirational language of the CZD and to present clear legal provisions and definitions, including one for ‘pandemic’, for Member States to negotiate in earnest. The INB Bureau is expected to circulate the zero draft in early February 2023. At this stage, the negotiation process will likely shift from a consultation and information gathering process to become a more politicized, polarized and consequential debate. The time available to negotiators is constrained. The 2023-2024 agenda includes 6 additional INB meetings scheduled over 14 months in addition to meetings of the drafting groups, with the IHR revision process unfolding in parallel. Considering the complexity of the issues on the table, the existing divisions between Member States, and the limited time available to negotiators, achieving meaningful progress in this new highly-political phase is the tall order for 2023. An existential moment for the International Health Regulations Dr Hiroki Nakatani, chairman of the May World Health Assembly, applauds the WHA decision to revise the International Health Regulations. By Gian Luca Burci While negotiations on a new pandemic instrument continue in 2023-24, the International Health Regulations (IHR) remain the sole global legally-binding instrument devoted to the prevention and control of the international spread of disease – and revisions to those are already underway. Can the two parallel processes complement each other or will they add new layers of confusion? That is the challenge negotiators and member states will face. Although considered an essential component of the global health security toolbox, the IHR attracted severe criticism and allegedly low compliance during the COVID-19 pandemic. The momentum towards a new “pandemic treaty”, beginning in late 2020, was in part a reaction to the perceived weaknesses and limitations of the IHR. The difficult and sometimes confusing discussions in the Working Group on strengthening WHO preparedness and response to health emergencies created by the 74th World Health Assembly in 2021 to discuss reforms, ultimately led to a WHA decision in December 2021 to launch negotiations on a new legal instrument (“pandemic treaty”) to be adopted by 2024. Then, in 2022, attention turned back to the IHR as member states sought faster solutions for the most burning issues that had surfaced during the pandemic – particularly around outbreak reporting and IHR compliance. As a result, a complex IHR amendment process is also now underway. The two processes (IHR revisions and pandemic accord) are thus now proceeding in parallel, with hard decisions still to be made on the issues that the revised IHR will tackle – as compared to the new pandemic accord. Negotiations to amend the IHR in 2023/2024 raise an existential question about their raison d’etre: should they retain their technical, operational character, or expand significantly to address highly political questions such as those on international assistance, equity and access to technologies for disease outbreaks? The US broke the ice by proposing its own substantial set of amendments in January 2022, and successfully winning agreement at the 75th WHA in May 2022, to both adopt a set of limited technical IHR amendments and to open up a broader process for further amendments. The WHA thus launched negotiations towards “targeted amendments” of the IHR with the same 2024 deadline for WHA adoption as the new pandemic accord. Member States submitted their proposed amendments by 30 September 2022 and an expert “review committee” analyzed them and presented its recommendations to the Director-General in January 2023. A Working Group open to all Member States will work from February 2023 towards a negotiated package. The process is unusual compared to other intergovernmental negotiations, in that states hardly ever place on the table all their proposed amendments at the outset; the initial US disclosure of all its amendments, however, required a similar treatment for other states and made that approach inevitable. Wildly diverse amendments but a few trends emerge A patchwork of national rules around international travel, vaccines and border controls were a feature of the COVID pandemic, highlighting the inconsistent application of key IHR provisions aimed at ensuring international trade and travel during health emergencies. The outcome of the first phase of this process is a massive aggregation of wildly diverse amendments (available here) proposed or supported by almost 100 states. They range from focused technical amendments to far-reaching changes. Despite their diversity, a few trends emerge dividing Global South and Global North countries. The most political proposals, coming in particular from the African Region, Bangladesh and India, aim at ensuring equitable access to vaccines, distributed manufacturing capacities, technology transfer, limitations on patenting and sustainable financing of national capacities. These proposals reflect the North-South divide that we have been witnessing in the recent treaty conferences on climate change and biodiversity and are clearly also a consequence of the inequities in access to life-saving medical countermeasures displayed during the COVID-19 pandemic. Other proposals, in particular from the European Union, the Eurasian Economic Union (submitted by the Russian Federation) and the United States, aim at strengthening the IHR within their current approach, e.g. by tightening compliance and accountability for information sharing, encouraging the sharing of genetic sequence data and through the use of digital technologies. Two negotiating processes unfolding at the same time The challenge in reaching an agreed package in time for the 2024 WHA is increased by the unprecedented parallel unfolding of two negotiating processes with the same timeline, where countries will probably submit the same types of proposals for both instruments to secure an overall favorable outcome. An important point in this respect that is often overlooked is that amendments to the IHR will in principle enter into force at the same time for all its 196 parties, whereas the pandemic instrument – since it will likely be an international treaty – will enter into force once a critical mass of countries has ratified it and only for them, with new countries joining once they ratify. The broad range of proposals for the pandemic instrument and the likelihood that the US will eventually not ratify it may actually lead Global South countries to prioritize the IHR for some of the most ambitious proposals. This possibility raises one final issue. Currently, the IHR is essentially an operational instrument to coordinate outbreak prevention and control and depoliticize WHO’s role in managing them. There is no emphasis on equity, assistance or international cooperation. Amendments proposed by Global South countries would transform it into a regulatory and transactional instrument with a more political role for WHO and differential treatment for developing countries to improve equity in the availability of health technologies. Fundamentally, negotiators will have to decide what they want the IHR to be – and if the IHR is expanded to encompass the issues of health equity then what role would the new pandemic instrument play? For essays on financing pandemics and pathogen and benefit sharing, see the full Governing Pandemics Snapshot here. This is the first in a periodic series of updates to be published during the year. About the authors Daniela Morich is Manager and Adviser of the Governing Pandemics initiative at the Global Health Centre, and a lawyer with experience in multilateral negotiations. Dr Gian Luca Burci is Adjunct Professor of International Law at the Geneva Graduate Institute. He was a member of the IHR Review Committee that completed its expert analysis of the proposed IHR amendments in January 2023. He co-leads the Governing Pandemics initiative. Dr Suerie Moon is Professor of Practice and Co-Director of the Global Health Centre, and co-leads the Governing Pandemics initiative. Adam Strobeyko is a Hauser Global Fellow at NYU Law and was a Doctoral Researcher for the Governing Pandemics initiative. Moeen Hosseinalipour is a master’s student in global health and international affairs at the University of Geneva and Geneva Graduate Institute, and a research assistant for the Governing Pandemics initiative. Image Credits: Geneva Graduate Institute. Posts navigation Older postsNewer posts This site uses cookies to help give you the best experience on our website. Cookies enable us to collect information that helps us personalise your experience and improve the functionality and performance of our site. 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Conflicts and Health Emergencies Overshadow WHO Successes as Executive Board Gets Underway 30/01/2023 Kerry Cullinan Dr Tedros opens the WHO executive board meeting. Supporting 100 million tobacco users to quit, increasing exclusive breastfeeding for babies under six months to 48% globally, and helping 63 countries to build climate-resilient health systems are some of the recent successes of the World Health Organization (WHO), said Director General Dr Tedros Adhanom Ghebreyesus. Addressing the opening of the WHO’s executive board (EB) meeting on Monday, Tedros said that the global body was focused on “promoting, providing, protecting, powering and performing for health”. The 152nd session of the Executive Board, which runs until 7 February, has a very heavy agenda – ranging from a series of initiatives to improve global emergency response to an updated menu of WHO-recommended “best buys” to fight non-communicable diseases. The EB’s approval of draft resolutions and decisions is a prerequisite to bringing most proposals before the World Health Assembly (WHA) in May. The EB also plays a watchdog role, vis a vis the 9000-member WHO’s finance and budet planning, advising on strategic directions for the global body’s work. Protecting health during conflicts and humanitarian crises constituted a huge part of the WHO’s work in 2022 as it responded to 72 graded emergencies last year, “including three public health emergencies of international concern, outbreaks of Ebola and cholera, conflicts in Ethiopia, Syria, Ukraine and Yemen, and humanitarian crises in the greater Horn of Africa, the Sahel and much more”, said Tedros. “Thanks to the generosity of donors to the Contingency Fund for Emergencies, we were able to release more than $87 million immediately to support rapid response, and we delivered essential health supplies to 90 countries from our Dubai logistics hub in the United Arab Emirates,” said Tedros. Africa demands an increase in country allocations However, in reaction to the speech, Botswana for African Union called on the WHO to strengthen the African region, and particularly strengthen the region’s WHO country offices, which are historically under-resourced and staffed, so that they can better support national ministries responding to health crises. “We call on the WHO to enhance capacity at the regional and national levels in order to accelerate progress. Currently, the regional office needs both technical and financial support in order to effectively address and support country needs,” said Botswana. While for the first time, over one-half of WHO’s 2024-25 budget has been earmarked for country offices, Botswana called for this to be increased to 75% to “address the budget and funding imbalances”, declaring that this was “a precondition for the increase in assessed contributions” from member states. For many member states’ reacting to Tedros’s speech, Russia’s war in Ukraine loomed large as a huge impediment to global well-being. Demark condemns Russia’s aggression in Ukraine. Russia’s war in Ukraine Denmark, representing the 27 European Union member states and seven aligned countries, said that “nearly 750 attacks on health care have been verified in Ukraine” while the Office of the UN High Commissioner for Human Rights has reported a total of 17,023 casualties in Ukraine”. “Russia’s military aggression has triggered energy and food supply challenges, exacerbating existing food system vulnerabilities that have already been weakened by the effect of climate change and the COVID-19 pandemic. The huge impact of conflict on health and well being of people and societies is the case in all ongoing conflicts across the world.” Canada, the US, the UK and Japan also condemned Russian aggression and its impact on the people of Ukraine and food security. However, in response, Russia warned that “the politicisation of the WHO agenda is unacceptable and this will simply lead to increased inequality and a deterioration of the situation in developing states”. US warning on sexual and reproductive rights US assistant secretary of state for global public affairs Loyce Pace Meanwhile, both the US and Brazil indicated that they would oppose any attacks on sexual and reproductive health and rights. Loyce Pace, US assistant secretary of state for global public affairs, said that the US “prioritises efforts to promote universal health coverage through strengthening primary health care and protecting people from catastrophic spending”. In addition, said Pace, US is focused on “ensuring the health and rights of lesbian, gay, bisexual, transgender, queer and intersex individuals and communities because we will not accept intolerance or discrimination of any people. We look forward to the EB’s discussions in this area”. Last year’s World Health Assembly stalled for hours over the inclusion of phrases such as men who have sex with men in a technical document on HIV, facing significant opposition from countries form the Mediterranean and North Africa (MENA) region of WHO. Brazil backed the US, saying that it too will “work with all the partners to improve the respect for human rights, in particular when it comes to gender and racial equality, sexual and reproductive health and rights”. “We will fight discrimination based on sexual orientation and gender identity and promote the rights of people with disabilities and indigenous peoples. In this regard, I would like to announce our intention to put forward the resolution on the health of indigenous peoples a topic never addressed directly before by the World Health Assembly with the objective of ensuring the right to health according to their own requirements and under their own administration,” said Brazil’s representative. Bringing Neglected Tropical Diseases out of the Silo 30/01/2023 Simon Bland A man with symptoms of the deadly NTD African trypanosomiasis (sleeping sickness), is examined by Dr Victor Kande in the Democratic Republic of Congo (DRC). The number of people requiring treatment for Neglected Tropical Diseases (NTDs) decreased from 2.19 to 1.65 billion between 2010 and 2021 – an impressive 25 percent decline. However, interlinked challenges, including the COVID pandemic and, now, accelerating patterns of climate change are putting this progress at risk. On World NTD Day, we need to recognise these emerging challenges and look to more integrated approaches. The impressive 25 percent decrease in the number of people requiring treatment for NTDs and the mounting number of countries that have eliminated at least one NTD are testimony to the progress being made to stamp out some of the world’s most deadly and debilitating diseases – which strike mostly at communities in developing countries and at people living in poverty. According to the World Health Organization (WHO), 47 countries have eliminated at least one NTD since 2010, and NTD programmes have performed better in the past year than in 2021. But while this progress is admirable, it is too slow for millions of people still living with, or at risk of infection from these 20 viral, parasitic and bacterial diseases considered NTDs which range from river blindness to leprosy, rabies and more, and continue to defy national and global elimination plans in many parts of the world today. Storm clouds on the horizon Moreover, new challenges like the COVID-19 pandemic and climate change are putting recent progress at risk, threatening to reverse the tremendous gains that have been made over the last few years. During the pandemic, services for NTDs were the second most frequently disrupted set of health systems services. Looking ahead, changing temperature and rainfall patterns will exacerbate poverty and displace people, and climate change will influence the emergence and re-emergence of multiple NTDs in higher latitudes and altitudes and pose a major risk for communities. This year’s World NTD Day is an opportunity to revitalise the way we tackle NTDs to not only maintain the progress we achieved so far, but to catalyse better, more efficient, bolder strategies for elimination in the future – harnessing the power of collective action. The climate threat Water shortage in Ethiopia. Population exposure to heat is increasing due to climate change. Globally, extreme temperature events are observed to be increasing in their frequency, duration, and magnitude. This is especially crucial in addressing the added challenges that climate change poses. NTDs are highly influenced by temperature, rainfall, humidity, and other climatic changes, and even small fluctuations can greatly increase transmission and spread, with potentially devastating effects. Climate change is thus threatening the re-emergence of NTDs in many parts of the world and will likely result in negative health outcomes and disruptions to healthcare systems. The threat to progress expands beyond NTDs to other infectious diseases. For malaria alone, studies show that climate change could lead to an additional 60,000 malaria deaths per year between 2030 and 2050. Despite the risks, the world is paying little attention to the climate-health nexus and the impact it could have on the resurgence of NTDs and their transmission. Up until now, approaches to address health and climate emergencies have remained largely separate, perhaps partly due to the lack of knowledge and guidance surrounding the health impact of climate change. The current literature on the intersection between climate and health also is insufficient to guide policy development. This is why countries, world leaders, and all stakeholders involved should prioritise research in this area. By exploring new and under-explored areas of the interface between climate and infectious disease, we can start to tackle the challenge and protect the gains and accelerate progress towards elimination. Removing NTDs from the disease control silo Fulfilling the goal of elimination begins by taking NTDs prevention and control out of isolation and adopting a more integrated approach. At the Global Institute for Disease Elimination (GLIDE) we see the intrinsic value of promoting and adopting cross-disease, cross-border, multi-stakeholder and multi-sector, approaches to innovatively and effectively control, eliminate, and eradicate NTDs. For this to work in global health, we must make way for more integrated healthcare systems that address preventable infectious diseases of poverty. The COVID-19 pandemic has exposed the pre-existing cracks in our healthcare systems, spotlighting the dangerous link between NTDs, other communicable diseases, and health emergencies. It has also reinforced the need to address health issues in a more holistic manner. A stronger, more systems-wide approach to health will strengthen surveillance, early warning, and pandemic preparedness. Mainstreaming NTDs within health systems and primary health care services, and promoting country ownership and accountability is an effective jumping off point, according to WHO’s NTD road map 2021-2023. In fact, this will contribute to sustainable and efficient NTD prevention and control, yielding better health outcomes and program management, and cost-effective solutions. But we must understand the economics of neglected diseases and elimination better in order to develop and refine investment cases in a more holistic way, using the health system and packages of essential health care as an important entry point to this mainstreaming. Water, sanitation and hygiene as a starting point Africa and Asia have the least access to basic sanitation facilities in the whole world Another starting point is to consider cross-sector coordination such as with water, sanitation, and hygiene (WASH) for disease prevention. WHO’s roadmap lays out a plan for effective elimination efforts, citing WASH as one of the key interventions in tackling 18 of the 20 NTDs. Improved access to clean water and sanitation can reduce the transmission of many NTDs, such as schistosomiasis, trachoma and guinea worm which, according to the Centers for DIsease Control and Prevention (CDC), is caused by the parasite Dracunculus medinensis and contracted when people do not have access to safe water for drinking. There is no vaccine or medicine available against guinea worm. However, eradication is being achieved by implementing WASH-related preventive measures. These include filtering drinking water to remove the water fleas that carry the parasite, providing improved water sources and preventing infected individuals from wading or swimming in drinking-water sources. The measures – supplemented by active surveillance and case containment, vector control and provision of improved water sources – have led to great progress toward eliminating guinea worm, with the number of human cases annually falling from 3.5 million in the mid-1980s to just 13 cases in 2022, poising it to become the second disease in human history that could be eradicated altogether, according to a report last week by the Carter Center. Breaking down silos The elimination of NTDs is feasible, but we need new approaches. The upcoming 28th Conference of the Parties (COP28) to the United Nations Framework Convention on Climate Change (UNFCCC), hosted by the United Arab Emirates (UAE) between 30 November and 12 December 2023, will be an opportunity for world leaders to both recognise and commit to addressing the health impacts of climate change. The World Health Assembly’s NTD road map 2021-2030, meanwhile, emphasizes the importance of integrating NTD programs and establishing links with other sectors such as education, nutrition, WASH, animal, and environmental health. We also must increase spending on NTD control and elimination, strengthening the case for investment. There is an intimate connection between the health of individuals and the interlinked, cross-boundary events across the globe. Recognizing this, we need an approach that engages all sectors and geographies in ways that facilitate collaboration, stimulate innovation and continued investment and, finally, by staying committed to delivering a world free of NTDs. ____________________________________ Simon Bland is the CEO of the Global Institute for Disease Elimination (GLIDE), based in the United Arab Emirates (UAE) and focused on accelerating the elimination of four preventable infectious diseases – malaria, polio, lymphatic filariasis, and river blindness – by 2030 and beyond. Founded in 2019 as the result of a collaboration between UAE President, His Highness Sheikh Mohamed bin Zayed Al Nahyan, and the Bill & Melinda Gates Foundation, GLIDE works to elevate awareness and engagement, advance elimination strategies, and foster and scale innovation for disease elimination and eradication. Image Credits: DNDi, Oxfam East Africa, Deep Knowledge Group. Influential WHO Committee Greenlights Initiative for ‘Replenishment Fund’ to Bolster Finance 30/01/2023 Kerry Cullinan Last year’s World Health Assembly mandated the secretariat to look into a replenishment fund. An influential sub-committee of the World Health Organisation (WHO)’s Executive Board (EB) has greenlighted a proposal by the cash-strapped global body’s Secretariat to seek additional funds via a replenishment fund, that would be filled by voluntary donations from both member states and philanthropies recruited at high-profile events. In its report published on Monday just as the WHO’s Executive Board’s began a week-long meeting, the Programme, Budget and Administration Committee (PBAC), accepted that a replenishment fund could provide an avenue for flexible funding that the WHO so desperately needs. “The committee acknowledged WHO’s need for more flexible, predictable and sustainable financing and considered that a replenishment mechanism provided a possible solution, especially for chronically underfunded areas of the organization’s programme budget,” according to the report, which concluded the deliberations of the three-day meeting of the PBAC last week. The Global Fund to fight AIDS, Tuberculosis and Malaria raised $15.7 billion in its ‘replenishment drive’ last year, while Gavi, The Vaccine Alliance as well as the World Bank and other UN-backed global organisations also run replenishment fundraising drives to attract additional funds from donors. Last year’s World Health Assembly mandated the WHO Secretariat to explore a replenishment fund based on six principles, including that it is driven by member states, allows flexibility in allocation, covers the base budget, and aligns with the WHO’s resolutions. Funding crisis The Executive Board is now expected to consider the proposal further this week in a series of discussions on improving WHO’s financial sustainability. A nod by the EB would pave the way for a full-fledged vote by the World Health Assembly in May. At the EB’s opening session on Monday, Director General Dr Tedros Adhanom Ghebreyesus confirmed that he expected that the proposal for a replenishment process would be submitted to member states for consideration. “We recognize that with increased flexibility and sustainability come increased expectations for transparency, efficiency, compliance and accountability. All of this leading to results,” said Tedros. Only around one-fifth of the WHO’s budget comes from members’ countries’ “assessed contributors” (calculated on their GDP), with the rest being made up from donations. But the donations are usually tied to particular programmes, inflexible and can be withdrawn at any time. At last year’s World Health Assembly, member states agreed to increase their contributions to cover half of the WHO’s budget. This year, members’ annual contributions are slated to be increased by around 20%. However, even when member states increase their contributions, there will still be a gaping shortfall, obviously undesirable given disease outbreaks and other demands. Developing the replenishment option Recommending that the executive board accepts the replenishment mechanism, the PBAC has advised the secretariat to develop the proposal further by examining “replenishment mechanisms established by other global health organizations and [analysing] the advantages and disadvantages of the various systems”. It also recommended that the “funding envelope for a replenishment mechanism should be based on the base segment of the programme budget, minus approved assessed contributions”. Still up for discussion is whether the fund will be based on the budget over one (two-year) budget cycle or two (four-year). More money for country offices PBAC has also recommended that the WHO secretariat consider further increases to its country operations rather than head office and regional structures. However, while the secretariat confirmed its commitment to strengthen country offices, it said that this would only be possible “gradually over time”. The WHO secretariat told PBAC that the main reason for the uneven financing of its programmes was “the extremely tight earmarking of the funds it received”. Director-General Dr Tedros Adhanom Ghebreyesus told the committee that member states’ agreement to an increase in assessed contributions would “make all the difference”. In response, the committee proposed that the Secretariat should “improve the persistent uneven financing across programmes, major offices and levels of the organization, including by distributing undistributed funds”. As far as the 2024/25 WHO budget is concerned, PBAC has recommended that member states should have until 10 February “to study and provide feedback on the programme budget digital platform” to allow proper consideration of the proposed budget ahead of the World Health Assembly in May. It’s Still a Pandemic: WHO Advisers and Chief Concur 30/01/2023 John Heilprin A healthcare worker wearing PPE disinfecting a street in the early days of the COVID-19 pandemic. The World Health Organization’s Emergency Committee on the COVID-19 pandemic and Director General Dr Tedros Adhanom Ghebreyesus both agree: the event continues to constitute a public health emergency of international concern (PHEIC). The UN health agency agreed on Monday that ending the state of international public health emergency over the coronavirus would be premature even after three long years since its appearance upended the world of normality as we knew it three years ago. Tedros said in a statement that he concurs with the advice offered by committee in its report based on a closed videoconference on Friday. He acknowledged the committee’s views that the COVID-19 pandemic is “probably at a transition point” that must be navigated carefully while ensuring the world is able to mitigate the potential negative consequences. “Achieving higher levels of population immunity globally, either through infection and/or vaccination, may limit the impact of SARS-CoV-2 on morbidity and mortality, but there is little doubt that this virus will remain a permanently established pathogen in humans and animals for the foreseeable future,” the committee reported. “As such, long-term public health action is critically needed,” it said. “While eliminating this virus from human and animal reservoirs is highly unlikely, mitigation of its devastating impact on morbidity and mortality is achievable and should continue to be a prioritized goal.” Personal protective equipment was essential to protect healthcare workers during the pandemic Seven pandemic recommendations As a result of his decision, Tedros advised nations to: Maintain momentum for COVID-19 vaccination to achieve 100% coverage of high-priority groups. Improve reporting of SARS-CoV-2 surveillance data to WHO Increase uptake and ensure long-term availability of medical countermeasures. Maintain strong national response capacity and prepare for future events Continue working with communities and their leaders to address the infodemic Continue to adjust any remaining international travel-related measures and do not require proof of vaccination for international travel Continue to support research for improved vaccines that reduce transmission and have broad applicability The committee said moving forward past the PHEIC will require a focused commitment by WHO and its 194 member nations, along with other international organizations, put in place “systematic, long-term prevention, surveillance, and control action plans.” The committee members, whose statement comes on the three-year anniversary of the determination of the COVID-19 PHEIC in January 2020, said it agreed the world is in a better position than it was during the peak of the Omicron transmission a year ago, yet more than 170,000 COVID-19-related deaths have been reported globally in the past eight weeks. It agreed surveillance and genetic sequencing declined globally, making it more harder to track known variants and detect new ones, while health systems are struggling with COVID-19 and caring for patients with influenza and respiratory syncytial virus (RSV), health workforce shortages, and fatigued health workers. Investment in strong health systems is key to pandemic=proofing the world. WHO asked to study impact of ending pandemic Vaccines, therapeutics, and diagnostics have been and remain critical in preventing severe disease, saving lives and taking the pressure off health systems and health workers globally, it said, but “the COVID-19 response remains hobbled in too many countries unable to provide these tools to the populations most in need, older people and health workers.” Some 13.1 billion doses of COVID-19 vaccines have been administered, with 89% of health workers and 81% of adults older than 60 years completing the primary series, WHO said. “COVID-19 remains a dangerous infectious disease with the capacity to cause substantial damage to health and health systems,” the committee said, adding that has asked the WHO Secretariat to provide an assessment of the regulatory implications for developing and authorizing vaccines, diagnostics, and therapeutics if the PHEIC were ended sometime “in the coming months.” Image Credits: Photo by Maksym Kaharlytskyi on Unsplash, Tehran Heart Centre . WHO Experts Confer on Possible End to COVID International Health Emergency 27/01/2023 Elaine Ruth Fletcher WHO Director General Dr Tedros Adhanom Gehebreyesus (left) and Didier Houssin, chair of the WHO Emergency Committee. on 30 January 2020, when the COVID International Health Emergency was first declared. The World Health Organization’s Emergency Committee on the COVID-19 pandemic was meeting Friday evening – with mixed signals emerging about whether the expert advisory group would recommend that the global health agency end the state of international public health emergency over the virus whose emergence stunned the world a little more than three years ago. At a press conference in December 2022, WHO’s Director General Dr Tedros Adhanom Ghebreyesus expressed hopes that the emergency that he first declared on 30 January, 2020, under WHO’s International Health Regulations, could finally be concluded sometime in 2023. But in his remarks to the Emergency Committee’s 14th meeting, the WHO Director General hinted for a second time this week that the time may not yet be ripe – as cases of new infection increased again worldwide only recently and a new wave of the virus continues to rip through China shortly after strict lockdown policies were finally relaxed. “As we enter the fourth year of the pandemic, we are certainly in a much better position now than we were a year ago, when the Omicron wave was at its peak, and more than 70,000 deaths were being reported to WHO each week,” said Tedros in his remarks at the closed meeting, reported by WHO in a press release. “When you last met in October, the number of weekly reported deaths was near the lowest since the pandemic began – less than 10,000 a week,” he added. “However, since the beginning of December, the number of weekly reported deaths globally has been rising.” China trends create a second level of concerns Following a massive wave of protests in autumn 2022, China lifted most of its COVID restrictions – which had been among the strictest in the world. In addition, Tedros noted, the lifting of COVID restrictions in China has led to a spike in deaths in the world’s most populous nation, whose citizens were poorly protected by vaccinations as well as having low natural immunity thanks to months of social isolation. “Last week, almost 40 thousand deaths were reported to WHO, more than half of them from China,” Tedros said. “In total, over the past eight weeks, more than 170,000 deaths have been reported. The actual number is certainly much higher.” Earlier this week, Tedros also expressed his mixed feelings about declaring an end to the pandemic even more bluntly, saying: “While I will not preempt the advice of the emergency committee, I remain very concerned by the situation in many countries and the rising number of deaths,” he said, speaking at WHO’s weekly press briefing. “While we’re clearly in better shape than three years ago when this pandemic first hit, the global collective response is once again under strain.” In fact, after reaching a peak in mid-December, the wave of new cases in China and worldwide have been declining for the past month – both according to WHO data and other data monitoring platforms. However, in light of the reduced amount of COVID testing worldwide, the confirmed case count is an increasingly unreliable measure of true cases. “Surveillance and genetic sequencing have declined dramatically around the world, making it more difficult to track known variants and detect new ones,” Tedros told the committee at the outset of Friday’s meeting. Revolution in vaccines, treatments and diagnostics has not reached everyone Related to that, the global response to COVID remains “hobbled” because “powerful, life-saving tools are still not getting to the population that need them most – especially older people and health workers, Tedros said. “Many health systems around the world are struggling to cope with COVID-19, on top of caring for patients with other diseases including influenza and RSV, and with work shortages and fatigued health workers. “And public trust in the safe and effective tools for controlling COVID-19 is being undermined by a continuous torrent of mis- and disinformation.” It was unclear as to whether the committee’s deliberations would continue into the weekend, or when their conclusions will finally be announced. However, there was speculation that their report might only be published on Monday, when the WHO Executive Board, WHO’s governing body, begins its first annual round of meetings for 2023. Among the nearly 50 items on the week-long agenda are a raft of reports and recommendations on strengthening global preparedness and response to health emergencies. The WHO Public Health Emergency of International Concern (PHEIC) was declared in the framework of the 2005 International Health Regulations, which constitute a legally binding agreement between WHO member states regarding emergency outbreak and response. In March 2020, Tedros also declared that the emergency also constituted a “pandemic” – although there is in fact no legal provision for a pandemic declaration in the IHR. However, the weaknesses in the IHR system of outbreak alerts, notification and resonses, highlighted by the faltering and inconsistent reponse to the COVID pandemic, have paved the way for major reconsideration of global pandemic response frameworks, with debates over a new pandemic treaty, as well as IHR revisions, set to continue throughout 2023 and into 2024. See related story here: Governing Pandemics Snapshot Image Credits: Twitter: @WHO. WHO Provides New Medicines List, Policy Recommendations for Nuclear Emergency 27/01/2023 Maayan Hoffman A Nuclear powerplant in Belgium. The World Health Organization (WHO) on Friday released an updated list of medicines that should be stockpiled in the event of a radiological and nuclear emergency, along with new policy advice in the event of such an incident. “Preparedness for radiation emergencies is consistently reported as the weakest area of preparedness in many countries,” the 66-page report said. This newest report updates the one released over 15 years ago, in 2007, and thus includes a host of new pharmaceutical developments. “In radiation emergencies, people may be exposed to radiation at doses ranging from negligible to life-threatening. Governments need to make treatments available for those in need – fast,” said Dr Maria Neira, WHO Acting Assistant Director-General of the Healthier Populations Division. “It is essential that governments are prepared to protect the health of populations and respond immediately to emergencies. This includes having ready supplies of lifesaving medicines that will reduce risks and treat injuries from radiation.” Added Dr Mike Ryan, Executive Director of WHO’s Health Emergencies Programme: “This updated critical medicines list will be a vital preparedness and readiness tool for our partners to identify, procure, stockpile and deliver effective countermeasures in a timely fashion to those at risk or exposed in these events.” Radiological or nuclear emergencies could occur at nuclear power plants, medical or research facilities or be the result of accidents during transport of radioactive materials, WHO explained. In addition, these emergencies could be the result of a malicious event, such as a nuclear bombing. To date, there were two massive nuclear incidents: The 1945 atomic bombings of Hiroshima and Nagasaki by the United States, the consequences of which have been continually studied. There was also the 1986 accident at the Chernobyl nuclear plant in Ukraine – the largest uncontrolled radioactive release in history. Former Russian President Dmitry Medvedev warned this month in yet another Telegram post that a defeat of Russia in Ukraine could trigger a nuclear war. “The defeat of a nuclear power in a conventional war may trigger a nuclear war,” Medvedev wrote. Exposure to high doses of radiation can have severe consequences on a person’s long-term health or lead to immediate or early death. As such, aside from generic supplies and materials used for any type of emergencies, stockpiles should include medicines that either prevent or reduce exposure to radiation, WHO explained. Only a handful of recommended medicines There are only a handful of specific drugs that have been proven effective in the treatment of over-exposure to radiation and these are included in the report. They include: stable iodine; chelating sand (decorporating agents); cytokines used for mitigation of damage to the bone marrow; and medicines to treat vomiting, diarrhea and infections. “One of the most serious outcomes of over-exposure to radiation is acute radiation syndrome (ARS), which manifests as a haematopoietic syndrome”. The latter, also called bone marrow syndrome, impacts blood cell production and in cases of acute poisoning, can lead to death through infection or hemorrhage. “Depending on the severity of the exposure may further progress as gastrointestinal, cardiovascular and neurological syndromes,” the report states. However, the WHO recommendations only include treatments of haematopoietic and gastrointestinal syndromes, “as cardiovascular and neurological syndromes are considered non-salvageable and require only palliative care.” Blocking agents such as stable iodine, could be used to block the uptake of radionuclides in the body, the WHO report added. Other agents like Prussian blue are applied to remove radioactive ceasium from the body. Calcium or zinc diethylenetriaminepentaacetic acid can treat internal contamination with transuranium radionuclides. “These and other elements of such stockpiles should be made rapidly available in case of radiation emergencies,” wrote WHO. Bone marrow syndrome – emerging treatments In the case of haematopoietic, or bone marrow syndrome, radiation attacks all three blood lineages – white and red blood cells and platelets. Low white blood cell count weakens the immune system, making an individual vulnerable to infection. Red blood cells carry oxygen to the body and platelets are responsible for coagulation, which prevents bleeding, explained Yaky Yanay, CEO and president of Pluri – an Israeli-based biotech firm developing an injection of placenta cells for the treatment of ARS. The treatment has been approved by the United States Food and Drug Administration as an “Investigational New Drug” (IND) for use in the event of a nuclear incident – although it is not yet mature enough to be considered for the WHO list of recommended medicines. The WHO report notes, however, that researchers are making progress on developing novel treatments, although none of them have been approved by the global health agency for use in a nuclear emergency. WHO: Stockpile based on population size WHO stressed that a country’s nuclear medicines stockpile should be based on reliable data for national risk profiles, the size of the population and available resources and capabilities of their health system. Finally, WHO called on national health authorities, health-care facilities, pharmaceutical suppliers and logistics, civil defense and emergency services to be leveraged in the event of an emergency. These teams should be coordinated in advance to be able to function effectively in the event of a nuclear incident. Image Credits: Photo by Frédéric Paulussen on Unsplash. Governing Pandemics Snapshot 27/01/2023 Gian Luca Burci, Suerie Moon, Daniela Morich, Adam Strobeyko & Seyed-Moeen Hosseinalipour Standing ovation at the close of the special World Health Assembly session 1 December 2021, in which member states agreed to negotiate a new pandemic accord. A briefing series on the status of moves to reform the global system of pandemic preparedness and response launches today, just ahead of the WHO Executive Board review of progress next week. Looking back at 2022 and forward into 2023, this series by the Global Health Center of the Geneva Graduate Institute, published in collaboration with Health Policy Watch, provides an update on the progress so far in the WHO-led negotiations over a new pandemic treaty. It also looks at the progress in revisions to the existing emergency rules of the International Health Regulations (IHR) – while considering what could happen next. The complete “Governing Pandemics Snapshot”, also includes briefings on reforms being considered in the financing of pandemics as well as the rules around pathogen access and benefit-sharing. Pandemic treaty: tough political negotiations ahead By Daniela Morich Following a milestone World Health Assembly decision in late 2021, WHO Member States have been negotiating an international agreement on pandemic prevention, preparedness and response to strengthen global capacities and resilience for future pandemics. The year 2022 was the year for the advance of these pandemic treaty talks with the establishment of a formal process, a strict timeline, and initial discussions on principles. In 2023, negotiations will shift from broad consultations to tough politics. The Covid-19 pandemic brought to the surface the shortcomings of global health governance for emergencies and accelerated discussions to reform it. At a special WHA session in late 2021, the second-ever convened by the World Health Assembly, WHO Member States agreed to establish an intergovernmental negotiating body (INB) to negotiate a new “instrument” to strengthen pandemic prevention, preparedness and response – or, a pandemic treaty. The INB initiated its work in early 2022 and is to present the outcome of the negotiations to the 77th World Health Assembly (WHA) in May 2024. This is an ambitious timeline for a complex international rule-making process, especially as it will run in parallel to the process to revise the International Health Regulations (IHR), a pre-existing WHO instrument that governs the cross-border spread of infectious disease. Nonetheless, the INB is moving forward and achieved two mid-term milestones in 2022. In July, at the second INB meeting, Member States agreed that the instrument should be legally binding, which suggests countries are ready to accept new international obligations to improve pandemic prevention and response. In addition, the INB engaged in intensive intersessional consultations to seek input not only from governments or well-established experts – the traditional protagonists of international rulemaking – but also from civil society organizations and the public. Despite these efforts, commentators have argued that the process is still not as inclusive as it should be. As work on the instrument progresses, negotiators should expect more demands to expand meaningful participation of stakeholders beyond governments. The INB’s Bureau (six countries elected to lead the process) released the ‘conceptual zero draft’ (CZD) ahead of the third meeting of the INB, which took place in December 2022. The CZD –which can be seen as the first rough draft of the accord – brought to the negotiating table a broad set of issues and highlighted a collective willingness to ensure a more equitable response to future threats. It also reflected tough divisions on several issues, in particular, intellectual property (IP), pathogen- and benefit- sharing, One Health, financing and accountability, which will likely become more visible and contentious as negotiations move to the next phase. At the conclusion of the gathering, Member States directed the INB Bureau to develop the ‘zero draft’. Delegates strongly encouraged the Bureau to move away from the vague and aspirational language of the CZD and to present clear legal provisions and definitions, including one for ‘pandemic’, for Member States to negotiate in earnest. The INB Bureau is expected to circulate the zero draft in early February 2023. At this stage, the negotiation process will likely shift from a consultation and information gathering process to become a more politicized, polarized and consequential debate. The time available to negotiators is constrained. The 2023-2024 agenda includes 6 additional INB meetings scheduled over 14 months in addition to meetings of the drafting groups, with the IHR revision process unfolding in parallel. Considering the complexity of the issues on the table, the existing divisions between Member States, and the limited time available to negotiators, achieving meaningful progress in this new highly-political phase is the tall order for 2023. An existential moment for the International Health Regulations Dr Hiroki Nakatani, chairman of the May World Health Assembly, applauds the WHA decision to revise the International Health Regulations. By Gian Luca Burci While negotiations on a new pandemic instrument continue in 2023-24, the International Health Regulations (IHR) remain the sole global legally-binding instrument devoted to the prevention and control of the international spread of disease – and revisions to those are already underway. Can the two parallel processes complement each other or will they add new layers of confusion? That is the challenge negotiators and member states will face. Although considered an essential component of the global health security toolbox, the IHR attracted severe criticism and allegedly low compliance during the COVID-19 pandemic. The momentum towards a new “pandemic treaty”, beginning in late 2020, was in part a reaction to the perceived weaknesses and limitations of the IHR. The difficult and sometimes confusing discussions in the Working Group on strengthening WHO preparedness and response to health emergencies created by the 74th World Health Assembly in 2021 to discuss reforms, ultimately led to a WHA decision in December 2021 to launch negotiations on a new legal instrument (“pandemic treaty”) to be adopted by 2024. Then, in 2022, attention turned back to the IHR as member states sought faster solutions for the most burning issues that had surfaced during the pandemic – particularly around outbreak reporting and IHR compliance. As a result, a complex IHR amendment process is also now underway. The two processes (IHR revisions and pandemic accord) are thus now proceeding in parallel, with hard decisions still to be made on the issues that the revised IHR will tackle – as compared to the new pandemic accord. Negotiations to amend the IHR in 2023/2024 raise an existential question about their raison d’etre: should they retain their technical, operational character, or expand significantly to address highly political questions such as those on international assistance, equity and access to technologies for disease outbreaks? The US broke the ice by proposing its own substantial set of amendments in January 2022, and successfully winning agreement at the 75th WHA in May 2022, to both adopt a set of limited technical IHR amendments and to open up a broader process for further amendments. The WHA thus launched negotiations towards “targeted amendments” of the IHR with the same 2024 deadline for WHA adoption as the new pandemic accord. Member States submitted their proposed amendments by 30 September 2022 and an expert “review committee” analyzed them and presented its recommendations to the Director-General in January 2023. A Working Group open to all Member States will work from February 2023 towards a negotiated package. The process is unusual compared to other intergovernmental negotiations, in that states hardly ever place on the table all their proposed amendments at the outset; the initial US disclosure of all its amendments, however, required a similar treatment for other states and made that approach inevitable. Wildly diverse amendments but a few trends emerge A patchwork of national rules around international travel, vaccines and border controls were a feature of the COVID pandemic, highlighting the inconsistent application of key IHR provisions aimed at ensuring international trade and travel during health emergencies. The outcome of the first phase of this process is a massive aggregation of wildly diverse amendments (available here) proposed or supported by almost 100 states. They range from focused technical amendments to far-reaching changes. Despite their diversity, a few trends emerge dividing Global South and Global North countries. The most political proposals, coming in particular from the African Region, Bangladesh and India, aim at ensuring equitable access to vaccines, distributed manufacturing capacities, technology transfer, limitations on patenting and sustainable financing of national capacities. These proposals reflect the North-South divide that we have been witnessing in the recent treaty conferences on climate change and biodiversity and are clearly also a consequence of the inequities in access to life-saving medical countermeasures displayed during the COVID-19 pandemic. Other proposals, in particular from the European Union, the Eurasian Economic Union (submitted by the Russian Federation) and the United States, aim at strengthening the IHR within their current approach, e.g. by tightening compliance and accountability for information sharing, encouraging the sharing of genetic sequence data and through the use of digital technologies. Two negotiating processes unfolding at the same time The challenge in reaching an agreed package in time for the 2024 WHA is increased by the unprecedented parallel unfolding of two negotiating processes with the same timeline, where countries will probably submit the same types of proposals for both instruments to secure an overall favorable outcome. An important point in this respect that is often overlooked is that amendments to the IHR will in principle enter into force at the same time for all its 196 parties, whereas the pandemic instrument – since it will likely be an international treaty – will enter into force once a critical mass of countries has ratified it and only for them, with new countries joining once they ratify. The broad range of proposals for the pandemic instrument and the likelihood that the US will eventually not ratify it may actually lead Global South countries to prioritize the IHR for some of the most ambitious proposals. This possibility raises one final issue. Currently, the IHR is essentially an operational instrument to coordinate outbreak prevention and control and depoliticize WHO’s role in managing them. There is no emphasis on equity, assistance or international cooperation. Amendments proposed by Global South countries would transform it into a regulatory and transactional instrument with a more political role for WHO and differential treatment for developing countries to improve equity in the availability of health technologies. Fundamentally, negotiators will have to decide what they want the IHR to be – and if the IHR is expanded to encompass the issues of health equity then what role would the new pandemic instrument play? For essays on financing pandemics and pathogen and benefit sharing, see the full Governing Pandemics Snapshot here. This is the first in a periodic series of updates to be published during the year. About the authors Daniela Morich is Manager and Adviser of the Governing Pandemics initiative at the Global Health Centre, and a lawyer with experience in multilateral negotiations. Dr Gian Luca Burci is Adjunct Professor of International Law at the Geneva Graduate Institute. He was a member of the IHR Review Committee that completed its expert analysis of the proposed IHR amendments in January 2023. He co-leads the Governing Pandemics initiative. Dr Suerie Moon is Professor of Practice and Co-Director of the Global Health Centre, and co-leads the Governing Pandemics initiative. Adam Strobeyko is a Hauser Global Fellow at NYU Law and was a Doctoral Researcher for the Governing Pandemics initiative. Moeen Hosseinalipour is a master’s student in global health and international affairs at the University of Geneva and Geneva Graduate Institute, and a research assistant for the Governing Pandemics initiative. Image Credits: Geneva Graduate Institute. Posts navigation Older postsNewer posts This site uses cookies to help give you the best experience on our website. Cookies enable us to collect information that helps us personalise your experience and improve the functionality and performance of our site. 