SAGE chairperson Hanna Nohynek

Additional COVID-19 vaccine boosters are not recommended for people at low to medium risk of the disease who have been vaccinated and boosted once, according to the World Health Organization’s (WHO) Strategic Advisory Group of Experts on Immunization (SAGE).

SAGE recommends an additional booster six to 12 months after the last dose for “high priority” people, depending on factors such as age and immuno-compromising conditions.

It defines the high-priority group as older adults, adults with significant comorbidities (eg diabetes and heart disease); those with immunocompromising conditions, including children from six months and older (eg people living with HIV and transplant recipients); pregnant women and frontline health workers.

New SAGE chair, Finland’s Dr Hanna Nohynek, said that the recommendations were “updated to reflect that much of the population is either vaccinated or previously infected with COVID-19, or both”.

“Countries should consider their specific context in deciding whether to continue vaccinating low-risk groups, like healthy children and adolescents, while not compromising the routine vaccines that are so crucial for the health and well-being of this age group,” she added.

SAGE, which met last week, also stressed that its recommendation for additional boosters applied in the current context only, and was not a recommendation for annual COVID-19 vaccine boosters.

It also urged countries to base decisions to continue vaccinating the low-priority group, primarily healthy children, on disease burden and cost-effectiveness “considering the low burden of disease” in this group.

This comes as vaccine manufacturers prepare to hike the cost of vaccines. Moderna and Pfizer are both planning an price increase of around 400% – from around $26 directly to the US government to $130 for the private market when government-sponsored vaccines are phased out.

Measles concern

Nohynek noted that every region of the world was reporting measles outbreaks, an indication that routine vaccinations for children had slipped during the COVID-19 pandemic.

SAGE will be reviewing the evidence “for vaccinating infants below six months and during pregnancy” which might lead to policy change, she added.In 2021, an estimated 25 million children missed their first dose of the measles vaccine, the worst level since 2008.

Impact of malaria vaccine

Dr Kate O’Brien

Dr Kate O’Brien, WHO’s Director of Immunization, Vaccines and Biologicals, said that the introduction of the RTS,S malaria vaccine in some of the worst affected malaria regions in Ghana, Kenya and Malawi, had resulted in a 10% reduction in all-cause mortality among children eligible to receive the vaccine.

“This is really a very remarkable impact of introducing this vaccine,” said O’Brien, stressing that it was only being introduced in areas with very high malaria rates.

However, there is high demand for the vaccine, with at least 28 countries expressing interest in introducing the vaccine, but supply remains highly constrained. For that reason, SAGE recommends flexibility in the immunization schedule in interval between the last two doses.

Four doses are currently indicated for children, from five months of age with doses administered monthly. 

The new R21/ Matrix-M malaria vaccine developed by Oxford University, “is in the late stages of clinical development, and we hope to review the final file in the coming months”, said Nohynek.

Identifying priority pathogens for new vaccines

WHO is in the process of defining regional priority targets for new vaccine development for non-epidemic pathogens. 

Early results indicate that tuberculosis, HIV, and antimicrobial-resistant pathogens such as Klebsiella pneumonia are important across all regions. Streptococcus pyogenes (Group A), Shigella, and respiratory syncytial virus (RSV) were identified as important by four or more regions, as was Plasmodium falciparum (malaria) by the African region.

There are “several candidate vaccines for TB in late-stage clinical trials” with the potential for multiple vaccines to receive regulatory authorization within three years, according to SAGE.

The candidate vaccine M72/ AS01E is showing the most promise 

Image Credits: Samy Rakotoniaina/MSH.

WHO Director General Dr Tedros Adhanom Ghebreyesus speaks at the 152nd Executive Board meeting, 31 January, where WHO’s policies on the prevention and response to sexual exploitation, abuse and harassment were a key topic of discussion.

When Rosie James, a British medical doctor, publicly accused a senior WHO staff member of groping her at a WHO event in Berlin last October, the WHO Director General responded swiftly,  saying he was “sorry and horrified” and urged her to report the incident promptly to WHO’s Internal Oversight Services (IOS), which manages such complaints. 

Dr Tedros Adhanom Ghebreyusus’s remarks were immediately followed by supportive comments from other senior WHO staff, including WHO’s then-Chief Scientist Soumya Swaminathan and Ren Mengui, then Assistant Director General of Universal Health Coverage.  

Five months later, however, James is still waiting for a decision on her case, the UK doctor told Health Policy Watch on Monday, March 27.

At February’s WHO Executive Board (EB) meeting, Tedros told member states that the global health agency had reformed its approach to sexual exploitation, abuse and harassment (SEAH), including a major initiative on prevention and the speedier processing of cases.  In early March, the organization also published an updated policy on preventing and addressing sexual misconduct.  

Systemic flaws in WHO’s internal justice process 

Infographic from WHO’s 2021 Policy on Addressing Abusive Conduct, which includes sexual exploitation, abuse and harassment (SEAH), March 2021. A new policy specific to SEAH was issued in March 2023.  It does not contain any updated organigram or flow chart of the process.

But as James’ case drags on, the question remains whether the agency has really tackled some of the more fundamental flaws in its internal justice system.

Despite the many steps WHO has taken, key, unresolved issues remain, according to seasoned WHO insiders, outside experts, member states, and people involved in cases, interviewed by Health Policy Watch over the past  month. These issues include:  

  • A complex and slow-moving internal justice bureaucracy, which continues to make the pursuit of formal complaints intimidating despite recent overhaul efforts;
  • Inexperienced investigators recruited by Geneva’s WHO headquarters on short-term consultancies without a Geneva post assignment for face-to-face interviews, health insurance, tax benefits or job security that regular WHO staff would typically enjoy; 
  • Flaws in due process, with neither the accused nor accusers able to respond to the final investigation report produced by WHO’s Department of Internal Oversight Services (IOS) until a decision is already made on the case. That means that the DG’s decision to “charge” is based almost entirely on the IOS synthesis of the facts;  
  • Lines of authority that leave the Director General as both the judge and the jury of the most serious investigations in a portfolio of hundreds of claims. 

The shortcomings in the process continue to demoralize staff, member states and complainants who had hoped that the bar of justice would be higher after nearly two years of revelations and reforms.

Exonerated on a legal loophole 

Ebola response workers in the DRC in July 2020

WHO’s internal justice system first burst onto the media stage following revelations in 2020  by The New Humanitarian that dozens of women in the Democratic Republic of Congo (DRC) has been sexually exploited, and even raped, by WHO and UN responders during the 2018-2020 Ebola outbreak, leaving behind a trail of victims, at least 20 of whom later bore children.  

A scathing report by a WHO-named Independent Commission released in September 2021 found major shortcomings in WHO’s processes of prevention, reporting and case management. It called for investigations against alleged perpetrators and managers “and disciplinary sanctions” for those found culpable. 

But more than two years after the first revelations, there have so far been no reports by WHO of disciplinary action against any staff – or of referrals to national authorities, particularly for cases involving consultants who are no longer employed by WHO.  

Then, in February, Tedros announced that three WHO managers implicated in the hush-up of several SEAH cases had been cleared of charges by the United Nations Office of Internal Oversight Services (UN OIOS), which had launched an independent investigation of those high-profile cases at WHO’s request. 

Speaking to the WHO EB, Tedros said that “the allegations of managerial misconduct against the three staff members identified by the Independent Commission were unsubstantiated.” 

Loopholes in WHO policies allowed exoneration of DRC managers  

Julienne Lusenge, DRC human rights activist and co-president of the Independent Commission that investigated allegations of WHO and UN SEAH violations in the DRC.

The findings of the UN OIOS report, seen by Health Policy Watch, makes it clear that WHO managers who failed to report the DRC cases were cleared on the basis of a legal loophole in WHO’s policy in 2018-2020. 

In that period, WHO’s SEAH policies only applied to WHO staff or direct “beneficiaries” of WHO aid. So managers who learned about women in the “broader community”, enticed or coerced into sex, were not technically obligated to report them through the agency’s internal justice system, the UN report concluded. 

“At the time of the 10th Ebola response, WHO’s SEA policies were interpreted by WHO accountability stakeholders as being limited to victims who were beneficiaries of WHO assistance. The policies did not apply to SEA complaints brought by the broader community,” stated the final UN OIOS report. 

That shortcoming in WHO’s policies was brought to the WHO Director General’s attention already in February 2018 – in a memo co-signed by WHO’s legal counsel, the UN OIOS report further points out. But nothing was done about it then: 

“The current WHO Director-General….. was advised that the SEA policies were ambiguous as to whether they extended beyond beneficiaries of assistance, and that this created an institutional risk,” the report relates. 