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Bringing Neglected Tropical Diseases out of the Silo 30/01/2023 Simon Bland A man with symptoms of the deadly NTD African trypanosomiasis (sleeping sickness), is examined by Dr Victor Kande in the Democratic Republic of Congo (DRC). The number of people requiring treatment for Neglected Tropical Diseases (NTDs) decreased from 2.19 to 1.65 billion between 2010 and 2021 – an impressive 25 percent decline. However, interlinked challenges, including the COVID pandemic and, now, accelerating patterns of climate change are putting this progress at risk. On World NTD Day, we need to recognise these emerging challenges and look to more integrated approaches. The impressive 25 percent decrease in the number of people requiring treatment for NTDs and the mounting number of countries that have eliminated at least one NTD are testimony to the progress being made to stamp out some of the world’s most deadly and debilitating diseases – which strike mostly at communities in developing countries and at people living in poverty. According to the World Health Organization (WHO), 47 countries have eliminated at least one NTD since 2010, and NTD programmes have performed better in the past year than in 2021. But while this progress is admirable, it is too slow for millions of people still living with, or at risk of infection from these 20 viral, parasitic and bacterial diseases considered NTDs which range from river blindness to leprosy, rabies and more, and continue to defy national and global elimination plans in many parts of the world today. Storm clouds on the horizon Moreover, new challenges like the COVID-19 pandemic and climate change are putting recent progress at risk, threatening to reverse the tremendous gains that have been made over the last few years. During the pandemic, services for NTDs were the second most frequently disrupted set of health systems services. Looking ahead, changing temperature and rainfall patterns will exacerbate poverty and displace people, and climate change will influence the emergence and re-emergence of multiple NTDs in higher latitudes and altitudes and pose a major risk for communities. This year’s World NTD Day is an opportunity to revitalise the way we tackle NTDs to not only maintain the progress we achieved so far, but to catalyse better, more efficient, bolder strategies for elimination in the future – harnessing the power of collective action. The climate threat Water shortage in Ethiopia. Population exposure to heat is increasing due to climate change. Globally, extreme temperature events are observed to be increasing in their frequency, duration, and magnitude. This is especially crucial in addressing the added challenges that climate change poses. NTDs are highly influenced by temperature, rainfall, humidity, and other climatic changes, and even small fluctuations can greatly increase transmission and spread, with potentially devastating effects. Climate change is thus threatening the re-emergence of NTDs in many parts of the world and will likely result in negative health outcomes and disruptions to healthcare systems. The threat to progress expands beyond NTDs to other infectious diseases. For malaria alone, studies show that climate change could lead to an additional 60,000 malaria deaths per year between 2030 and 2050. Despite the risks, the world is paying little attention to the climate-health nexus and the impact it could have on the resurgence of NTDs and their transmission. Up until now, approaches to address health and climate emergencies have remained largely separate, perhaps partly due to the lack of knowledge and guidance surrounding the health impact of climate change. The current literature on the intersection between climate and health also is insufficient to guide policy development. This is why countries, world leaders, and all stakeholders involved should prioritise research in this area. By exploring new and under-explored areas of the interface between climate and infectious disease, we can start to tackle the challenge and protect the gains and accelerate progress towards elimination. Removing NTDs from the disease control silo Fulfilling the goal of elimination begins by taking NTDs prevention and control out of isolation and adopting a more integrated approach. At the Global Institute for Disease Elimination (GLIDE) we see the intrinsic value of promoting and adopting cross-disease, cross-border, multi-stakeholder and multi-sector, approaches to innovatively and effectively control, eliminate, and eradicate NTDs. For this to work in global health, we must make way for more integrated healthcare systems that address preventable infectious diseases of poverty. The COVID-19 pandemic has exposed the pre-existing cracks in our healthcare systems, spotlighting the dangerous link between NTDs, other communicable diseases, and health emergencies. It has also reinforced the need to address health issues in a more holistic manner. A stronger, more systems-wide approach to health will strengthen surveillance, early warning, and pandemic preparedness. Mainstreaming NTDs within health systems and primary health care services, and promoting country ownership and accountability is an effective jumping off point, according to WHO’s NTD road map 2021-2023. In fact, this will contribute to sustainable and efficient NTD prevention and control, yielding better health outcomes and program management, and cost-effective solutions. But we must understand the economics of neglected diseases and elimination better in order to develop and refine investment cases in a more holistic way, using the health system and packages of essential health care as an important entry point to this mainstreaming. Water, sanitation and hygiene as a starting point Africa and Asia have the least access to basic sanitation facilities in the whole world Another starting point is to consider cross-sector coordination such as with water, sanitation, and hygiene (WASH) for disease prevention. WHO’s roadmap lays out a plan for effective elimination efforts, citing WASH as one of the key interventions in tackling 18 of the 20 NTDs. Improved access to clean water and sanitation can reduce the transmission of many NTDs, such as schistosomiasis, trachoma and guinea worm which, according to the Centers for DIsease Control and Prevention (CDC), is caused by the parasite Dracunculus medinensis and contracted when people do not have access to safe water for drinking. There is no vaccine or medicine available against guinea worm. However, eradication is being achieved by implementing WASH-related preventive measures. These include filtering drinking water to remove the water fleas that carry the parasite, providing improved water sources and preventing infected individuals from wading or swimming in drinking-water sources. The measures – supplemented by active surveillance and case containment, vector control and provision of improved water sources – have led to great progress toward eliminating guinea worm, with the number of human cases annually falling from 3.5 million in the mid-1980s to just 13 cases in 2022, poising it to become the second disease in human history that could be eradicated altogether, according to a report last week by the Carter Center. Breaking down silos The elimination of NTDs is feasible, but we need new approaches. The upcoming 28th Conference of the Parties (COP28) to the United Nations Framework Convention on Climate Change (UNFCCC), hosted by the United Arab Emirates (UAE) between 30 November and 12 December 2023, will be an opportunity for world leaders to both recognise and commit to addressing the health impacts of climate change. The World Health Assembly’s NTD road map 2021-2030, meanwhile, emphasizes the importance of integrating NTD programs and establishing links with other sectors such as education, nutrition, WASH, animal, and environmental health. We also must increase spending on NTD control and elimination, strengthening the case for investment. There is an intimate connection between the health of individuals and the interlinked, cross-boundary events across the globe. Recognizing this, we need an approach that engages all sectors and geographies in ways that facilitate collaboration, stimulate innovation and continued investment and, finally, by staying committed to delivering a world free of NTDs. ____________________________________ Simon Bland is the CEO of the Global Institute for Disease Elimination (GLIDE), based in the United Arab Emirates (UAE) and focused on accelerating the elimination of four preventable infectious diseases – malaria, polio, lymphatic filariasis, and river blindness – by 2030 and beyond. Founded in 2019 as the result of a collaboration between UAE President, His Highness Sheikh Mohamed bin Zayed Al Nahyan, and the Bill & Melinda Gates Foundation, GLIDE works to elevate awareness and engagement, advance elimination strategies, and foster and scale innovation for disease elimination and eradication. Image Credits: DNDi, Oxfam East Africa, Deep Knowledge Group. Influential WHO Committee Greenlights Initiative for ‘Replenishment Fund’ to Bolster Finance 30/01/2023 Kerry Cullinan Last year’s World Health Assembly mandated the secretariat to look into a replenishment fund. An influential sub-committee of the World Health Organisation (WHO)’s Executive Board (EB) has greenlighted a proposal by the cash-strapped global body’s Secretariat to seek additional funds via a replenishment fund, that would be filled by voluntary donations from both member states and philanthropies recruited at high-profile events. In its report published on Monday just as the WHO’s Executive Board’s began a week-long meeting, the Programme, Budget and Administration Committee (PBAC), accepted that a replenishment fund could provide an avenue for flexible funding that the WHO so desperately needs. “The committee acknowledged WHO’s need for more flexible, predictable and sustainable financing and considered that a replenishment mechanism provided a possible solution, especially for chronically underfunded areas of the organization’s programme budget,” according to the report, which concluded the deliberations of the three-day meeting of the PBAC last week. The Global Fund to fight AIDS, Tuberculosis and Malaria raised $15.7 billion in its ‘replenishment drive’ last year, while Gavi, The Vaccine Alliance as well as the World Bank and other UN-backed global organisations also run replenishment fundraising drives to attract additional funds from donors. Last year’s World Health Assembly mandated the WHO Secretariat to explore a replenishment fund based on six principles, including that it is driven by member states, allows flexibility in allocation, covers the base budget, and aligns with the WHO’s resolutions. Funding crisis The Executive Board is now expected to consider the proposal further this week in a series of discussions on improving WHO’s financial sustainability. A nod by the EB would pave the way for a full-fledged vote by the World Health Assembly in May. At the EB’s opening session on Monday, Director General Dr Tedros Adhanom Ghebreyesus confirmed that he expected that the proposal for a replenishment process would be submitted to member states for consideration. “We recognize that with increased flexibility and sustainability come increased expectations for transparency, efficiency, compliance and accountability. All of this leading to results,” said Tedros. Only around one-fifth of the WHO’s budget comes from members’ countries’ “assessed contributors” (calculated on their GDP), with the rest being made up from donations. But the donations are usually tied to particular programmes, inflexible and can be withdrawn at any time. At last year’s World Health Assembly, member states agreed to increase their contributions to cover half of the WHO’s budget. This year, members’ annual contributions are slated to be increased by around 20%. However, even when member states increase their contributions, there will still be a gaping shortfall, obviously undesirable given disease outbreaks and other demands. Developing the replenishment option Recommending that the executive board accepts the replenishment mechanism, the PBAC has advised the secretariat to develop the proposal further by examining “replenishment mechanisms established by other global health organizations and [analysing] the advantages and disadvantages of the various systems”. It also recommended that the “funding envelope for a replenishment mechanism should be based on the base segment of the programme budget, minus approved assessed contributions”. Still up for discussion is whether the fund will be based on the budget over one (two-year) budget cycle or two (four-year). More money for country offices PBAC has also recommended that the WHO secretariat consider further increases to its country operations rather than head office and regional structures. However, while the secretariat confirmed its commitment to strengthen country offices, it said that this would only be possible “gradually over time”. The WHO secretariat told PBAC that the main reason for the uneven financing of its programmes was “the extremely tight earmarking of the funds it received”. Director-General Dr Tedros Adhanom Ghebreyesus told the committee that member states’ agreement to an increase in assessed contributions would “make all the difference”. In response, the committee proposed that the Secretariat should “improve the persistent uneven financing across programmes, major offices and levels of the organization, including by distributing undistributed funds”. As far as the 2024/25 WHO budget is concerned, PBAC has recommended that member states should have until 10 February “to study and provide feedback on the programme budget digital platform” to allow proper consideration of the proposed budget ahead of the World Health Assembly in May. It’s Still a Pandemic: WHO Advisers and Chief Concur 30/01/2023 John Heilprin A healthcare worker wearing PPE disinfecting a street in the early days of the COVID-19 pandemic. The World Health Organization’s Emergency Committee on the COVID-19 pandemic and Director General Dr Tedros Adhanom Ghebreyesus both agree: the event continues to constitute a public health emergency of international concern (PHEIC). The UN health agency agreed on Monday that ending the state of international public health emergency over the coronavirus would be premature even after three long years since its appearance upended the world of normality as we knew it three years ago. Tedros said in a statement that he concurs with the advice offered by committee in its report based on a closed videoconference on Friday. He acknowledged the committee’s views that the COVID-19 pandemic is “probably at a transition point” that must be navigated carefully while ensuring the world is able to mitigate the potential negative consequences. “Achieving higher levels of population immunity globally, either through infection and/or vaccination, may limit the impact of SARS-CoV-2 on morbidity and mortality, but there is little doubt that this virus will remain a permanently established pathogen in humans and animals for the foreseeable future,” the committee reported. “As such, long-term public health action is critically needed,” it said. “While eliminating this virus from human and animal reservoirs is highly unlikely, mitigation of its devastating impact on morbidity and mortality is achievable and should continue to be a prioritized goal.” Personal protective equipment was essential to protect healthcare workers during the pandemic Seven pandemic recommendations As a result of his decision, Tedros advised nations to: Maintain momentum for COVID-19 vaccination to achieve 100% coverage of high-priority groups. Improve reporting of SARS-CoV-2 surveillance data to WHO Increase uptake and ensure long-term availability of medical countermeasures. Maintain strong national response capacity and prepare for future events Continue working with communities and their leaders to address the infodemic Continue to adjust any remaining international travel-related measures and do not require proof of vaccination for international travel Continue to support research for improved vaccines that reduce transmission and have broad applicability The committee said moving forward past the PHEIC will require a focused commitment by WHO and its 194 member nations, along with other international organizations, put in place “systematic, long-term prevention, surveillance, and control action plans.” The committee members, whose statement comes on the three-year anniversary of the determination of the COVID-19 PHEIC in January 2020, said it agreed the world is in a better position than it was during the peak of the Omicron transmission a year ago, yet more than 170,000 COVID-19-related deaths have been reported globally in the past eight weeks. It agreed surveillance and genetic sequencing declined globally, making it more harder to track known variants and detect new ones, while health systems are struggling with COVID-19 and caring for patients with influenza and respiratory syncytial virus (RSV), health workforce shortages, and fatigued health workers. Investment in strong health systems is key to pandemic=proofing the world. WHO asked to study impact of ending pandemic Vaccines, therapeutics, and diagnostics have been and remain critical in preventing severe disease, saving lives and taking the pressure off health systems and health workers globally, it said, but “the COVID-19 response remains hobbled in too many countries unable to provide these tools to the populations most in need, older people and health workers.” Some 13.1 billion doses of COVID-19 vaccines have been administered, with 89% of health workers and 81% of adults older than 60 years completing the primary series, WHO said. “COVID-19 remains a dangerous infectious disease with the capacity to cause substantial damage to health and health systems,” the committee said, adding that has asked the WHO Secretariat to provide an assessment of the regulatory implications for developing and authorizing vaccines, diagnostics, and therapeutics if the PHEIC were ended sometime “in the coming months.” Image Credits: Photo by Maksym Kaharlytskyi on Unsplash, Tehran Heart Centre . WHO Experts Confer on Possible End to COVID International Health Emergency 27/01/2023 Elaine Ruth Fletcher WHO Director General Dr Tedros Adhanom Gehebreyesus (left) and Didier Houssin, chair of the WHO Emergency Committee. on 30 January 2020, when the COVID International Health Emergency was first declared. The World Health Organization’s Emergency Committee on the COVID-19 pandemic was meeting Friday evening – with mixed signals emerging about whether the expert advisory group would recommend that the global health agency end the state of international public health emergency over the virus whose emergence stunned the world a little more than three years ago. At a press conference in December 2022, WHO’s Director General Dr Tedros Adhanom Ghebreyesus expressed hopes that the emergency that he first declared on 30 January, 2020, under WHO’s International Health Regulations, could finally be concluded sometime in 2023. But in his remarks to the Emergency Committee’s 14th meeting, the WHO Director General hinted for a second time this week that the time may not yet be ripe – as cases of new infection increased again worldwide only recently and a new wave of the virus continues to rip through China shortly after strict lockdown policies were finally relaxed. “As we enter the fourth year of the pandemic, we are certainly in a much better position now than we were a year ago, when the Omicron wave was at its peak, and more than 70,000 deaths were being reported to WHO each week,” said Tedros in his remarks at the closed meeting, reported by WHO in a press release. “When you last met in October, the number of weekly reported deaths was near the lowest since the pandemic began – less than 10,000 a week,” he added. “However, since the beginning of December, the number of weekly reported deaths globally has been rising.” China trends create a second level of concerns Following a massive wave of protests in autumn 2022, China lifted most of its COVID restrictions – which had been among the strictest in the world. In addition, Tedros noted, the lifting of COVID restrictions in China has led to a spike in deaths in the world’s most populous nation, whose citizens were poorly protected by vaccinations as well as having low natural immunity thanks to months of social isolation. “Last week, almost 40 thousand deaths were reported to WHO, more than half of them from China,” Tedros said. “In total, over the past eight weeks, more than 170,000 deaths have been reported. The actual number is certainly much higher.” Earlier this week, Tedros also expressed his mixed feelings about declaring an end to the pandemic even more bluntly, saying: “While I will not preempt the advice of the emergency committee, I remain very concerned by the situation in many countries and the rising number of deaths,” he said, speaking at WHO’s weekly press briefing. “While we’re clearly in better shape than three years ago when this pandemic first hit, the global collective response is once again under strain.” In fact, after reaching a peak in mid-December, the wave of new cases in China and worldwide have been declining for the past month – both according to WHO data and other data monitoring platforms. However, in light of the reduced amount of COVID testing worldwide, the confirmed case count is an increasingly unreliable measure of true cases. “Surveillance and genetic sequencing have declined dramatically around the world, making it more difficult to track known variants and detect new ones,” Tedros told the committee at the outset of Friday’s meeting. Revolution in vaccines, treatments and diagnostics has not reached everyone Related to that, the global response to COVID remains “hobbled” because “powerful, life-saving tools are still not getting to the population that need them most – especially older people and health workers, Tedros said. “Many health systems around the world are struggling to cope with COVID-19, on top of caring for patients with other diseases including influenza and RSV, and with work shortages and fatigued health workers. “And public trust in the safe and effective tools for controlling COVID-19 is being undermined by a continuous torrent of mis- and disinformation.” It was unclear as to whether the committee’s deliberations would continue into the weekend, or when their conclusions will finally be announced. However, there was speculation that their report might only be published on Monday, when the WHO Executive Board, WHO’s governing body, begins its first annual round of meetings for 2023. Among the nearly 50 items on the week-long agenda are a raft of reports and recommendations on strengthening global preparedness and response to health emergencies. The WHO Public Health Emergency of International Concern (PHEIC) was declared in the framework of the 2005 International Health Regulations, which constitute a legally binding agreement between WHO member states regarding emergency outbreak and response. In March 2020, Tedros also declared that the emergency also constituted a “pandemic” – although there is in fact no legal provision for a pandemic declaration in the IHR. However, the weaknesses in the IHR system of outbreak alerts, notification and resonses, highlighted by the faltering and inconsistent reponse to the COVID pandemic, have paved the way for major reconsideration of global pandemic response frameworks, with debates over a new pandemic treaty, as well as IHR revisions, set to continue throughout 2023 and into 2024. See related story here: Governing Pandemics Snapshot Image Credits: Twitter: @WHO. WHO Provides New Medicines List, Policy Recommendations for Nuclear Emergency 27/01/2023 Maayan Hoffman A Nuclear powerplant in Belgium. The World Health Organization (WHO) on Friday released an updated list of medicines that should be stockpiled in the event of a radiological and nuclear emergency, along with new policy advice in the event of such an incident. “Preparedness for radiation emergencies is consistently reported as the weakest area of preparedness in many countries,” the 66-page report said. This newest report updates the one released over 15 years ago, in 2007, and thus includes a host of new pharmaceutical developments. “In radiation emergencies, people