“The memorandum recommended that the SEA policies be revised. Neither the Legal Counsel nor [name redacted] were aware of a response to the memorandum,” states the version of the report seen by Health Policy Watch, which redacted the names of WHO staff involved in the policy discussions, as well as those under investigation. 

Loophole closed years later

WHO Director General Dr Tedros Adhanom Ghebreyesus (center) on a field visit to the DRC on 16 June, 2019 with then-WHO consultant  Dr Boubacar Diallo (left), and WHO Emergency Response Team leader, Dr Michel Yao (right).

In 2021, WHO moved to close this loophole, a WHO spokesperson said in response to Health Policy Watch queries.  That update, aligning WHO with UN-wide policies on SEAH stated: “Where WHO has a mandate to serve the population at large, ‘beneficiaries of assistance’ should be broadly interpreted to cover the local population.”

Then a new WHO policy, published in early March, makes it more explicit.  WHO’s definition of “victims” was expanded to include “victims/ survivors of sexual exploitation, sexual abuse and any other forms of sexual violence or prohibited sexual behaviour may include staff members, collaborators of WHO, and members of the public in locations where WHO staff and/ or collaborators operate.”

In February, Tedros also revealed that WHO had set up a $2 million fund to help the victims. But to date, the most the victims had been offered was a one-time payment of $250, along with some limited medical support and training, stated an 8 March report by The New Humanitarian, which followed up on the fate of the victims five years later. And that, the women complained, was “too little, too late”.  

WHO Director General: more authority than ever in the process  

WHO investigator into sexual abuse allegations.
Lisa McLennon, head of Investigations at WHO’s Office of Internal Oversight Services (IOS), is reporting directly to the Director General, since January 2022.

The DRC cases involving WHO staff have been the focus of an exceptional review by the UN’s OIOS, operating out of UN headquarters.   

For other complaints both of sexual and other forms of harassment, all roads still lead through WHO’s own internal apparatus – and to the Director General.  And that apparatus, critics say, still contains major flaws, as well as being a possible victim of some of Tedros’ recent reforms. 

Most notably,  WHO’s new head of investigations of sexual misconduct and other abusive conduct, Lisa McClennon, has been reporting directly to Tedros for over a year as per a special EB exception granted at Tedros’s request in January 2022.  

“During this period of suspension …. the Head, Investigations was made responsible for all investigations of allegations and complaints of sexual exploitation and abuse and abusive conduct and, while situated in
the Office of Internal Oversight Services, was granted the same reporting lines, namely directly to the Director-General, and the same authority as those granted to the Director of Internal Oversight Services,” states a report to the January 2023 EB session.

That means that WHO’s long-time Director of Internal Oversight Services (IOS), David Webb, a chartered accountant by training, has effectively been sidestepped.

While the aim, ostensibly, was to “fast-track investigations” of sexual exploitation and abusive conduct, including the processing of claims that had backlogged under Webb, it also means that the chief investigator responsible for IOS reports of findings, and subsequent recommendations, is also reporting directly to Tedros, who makes the final decision.  

And this creates an inherent conflict of interest by putting the DG in the position in which he could, in theory, tread more lightly on senior staff who he perceived as allies, according to some insiders.

In its February session, the EB endorsed for the third time, an extension of that special reporting arrangement until May 2023. The EB decision stated that the short-cut, instituted at the EB’s 150th session in January 2022, would remain in place “until the 153rd session of the Executive Board in May 2023.” 

Who will hold the reins of IOS following the director’s retirement?  

Advertisement for a new WHO director of Internal Oversight Services, posted in February 2023 on a UN job search site.

With Webb’s retirement imminent, the WHO’s search for a new IOS director actively underway, it remains to be seen if the traditional lines of authority whereby the IOS head of Investigations resumes reporting to the Director, IOS will be restored in May – or postponed once more.  

Meanwhile, however, what some describe as the ‘bifurcation’ of the WHO IOS system may have added to the pre-existing confusion in a system that critics say is a time-consuming maze. Given the many actors and players involved, it can be intimidating for anyone wishing to file a complaint. 

Speaking to the EB in February, Tedros said that SEAH complaints to WHO had increased substantially over the past year, reflecting increased confidence in the reforms put into place. 

However, WHO’s SEAH dashboard only provides information on cases opened and closed over the past year, rather than a year by year comparison.  Repeated requests to WHO for clarifications yield no comment.  What appears clear, however, is that there has been a steady upswing in SEAH cases filed over the past 12 months. 

Over most of the past year, more cases of SEAH, and other forms of abuse and harassment, have still been opened, as compared to closed –  leaving 403 open cases at the time of publication.

WHO Oversight Committee raised questions about shortcut to DG 

The current shortcut to the DG in reporting lines is not an arrangement with which independent observers of the WHO system are comfortable. 

As a WHO Independent Expert Oversight Advisory Committee (IEOAC) stated in April 2022:    “While such an arrangement is appropriate given the current circumstances, it may not be sustainable over the long term. A sharp, permanent division between SEAH [sexual exploitation, abuse and harassment] and other investigations risks overlaps and duplication of efforts and inefficiency in the use of investigatory resources.  

“More broadly, investigation, audit, and evaluation functions deliver the greatest collective value when they cooperate and share knowledge with each other while respecting their independence. 

“The Committee understands that WHO intends to maintain the current arrangement of splitting up investigation responsibilities until the end of 2022. The Committee recommends that WHO develop a plan for how it will manage SEAH investigations going forward.”

In his remarks to the EB this month, Tedros declared that WHO’s OIS organization had been revamped and that a “new organigram” for this all-important department was being implemented “in January 2023”. 

“The changes we have made have increased confidence and trust in our systems, as evidenced by tripling in the number of people coming forward with complaints from 166 in 2021 to 491 in 2022,” asserted Tedros to the EB. 

No further details of the department’s new structure, however, have been made publicly available. In a post-publication reply, WHO told Health Policy Watch that a new organigram would be published soon. 

As for the change in reporting lines, whereby the head of investigations reports directly to the DG, rather than to the Webb as director of IOS, WHO’s Chaib said, “David Webb has not been side-stepped. He retained his reporting lines and authorities over matters for which he was not recused. The reporting lines were granted by the EB and endorsed by the IOAC and the IEOAC as well as Member States, not by a WHO Secretariat decision.”  She added that both Webb and McClennon also report to the EB on “results of work undertaken” as well as to the DIrector General. 

Inexperienced investigators?

Ad for short-term consultants to work as WHO investigators into complaints of abuse, harassment and exploitation.

The qualifications of investigators is another issue that can draw out procedures, and even lead to faulty or slower decisions, according to other informed observers. 

A recent WHO advertisement  for consultants to work as IOS investigators  calls for candidates with “advanced degree in law, investigations, public administration, or related areas” and “five to 10 years of relevant experience in administrative investigations, some of which should include experience in an international organization.”

However, the monthly pay scale offered is between $7,000 and $9,000 with none of the health, pension, or social security benefits that WHO and other UN agencies provide regular staff with commensurate years of experience.  The consultants, moreover, are hired as “at home” contractors, meaning that they don’t regularly meet complainants face-to-face. 

While the salary scale might indeed be adequate to attract a certain talent pool hired remotely, hires from cities like Geneva, where the massive WHO headquarters is located, would have a comparatively low net pay due to the city’s high cost of living and social costs.  

“Some of the investigators come mainly from management backgrounds. Others are pretty young kids. They may lack both life experience as well as training in this very specialized field of human resources,” said one expert close to the IOS. 

“So they don’t even know how to put forth pertinent questions. If you see the reports, then you realize that they mainly investigate inculpatory facts (incriminating the accused), but fail to investigate exculpatory facts – in violation of their mandate. 

“And we don’t have enough investigators,” that source added. 

Speaking in response, WHO Spokesperson, Fadela Chaib said: “WHO has 18 investigators for misconduct investigations, the highest number for any UN agency. The team of investigators for SEA/SH investigations are experienced. They are a multi-disciplinary team experienced in trauma-informed, survivor-centered approaches to investigating sexual misconduct and other abusive conduct. They work full time on WHO investigative matters and have consistently done so for the previous 15 months. In their roles, they provide surge capacity for the investigative function and are not expected to establish careers with WHO. This is an interim measure while the new structure is being set up with long term contracts.

“The consultants hired as investigators were qualified in investigating misconduct, most have criminal investigation backgrounds, and had training in trauma-informed approaches. They come from a diverse range of countries, and cultures so as to better work with victims, survivors,  witnesses and alleged subjects of investigation. They set and have consistently met a benchmark of 120 days to complete sexual misconduct investigations.  And asyou know, you can be young but highly qualified for the task, or older and qualified.”

Litmus test of new policies?