may be exposed to radiation at doses ranging from negligible to life-threatening. Governments need to make treatments available for those in need – fast,” said Dr Maria Neira, WHO Acting Assistant Director-General of the Healthier Populations Division. “It is essential that governments are prepared to protect the health of populations and respond immediately to emergencies. This includes having ready supplies of lifesaving medicines that will reduce risks and treat injuries from radiation.” Added Dr Mike Ryan, Executive Director of WHO’s Health Emergencies Programme: “This updated critical medicines list will be a vital preparedness and readiness tool for our partners to identify, procure, stockpile and deliver effective countermeasures in a timely fashion to those at risk or exposed in these events.” Radiological or nuclear emergencies could occur at nuclear power plants, medical or research facilities or be the result of accidents during transport of radioactive materials, WHO explained. In addition, these emergencies could be the result of a malicious event, such as a nuclear bombing. To date, there were two massive nuclear incidents: The 1945 atomic bombings of Hiroshima and Nagasaki by the United States, the consequences of which have been continually studied. There was also the 1986 accident at the Chernobyl nuclear plant in Ukraine – the largest uncontrolled radioactive release in history. Former Russian President Dmitry Medvedev warned this month in yet another Telegram post that a defeat of Russia in Ukraine could trigger a nuclear war. “The defeat of a nuclear power in a conventional war may trigger a nuclear war,” Medvedev wrote. Exposure to high doses of radiation can have severe consequences on a person’s long-term health or lead to immediate or early death. As such, aside from generic supplies and materials used for any type of emergencies, stockpiles should include medicines that either prevent or reduce exposure to radiation, WHO explained. Only a handful of recommended medicines There are only a handful of specific drugs that have been proven effective in the treatment of over-exposure to radiation and these are included in the report. They include: stable iodine; chelating sand (decorporating agents); cytokines used for mitigation of damage to the bone marrow; and medicines to treat vomiting, diarrhea and infections. “One of the most serious outcomes of over-exposure to radiation is acute radiation syndrome (ARS), which manifests as a haematopoietic syndrome”. The latter, also called bone marrow syndrome, impacts blood cell production and in cases of acute poisoning, can lead to death through infection or hemorrhage. “Depending on the severity of the exposure may further progress as gastrointestinal, cardiovascular and neurological syndromes,” the report states. However, the WHO recommendations only include treatments of haematopoietic and gastrointestinal syndromes, “as cardiovascular and neurological syndromes are considered non-salvageable and require only palliative care.” Blocking agents such as stable iodine, could be used to block the uptake of radionuclides in the body, the WHO report added. Other agents like Prussian blue are applied to remove radioactive ceasium from the body. Calcium or zinc diethylenetriaminepentaacetic acid can treat internal contamination with transuranium radionuclides. “These and other elements of such stockpiles should be made rapidly available in case of radiation emergencies,” wrote WHO. Bone marrow syndrome – emerging treatments In the case of haematopoietic, or bone marrow syndrome, radiation attacks all three blood lineages – white and red blood cells and platelets. Low white blood cell count weakens the immune system, making an individual vulnerable to infection. Red blood cells carry oxygen to the body and platelets are responsible for coagulation, which prevents bleeding, explained Yaky Yanay, CEO and president of Pluri – an Israeli-based biotech firm developing an injection of placenta cells for the treatment of ARS. The treatment has been approved by the United States Food and Drug Administration as an “Investigational New Drug” (IND) for use in the event of a nuclear incident – although it is not yet mature enough to be considered for the WHO list of recommended medicines. The WHO report notes, however, that researchers are making progress on developing novel treatments, although none of them have been approved by the global health agency for use in a nuclear emergency. WHO: Stockpile based on population size WHO stressed that a country’s nuclear medicines stockpile should be based on reliable data for national risk profiles, the size of the population and available resources and capabilities of their health system. Finally, WHO called on national health authorities, health-care facilities, pharmaceutical suppliers and logistics, civil defense and emergency services to be leveraged in the event of an emergency. These teams should be coordinated in advance to be able to function effectively in the event of a nuclear incident. Image Credits: Photo by Frédéric Paulussen on Unsplash. Governing Pandemics Snapshot 27/01/2023 Gian Luca Burci, Suerie Moon, Daniela Morich, Adam Strobeyko & Seyed-Moeen Hosseinalipour Standing ovation at the close of the special World Health Assembly session 1 December 2021, in which member states agreed to negotiate a new pandemic accord. A briefing series on the status of moves to reform the global system of pandemic preparedness and response launches today, just ahead of the WHO Executive Board review of progress next week. Looking back at 2022 and forward into 2023, this series by the Global Health Center of the Geneva Graduate Institute, published in collaboration with Health Policy Watch, provides an update on the progress so far in the WHO-led negotiations over a new pandemic treaty. It also looks at the progress in revisions to the existing emergency rules of the International Health Regulations (IHR) – while considering what could happen next. The complete “Governing Pandemics Snapshot”, also includes briefings on reforms being considered in the financing of pandemics as well as the rules around pathogen access and benefit-sharing. Pandemic treaty: tough political negotiations ahead By Daniela Morich Following a milestone World Health Assembly decision in late 2021, WHO Member States have been negotiating an international agreement on pandemic prevention, preparedness and response to strengthen global capacities and resilience for future pandemics. The year 2022 was the year for the advance of these pandemic treaty talks with the establishment of a formal process, a strict timeline, and initial discussions on principles. In 2023, negotiations will shift from broad consultations to tough politics. The Covid-19 pandemic brought to the surface the shortcomings of global health governance for emergencies and accelerated discussions to reform it. At a special WHA session in late 2021, the second-ever convened by the World Health Assembly, WHO Member States agreed to establish an intergovernmental negotiating body (INB) to negotiate a new “instrument” to strengthen pandemic prevention, preparedness and response – or, a pandemic treaty. The INB initiated its work in early 2022 and is to present the outcome of the negotiations to the 77th World Health Assembly (WHA) in May 2024. This is an ambitious timeline for a complex international rule-making process, especially as it will run in parallel to the process to revise the International Health Regulations (IHR), a pre-existing WHO instrument that governs the cross-border spread of infectious disease. Nonetheless, the INB is moving forward and achieved two mid-term milestones in 2022. In July, at the second INB meeting, Member States agreed that the instrument should be legally binding, which suggests countries are ready to accept new international obligations to improve pandemic prevention and response. In addition, the INB engaged in intensive intersessional consultations to seek input not only from governments or well-established experts – the traditional protagonists of international rulemaking – but also from civil society organizations and the public. Despite these efforts, commentators have argued that the process is still not as inclusive as it should be. As work on the instrument progresses, negotiators should expect more demands to expand meaningful participation of stakeholders beyond governments. The INB’s Bureau (six countries elected to lead the process) released the ‘conceptual zero draft’ (CZD) ahead of the third meeting of the INB, which took place in December 2022. The CZD –which can be seen as the first rough draft of the accord – brought to the negotiating table a broad set of issues and highlighted a collective willingness to ensure a more equitable response to future threats. It also reflected tough divisions on several issues, in particular, intellectual property (IP), pathogen- and benefit- sharing, One Health, financing and accountability, which will likely become more visible and contentious as negotiations move to the next phase. At the conclusion of the gathering, Member States directed the INB Bureau to develop the ‘zero draft’. Delegates strongly encouraged the Bureau to move away from the vague and aspirational language of the CZD and to present clear legal provisions and definitions, including one for ‘pandemic’, for Member States to negotiate in earnest. The INB Bureau is expected to circulate the zero draft in early February 2023. At this stage, the negotiation process will likely shift from a consultation and information gathering process to become a more politicized, polarized and consequential debate. The time available to negotiators is constrained. The 2023-2024 agenda includes 6 additional INB meetings scheduled over 14 months in addition to meetings of the drafting groups, with the IHR revision process unfolding in parallel. Considering the complexity of the issues on the table, the existing divisions between Member States, and the limited time available to negotiators, achieving meaningful progress in this new highly-political phase is the tall order for 2023. An existential moment for the International Health Regulations Dr Hiroki Nakatani, chairman of the May World Health Assembly, applauds the WHA decision to revise the International Health Regulations. By Gian Luca Burci While negotiations on a new pandemic instrument continue in 2023-24, the International Health Regulations (IHR) remain the sole global legally-binding instrument devoted to the prevention and control of the international spread of disease – and revisions to those are already underway. Can the two parallel processes complement each other or will they add new layers of confusion? That is the challenge negotiators and member states will face. Although considered an essential component of the global health security toolbox, the IHR attracted severe criticism and allegedly low compliance during the COVID-19 pandemic. The momentum towards a new “pandemic treaty”, beginning in late 2020, was in part a reaction to the perceived weaknesses and limitations of the IHR. The difficult and sometimes confusing discussions in the Working Group on strengthening WHO preparedness and response to health emergencies created by the 74th World Health Assembly in 2021 to discuss reforms, ultimately led to a WHA decision in December 2021 to launch negotiations on a new legal instrument (“pandemic treaty”) to be adopted by 2024. Then, in 2022, attention turned back to the IHR as member states sought faster solutions for the most burning issues that had surfaced during the pandemic – particularly around outbreak reporting and IHR compliance. As a result, a complex IHR amendment process is also now underway. The two processes (IHR revisions and pandemic accord) are thus now proceeding in parallel, with hard decisions still to be made on the issues that the revised IHR will tackle – as compared to the new pandemic accord. Negotiations to amend the IHR in 2023/2024 raise an existential question about their raison d’etre: should they retain their technical, operational character, or expand significantly to address highly political questions such as those on international assistance, equity and access to technologies for disease outbreaks? The US broke the ice by proposing its own substantial set of amendments in January 2022, and successfully winning agreement at the 75th WHA in May 2022, to both adopt a set of limited technical IHR amendments and to open up a broader process for further amendments. The WHA thus launched negotiations towards “targeted amendments” of the IHR with the same 2024 deadline for WHA adoption as the new pandemic accord. Member States submitted their proposed amendments by 30 September 2022 and an expert “review committee” analyzed them and presented its recommendations to the Director-General in January 2023. A Working Group open to all Member States will work from February 2023 towards a negotiated package. The process is unusual compared to other intergovernmental negotiations, in that states hardly ever place on the table all their proposed amendments at the outset; the initial US disclosure of all its amendments, however, required a similar treatment for other states and made that approach inevitable. Wildly diverse amendments but a few trends emerge A patchwork of national rules around international travel, vaccines and border controls were a feature of the COVID pandemic, highlighting the inconsistent application of key IHR provisions aimed at ensuring international trade and travel during health emergencies. The outcome of the first phase of this process is a massive aggregation of wildly diverse amendments (available here) proposed or supported by almost 100 states. They range from focused technical amendments to far-reaching changes. Despite their diversity, a few trends emerge dividing Global South and Global North countries. The most political proposals, coming in particular from the African Region, Bangladesh and India, aim at ensuring equitable access to vaccines, distributed manufacturing capacities, technology transfer, limitations on patenting and sustainable financing of national capacities. These proposals reflect the North-South divide that we have been witnessing in the recent treaty conferences on climate change and biodiversity and are clearly also a consequence of the inequities in access to life-saving medical countermeasures displayed during the COVID-19 pandemic. Other proposals, in particular from the European Union, the Eurasian Economic Union (submitted by the Russian Federation) and the United States, aim at strengthening the IHR within their current approach, e.g. by tightening compliance and accountability for information sharing, encouraging the sharing of genetic sequence data and through the use of digital technologies. Two negotiating processes unfolding at the same time The challenge in reaching an agreed package in time for the 2024 WHA is increased by the unprecedented parallel unfolding of two negotiating processes with the same timeline, where countries will probably submit the same types of proposals for both instruments to secure an overall favorable outcome. An important point in this respect that is often overlooked is that amendments to the IHR will in principle enter into force at the same time for all its 196 parties, whereas the pandemic instrument – since it will likely be an international treaty – will enter into force once a critical mass of countries has ratified it and only for them, with new countries joining once they ratify. The broad range of proposals for the pandemic instrument and the likelihood that the US will eventually not ratify it may actually lead Global South countries to prioritize the IHR for some of the most ambitious proposals. This possibility raises one final issue. Currently, the IHR is essentially an operational instrument to coordinate outbreak prevention and control and depoliticize WHO’s role in managing them. There is no emphasis on equity, assistance or international cooperation. Amendments proposed by Global South countries would transform it into a regulatory and transactional instrument with a more political role for WHO and differential treatment for developing countries to improve equity in the availability of health technologies. Fundamentally, negotiators will have to decide what they want the IHR to be – and if the IHR is expanded to encompass the issues of health equity then what role would the new pandemic instrument play? For essays on financing pandemics and pathogen and benefit sharing, see the full Governing Pandemics Snapshot here. This is the first in a periodic series of updates to be published during the year. About the authors Daniela Morich is Manager and Adviser of the Governing Pandemics initiative at the Global Health Centre, and a lawyer with experience in multilateral negotiations. Dr Gian Luca Burci is Adjunct Professor of International Law at the Geneva Graduate Institute. He was a member of the IHR Review Committee that completed its expert analysis of the proposed IHR amendments in January 2023. He co-leads the Governing Pandemics initiative. Dr Suerie Moon is Professor of Practice and Co-Director of the Global Health Centre, and co-leads the Governing Pandemics initiative. Adam Strobeyko is a Hauser Global Fellow at NYU Law and was a Doctoral Researcher for the Governing Pandemics initiative. Moeen Hosseinalipour is a master’s student in global health and international affairs at the University of Geneva and Geneva Graduate Institute, and a research assistant for the Governing Pandemics initiative. Image Credits: Geneva Graduate Institute. Posts navigation Older postsNewer posts This site uses cookies to help give you the best experience on our website. Cookies enable us to collect information that helps us personalise your experience and improve the functionality and performance of our site. 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Influential WHO Committee Greenlights Initiative for ‘Replenishment Fund’ to Bolster Finance 30/01/2023 Kerry Cullinan Last year’s World Health Assembly mandated the secretariat to look into a replenishment fund. An influential sub-committee of the World Health Organisation (WHO)’s Executive Board (EB) has greenlighted a proposal by the cash-strapped global body’s Secretariat to seek additional funds via a replenishment fund, that would be filled by voluntary donations from both member states and philanthropies recruited at high-profile events. In its report published on Monday just as the WHO’s Executive Board’s began a week-long meeting, the Programme, Budget and Administration Committee (PBAC), accepted that a replenishment fund could provide an avenue for flexible funding that the WHO so desperately needs. “The committee acknowledged WHO’s need for more flexible, predictable and sustainable financing and considered that a replenishment mechanism provided a possible solution, especially for chronically underfunded areas of the organization’s programme budget,” according to the report, which concluded the deliberations of the three-day meeting of the PBAC last week. The Global Fund to fight AIDS, Tuberculosis and Malaria raised $15.7 billion in its ‘replenishment drive’ last year, while Gavi, The Vaccine Alliance as well as the World Bank and other UN-backed global organisations also run replenishment fundraising drives to attract additional funds from donors. Last year’s World Health Assembly mandated the WHO Secretariat to explore a replenishment fund based on six principles, including that it is driven by member states, allows flexibility in allocation, covers the base budget, and aligns with the WHO’s resolutions. Funding crisis The Executive Board is now expected to consider the proposal further this week in a series of discussions on improving WHO’s financial sustainability. A nod by the EB would pave the way for a full-fledged vote by the World Health Assembly in May. At the EB’s opening session on Monday, Director General Dr Tedros Adhanom Ghebreyesus confirmed that he expected that the proposal for a replenishment process would be submitted to member states for consideration. “We recognize that with increased flexibility and sustainability come increased expectations for transparency, efficiency, compliance and accountability. All of this leading to results,” said Tedros. Only around one-fifth of the WHO’s budget comes from members’ countries’ “assessed contributors” (calculated on their GDP), with the rest being made up from donations. But the donations are usually tied to particular programmes, inflexible and can be withdrawn at any time. At last year’s World Health Assembly, member states agreed to increase their contributions to cover half of the WHO’s budget. This year, members’ annual contributions are slated to be increased by around 20%. However, even when member states increase their contributions, there will still be a gaping shortfall, obviously undesirable given disease outbreaks and other demands. Developing the replenishment option Recommending that the executive board accepts the replenishment mechanism, the PBAC has advised the secretariat to develop the proposal further by examining “replenishment mechanisms established by other global health organizations and [analysing] the advantages and disadvantages of the various systems”. It also recommended that the “funding envelope for a replenishment mechanism should be based on the base segment of the programme budget, minus approved assessed contributions”. Still up for discussion is whether the fund will be based on the budget over one (two-year) budget cycle or two (four-year). More money for country offices PBAC has also recommended that the WHO secretariat consider further increases to its country operations rather than head office and regional structures. However, while the secretariat confirmed its commitment to strengthen country offices, it said that this would only be possible “gradually over time”. The WHO secretariat told PBAC that the main reason for the uneven financing of its programmes was “the extremely tight earmarking of the funds it received”. Director-General Dr Tedros Adhanom Ghebreyesus told the committee that member states’ agreement to an increase in assessed contributions would “make all the difference”. In response, the committee proposed that the Secretariat should “improve the persistent uneven financing across programmes, major offices and levels of the organization, including by distributing undistributed funds”. As far as the 2024/25 WHO budget is concerned, PBAC has recommended that member states should have until 10 February “to study and provide feedback on the programme budget digital platform” to allow proper consideration of the proposed budget ahead of the World Health Assembly in May. It’s Still a Pandemic: WHO Advisers and Chief Concur 30/01/2023 John Heilprin A healthcare worker wearing PPE disinfecting a street in the early days of the COVID-19 pandemic. The World Health Organization’s Emergency Committee on the COVID-19 pandemic and Director General Dr Tedros Adhanom Ghebreyesus both agree: the event continues to constitute a public health emergency of international concern (PHEIC). The UN health agency agreed on Monday that ending the state of international public health emergency over the coronavirus would be premature even after three long years since its appearance upended the world of normality as we knew it three years ago. Tedros said in a statement that he concurs with the advice offered by committee in its report based on a closed videoconference on Friday. He acknowledged the committee’s views that the COVID-19 pandemic is “probably at a transition point” that must be navigated carefully while ensuring the world is able to mitigate the potential negative consequences. “Achieving higher levels of population immunity globally, either through infection and/or vaccination, may limit the impact of SARS-CoV-2 on morbidity and mortality, but there is little doubt that this virus will remain a permanently established pathogen in humans and animals for the foreseeable future,” the committee reported. “As such, long-term public health action is critically needed,” it said. “While eliminating this virus from human and animal reservoirs is highly unlikely, mitigation of its devastating impact on morbidity and mortality is achievable and should continue to be a prioritized goal.” Personal protective equipment was essential to protect healthcare workers during the pandemic Seven pandemic recommendations As a result of his decision, Tedros advised nations to: Maintain momentum for COVID-19 vaccination to achieve 100% coverage of high-priority groups. Improve reporting of SARS-CoV-2 surveillance data to WHO Increase uptake and ensure long-term availability of medical countermeasures. Maintain strong national response capacity and prepare for future events Continue working with communities and their leaders to address the infodemic Continue to adjust any remaining international travel-related measures and do not require proof of vaccination for international travel Continue to support research for improved vaccines that reduce transmission and have broad applicability The committee said moving forward past the PHEIC will require a focused commitment by WHO and its 194 member nations, along with other international organizations, put in place “systematic, long-term prevention, surveillance, and control action plans.” The committee members, whose statement comes on the three-year anniversary of the determination of the COVID-19 PHEIC in January 2020, said it agreed the world is in a better position than it was during the peak of the Omicron transmission a year ago, yet more than 170,000 COVID-19-related deaths have been reported globally in the past eight weeks. It agreed surveillance and genetic sequencing declined globally, making it more harder to track known variants and detect new ones, while health systems are struggling with COVID-19 and caring for patients with influenza and respiratory syncytial virus (RSV), health workforce shortages, and fatigued health workers. Investment in strong health systems is key to pandemic=proofing the world. WHO asked to study impact of ending pandemic Vaccines, therapeutics, and diagnostics have been and remain critical in preventing severe disease, saving lives and taking the pressure off health systems and health workers globally, it said, but “the COVID-19 response remains hobbled in too many countries unable to provide these tools to the populations most in need, older people and health workers.” Some 13.1 billion doses of COVID-19 vaccines have been administered, with 89% of health workers and 81% of adults older than 60 years completing the primary series, WHO said. “COVID-19 remains a dangerous infectious disease with the capacity to cause substantial damage to health and health systems,” the committee said, adding that has asked the WHO Secretariat to provide an assessment of the regulatory implications for developing and authorizing vaccines, diagnostics, and therapeutics if the PHEIC were ended sometime “in the coming months.” Image Credits: Photo by Maksym Kaharlytskyi on Unsplash, Tehran Heart Centre . WHO Experts Confer on Possible End to COVID International Health Emergency 27/01/2023 Elaine Ruth Fletcher WHO Director General Dr Tedros Adhanom Gehebreyesus (left) and Didier Houssin, chair of the WHO Emergency Committee. on 30 January 2020, when the COVID International Health Emergency was first declared. The World Health Organization’s Emergency Committee on the COVID-19 pandemic was meeting Friday evening – with mixed signals emerging about whether the expert advisory group would recommend that the global health agency end the state of international public health emergency over the virus whose emergence stunned the world a little more than three years ago. At a press conference in December 2022, WHO’s Director General Dr Tedros Adhanom Ghebreyesus expressed hopes that the emergency that he first declared on 30 January, 2020, under WHO’s International Health Regulations, could finally be concluded sometime in 2023. But in his remarks to the Emergency Committee’s 14th meeting, the WHO Director General hinted for a second time this week that the time may not yet be ripe – as cases of new infection increased again worldwide only recently and a new wave of the virus continues to rip through China shortly after strict lockdown policies were finally relaxed. “As we enter the fourth year of the pandemic, we are certainly in a much better position now than we were a year ago, when the Omicron wave was at its peak, and more than 70,000 deaths were being reported to WHO each week,” said Tedros in his remarks at the closed meeting, reported by WHO in a press release. “When you last met in October, the number of weekly reported deaths was near the lowest since the pandemic began – less than 10,000 a week,” he added. “However, since the beginning of December, the number of weekly reported deaths globally has been rising.” China trends create a second level of concerns Following a massive wave of protests in autumn 2022, China lifted most of its COVID restrictions – which had been among the strictest in the world. In addition, Tedros noted, the lifting of COVID restrictions in China has led to a spike in deaths in the world’s most populous nation, whose citizens were poorly protected by vaccinations as well as having low natural immunity thanks to months of social isolation. “Last week, almost 40 thousand deaths were reported to WHO, more than half of them from China,” Tedros said. “In total, over the past eight weeks, more than 170,000 deaths have been reported. The actual number is certainly much higher.” Earlier this week, Tedros also expressed his mixed feelings about declaring an end to the pandemic even more bluntly, saying: “While I will not preempt the advice of the emergency committee, I remain very concerned by the situation in many countries and the rising number of deaths,” he said, speaking at WHO’s weekly press briefing. “While we’re clearly in better shape than three years ago when this pandemic first hit, the global collective response is once again under strain.” In fact, after reaching a peak in mid-December, the wave of new cases in China and worldwide have been declining for the past month – both according to WHO data and other data monitoring platforms. However, in light of the reduced amount of COVID testing worldwide, the confirmed case count is an increasingly unreliable measure of true cases. “Surveillance and genetic sequencing have declined dramatically around the world, making it more difficult to track known variants and detect new ones,” Tedros told the committee at the outset of Friday’s meeting. Revolution in vaccines, treatments and diagnostics has not reached everyone Related to that, the global response to COVID remains “hobbled” because “powerful, life-saving tools are still not getting to the population that need them most – especially older people and health workers, Tedros said. “Many health systems around the world are struggling to cope with COVID-19, on top of caring for patients with other diseases including influenza and RSV, and with work shortages and fatigued health workers. “And public trust in the safe and effective tools for controlling COVID-19 is being undermined by a continuous torrent of mis- and disinformation.” It was unclear as to whether the committee’s deliberations would continue into the weekend, or when their conclusions will finally be announced. However, there was speculation that their report might only be published on Monday, when the WHO Executive Board, WHO’s governing body, begins its first annual round of meetings for 2023. Among the nearly 50 items on the week-long agenda are a raft of reports and recommendations on strengthening global preparedness and response to health emergencies. The WHO Public Health Emergency of International Concern (PHEIC) was declared in the framework of the 2005 International Health Regulations, which constitute a legally binding agreement between WHO member states regarding emergency outbreak and response. In March 2020, Tedros also declared that the emergency also constituted a “pandemic” – although there is in fact no legal provision for a pandemic declaration in the IHR. However, the weaknesses in the IHR system of outbreak alerts, notification and resonses, highlighted by the faltering and inconsistent reponse to the COVID pandemic, have paved the way for major reconsideration of global pandemic response frameworks, with debates over a new pandemic treaty, as well as IHR revisions, set to continue throughout 2023 and into 2024. See related story here: Governing Pandemics Snapshot Image Credits: Twitter: @WHO. WHO Provides New Medicines List, Policy Recommendations for Nuclear Emergency 27/01/2023 Maayan Hoffman A Nuclear powerplant in Belgium. The World Health Organization (WHO) on Friday released an updated list of medicines that should be stockpiled in the event of a radiological and nuclear emergency, along with new policy advice in the event of such an incident. “Preparedness for radiation emergencies is consistently reported as the weakest area of preparedness in many countries,” the 66-page report said. This newest report updates the one released over 15 years ago, in 2007, and thus includes a host of new pharmaceutical developments. “In radiation emergencies, people may be exposed to radiation at doses ranging from negligible to life-threatening. Governments need to make treatments available for those in need – fast,” said Dr Maria Neira, WHO Acting Assistant Director-General of the Healthier Populations Division. “It is essential that governments are prepared to protect the health of populations and respond immediately to emergencies. This includes having ready supplies of lifesaving medicines that will reduce risks and treat injuries from radiation.” Added Dr Mike Ryan, Executive Director of WHO’s Health Emergencies Programme: “This updated critical medicines list will be a vital preparedness and readiness tool for our partners to identify, procure, stockpile and deliver effective countermeasures in a timely fashion to those at risk or exposed in these events.” Radiological or nuclear emergencies could occur at nuclear power plants, medical or research facilities or be the result of accidents during transport of radioactive materials, WHO explained. In addition, these emergencies could be the result of a malicious event, such as a nuclear bombing. To date, there were two massive nuclear incidents: The 1945 atomic bombings of Hiroshima and Nagasaki by the United States, the consequences of which have been continually studied. There was also the 1986 accident at the Chernobyl nuclear plant in Ukraine – the largest uncontrolled radioactive release in history. Former Russian President Dmitry Medvedev warned this month in yet another Telegram post that a defeat of Russia in Ukraine could trigger a nuclear war. “The defeat of a nuclear power in a conventional war may trigger a nuclear war,” Medvedev wrote. Exposure to high doses of radiation can have severe consequences on a person’s long-term health or lead to immediate or early death. As such, aside from generic supplies and materials used for any type of emergencies, stockpiles should include medicines that either prevent or reduce exposure to radiation, WHO explained. Only a handful of recommended medicines There are only a handful of specific drugs that have been proven effective in the treatment of over-exposure to radiation and these are included in the report. They include: stable iodine; chelating sand (decorporating agents); cytokines used for mitigation of damage to the bone marrow; and medicines to treat vomiting, diarrhea and infections. “One of the most serious outcomes of over-exposure to radiation is acute radiation syndrome (ARS), which manifests as a haematopoietic syndrome”. The latter, also called bone marrow syndrome, impacts blood cell production and in cases of acute poisoning, can lead to death through infection or hemorrhage. “Depending on the severity of the exposure may further progress as gastrointestinal, cardiovascular and neurological syndromes,” the report states. However, the WHO recommendations only include treatments of haematopoietic and gastrointestinal syndromes, “as cardiovascular and neurological syndromes are considered non-salvageable and require only palliative care.” Blocking agents such as stable iodine, could be used to block the uptake of radionuclides in the body, the WHO report added. Other agents like Prussian blue are applied to remove radioactive ceasium from the body. Calcium or zinc diethylenetriaminepentaacetic acid can treat internal contamination with transuranium radionuclides. “These and other elements of such stockpiles should be made rapidly available in case of radiation emergencies,” wrote WHO. Bone marrow syndrome – emerging treatments In the case of haematopoietic, or bone marrow syndrome, radiation attacks all three blood lineages – white and red blood cells and platelets. Low white blood cell count weakens the immune system, making an individual vulnerable to infection. Red blood cells carry oxygen to the body and platelets are responsible for coagulation, which prevents bleeding, explained Yaky Yanay, CEO and president of Pluri – an Israeli-based biotech firm developing an injection of placenta cells for the treatment of ARS. The treatment has been approved by the United States Food and Drug Administration as an “Investigational New Drug” (IND) for use in the event of a nuclear incident – although it is not yet mature enough to be considered for the WHO list of recommended medicines. The WHO report notes, however, that researchers are making progress on developing novel treatments, although none of them have been approved by the global health agency for use in a nuclear emergency. WHO: Stockpile based on population size WHO stressed that a country’s nuclear medicines stockpile should be based on reliable data for national risk profiles, the size of the population and available resources and capabilities of their health system. Finally, WHO called on national health authorities, health-care facilities, pharmaceutical suppliers and logistics, civil defense and emergency services to be leveraged in the event of an emergency. These teams should be coordinated in advance to be able to function effectively in the event of a nuclear incident. Image Credits: Photo by Frédéric Paulussen on Unsplash. Governing Pandemics Snapshot 27/01/2023 Gian Luca Burci, Suerie Moon, Daniela Morich, Adam Strobeyko & Seyed-Moeen Hosseinalipour Standing ovation at the close of the special World Health Assembly session 1 December 2021, in which member states agreed to negotiate a new pandemic accord. A briefing series on the status of moves to reform the global system of pandemic preparedness and response launches today, just ahead of the WHO Executive Board review of progress next week. Looking back at 2022 and forward into 2023, this series by the Global Health Center of the Geneva Graduate Institute, published in collaboration with Health Policy Watch, provides an update on the progress so far in the WHO-led negotiations over a new pandemic treaty. It also looks at the progress in revisions to the existing emergency rules of the International Health Regulations (IHR) – while considering what could happen next. The complete “Governing Pandemics Snapshot”, also includes briefings on reforms being considered in the financing of pandemics as well as the rules around pathogen access and benefit-sharing. Pandemic treaty: tough political negotiations ahead By Daniela Morich Following a milestone World Health Assembly decision in late 2021, WHO Member States have been negotiating an international agreement on pandemic prevention, preparedness and response to strengthen global capacities and resilience for future pandemics. The year 2022 was the year for the advance of these pandemic treaty talks with the establishment of a formal process, a strict timeline, and initial discussions on principles. In 2023, negotiations will shift from broad consultations to tough politics. The Covid-19 pandemic brought to the surface the shortcomings of global health governance for emergencies and accelerated discussions to reform it. At a special WHA session in late 2021, the second-ever convened by the World Health Assembly, WHO Member States agreed to establish an intergovernmental negotiating body (INB) to negotiate a new “instrument” to strengthen pandemic prevention, preparedness and response – or, a pandemic treaty. The INB initiated its work in early 2022 and is to present the outcome of the negotiations to the 77th World Health Assembly (WHA) in May 2024. This is an ambitious timeline for a complex international rule-making process, especially as it will run in parallel to the process to revise the International Health Regulations (IHR), a pre-existing WHO instrument that governs the cross-border spread of infectious disease. Nonetheless, the INB is moving forward and achieved two mid-term milestones in 2022. In July, at the second INB meeting, Member States agreed that the instrument should be legally binding, which suggests countries are ready to accept new international obligations to improve pandemic prevention and response. In addition, the INB engaged in intensive intersessional consultations to seek input not only from governments or well-established experts – the traditional protagonists of international rulemaking – but also from civil society organizations and the public. Despite these efforts, commentators have argued that the process is still not as inclusive as it should be. As work on the instrument progresses, negotiators should expect more demands to expand meaningful participation of stakeholders beyond governments. The INB’s Bureau (six countries elected to lead the process) released the ‘conceptual zero draft’ (CZD) ahead of the third meeting of the INB, which took place in December 2022. The CZD –which can be seen as the first rough draft of the accord – brought to the negotiating table a broad set of issues and highlighted a collective willingness to ensure a more equitable response to future threats. It also reflected tough divisions on several issues, in particular, intellectual property (IP), pathogen- and benefit- sharing, One Health, financing and accountability, which will likely become more visible and contentious as negotiations move to the next phase. At the conclusion of the gathering, Member States directed the INB Bureau to develop the ‘zero draft’. Delegates strongly encouraged the Bureau to move away from the vague and aspirational language of the CZD and to present clear legal provisions and definitions, including one for ‘pandemic’, for Member States to negotiate in earnest. The INB Bureau is expected to circulate the zero draft in early February 2023. At this stage, the negotiation process will likely shift from a consultation and information gathering process to become a more politicized, polarized and consequential debate. The time available to negotiators is constrained. The 2023-2024 agenda includes 6 additional INB meetings scheduled over 14 months in addition to meetings of the drafting groups, with the IHR revision process unfolding in parallel. Considering the complexity of the issues on the table, the existing divisions between Member States, and the limited time available to negotiators, achieving meaningful progress in this new highly-political phase is the tall order for 2023. An existential moment for the International Health Regulations Dr Hiroki Nakatani, chairman of the May World Health Assembly, applauds the WHA decision to revise the International Health Regulations. By Gian Luca Burci While negotiations on a new pandemic instrument continue in 2023-24, the International Health Regulations (IHR) remain the sole global legally-binding instrument devoted to the prevention and control of the international spread of disease – and revisions to those are already underway. Can the two parallel processes complement each other or will they add new layers of confusion? That is the challenge negotiators and member states will face. Although considered an essential component of the global health security toolbox, the IHR attracted severe criticism and allegedly low compliance during the COVID-19 pandemic. The momentum towards a new “pandemic treaty”, beginning in late 2020, was in part a reaction to the perceived weaknesses and limitations of the IHR. The difficult and sometimes confusing discussions in the Working Group on strengthening WHO preparedness and response to health emergencies created by the 74th World Health Assembly in 2021 to discuss reforms, ultimately led to a WHA decision in December 2021 to launch negotiations on a new legal instrument (“pandemic treaty”) to be adopted by 2024. Then, in 2022, attention turned back to the IHR as member states sought faster solutions for the most burning issues that had surfaced during the pandemic – particularly around outbreak reporting and IHR compliance. As a result, a complex IHR amendment process is also now underway. The two processes (IHR revisions and pandemic accord) are thus now proceeding in parallel, with hard decisions still to be made on the issues that the revised IHR will tackle – as compared to the new pandemic accord. Negotiations to amend the IHR in 2023/2024 raise an existential question about their raison d’etre: should they retain their technical, operational character, or expand significantly to address highly political questions such as those on international assistance, equity and access to technologies for disease outbreaks? The US broke the ice by proposing its own substantial set of amendments in January 2022, and successfully winning agreement at the 75th WHA in May 2022, to both adopt a set of limited technical IHR amendments and to open up a broader process for further amendments. The WHA thus launched negotiations towards “targeted amendments” of the IHR with the same 2024 deadline for WHA adoption as the new pandemic accord. Member States submitted their proposed amendments by 30 September 2022 and an expert “review committee” analyzed them and presented its recommendations to the Director-General in January 2023. A Working Group open to all Member States will work from February 2023 towards a negotiated package. The process is unusual compared to other intergovernmental negotiations, in that states hardly ever place on the table all their proposed amendments at the outset; the initial US disclosure of all its amendments, however, required a similar treatment for other states and made that approach inevitable. Wildly diverse amendments but a few trends emerge A patchwork of national rules around international travel, vaccines and border controls were a feature of the COVID pandemic, highlighting the inconsistent application of key IHR provisions aimed at ensuring international trade and travel during health emergencies. The outcome of the first phase of this process is a massive aggregation of wildly diverse amendments (available here) proposed or supported by almost 100 states. They range from focused technical amendments to far-reaching changes. Despite their diversity, a few trends emerge dividing Global South and Global North countries. The most political proposals, coming in particular from the African Region, Bangladesh and India, aim at ensuring equitable access to vaccines, distributed manufacturing capacities, technology transfer, limitations on patenting and sustainable financing of national capacities. These proposals reflect the North-South divide that we have been witnessing in the recent treaty conferences on climate change and biodiversity and are clearly also a consequence of the inequities in access to life-saving medical countermeasures displayed during the COVID-19 pandemic. Other proposals, in particular from the European Union, the Eurasian Economic Union (submitted by the Russian Federation) and the United States, aim at strengthening the IHR within their current approach, e.g. by tightening compliance and accountability for information sharing, encouraging the sharing of genetic sequence data and through the use of digital technologies. Two negotiating processes unfolding at the same time The challenge in reaching an agreed package in time for the 2024 WHA is increased by the unprecedented parallel unfolding of two negotiating processes with the same timeline, where countries will probably submit the same types of proposals for both instruments to secure an overall favorable outcome. An important point in this respect that is often overlooked is that amendments to the IHR will in principle enter into force at the same time for all its 196 parties, whereas the pandemic instrument – since it will likely be an international treaty – will enter into force once a critical mass of countries has ratified it and only for them, with new countries joining once they ratify. The broad range of proposals for the pandemic instrument and the likelihood that the US will eventually not ratify it may actually lead Global South countries to prioritize the IHR for some of the most ambitious proposals. This possibility raises one final issue. Currently, the IHR is essentially an operational instrument to coordinate outbreak prevention and control and depoliticize WHO’s role in managing them. There is no emphasis on equity, assistance or international cooperation. Amendments proposed by Global South countries would transform it into a regulatory and transactional instrument with a more political role for WHO and differential treatment for developing countries to improve equity in the availability of health technologies. Fundamentally, negotiators will have to decide what they want the IHR to be – and if the IHR is expanded to encompass the issues of health equity then what role would the new pandemic instrument play? For essays on financing pandemics and pathogen and benefit sharing, see the full Governing Pandemics Snapshot here. This is the first in a periodic series of updates to be published during the year. About the authors Daniela Morich is Manager and Adviser of the Governing Pandemics initiative at the Global Health Centre, and a lawyer with experience in multilateral negotiations. Dr Gian Luca Burci is Adjunct Professor of International Law at the Geneva Graduate Institute. He was a member of the IHR Review Committee that completed its expert analysis of the proposed IHR amendments in January 2023. He co-leads the Governing Pandemics initiative. Dr Suerie Moon is Professor of Practice and Co-Director of the Global Health Centre, and co-leads the Governing Pandemics initiative. Adam Strobeyko is a Hauser Global Fellow at NYU Law and was a Doctoral Researcher for the Governing Pandemics initiative. Moeen Hosseinalipour is a master’s student in global health and international affairs at the University of Geneva and Geneva Graduate Institute, and a research assistant for the Governing Pandemics initiative. Image Credits: Geneva Graduate Institute. Posts navigation Older postsNewer posts This site uses cookies to help give you the best experience on our website. Cookies enable us to collect information that helps us personalise your experience and improve the functionality and performance of our site. 