Against those ongoing, internal issues, cases like James’ are being closely watched as a litmus test of WHO’s new policies. 

Can a charge of harassment by a young British doctor against a senior WHO official, about an event that reportedly occurred in the presence of witnesses, actually stick? 

After the initial posting about her experience at a WHO co-sponsored event in Berlin in October 2022, James initially expressed gratitude to WHO for the support she had received.

By January, three months after filing a formal complaint, that sense of support had evaporated. 

“In my humble opinion, I definitely think the investigation is taking too long,” James told Health Policy Watch in mid-January.

WHO’s chief investigator, Lisa McClennon, meanwhile, denied allegations of foot-dragging.

“We are fast, we’re rigorous, we’re thorough. We take a contemporary and survivor-centric approach to the matters that are referred to us in this effort,” she said. “This increased effort and focus in increased resources towards this matter began over a year ago, and we have been able to clear up several cases that had perhaps languished in the past,” she told a press conference on 14 January.  “We are working these types of cases in real-time.” 

‘Frightening IOS process’

As of late March, James says she is still waiting for a decision on her case, now in its fifth month.

“I feel like I’ve opened a huge can of worms,” James told Health Policy Watch.  “I hope that no one else has to be subject to sexual harassment or abuse at WHO. And I stand in solidarity with those that have had to go through this frightening [IOS] process. 

“I am only doing it to protect others. Hopefully, we will begin to see some cultural and systemic change in WHO and other global health organizations.” 

Chaib, on behalf of WHO, says that the agency hopes to have a decision within the next month.

“WHO has set a benchmark of six months from the receipt of a complaint to the disciplinary action being taken if allegations are substantiated,” she said. “We hope to finish the process in the next month, but are committed to respecting due process for all parties.”

New WHO Advisory Board also packed by DG appointments 

Most GAC appointments made by the Director General.

In mid-February, James was informed that the IOS report on the investigation of her case was ready for review. According to the process, 3-5 members of WHO’s Global Advisory Committee on Formal Complaints of Abusive Conduct (GAC), review the IOS report, and based on that, make a recommendation to the DG on whether a ‘charge’ should be made. 

“They said I won’t have any access to that report, but it’s been submitted to the panel,” James said.  

“They gave me the names of the panellists and they said that I have five days to respond, to let them know if I have any objections to any of these panel members. I don’t know more than that,” she told Health Policy Watch.   

The panel of reviewers are drawn from a standing, 15-member “GAC Committee.” Five of its members are elected by staff. The other 10, including five senior staff, are appointed by the Director-General in consultation with WHO’s Regional Directors, according to the latest WHO policy, dated March 2021 but only made operational in January 2023.  

This means that the Director General’s appointees have the majority say in every decision taken.  

Nominally, the panel has 60 days to review the report by the investigator and then make a recommendation to the Director General, who has 30 days to render his ruling. 

And that person is, of course, Tedros. 

Lack of rebuttal process is another systemic flaw

The lack of an opportunity to review and respond to a WHO IOS report before it goes to the GAC is another flaw in the existing WHO system that hasn’t yet been repaired, experts familiar with the system assert. 

That holds true both for alleged victims as well as those accused of harassment or other forms of misbehavior. 

“Neither the accused nor the accuser can respond to the witness statements of the other side before the report goes to the GAC and the Director General takes the decision on whether or not to charge,” observed one expert source close to the WHO investigation processes. 

“So you [as the accuser or the accused] only know what you said. You don’t know what the other side said. Your right to be heard is not given and the GAC never sees the other side. The GAC regularly does not question too much what IOS is doing. They are not specialized in that field.” 

The GAC makes a judgment based on a single report

“Effectively, the GAC is forced to make a judgment, and give advice to the DG, based solely on the view of one person, the IOS investigator who wrote the report,” added the source. “They have not seen the other views. So how can they make a good judgment?” asked the source, who said that the investigative process in other UN organizations is more transparent.  

“Then, if the DG decides to charge the person, it gets even more perverse. 

“The accused and accuser finally receive the IOS report. It may be 80 pages, with hundreds more of documents with only eight days to reply to the notification of charge. You cannot do solid work in eight days.  

“The reply given by the administration [to the rebuttals] is normally not discussed in detail. You put in a detailed and substantiated 40 page reply, and receive a cursory 2-5 pages reply back. That’s also a violation of the right to be heard. Then the DG makes a final decision.”