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It’s Still a Pandemic: WHO Advisers and Chief Concur 30/01/2023 John Heilprin A healthcare worker wearing PPE disinfecting a street in the early days of the COVID-19 pandemic. The World Health Organization’s Emergency Committee on the COVID-19 pandemic and Director General Dr Tedros Adhanom Ghebreyesus both agree: the event continues to constitute a public health emergency of international concern (PHEIC). The UN health agency agreed on Monday that ending the state of international public health emergency over the coronavirus would be premature even after three long years since its appearance upended the world of normality as we knew it three years ago. Tedros said in a statement that he concurs with the advice offered by committee in its report based on a closed videoconference on Friday. He acknowledged the committee’s views that the COVID-19 pandemic is “probably at a transition point” that must be navigated carefully while ensuring the world is able to mitigate the potential negative consequences. “Achieving higher levels of population immunity globally, either through infection and/or vaccination, may limit the impact of SARS-CoV-2 on morbidity and mortality, but there is little doubt that this virus will remain a permanently established pathogen in humans and animals for the foreseeable future,” the committee reported. “As such, long-term public health action is critically needed,” it said. “While eliminating this virus from human and animal reservoirs is highly unlikely, mitigation of its devastating impact on morbidity and mortality is achievable and should continue to be a prioritized goal.” Personal protective equipment was essential to protect healthcare workers during the pandemic Seven pandemic recommendations As a result of his decision, Tedros advised nations to: Maintain momentum for COVID-19 vaccination to achieve 100% coverage of high-priority groups. Improve reporting of SARS-CoV-2 surveillance data to WHO Increase uptake and ensure long-term availability of medical countermeasures. Maintain strong national response capacity and prepare for future events Continue working with communities and their leaders to address the infodemic Continue to adjust any remaining international travel-related measures and do not require proof of vaccination for international travel Continue to support research for improved vaccines that reduce transmission and have broad applicability The committee said moving forward past the PHEIC will require a focused commitment by WHO and its 194 member nations, along with other international organizations, put in place “systematic, long-term prevention, surveillance, and control action plans.” The committee members, whose statement comes on the three-year anniversary of the determination of the COVID-19 PHEIC in January 2020, said it agreed the world is in a better position than it was during the peak of the Omicron transmission a year ago, yet more than 170,000 COVID-19-related deaths have been reported globally in the past eight weeks. It agreed surveillance and genetic sequencing declined globally, making it more harder to track known variants and detect new ones, while health systems are struggling with COVID-19 and caring for patients with influenza and respiratory syncytial virus (RSV), health workforce shortages, and fatigued health workers. Investment in strong health systems is key to pandemic=proofing the world. WHO asked to study impact of ending pandemic Vaccines, therapeutics, and diagnostics have been and remain critical in preventing severe disease, saving lives and taking the pressure off health systems and health workers globally, it said, but “the COVID-19 response remains hobbled in too many countries unable to provide these tools to the populations most in need, older people and health workers.” Some 13.1 billion doses of COVID-19 vaccines have been administered, with 89% of health workers and 81% of adults older than 60 years completing the primary series, WHO said. “COVID-19 remains a dangerous infectious disease with the capacity to cause substantial damage to health and health systems,” the committee said, adding that has asked the WHO Secretariat to provide an assessment of the regulatory implications for developing and authorizing vaccines, diagnostics, and therapeutics if the PHEIC were ended sometime “in the coming months.” Image Credits: Photo by Maksym Kaharlytskyi on Unsplash, Tehran Heart Centre . WHO Experts Confer on Possible End to COVID International Health Emergency 27/01/2023 Elaine Ruth Fletcher WHO Director General Dr Tedros Adhanom Gehebreyesus (left) and Didier Houssin, chair of the WHO Emergency Committee. on 30 January 2020, when the COVID International Health Emergency was first declared. The World Health Organization’s Emergency Committee on the COVID-19 pandemic was meeting Friday evening – with mixed signals emerging about whether the expert advisory group would recommend that the global health agency end the state of international public health emergency over the virus whose emergence stunned the world a little more than three years ago. At a press conference in December 2022, WHO’s Director General Dr Tedros Adhanom Ghebreyesus expressed hopes that the emergency that he first declared on 30 January, 2020, under WHO’s International Health Regulations, could finally be concluded sometime in 2023. But in his remarks to the Emergency Committee’s 14th meeting, the WHO Director General hinted for a second time this week that the time may not yet be ripe – as cases of new infection increased again worldwide only recently and a new wave of the virus continues to rip through China shortly after strict lockdown policies were finally relaxed. “As we enter the fourth year of the pandemic, we are certainly in a much better position now than we were a year ago, when the Omicron wave was at its peak, and more than 70,000 deaths were being reported to WHO each week,” said Tedros in his remarks at the closed meeting, reported by WHO in a press release. “When you last met in October, the number of weekly reported deaths was near the lowest since the pandemic began – less than 10,000 a week,” he added. “However, since the beginning of December, the number of weekly reported deaths globally has been rising.” China trends create a second level of concerns Following a massive wave of protests in autumn 2022, China lifted most of its COVID restrictions – which had been among the strictest in the world. In addition, Tedros noted, the lifting of COVID restrictions in China has led to a spike in deaths in the world’s most populous nation, whose citizens were poorly protected by vaccinations as well as having low natural immunity thanks to months of social isolation. “Last week, almost 40 thousand deaths were reported to WHO, more than half of them from China,” Tedros said. “In total, over the past eight weeks, more than 170,000 deaths have been reported. The actual number is certainly much higher.” Earlier this week, Tedros also expressed his mixed feelings about declaring an end to the pandemic even more bluntly, saying: “While I will not preempt the advice of the emergency committee, I remain very concerned by the situation in many countries and the rising number of deaths,” he said, speaking at WHO’s weekly press briefing. “While we’re clearly in better shape than three years ago when this pandemic first hit, the global collective response is once again under strain.” In fact, after reaching a peak in mid-December, the wave of new cases in China and worldwide have been declining for the past month – both according to WHO data and other data monitoring platforms. However, in light of the reduced amount of COVID testing worldwide, the confirmed case count is an increasingly unreliable measure of true cases. “Surveillance and genetic sequencing have declined dramatically around the world, making it more difficult to track known variants and detect new ones,” Tedros told the committee at the outset of Friday’s meeting. Revolution in vaccines, treatments and diagnostics has not reached everyone Related to that, the global response to COVID remains “hobbled” because “powerful, life-saving tools are still not getting to the population that need them most – especially older people and health workers, Tedros said. “Many health systems around the world are struggling to cope with COVID-19, on top of caring for patients with other diseases including influenza and RSV, and with work shortages and fatigued health workers. “And public trust in the safe and effective tools for controlling COVID-19 is being undermined by a continuous torrent of mis- and disinformation.” It was unclear as to whether the committee’s deliberations would continue into the weekend, or when their conclusions will finally be announced. However, there was speculation that their report might only be published on Monday, when the WHO Executive Board, WHO’s governing body, begins its first annual round of meetings for 2023. Among the nearly 50 items on the week-long agenda are a raft of reports and recommendations on strengthening global preparedness and response to health emergencies. The WHO Public Health Emergency of International Concern (PHEIC) was declared in the framework of the 2005 International Health Regulations, which constitute a legally binding agreement between WHO member states regarding emergency outbreak and response. In March 2020, Tedros also declared that the emergency also constituted a “pandemic” – although there is in fact no legal provision for a pandemic declaration in the IHR. However, the weaknesses in the IHR system of outbreak alerts, notification and resonses, highlighted by the faltering and inconsistent reponse to the COVID pandemic, have paved the way for major reconsideration of global pandemic response frameworks, with debates over a new pandemic treaty, as well as IHR revisions, set to continue throughout 2023 and into 2024. See related story here: Governing Pandemics Snapshot Image Credits: Twitter: @WHO. WHO Provides New Medicines List, Policy Recommendations for Nuclear Emergency 27/01/2023 Maayan Hoffman A Nuclear powerplant in Belgium. The World Health Organization (WHO) on Friday released an updated list of medicines that should be stockpiled in the event of a radiological and nuclear emergency, along with new policy advice in the event of such an incident. “Preparedness for radiation emergencies is consistently reported as the weakest area of preparedness in many countries,” the 66-page report said. This newest report updates the one released over 15 years ago, in 2007, and thus includes a host of new pharmaceutical developments. “In radiation emergencies, people may be exposed to radiation at doses ranging from negligible to life-threatening. Governments need to make treatments available for those in need – fast,” said Dr Maria Neira, WHO Acting Assistant Director-General of the Healthier Populations Division. “It is essential that governments are prepared to protect the health of populations and respond immediately to emergencies. This includes having ready supplies of lifesaving medicines that will reduce risks and treat injuries from radiation.” Added Dr Mike Ryan, Executive Director of WHO’s Health Emergencies Programme: “This updated critical medicines list will be a vital preparedness and readiness tool for our partners to identify, procure, stockpile and deliver effective countermeasures in a timely fashion to those at risk or exposed in these events.” Radiological or nuclear emergencies could occur at nuclear power plants, medical or research facilities or be the result of accidents during transport of radioactive materials, WHO explained. In addition, these emergencies could be the result of a malicious event, such as a nuclear bombing. To date, there were two massive nuclear incidents: The 1945 atomic bombings of Hiroshima and Nagasaki by the United States, the consequences of which have been continually studied. There was also the 1986 accident at the Chernobyl nuclear plant in Ukraine – the largest uncontrolled radioactive release in history. Former Russian President Dmitry Medvedev warned this month in yet another Telegram post that a defeat of Russia in Ukraine could trigger a nuclear war. “The defeat of a nuclear power in a conventional war may trigger a nuclear war,” Medvedev wrote. Exposure to high doses of radiation can have severe consequences on a person’s long-term health or lead to immediate or early death. As such, aside from generic supplies and materials used for any type of emergencies, stockpiles should include medicines that either prevent or reduce exposure to radiation, WHO explained. Only a handful of recommended medicines There are only a handful of specific drugs that have been proven effective in the treatment of over-exposure to radiation and these are included in the report. They include: stable iodine; chelating sand (decorporating agents); cytokines used for mitigation of damage to the bone marrow; and medicines to treat vomiting, diarrhea and infections. “One of the most serious outcomes of over-exposure to radiation is acute radiation syndrome (ARS), which manifests as a haematopoietic syndrome”. The latter, also called bone marrow syndrome, impacts blood cell production and in cases of acute poisoning, can lead to death through infection or hemorrhage. “Depending on the severity of the exposure may further progress as gastrointestinal, cardiovascular and neurological syndromes,” the report states. However, the WHO recommendations only include treatments of haematopoietic and gastrointestinal syndromes, “as cardiovascular and neurological syndromes are considered non-salvageable and require only palliative care.” Blocking agents such as stable iodine, could be used to block the uptake of radionuclides in the body, the WHO report added. Other agents like Prussian blue are applied to remove radioactive ceasium from the body. Calcium or zinc diethylenetriaminepentaacetic acid can treat internal contamination with transuranium radionuclides. “These and other elements of such stockpiles should be made rapidly available in case of radiation emergencies,” wrote WHO. Bone marrow syndrome – emerging treatments In the case of haematopoietic, or bone marrow syndrome, radiation attacks all three blood lineages – white and red blood cells and platelets. Low white blood cell count weakens the immune system, making an individual vulnerable to infection. Red blood cells carry oxygen to the body and platelets are responsible for coagulation, which prevents bleeding, explained Yaky Yanay, CEO and president of Pluri – an Israeli-based biotech firm developing an injection of placenta cells for the treatment of ARS. The treatment has been approved by the United States Food and Drug Administration as an “Investigational New Drug” (IND) for use in the event of a nuclear incident – although it is not yet mature enough to be considered for the WHO list of recommended medicines. The WHO report notes, however, that researchers are making progress on developing novel treatments, although none of them have been approved by the global health agency for use in a nuclear emergency. WHO: Stockpile based on population size WHO stressed that a country’s nuclear medicines stockpile should be based on reliable data for national risk profiles, the size of the population and available resources and capabilities of their health system. Finally, WHO called on national health authorities, health-care facilities, pharmaceutical suppliers and logistics, civil defense and emergency services to be leveraged in the event of an emergency. These teams should be coordinated in advance to be able to function effectively in the event of a nuclear incident. Image Credits: Photo by Frédéric Paulussen on Unsplash. Governing Pandemics Snapshot 27/01/2023 Gian Luca Burci, Suerie Moon, Daniela Morich, Adam Strobeyko & Seyed-Moeen Hosseinalipour Standing ovation at the close of the special World Health Assembly session 1 December 2021, in which member states agreed to negotiate a new pandemic accord. A briefing series on the status of moves to reform the global system of pandemic preparedness and response launches today, just ahead of the WHO Executive Board review of progress next week. Looking back at 2022 and forward into 2023, this series by the Global Health Center of the Geneva Graduate Institute, published in collaboration with Health Policy Watch, provides an update on the progress so far in the WHO-led negotiations over a new pandemic treaty. It also looks at the progress in revisions to the existing emergency rules of the International Health Regulations (IHR) – while considering what could happen next. The complete “Governing Pandemics Snapshot”, also includes briefings on reforms being considered in the financing of pandemics as well as the rules around pathogen access and benefit-sharing. Pandemic treaty: tough political negotiations ahead By Daniela Morich Following a milestone World Health Assembly decision in late 2021, WHO Member States have been negotiating an international agreement on pandemic prevention, preparedness and response to strengthen global capacities and resilience for future pandemics. The year 2022 was the year for the advance of these pandemic treaty talks with the establishment of a formal process, a strict timeline, and initial discussions on principles. In 2023, negotiations will shift from broad consultations to tough politics. The Covid-19 pandemic brought to the surface the shortcomings of global health governance for emergencies and accelerated discussions to reform it. At a special WHA session in late 2021, the second-ever convened by the World Health Assembly, WHO Member States agreed to establish an intergovernmental negotiating body (INB) to negotiate a new “instrument” to strengthen pandemic prevention, preparedness and response – or, a pandemic treaty. The INB initiated its work in early 2022 and is to present the outcome of the negotiations to the 77th World Health Assembly (WHA) in May 2024. This is an ambitious timeline for a complex international rule-making process, especially as it will run in parallel to the process to revise the International Health Regulations (IHR), a pre-existing WHO instrument that governs the cross-border spread of infectious disease. Nonetheless, the INB is moving forward and achieved two mid-term milestones in 2022. In July, at the second INB meeting, Member States agreed that the instrument should be legally binding, which suggests countries are ready to accept new international obligations to improve pandemic prevention and response. In addition, the INB engaged in intensive intersessional consultations to seek input not only from governments or well-established experts – the traditional protagonists of international rulemaking – but also from civil society organizations and the public. Despite these efforts, commentators have argued that the process is still not as inclusive as it should be. As work on the instrument progresses, negotiators should expect more demands to expand meaningful participation of stakeholders beyond governments. The INB’s Bureau (six countries elected to lead the process) released the ‘conceptual zero draft’ (CZD) ahead of the third meeting of the INB, which took place in December 2022. The CZD –which can be seen as the first rough draft of the accord – brought to the negotiating table a broad set of issues and highlighted a collective willingness to ensure a more equitable response to future threats. It also reflected tough divisions on several issues, in particular, intellectual property (IP), pathogen- and benefit- sharing, One Health, financing and accountability, which will likely become more visible and contentious as negotiations move to the next phase. At the conclusion of the gathering, Member States directed the INB Bureau to develop the ‘zero draft’. Delegates strongly encouraged the Bureau to move away from the vague and aspirational language of the CZD and to present clear legal provisions and definitions, including one for ‘pandemic’, for Member States to negotiate in earnest. The INB Bureau is expected to circulate the zero draft in early February 2023. At this stage, the negotiation process will likely shift from a consultation and information gathering process to become a more politicized, polarized and consequential debate. The time available to negotiators is constrained. The 2023-2024 agenda includes 6 additional INB meetings scheduled over 14 months in addition to meetings of the drafting groups, with the IHR revision process unfolding in parallel. Considering the complexity of the issues on the table, the existing divisions between Member States, and the limited time available to negotiators, achieving meaningful progress in this new highly-political phase is the tall order for 2023. An existential moment for the International Health Regulations Dr Hiroki Nakatani, chairman of the May World Health Assembly, applauds the WHA decision to revise the International Health Regulations. By Gian Luca Burci While negotiations on a new pandemic instrument continue in 2023-24, the International Health Regulations (IHR) remain the sole global legally-binding instrument devoted to the prevention and control of the international spread of disease – and revisions to those are already underway. Can the two parallel processes complement each other or will they add new layers of confusion? That is the challenge negotiators and member states will face. Although considered an essential component of the global health security toolbox, the IHR attracted severe criticism and allegedly low compliance during the COVID-19 pandemic. The momentum towards a new “pandemic treaty”, beginning in late 2020, was in part a reaction to the perceived weaknesses and limitations of the IHR. The difficult and sometimes confusing discussions in the Working Group on strengthening WHO preparedness and response to health emergencies created by the 74th World Health Assembly in 2021 to discuss reforms, ultimately led to a WHA decision in December 2021 to launch negotiations on a new legal instrument (“pandemic treaty”) to be adopted by 2024. Then, in 2022, attention turned back to the IHR as member states sought faster solutions for the most burning issues that had surfaced during the pandemic – particularly around outbreak reporting and IHR compliance. As a result, a complex IHR amendment process is also now underway. The two processes (IHR revisions and pandemic accord) are thus now proceeding in parallel, with hard decisions still to be made on the issues that the revised IHR will tackle – as compared to the new pandemic accord. Negotiations to amend the IHR in 2023/2024 raise an existential question about their raison d’etre: should they retain their technical, operational character, or expand significantly to address highly political questions such as those on international assistance, equity and access to technologies for disease outbreaks? The US broke the ice by proposing its own substantial set of amendments in January 2022, and successfully winning agreement at the 75th WHA in May 2022, to both adopt a set of limited technical IHR amendments and to open up a broader process for further amendments. The WHA thus launched negotiations towards “targeted amendments” of the IHR with the same 2024 deadline for WHA adoption as the new pandemic accord. Member States submitted their proposed amendments by 30 September 2022 and an expert “review committee” analyzed them and presented its recommendations to the Director-General in January 2023. A Working Group open to all Member States will work from February 2023 towards a negotiated package. The process is unusual compared to other intergovernmental negotiations, in that states hardly ever place on the table all their proposed amendments at the outset; the initial US disclosure of all its amendments, however, required a similar treatment for other states and made that approach inevitable. Wildly diverse amendments but a few trends emerge A patchwork of national rules around international travel, vaccines and border controls were a feature of the COVID pandemic, highlighting the inconsistent application of key IHR provisions aimed at ensuring international trade and travel during health emergencies. The outcome of the first phase of this process is a massive aggregation of wildly diverse amendments (available here) proposed or supported by almost 100 states. They range from focused technical amendments to far-reaching changes. Despite their diversity, a few trends emerge dividing Global South and Global North countries. The most political proposals, coming in particular from the African Region, Bangladesh and India, aim at ensuring equitable access to vaccines, distributed manufacturing capacities, technology transfer, limitations on patenting and sustainable financing of national capacities. These proposals reflect the North-South divide that we have been witnessing in the recent treaty conferences on climate change and biodiversity and are clearly also a consequence of the inequities in access to life-saving medical countermeasures displayed during the COVID-19 pandemic. Other proposals, in particular from the European Union, the Eurasian Economic Union (submitted by the Russian Federation) and the United States, aim at strengthening the IHR within their current approach, e.g. by tightening compliance and accountability for information sharing, encouraging the sharing of genetic sequence data and through the use of digital technologies. Two negotiating processes unfolding at the same time The challenge in reaching an agreed package in time for the 2024 WHA is increased by the unprecedented parallel unfolding of two negotiating processes with the same timeline, where countries will probably submit the same types of proposals for both instruments to secure an overall favorable outcome. An important point in this respect that is often overlooked is that amendments to the IHR will in principle enter into force at the same time for all its 196 parties, whereas the pandemic instrument – since it will likely be an international treaty – will enter into force once a critical mass of countries has ratified it and only for them, with new countries joining once they ratify. The broad range of proposals for the pandemic instrument and the likelihood that the US will eventually not ratify it may actually lead Global South countries to prioritize the IHR for some of the most ambitious proposals. This possibility raises one final issue. Currently, the IHR is essentially an operational instrument to coordinate outbreak prevention and control and depoliticize WHO’s role in managing them. There is no emphasis on equity, assistance or international cooperation. Amendments proposed by Global South countries would transform it into a regulatory and transactional instrument with a more political role for WHO and differential treatment for developing countries to improve equity in the availability of health technologies. Fundamentally, negotiators will have to decide what they want the IHR to be – and if the IHR is expanded to encompass the issues of health equity then what role would the new pandemic instrument play? For essays on financing pandemics and pathogen and benefit sharing, see the full Governing Pandemics Snapshot here. This is the first in a periodic series of updates to be published during the year. About the authors Daniela Morich is Manager and Adviser of the Governing Pandemics initiative at the Global Health Centre, and a lawyer with experience in multilateral negotiations. Dr Gian Luca Burci is Adjunct Professor of International Law at the Geneva Graduate Institute. He was a member of the IHR Review Committee that completed its expert analysis of the proposed IHR amendments in January 2023. He co-leads the Governing Pandemics initiative. Dr Suerie Moon is Professor of Practice and Co-Director of the Global Health Centre, and co-leads the Governing Pandemics initiative. Adam Strobeyko is a Hauser Global Fellow at NYU Law and was a Doctoral Researcher for the Governing Pandemics initiative. Moeen Hosseinalipour is a master’s student in global health and international affairs at the University of Geneva and Geneva Graduate Institute, and a research assistant for the Governing Pandemics initiative. Image Credits: Geneva Graduate Institute. Posts navigation Older postsNewer posts This site uses cookies to help give you the best experience on our website. Cookies enable us to collect information that helps us personalise your experience and improve the functionality and performance of our site. 