WHO Global Board of Appeal: also controlled by Director-General’s Office

WHO’s Staff Association representative speaks at the EB about internal justice reform in May 2022.

Following those steps, a staff member who feels that they have been wrongly charged and penalized may appeal the decision to a three-person panel of the WHO Global Board of Appeals (GBA), followed by the International Labour Organization’s Administrative Tribunal, which functions like the High Court of the UN system. But that process takes years, with judgment rendered long after the demotion or dismissal occurred.  

At a WHO Executive Board meeting in May 2022, WHO’s Staff Association proposed a remake of the GBA, whose members are appointed by a high-ranking official in the Director-General’s office, meaning that the GBA is more of an administrative rubber stamp than an independent body.  

“The panel of the Global Board of Appeal (GBA) should have five members,” stated the WHO Staff Association written statement. “A three-member panel – the current practice – is simply not reassuring staff that GBA deliberations are sufficiently robust. Furthermore, the staff representatives on each of the GBA panels should be selected by the respective staff association rather than selected by the GBA Chair or Deputy-Chair.”

Balancing the rights of victims and accused 

Throughout the process, balancing the rights of victims and alleged perpetrators remains a major institutional challenge. Victims may feel the need to raise their voices publicly to ensure that misdeeds aren’t just hushed up.  On the other hand, alleged perpetrators need to be granted a fair hearing over the facts that can have life-changing consequences.

James says she signed an undertaking of confidentiality to proceed with the IOS investigation when she initially reported the incident, so she has limited her public comments on the actual substance of her case since then. 

But months after her complaint was filed, the senior WHO official Dr Temo Waqanivalu was named by the Associated Press as the alleged perpetrator – in a report that uncovered similar accusations against him of misconduct during a 2017 WHO workshop in Japan – which top officials at the agency largely ignored. 

James has never publicly confirmed the identity of her alleged aggressor. But she confirms that a copy of a letter from Waqanivalu to WHO was shared with her by WHO’s IOS investigators asking for WHO to take action with respect to the media reports around his case and the reputational damage he faces.  

Election hopes – dashed? 

Dr Temo K Waqanivalu
Dr Temo K Waqanivalu, a senior WHO staffer accused of sexual misconduct, is also campaigning to become Director of WHO’s Western Pacific Regional Office.

Prior to the incident in Berlin in October 2022, Waqanivalu was in the process of mounting a campaign for election as WHO’s next regional director in the Western Pacific Region. The former director, Takeshi Kasai, was recently dismissed from the post as a result of unrelated charges of harassment and racism.    

After being named publicly as the alleged perpetrator of the incident in Berlin as well as an earlier event in Japan, Fiji, Waqanivalu’s native country, protested the media treatment of harassment cases while WHO investigations are ongoing.

In the case of James’s complaint, there were witnesses to the incident that occurred at the World Health Summit, a public WHO event. That places the case squarely within the scope of the new WHO policy, which applies to “locations where WHO staff and/or collaborators operate.” 

But without reference to any particular case, the reputational damage that an investigation can do to both the alleged victim and perpetrator makes it all the more critical that the system be fair and transparent – with investigations processed professionally and efficiently –  and decisions made by impartial leadership, observers of the process underline.  

WHO rejects allegations of flaws in due process

Speaking post-publication, WHO rejected the suggestion that there remain significant flaws in the due process of internal justice claims.

“During the course of investigations, witnesses and subjects are interviewed. Subjects are provided an opportunity to respond to the allegations against them. The statements of the survivor and the subject are provided to the other for comment. The comments, where relevant, are incorporated into the investigative report. This approach is consistent with the practices of other UN investigative bodies,” said Chaib, on behalf of the agency.

“The final report is issued to the action official with copies to the Office of Legal Counsel and Human Resources and Talent Management (Human Resources, Policy, and Administration of Justice). Where required by policy, the action official forwards the report to the Global Advisory Committee [under the new policy, sexual misconduct no longer goes to the GAC]. The GAC reviews the investigation report and provides its recommendation to the Director-General/Regional Director concerning an appropriate course of action. Unlike audit reports, investigative reports, across the globe and within rigorous investigative bodies, do not receive final external comment prior to issuance.”

Investigations into the DR Congo SEAH cases have not led to a “dead-end” Chaib added. “They are being handled by UN OIOS and are ongoing.

With regards to the three WHO managers who were cleared of charges by the UNOIS, that process is still “ongoing” as well, and “WHO has sought the advice of the Independent Expert Oversight Advisory Committee (IEOAC) which reports to WHO’s Executive Board to weigh in on the differences in the findings of the UN OIOS report and the Independent Commission report.”

Overall, she says, “The new system, policy and reporting procedures have simplified reporting and have resulted in a unprecedented number of allegations being lodged with IOS. WHO rules are clear and accountability mechanisms are strong.”

Leadership from the top needed 

Loyce Pace speaking at a 1 February EB session on WHO’s SEAH policies.

While WHO insists that most flaws in the IOS system have now been addressed, remarks by leading WHO member states both publicly at the recent EB meeting, and privately, suggest that at least some leading member states remain concerned – and hold that WHO still needs to demonstrate that it is walking the talk on needed reforms. 

Among other things, they say that stronger leadership from WHO’s senior leadership is still needed to pass the message to managers that they will be held responsible for bad behaviour amongst the people that they supervise.  

At the February EB meeting, the US delegate summed up some of the feelings among delegates in the room.

“Media reports indicating that at least one individual working in WHO recently alleged to have engaged in misconduct, and having had a record of prior accusations, really need to be addressed by WHO,” said Loyce Pace, US Assistant Secretary of State for Global Public Affairs, in what was understood by those in the room as a clear reference James’s case. 

“It’s important to many of us who have faced this personally, in our experience working in the global health and development space, and not just in terms of earlier in our careers, but even now, as seasoned global health professionals,” added Pace.

“There are many of us who stand with survivors and stand with those who identify as victims and are truly committed, but also frustrated, by where things have stood to date, and hope that we can all come together to do right by people like me, who have these stories to tell,” said Pace.

“I was really touched by the USA statement,” said James, as she waits for word about the outcome of her complaint to emerge from the WHO internal justice labyrinth.

-Updated with responses from a World Health Organization spokesperson to the issues raised, on 2 April, 2023

Image Credits: https://www.who.int/publications/m/item/preventing-and-addressing-abusive-conduct, WHO AFRO, WHO, Screengrab from WHO presser, UN Jobnet , UN jobnet , WHO staff email , WHO campaign brochure.

INB co-chair Precious Matsoso and Dr Tedros at the fourth INB meeting.

Negotiations on a global pandemic accord resume next Monday at the fifth meeting of the World Health Organization (WHO)’s Intergovernmental Negotiating Body (INB) amid calls for more attention to be paid to a One Health approach, and less to organised misinformation campaigns.

The meeting agenda is an extension of the INB meeting that ended on 3 March, as it will continue with the text-based negotiations, with member states rushing to meet the 14 April deadline for the submission of textual proposals.

In the three weeks since the fourth INB meeting ended, the INB Bureau has held three informal meetings to shed more light on a range of potentially tricky issues including the global supply chain, One Health, technology transfer and know-how and pathogen sharing.

Quadripartite Commitment to One Health

One of the key questions facing those crafting the pandemic accord is how to ensure that the One Health approach is central.

Monday saw the first annual meeting of the Quadripartite group – the WHO, Food and Agriculture Organization (FAO), United Nations Environment Programme (UNEP), and World Organisation for Animal Health (WOAH).

The leaders of the four bodies called for the One Health approach to “serve as a guiding principle in global mechanisms, including in the new pandemic instrument and the pandemic fund to strengthen pandemic prevention, preparedness and response”.

“Recent international health emergencies such as the COVID-19 pandemic, mpox, Ebola outbreaks, and continued threats of other zoonotic diseases, food safety, antimicrobial resistance (AMR) challenges, as well as ecosystem degradation and climate change clearly demonstrate the need for resilient health systems and accelerated global action,” according to the Quadripartite leaders.

The Quadripartite leaders urged all countries and key stakeholders to prioritize One Health in the international political agenda, strengthen their own national One Health policies, strategies and plans and accelerate their implementation.

They also called for strengthening and sustaining prevention of pandemics and health threats “at source” by targeting activities and places that increase the risk of zoonotic spillover between animals to humans.

More misinformation

However, alongside the negotiations, there has been an escalation of misinformation claiming that a pandemic accord will rob member states of their sovereignty, spread mostly by the same sources that pushed COVID-19 anti-vaccine messages.