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WHO Experts Confer on Possible End to COVID International Health Emergency 27/01/2023 Elaine Ruth Fletcher WHO Director General Dr Tedros Adhanom Gehebreyesus (left) and Didier Houssin, chair of the WHO Emergency Committee. on 30 January 2020, when the COVID International Health Emergency was first declared. The World Health Organization’s Emergency Committee on the COVID-19 pandemic was meeting Friday evening – with mixed signals emerging about whether the expert advisory group would recommend that the global health agency end the state of international public health emergency over the virus whose emergence stunned the world a little more than three years ago. At a press conference in December 2022, WHO’s Director General Dr Tedros Adhanom Ghebreyesus expressed hopes that the emergency that he first declared on 30 January, 2020, under WHO’s International Health Regulations, could finally be concluded sometime in 2023. But in his remarks to the Emergency Committee’s 14th meeting, the WHO Director General hinted for a second time this week that the time may not yet be ripe – as cases of new infection increased again worldwide only recently and a new wave of the virus continues to rip through China shortly after strict lockdown policies were finally relaxed. “As we enter the fourth year of the pandemic, we are certainly in a much better position now than we were a year ago, when the Omicron wave was at its peak, and more than 70,000 deaths were being reported to WHO each week,” said Tedros in his remarks at the closed meeting, reported by WHO in a press release. “When you last met in October, the number of weekly reported deaths was near the lowest since the pandemic began – less than 10,000 a week,” he added. “However, since the beginning of December, the number of weekly reported deaths globally has been rising.” China trends create a second level of concerns Following a massive wave of protests in autumn 2022, China lifted most of its COVID restrictions – which had been among the strictest in the world. In addition, Tedros noted, the lifting of COVID restrictions in China has led to a spike in deaths in the world’s most populous nation, whose citizens were poorly protected by vaccinations as well as having low natural immunity thanks to months of social isolation. “Last week, almost 40 thousand deaths were reported to WHO, more than half of them from China,” Tedros said. “In total, over the past eight weeks, more than 170,000 deaths have been reported. The actual number is certainly much higher.” Earlier this week, Tedros also expressed his mixed feelings about declaring an end to the pandemic even more bluntly, saying: “While I will not preempt the advice of the emergency committee, I remain very concerned by the situation in many countries and the rising number of deaths,” he said, speaking at WHO’s weekly press briefing. “While we’re clearly in better shape than three years ago when this pandemic first hit, the global collective response is once again under strain.” In fact, after reaching a peak in mid-December, the wave of new cases in China and worldwide have been declining for the past month – both according to WHO data and other data monitoring platforms. However, in light of the reduced amount of COVID testing worldwide, the confirmed case count is an increasingly unreliable measure of true cases. “Surveillance and genetic sequencing have declined dramatically around the world, making it more difficult to track known variants and detect new ones,” Tedros told the committee at the outset of Friday’s meeting. Revolution in vaccines, treatments and diagnostics has not reached everyone Related to that, the global response to COVID remains “hobbled” because “powerful, life-saving tools are still not getting to the population that need them most – especially older people and health workers, Tedros said. “Many health systems around the world are struggling to cope with COVID-19, on top of caring for patients with other diseases including influenza and RSV, and with work shortages and fatigued health workers. “And public trust in the safe and effective tools for controlling COVID-19 is being undermined by a continuous torrent of mis- and disinformation.” It was unclear as to whether the committee’s deliberations would continue into the weekend, or when their conclusions will finally be announced. However, there was speculation that their report might only be published on Monday, when the WHO Executive Board, WHO’s governing body, begins its first annual round of meetings for 2023. Among the nearly 50 items on the week-long agenda are a raft of reports and recommendations on strengthening global preparedness and response to health emergencies. The WHO Public Health Emergency of International Concern (PHEIC) was declared in the framework of the 2005 International Health Regulations, which constitute a legally binding agreement between WHO member states regarding emergency outbreak and response. In March 2020, Tedros also declared that the emergency also constituted a “pandemic” – although there is in fact no legal provision for a pandemic declaration in the IHR. However, the weaknesses in the IHR system of outbreak alerts, notification and resonses, highlighted by the faltering and inconsistent reponse to the COVID pandemic, have paved the way for major reconsideration of global pandemic response frameworks, with debates over a new pandemic treaty, as well as IHR revisions, set to continue throughout 2023 and into 2024. See related story here: Governing Pandemics Snapshot Image Credits: Twitter: @WHO. WHO Provides New Medicines List, Policy Recommendations for Nuclear Emergency 27/01/2023 Maayan Hoffman A Nuclear powerplant in Belgium. The World Health Organization (WHO) on Friday released an updated list of medicines that should be stockpiled in the event of a radiological and nuclear emergency, along with new policy advice in the event of such an incident. “Preparedness for radiation emergencies is consistently reported as the weakest area of preparedness in many countries,” the 66-page report said. This newest report updates the one released over 15 years ago, in 2007, and thus includes a host of new pharmaceutical developments. “In radiation emergencies, people may be exposed to radiation at doses ranging from negligible to life-threatening. Governments need to make treatments available for those in need – fast,” said Dr Maria Neira, WHO Acting Assistant Director-General of the Healthier Populations Division. “It is essential that governments are prepared to protect the health of populations and respond immediately to emergencies. This includes having ready supplies of lifesaving medicines that will reduce risks and treat injuries from radiation.” Added Dr Mike Ryan, Executive Director of WHO’s Health Emergencies Programme: “This updated critical medicines list will be a vital preparedness and readiness tool for our partners to identify, procure, stockpile and deliver effective countermeasures in a timely fashion to those at risk or exposed in these events.” Radiological or nuclear emergencies could occur at nuclear power plants, medical or research facilities or be the result of accidents during transport of radioactive materials, WHO explained. In addition, these emergencies could be the result of a malicious event, such as a nuclear bombing. To date, there were two massive nuclear incidents: The 1945 atomic bombings of Hiroshima and Nagasaki by the United States, the consequences of which have been continually studied. There was also the 1986 accident at the Chernobyl nuclear plant in Ukraine – the largest uncontrolled radioactive release in history. Former Russian President Dmitry Medvedev warned this month in yet another Telegram post that a defeat of Russia in Ukraine could trigger a nuclear war. “The defeat of a nuclear power in a conventional war may trigger a nuclear war,” Medvedev wrote. Exposure to high doses of radiation can have severe consequences on a person’s long-term health or lead to immediate or early death. As such, aside from generic supplies and materials used for any type of emergencies, stockpiles should include medicines that either prevent or reduce exposure to radiation, WHO explained. Only a handful of recommended medicines There are only a handful of specific drugs that have been proven effective in the treatment of over-exposure to radiation and these are included in the report. They include: stable iodine; chelating sand (decorporating agents); cytokines used for mitigation of damage to the bone marrow; and medicines to treat vomiting, diarrhea and infections. “One of the most serious outcomes of over-exposure to radiation is acute radiation syndrome (ARS), which manifests as a haematopoietic syndrome”. The latter, also called bone marrow syndrome, impacts blood cell production and in cases of acute poisoning, can lead to death through infection or hemorrhage. “Depending on the severity of the exposure may further progress as gastrointestinal, cardiovascular and neurological syndromes,” the report states. However, the WHO recommendations only include treatments of haematopoietic and gastrointestinal syndromes, “as cardiovascular and neurological syndromes are considered non-salvageable and require only palliative care.” Blocking agents such as stable iodine, could be used to block the uptake of radionuclides in the body, the WHO report added. Other agents like Prussian blue are applied to remove radioactive ceasium from the body. Calcium or zinc diethylenetriaminepentaacetic acid can treat internal contamination with transuranium radionuclides. “These and other elements of such stockpiles should be made rapidly available in case of radiation emergencies,” wrote WHO. Bone marrow syndrome – emerging treatments In the case of haematopoietic, or bone marrow syndrome, radiation attacks all three blood lineages – white and red blood cells and platelets. Low white blood cell count weakens the immune system, making an individual vulnerable to infection. Red blood cells carry oxygen to the body and platelets are responsible for coagulation, which prevents bleeding, explained Yaky Yanay, CEO and president of Pluri – an Israeli-based biotech firm developing an injection of placenta cells for the treatment of ARS. The treatment has been approved by the United States Food and Drug Administration as an “Investigational New Drug” (IND) for use in the event of a nuclear incident – although it is not yet mature enough to be considered for the WHO list of recommended medicines. The WHO report notes, however, that researchers are making progress on developing novel treatments, although none of them have been approved by the global health agency for use in a nuclear emergency. WHO: Stockpile based on population size WHO stressed that a country’s nuclear medicines stockpile should be based on reliable data for national risk profiles, the size of the population and available resources and capabilities of their health system. Finally, WHO called on national health authorities, health-care facilities, pharmaceutical suppliers and logistics, civil defense and emergency services to be leveraged in the event of an emergency. These teams should be coordinated in advance to be able to function effectively in the event of a nuclear incident. Image Credits: Photo by Frédéric Paulussen on Unsplash. Governing Pandemics Snapshot 27/01/2023 Gian Luca Burci, Suerie Moon, Daniela Morich, Adam Strobeyko & Seyed-Moeen Hosseinalipour Standing ovation at the close of the special World Health Assembly session 1 December 2021, in which member states agreed to negotiate a new pandemic accord. A briefing series on the status of moves to reform the global system of pandemic preparedness and response launches today, just ahead of the WHO Executive Board review of progress next week. Looking back at 2022 and forward into 2023, this series by the Global Health Center of the Geneva Graduate Institute, published in collaboration with Health Policy Watch, provides an update on the progress so far in the WHO-led negotiations over a new pandemic treaty. It also looks at the progress in revisions to the existing emergency rules of the International Health Regulations (IHR) – while considering what could happen next. The complete “Governing Pandemics Snapshot”, also includes briefings on reforms being considered in the financing of pandemics as well as the rules around pathogen access and benefit-sharing. Pandemic treaty: tough political negotiations ahead By Daniela Morich Following a milestone World Health Assembly decision in late 2021, WHO Member States have been negotiating an international agreement on pandemic prevention, preparedness and response to strengthen global capacities and resilience for future pandemics. The year 2022 was the year for the advance of these pandemic treaty talks with the establishment of a formal process, a strict timeline, and initial discussions on principles. In 2023, negotiations will shift from broad consultations to tough politics. The Covid-19 pandemic brought to the surface the shortcomings of global health governance for emergencies and accelerated discussions to reform it. At a special WHA session in late 2021, the second-ever convened by the World Health Assembly, WHO Member States agreed to establish an intergovernmental negotiating body (INB) to negotiate a new “instrument” to strengthen pandemic prevention, preparedness and response – or, a pandemic treaty. The INB initiated its work in early 2022 and is to present the outcome of the negotiations to the 77th World Health Assembly (WHA) in May 2024. This is an ambitious timeline for a complex international rule-making process, especially as it will run in parallel to the process to revise the International Health Regulations (IHR), a pre-existing WHO instrument that governs the cross-border spread of infectious disease. Nonetheless, the INB is moving forward and achieved two mid-term milestones in 2022. In July, at the second INB meeting, Member States agreed that the instrument should be legally binding, which suggests countries are ready to accept new international obligations to improve pandemic prevention and response. In addition, the INB engaged in intensive intersessional consultations to seek input not only from governments or well-established experts – the traditional protagonists of international rulemaking – but also from civil society organizations and the public. Despite these efforts, commentators have argued that the process is still not as inclusive as it should be. As work on the instrument progresses, negotiators should expect more demands to expand meaningful participation of stakeholders beyond governments. The INB’s Bureau (six countries elected to lead the process) released the ‘conceptual zero draft’ (CZD) ahead of the third meeting of the INB, which took place in December 2022. The CZD –which can be seen as the first rough draft of the accord – brought to the negotiating table a broad set of issues and highlighted a collective willingness to ensure a more equitable response to future threats. It also reflected tough divisions on several issues, in particular, intellectual property (IP), pathogen- and benefit- sharing, One Health, financing and accountability, which will likely become more visible and contentious as negotiations move to the next phase. At the conclusion of the gathering, Member States directed the INB Bureau to develop the ‘zero draft’. Delegates strongly encouraged the Bureau to move away from the vague and aspirational language of the CZD and to present clear legal provisions and definitions, including one for ‘pandemic’, for Member States to negotiate in earnest. The INB Bureau is expected to circulate the zero draft in early February 2023. At this stage, the negotiation process will likely shift from a consultation and information gathering process to become a more politicized, polarized and consequential debate. The time available to negotiators is constrained. The 2023-2024 agenda includes 6 additional INB meetings scheduled over 14 months in addition to meetings of the drafting groups, with the IHR revision process unfolding in parallel. Considering the complexity of the issues on the table, the existing divisions between Member States, and the limited time available to negotiators, achieving meaningful progress in this new highly-political phase is the tall order for 2023. An existential moment for the International Health Regulations Dr Hiroki Nakatani, chairman of the May World Health Assembly, applauds the WHA decision to revise the International Health Regulations. By Gian Luca Burci While negotiations on a new pandemic instrument continue in 2023-24, the International Health Regulations (IHR) remain the sole global legally-binding instrument devoted to the prevention and control of the international spread of disease – and revisions to those are already underway. Can the two parallel processes complement each other or will they add new layers of confusion? That is the challenge negotiators and member states will face. Although considered an essential component of the global health security toolbox, the IHR attracted severe criticism and allegedly low compliance during the COVID-19 pandemic. The momentum towards a new “pandemic treaty”, beginning in late 2020, was in part a reaction to the perceived weaknesses and limitations of the IHR. The difficult and sometimes confusing discussions in the Working Group on strengthening WHO preparedness and response to health emergencies created by the 74th World Health Assembly in 2021 to discuss reforms, ultimately led to a WHA decision in December 2021 to launch negotiations on a new legal instrument (“pandemic treaty”) to be adopted by 2024. Then, in 2022, attention turned back to the IHR as member states sought faster solutions for the most burning issues that had surfaced during the pandemic – particularly around outbreak reporting and IHR compliance. As a result, a complex IHR amendment process is also now underway. The two processes (IHR revisions and pandemic accord) are thus now proceeding in parallel, with hard decisions still to be made on the issues that the revised IHR will tackle – as compared to the new pandemic accord. Negotiations to amend the IHR in 2023/2024 raise an existential question about their raison d’etre: should they retain their technical, operational character, or expand significantly to address highly political questions such as those on international assistance, equity and access to technologies for disease outbreaks? The US broke the ice by proposing its own substantial set of amendments in January 2022, and successfully winning agreement at the 75th WHA in May 2022, to both adopt a set of limited technical IHR amendments and to open up a broader process for further amendments. The WHA thus launched negotiations towards “targeted amendments” of the IHR with the same 2024 deadline for WHA adoption as the new pandemic accord. Member States submitted their proposed amendments by 30 September 2022 and an expert “review committee” analyzed them and presented its recommendations to the Director-General in January 2023. A Working Group open to all Member States will work from February 2023 towards a negotiated package. The process is unusual compared to other intergovernmental negotiations, in that states hardly ever place on the table all their proposed amendments at the outset; the initial US disclosure of all its amendments, however, required a similar treatment for other states and made that approach inevitable. Wildly diverse amendments but a few trends emerge A patchwork of national rules around international travel, vaccines and border controls were a feature of the COVID pandemic, highlighting the inconsistent application of key IHR provisions aimed at ensuring international trade and travel during health emergencies. The outcome of the first phase of this process is a massive aggregation of wildly diverse amendments (available here) proposed or supported by almost 100 states. They range from focused technical amendments to far-reaching changes. Despite their diversity, a few trends emerge dividing Global South and Global North countries. The most political proposals, coming in particular from the African Region, Bangladesh and India, aim at ensuring equitable access to vaccines, distributed manufacturing capacities, technology transfer, limitations on patenting and sustainable financing of national capacities. These proposals reflect the North-South divide that we have been witnessing in the recent treaty conferences on climate change and biodiversity and are clearly also a consequence of the inequities in access to life-saving medical countermeasures displayed during the COVID-19 pandemic. Other proposals, in particular from the European Union, the Eurasian Economic Union (submitted by the Russian Federation) and the United States, aim at strengthening the IHR within their current approach, e.g. by tightening compliance and accountability for information sharing, encouraging the sharing of genetic sequence data and through the use of digital technologies. Two negotiating processes unfolding at the same time The challenge in reaching an agreed package in time for the 2024 WHA is increased by the unprecedented parallel unfolding of two negotiating processes with the same timeline, where countries will probably submit the same types of proposals for both instruments to secure an overall favorable outcome. An important point in this respect that is often overlooked is that amendments to the IHR will in principle enter into force at the same time for all its 196 parties, whereas the pandemic instrument – since it will likely be an international treaty – will enter into force once a critical mass of countries has ratified it and only for them, with new countries joining once they ratify. The broad range of proposals for the pandemic instrument and the likelihood that the US will eventually not ratify it may actually lead Global South countries to prioritize the IHR for some of the most ambitious proposals. This possibility raises one final issue. Currently, the IHR is essentially an operational instrument to coordinate outbreak prevention and control and depoliticize WHO’s role in managing them. There is no emphasis on equity, assistance or international cooperation. Amendments proposed by Global South countries would transform it into a regulatory and transactional instrument with a more political role for WHO and differential treatment for developing countries to improve equity in the availability of health technologies. Fundamentally, negotiators will have to decide what they want the IHR to be – and if the IHR is expanded to encompass the issues of health equity then what role would the new pandemic instrument play? For essays on financing pandemics and pathogen and benefit sharing, see the full Governing Pandemics Snapshot here. This is the first in a periodic series of updates to be published during the year. About the authors Daniela Morich is Manager and Adviser of the Governing Pandemics initiative at the Global Health Centre, and a lawyer with experience in multilateral negotiations. Dr Gian Luca Burci is Adjunct Professor of International Law at the Geneva Graduate Institute. He was a member of the IHR Review Committee that completed its expert analysis of the proposed IHR amendments in January 2023. He co-leads the Governing Pandemics initiative. Dr Suerie Moon is Professor of Practice and Co-Director of the Global Health Centre, and co-leads the Governing Pandemics initiative. Adam Strobeyko is a Hauser Global Fellow at NYU Law and was a Doctoral Researcher for the Governing Pandemics initiative. Moeen Hosseinalipour is a master’s student in global health and international affairs at the University of Geneva and Geneva Graduate Institute, and a research assistant for the Governing Pandemics initiative. Image Credits: Geneva Graduate Institute. Posts navigation Older postsNewer posts This site uses cookies to help give you the best experience on our website. Cookies enable us to collect information that helps us personalise your experience and improve the functionality and performance of our site. 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WHO Provides New Medicines List, Policy Recommendations for Nuclear Emergency 27/01/2023 Maayan Hoffman A Nuclear powerplant in Belgium. The World Health Organization (WHO) on Friday released an updated list of medicines that should be stockpiled in the event of a radiological and nuclear emergency, along with new policy advice in the event of such an incident. “Preparedness for radiation emergencies is consistently reported as the weakest area of preparedness in many countries,” the 66-page report said. This newest report updates the one released over 15 years ago, in 2007, and thus includes a host of new pharmaceutical developments. “In radiation emergencies, people may be exposed to radiation at doses ranging from negligible to life-threatening. Governments need to make treatments available for those in need – fast,” said Dr Maria Neira, WHO Acting Assistant Director-General of the Healthier Populations Division. “It is essential that governments are prepared to protect the health of populations and respond immediately to emergencies. This includes having ready supplies of lifesaving medicines that will reduce risks and treat injuries from radiation.” Added Dr Mike Ryan, Executive Director of WHO’s Health Emergencies Programme: “This updated critical medicines list will be a vital preparedness and readiness tool for our partners to identify, procure, stockpile and deliver effective countermeasures in a timely fashion to those at risk or exposed in these events.” Radiological or nuclear emergencies could occur at nuclear power plants, medical or research facilities or be the result of accidents during transport of radioactive materials, WHO explained. In addition, these emergencies could be the result of a malicious event, such as a nuclear bombing. To date, there were two massive nuclear incidents: The 1945 atomic bombings of Hiroshima and Nagasaki by the United States, the consequences of which have been continually studied. There was also the 1986 accident at the Chernobyl nuclear plant in Ukraine – the largest uncontrolled radioactive release in history. Former Russian President Dmitry Medvedev warned this month in yet another Telegram post that a defeat of Russia in Ukraine could trigger a nuclear war. “The defeat of a nuclear power in a conventional war may trigger a nuclear war,” Medvedev wrote. Exposure to high doses of radiation can have severe consequences on a person’s long-term health or lead to immediate or early death. As such, aside from generic supplies and materials used for any type of emergencies, stockpiles should include medicines that either prevent or reduce exposure to radiation, WHO explained. Only a handful of recommended medicines There are only a handful of specific drugs that have been proven effective in the treatment of over-exposure to radiation and these are included in the report. They include: stable iodine; chelating sand (decorporating agents); cytokines used for mitigation of damage to the bone marrow; and medicines to treat vomiting, diarrhea and infections. “One of the most serious outcomes of over-exposure to radiation is acute radiation syndrome (ARS), which manifests as a haematopoietic syndrome”. The latter, also called bone marrow syndrome, impacts blood cell production and in cases of acute poisoning, can lead to death through infection or hemorrhage. “Depending on the severity of the exposure may further progress as gastrointestinal, cardiovascular and neurological syndromes,” the report states. However, the WHO recommendations only include treatments of haematopoietic and gastrointestinal syndromes, “as cardiovascular and neurological syndromes are considered non-salvageable and require only palliative care.” Blocking agents such as stable iodine, could be used to block the uptake of radionuclides in the body, the WHO report added. Other agents like Prussian blue are applied to remove radioactive ceasium from the body. Calcium or zinc diethylenetriaminepentaacetic acid can treat internal contamination with transuranium radionuclides. “These and other elements of such stockpiles should be made rapidly available in case of radiation emergencies,” wrote WHO. Bone marrow syndrome – emerging treatments In the case of haematopoietic, or bone marrow syndrome, radiation attacks all three blood lineages – white and red blood cells and platelets. Low white blood cell count weakens the immune system, making an individual vulnerable to infection. Red blood cells carry oxygen to the body and platelets are responsible for coagulation, which prevents bleeding, explained Yaky Yanay, CEO and president of Pluri – an Israeli-based biotech firm developing an injection of placenta cells for the treatment of ARS. The treatment has been approved by the United States Food and Drug Administration as an “Investigational New Drug” (IND) for use in the event of a nuclear incident – although it is not yet mature enough to be considered for the WHO list of recommended medicines. The WHO report notes, however, that researchers are making progress on developing novel treatments, although none of them have been approved by the global health agency for use in a nuclear emergency. WHO: Stockpile based on population size WHO stressed that a country’s nuclear medicines stockpile should be based on reliable data for national risk profiles, the size of the population and available resources and capabilities of their health system. Finally, WHO called on national health authorities, health-care facilities, pharmaceutical suppliers and logistics, civil defense and emergency services to be leveraged in the event of an emergency. These teams should be coordinated in advance to be able to function effectively in the event of a nuclear incident. Image Credits: Photo by Frédéric Paulussen on Unsplash. Governing Pandemics Snapshot 27/01/2023 Gian Luca Burci, Suerie Moon, Daniela Morich, Adam Strobeyko & Seyed-Moeen Hosseinalipour Standing ovation at the close of the special World Health Assembly session 1 December 2021, in which member states agreed to negotiate a new pandemic accord. A briefing series on the status of moves to reform the global system of pandemic preparedness and response launches today, just ahead of the WHO Executive Board review of progress next week. Looking back at 2022 and forward into 2023, this series by the Global Health Center of the Geneva Graduate Institute, published in collaboration with Health Policy Watch, provides an update on the progress so far in the WHO-led negotiations over a new pandemic treaty. It also looks at the progress in revisions to the existing emergency rules of the International Health Regulations (IHR) – while considering what could happen next. The complete “Governing Pandemics Snapshot”, also includes briefings on reforms being considered in the financing of pandemics as well as the rules around pathogen access and benefit-sharing. Pandemic treaty: tough political negotiations ahead By Daniela Morich Following a milestone World Health Assembly decision in late 2021, WHO Member States have been negotiating an international agreement on pandemic prevention, preparedness and response to strengthen global capacities and resilience for future pandemics. The year 2022 was the year for the advance of these pandemic treaty talks with the establishment of a formal process, a strict timeline, and initial discussions on principles. In 2023, negotiations will shift from broad consultations to tough politics. The Covid-19 pandemic brought to the surface the shortcomings of global health governance for emergencies and accelerated discussions to reform it. At a special WHA session in late 2021, the second-ever convened by the World Health Assembly, WHO Member States agreed to establish an intergovernmental negotiating body (INB) to negotiate a new “instrument” to strengthen pandemic prevention, preparedness and response – or, a pandemic treaty. The INB initiated its work in early 2022 and is to present the outcome of the negotiations to the 77th World Health Assembly (WHA) in May 2024. This is an ambitious timeline for a complex international rule-making process, especially as it will run in parallel to the process to revise the International Health Regulations (IHR), a pre-existing WHO instrument that governs the cross-border spread of infectious disease. Nonetheless, the INB is moving forward and achieved two mid-term milestones in 2022. In July, at the second INB meeting, Member States agreed that the instrument should be legally binding, which suggests countries are ready to accept new international obligations to improve pandemic prevention and response. In addition, the INB engaged in intensive intersessional consultations to seek input not only from governments or well-established experts – the traditional protagonists of international rulemaking – but also from civil society organizations and the public. Despite these efforts, commentators have argued that the process is still not as inclusive as it should be. As work on the instrument progresses, negotiators should expect more demands to expand meaningful participation of stakeholders beyond governments. The INB’s Bureau (six countries elected to lead the process) released the ‘conceptual zero draft’ (CZD) ahead of the third meeting of the INB, which took place in December 2022. The CZD –which can be seen as the first rough draft of the accord – brought to the negotiating table a broad set of issues and highlighted a collective willingness to ensure a more equitable response to future threats. It also reflected tough divisions on several issues, in particular, intellectual property (IP), pathogen- and benefit- sharing, One Health, financing and accountability, which will likely become more visible and contentious as negotiations move to the next phase. At the conclusion of the gathering, Member States directed the INB Bureau to develop the ‘zero draft’. Delegates strongly encouraged the Bureau to move away from the vague and aspirational language of the CZD and to present clear legal provisions and definitions, including one for ‘pandemic’, for Member States to negotiate in earnest. The INB Bureau is expected to circulate the zero draft in early February 2023. At this stage, the negotiation process will likely shift from a consultation and information gathering process to become a more politicized, polarized and consequential debate. The time available to negotiators is constrained. The 2023-2024 agenda includes 6 additional INB meetings scheduled over 14 months in addition to meetings of the drafting groups, with the IHR revision process unfolding in parallel. Considering the complexity of the issues on the table, the existing divisions between Member States, and the limited time available to negotiators, achieving meaningful progress in this new highly-political phase is the tall order for 2023. An existential moment for the International Health Regulations Dr Hiroki Nakatani, chairman of the May World Health Assembly, applauds the WHA decision to revise the International Health Regulations. By Gian Luca Burci While negotiations on a new pandemic instrument continue in 2023-24, the International Health Regulations (IHR) remain the sole global legally-binding instrument devoted to the prevention and control of the international spread of disease – and revisions to those are already underway. Can the two parallel processes complement each other or will they add new layers of confusion? That is the challenge negotiators and member states will face. Although considered an essential component of the global health security toolbox, the IHR attracted severe criticism and allegedly low compliance during the COVID-19 pandemic. The momentum towards a new “pandemic treaty”, beginning in late 2020, was in part a reaction to the perceived weaknesses and limitations of the IHR. The difficult and sometimes confusing discussions in the Working Group on strengthening WHO preparedness and response to health emergencies created by the 74th World Health Assembly in 2021 to discuss reforms, ultimately led to a WHA decision in December 2021 to launch negotiations on a new legal instrument (“pandemic treaty”) to be adopted by 2024. Then, in 2022, attention turned back to the IHR as member states sought faster solutions for the most burning issues that had surfaced during the pandemic – particularly around outbreak reporting and IHR compliance. As a result, a complex IHR amendment process is also now underway. The two processes (IHR revisions and pandemic accord) are thus now proceeding in parallel, with hard decisions still to be made on the issues that the revised IHR will tackle – as compared to the new pandemic accord. Negotiations to amend the IHR in 2023/2024 raise an existential question about their raison d’etre: should they retain their technical, operational character, or expand significantly to address highly political questions such as those on international assistance, equity and access to technologies for disease outbreaks? The US broke the ice by proposing its own substantial set of amendments in January 2022, and successfully winning agreement at the 75th WHA in May 2022, to both adopt a set of limited technical IHR amendments and to open up a broader process for further amendments. The WHA thus launched negotiations towards “targeted amendments” of the IHR with the same 2024 deadline for WHA adoption as the new pandemic accord. Member States submitted their proposed amendments by 30 September 2022 and an expert “review committee” analyzed them and presented its recommendations to the Director-General in January 2023. A Working Group open to all Member States will work from February 2023 towards a negotiated package. The process is unusual compared to other intergovernmental negotiations, in that states hardly ever place on the table all their proposed amendments at the outset; the initial US disclosure of all its amendments, however, required a similar treatment for other states and made that approach inevitable. Wildly diverse amendments but a few trends emerge A patchwork of national rules around international travel, vaccines and border controls were a feature of the COVID pandemic, highlighting the inconsistent application of key IHR provisions aimed at ensuring international trade and travel during health emergencies. The outcome of the first phase of this process is a massive aggregation of wildly diverse amendments (available here) proposed or supported by almost 100 states. They range from focused technical amendments to far-reaching changes. Despite their diversity, a few trends emerge dividing Global South and Global North countries. The most political proposals, coming in particular from the African Region, Bangladesh and India, aim at ensuring equitable access to vaccines, distributed manufacturing capacities, technology transfer, limitations on patenting and sustainable financing of national capacities. These proposals reflect the North-South divide that we have been witnessing in the recent treaty conferences on climate change and biodiversity and are clearly also a consequence of the inequities in access to life-saving medical countermeasures displayed during the COVID-19 pandemic. Other proposals, in particular from the European Union, the Eurasian Economic Union (submitted by the Russian Federation) and the United States, aim at strengthening the IHR within their current approach, e.g. by tightening compliance and accountability for information sharing, encouraging the sharing of genetic sequence data and through the use of digital technologies. Two negotiating processes unfolding at the same time The challenge in reaching an agreed package in time for the 2024 WHA is increased by the unprecedented parallel unfolding of two negotiating processes with the same timeline, where countries will probably submit the same types of proposals for both instruments to secure an overall favorable outcome. An important point in this respect that is often overlooked is that amendments to the IHR will in principle enter into force at the same time for all its 196 parties, whereas the pandemic instrument – since it will likely be an international treaty – will enter into force once a critical mass of countries has ratified it and only for them, with new countries joining once they ratify. The broad range of proposals for the pandemic instrument and the likelihood that the US will eventually not ratify it may actually lead Global South countries to prioritize the IHR for some of the most ambitious proposals. This possibility raises one final issue. Currently, the IHR is essentially an operational instrument to coordinate outbreak prevention and control and depoliticize WHO’s role in managing them. There is no emphasis on equity, assistance or international cooperation. Amendments proposed by Global South countries would transform it into a regulatory and transactional instrument with a more political role for WHO and differential treatment for developing countries to improve equity in the availability of health technologies. Fundamentally, negotiators will have to decide what they want the IHR to be – and if the IHR is expanded to encompass the issues of health equity then what role would the new pandemic instrument play? For essays on financing pandemics and pathogen and benefit sharing, see the full Governing Pandemics Snapshot here. This is the first in a periodic series of updates to be published during the year. About the authors Daniela Morich is Manager and Adviser of the Governing Pandemics initiative at the Global Health Centre, and a lawyer with experience in multilateral negotiations. Dr Gian Luca Burci is Adjunct Professor of International Law at the Geneva Graduate Institute. He was a member of the IHR Review Committee that completed its expert analysis of the proposed IHR amendments in January 2023. He co-leads the Governing Pandemics initiative. Dr Suerie Moon is Professor of Practice and Co-Director of the Global Health Centre, and co-leads the Governing Pandemics initiative. Adam Strobeyko is a Hauser Global Fellow at NYU Law and was a Doctoral Researcher for the Governing Pandemics initiative. Moeen Hosseinalipour is a master’s student in global health and international affairs at the University of Geneva and Geneva Graduate Institute, and a research assistant for the Governing Pandemics initiative. Image Credits: Geneva Graduate Institute. Posts navigation Older postsNewer posts This site uses cookies to help give you the best experience on our website. Cookies enable us to collect information that helps us personalise your experience and improve the functionality and performance of our site. By continuing to read our website, we assume you agree to this, otherwise you can adjust your browser settings. Please read our cookie and Privacy Policy. Our Cookies and Privacy Policy
Governing Pandemics Snapshot 27/01/2023 Gian Luca Burci, Suerie Moon, Daniela Morich, Adam Strobeyko & Seyed-Moeen Hosseinalipour Standing ovation at the close of the special World Health Assembly session 1 December 2021, in which member states agreed to negotiate a new pandemic accord. A briefing series on the status of moves to reform the global system of pandemic preparedness and response launches today, just ahead of the WHO Executive Board review of progress next week. Looking back at 2022 and forward into 2023, this series by the Global Health Center of the Geneva Graduate Institute, published in collaboration with Health Policy Watch, provides an update on the progress so far in the WHO-led negotiations over a new pandemic treaty. It also looks at the progress in revisions to the existing emergency rules of the International Health Regulations (IHR) – while considering what could happen next. The complete “Governing Pandemics Snapshot”, also includes briefings on reforms being considered in the financing of pandemics as well as the rules around pathogen access and benefit-sharing. Pandemic treaty: tough political negotiations ahead By Daniela Morich Following a milestone World Health Assembly decision in late 2021, WHO Member States have been negotiating an international agreement on pandemic prevention, preparedness and response to strengthen global capacities and resilience for future pandemics. The year 2022 was the year for the advance of these pandemic treaty talks with the establishment of a formal process, a strict timeline, and initial discussions on principles. In 2023, negotiations will shift from broad consultations to tough politics. The Covid-19 pandemic brought to the surface the shortcomings of global health governance for emergencies and accelerated discussions to reform it. At a special WHA session in late 2021, the second-ever convened by the World Health Assembly, WHO Member States agreed to establish an intergovernmental negotiating body (INB) to negotiate a new “instrument” to strengthen pandemic prevention, preparedness and response – or, a pandemic treaty. The INB initiated its work in early 2022 and is to present the outcome of the negotiations to the 77th World Health Assembly (WHA) in May 2024. This is an ambitious timeline for a complex international rule-making process, especially as it will run in parallel to the process to revise the International Health Regulations (IHR), a pre-existing WHO instrument that governs the cross-border spread of infectious disease. Nonetheless, the INB is moving forward and achieved two mid-term milestones in 2022. In July, at the second INB meeting, Member States agreed that the instrument should be legally binding, which suggests countries are ready to accept new international obligations to improve pandemic prevention and response. In addition, the INB engaged in intensive intersessional consultations to seek input not only from governments or well-established experts – the traditional protagonists of international rulemaking – but also from civil society organizations and the public. Despite these efforts, commentators have argued that the process is still not as inclusive as it should be. As work on the instrument progresses, negotiators should expect more demands to expand meaningful participation of stakeholders beyond governments. The INB’s Bureau (six countries elected to lead the process) released the ‘conceptual zero draft’ (CZD) ahead of the third meeting of the INB, which took place in December 2022. The CZD –which can be seen as the first rough draft of the accord – brought to the negotiating table a broad set of issues and highlighted a collective willingness to ensure a more equitable response to future threats. It also reflected tough divisions on several issues, in particular, intellectual property (IP), pathogen- and benefit- sharing, One Health, financing and accountability, which will likely become more visible and contentious as negotiations move to the next phase. At the conclusion of the gathering, Member States directed the INB Bureau to develop the ‘zero draft’. Delegates strongly encouraged the Bureau to move away from the vague and aspirational language of the CZD and to present clear legal provisions and definitions, including one for ‘pandemic’, for Member States to negotiate in earnest. The INB Bureau is expected to circulate the zero draft in early February 2023. At this stage, the negotiation process will likely shift from a consultation and information gathering process to become a more politicized, polarized and consequential debate. The time available to negotiators is constrained. The 2023-2024 agenda includes 6 additional INB meetings scheduled over 14 months in addition to meetings of the drafting groups, with the IHR revision process unfolding in parallel. Considering the complexity of the issues on the table, the existing divisions between Member States, and the limited time available to negotiators, achieving meaningful progress in this new highly-political phase is the tall order for 2023. An existential moment for the International Health Regulations Dr Hiroki Nakatani, chairman of the May World Health Assembly, applauds the WHA decision to revise the International Health Regulations. By Gian Luca Burci While negotiations on a new pandemic instrument continue in 2023-24, the International Health Regulations (IHR) remain the sole global legally-binding instrument devoted to the prevention and control of the international spread of disease – and revisions to those are already underway. Can the two parallel processes complement each other or will they add new layers of confusion? That is the challenge negotiators and member states will face. Although considered an essential component of the global health security toolbox, the IHR attracted severe criticism and allegedly low compliance during the COVID-19 pandemic. The momentum towards a new “pandemic treaty”, beginning in late 2020, was in part a reaction to the perceived weaknesses and limitations of the IHR. The difficult and sometimes confusing discussions in the Working Group on strengthening WHO preparedness and response to health emergencies created by the 74th World Health Assembly in 2021 to discuss reforms, ultimately led to a WHA decision in December 2021 to launch negotiations on a new legal instrument (“pandemic treaty”) to be adopted by 2024. Then, in 2022, attention turned back to the IHR as member states sought faster solutions for the most burning issues that had surfaced during the pandemic – particularly around outbreak reporting and IHR compliance. As a result, a complex IHR amendment process is also now underway. The two processes (IHR revisions and pandemic accord) are thus now proceeding in parallel, with hard decisions still to be made on the issues that the revised IHR will tackle – as compared to the new pandemic accord. Negotiations to amend the IHR in 2023/2024 raise an existential question about their raison d’etre: should they retain their technical, operational character, or expand significantly to address highly political questions such as those on international assistance, equity and access to technologies for disease outbreaks? The US broke the ice by proposing its own substantial set of amendments in January 2022, and successfully winning agreement at the 75th WHA in May 2022, to both adopt a set of limited technical IHR amendments and to open up a broader process for further amendments. The WHA thus launched negotiations towards “targeted amendments” of the IHR with the same 2024 deadline for WHA adoption as the new pandemic accord. Member States submitted their proposed amendments by 30 September 2022 and an expert “review committee” analyzed them and presented its recommendations to the Director-General in January 2023. A Working Group open to all Member States will work from February 2023 towards a negotiated package. The process is unusual compared to other intergovernmental negotiations, in that states hardly ever place on the table all their proposed amendments at the outset; the initial US disclosure of all its amendments, however, required a similar treatment for other states and made that approach inevitable. Wildly diverse amendments but a few trends emerge A patchwork of national rules around international travel, vaccines and border controls were a feature of the COVID pandemic, highlighting the inconsistent application of key IHR provisions aimed at ensuring international trade and travel during health emergencies. The outcome of the first phase of this process is a massive aggregation of wildly diverse amendments (available here) proposed or supported by almost 100 states. They range from focused technical amendments to far-reaching changes. Despite their diversity, a few trends emerge dividing Global South and Global North countries. The most political proposals, coming in particular from the African Region, Bangladesh and India, aim at ensuring equitable access to vaccines, distributed manufacturing capacities, technology transfer, limitations on patenting and sustainable financing of national capacities. These proposals reflect the North-South divide that we have been witnessing in the recent treaty conferences on climate change and biodiversity and are clearly also a consequence of the inequities in access to life-saving medical countermeasures displayed during the COVID-19 pandemic. Other proposals, in particular from the European Union, the Eurasian Economic Union (submitted by the Russian Federation) and the United States, aim at strengthening the IHR within their current approach, e.g. by tightening compliance and accountability for information sharing, encouraging the sharing of genetic sequence data and through the use of digital technologies. Two negotiating processes unfolding at the same time The challenge in reaching an agreed package in time for the 2024 WHA is increased by the unprecedented parallel unfolding of two negotiating processes with the same timeline, where countries will probably submit the same types of proposals for both instruments to secure an overall favorable outcome. An important point in this respect that is often overlooked is that amendments to the IHR will in principle enter into force at the same time for all its 196 parties, whereas the pandemic instrument – since it will likely be an international treaty – will enter into force once a critical mass of countries has ratified it and only for them, with new countries joining once they ratify. The broad range of proposals for the pandemic instrument and the likelihood that the US will eventually not ratify it may actually lead Global South countries to prioritize the IHR for some of the most ambitious proposals. This possibility raises one final issue. Currently, the IHR is essentially an operational instrument to coordinate outbreak prevention and control and depoliticize WHO’s role in managing them. There is no emphasis on equity, assistance or international cooperation. Amendments proposed by Global South countries would transform it into a regulatory and transactional instrument with a more political role for WHO and differential treatment for developing countries to improve equity in the availability of health technologies. Fundamentally, negotiators will have to decide what they want the IHR to be – and if the IHR is expanded to encompass the issues of health equity then what role would the new pandemic instrument play? For essays on financing pandemics and pathogen and benefit sharing, see the full Governing Pandemics Snapshot here. This is the first in a periodic series of updates to be published during the year. About the authors Daniela Morich is Manager and Adviser of the Governing Pandemics initiative at the Global Health Centre, and a lawyer with experience in multilateral negotiations. Dr Gian Luca Burci is Adjunct Professor of International Law at the Geneva Graduate Institute. He was a member of the IHR Review Committee that completed its expert analysis of the proposed IHR amendments in January 2023. He co-leads the Governing Pandemics initiative. Dr Suerie Moon is Professor of Practice and Co-Director of the Global Health Centre, and co-leads the Governing Pandemics initiative. Adam Strobeyko is a Hauser Global Fellow at NYU Law and was a Doctoral Researcher for the Governing Pandemics initiative. Moeen Hosseinalipour is a master’s student in global health and international affairs at the University of Geneva and Geneva Graduate Institute, and a research assistant for the Governing Pandemics initiative. Image Credits: Geneva Graduate Institute. Posts navigation Older postsNewer posts