“We continue to see misinformation on social media and in mainstream media about the pandemic accord that countries are now negotiating. As I said last week, the claim that the accord will cede power to WHO is quite simply false. It’s fake news,” said WHO Director-General Dr Tedros Adhanom during the body’s weekly press briefing last Friday

“Countries will decide what the pandemic accord says, and countries alone. And countries will implement the accord in line with their own national laws. No country will cede any sovereignty to WHO.”

The sources of this misinformation have tended to be the same as those that opposed COVID-19 vaccines.

According to a report in late 2021 by the US- and UK-based Center for Countering Digital Hate (CCDH), almost two-thirds of anti-vaccine messaging on Facebook and Twitter could be traced to just 12 prominent individuals.

These include Robert F. Kennedy Jnr,who campaigns against vaccines for children; Joseph Mercola, who sells dietary supplements and false cures as alternatives to vaccines, and ‘intuitive medicine’ proponent Christiane Northrup, who has also been linked to the conspiracy group, Q-Anon. This misinformation had reached 59.2 million English speakers by December 2020. 

Last week, Twitter owner Elon Musk, who has 132.7 million followers, poured fuel on the fire by commenting that countries should not “cede authority” to the WHO.

This prompted Tedros to call him out directly on Twitter, along with another prominent anti-vaxxer who calls himself Kanekoa, who has also promoted the idea that the pandemic accord seeks to remove power from member states.

However, some right-wing politicians in the US, Australia and Europe are also claiming that the WHO is seeking to usurp countries’ sovereignty with the pandemic accord, while Russia and China have already shared their concerns about this issue in various WHO forums.

Tobacco
Tobacco advertising is banned at the World Cup, but companies are finding ways to get around the rules.

Tobacco companies in Indonesia, India and Mexico circumvented international football governing body FIFA’s advertising ban on their products by associating them with the World Cup, according to a new social media analysis by public health group Vital Strategies.

Data recorded by Vital Strategies’ digital media monitoring system found 354 instances of tobacco marketing in public posts across Facebook, Instagram and Twitter between September to December 2022 around the World Cup in Qatar.

The overwhelming majority of posts (92%) originated in Indonesia, followed by India (6%) and Mexico (2%). Over 70% of the marketing instances were found on Instagram.

“Despite tobacco being the antithesis to athleticism and health, tobacco marketing on social media platforms continues to use sports to mislead youth and hook them on these deadly products,” said Nandita Murukutla, vice-president of global policy and research at Vital Strategies.

“As traditional marketing channels shut out tobacco promotion, tobacco marketers have set their sights on social media to connect their products with sports, especially football, and have a direct channel to youth.”

Global regulatory efforts continue to struggle to reign in the prevalence of tobacco, which remains the leading cause of preventable death in the world, claiming more than eight million lives a year.

The largest advertising opportunity in the world

The final between France and Argentina was watched by around 1.5 billion people, according to FIFA.

FIFA banned tobacco advertising, promotion and sponsorship from the World Cup in the late 1980s. The last World Cup to feature a tobacco sponsor, RJ Reynold’s Camel, was held in Mexico in 1986.

But the unparalleled reach of the world’s most popular sports tournament makes it a one-of-a-kind opportunity for tobacco companies, and many still use the World Cup to market their products on the local and national level.

The opening match between host Qatar and Ecuador – a decidedly low-stakes affair – pulled in 550 million viewers, FIFA said, while the historic final between Argentina and France glued some 1.5 billion people around the world to their televisions. The tournament also generated almost six billion engagements on social media, resulting in a cumulative reach of 262 billion accounts.

“FIFA’s ban on tobacco promotion is a good first step, but by itself lacks teeth,” said Sandra Mullin, senior vice president for policy, advocacy and research at Vital Strategies. “FIFA and football celebrities must work more actively and explicitly to distance themselves from the tobacco industry by calling out its underhanded youth-oriented marketing practices.”

FIFA took its first overt step to fight tobacco use during the 2002 World Cup when it joined forces with the World Health Organization (WHO) to ban smoking on the tournament grounds for the first time. In Qatar in 2022, Qatar’s Ministry of Health, the WHO and FIFA partnered to implement the most stringent anti-tobacco measures ever applied at the World Cup – policies which were highly publicized.

Indonesian tobacco giant Djarum left to freely market to children

“Limited edition” World Cup cigarette packs promoted by Djarum during the tournament.

Indonesian tobacco giant Djarum, identified by Vital Strategies as the largest offender hijacking the World Cup to advertise its tobacco products, has a long history of associating itself with sports.

The company runs “corporate social responsibility” schemes that award scholarships to children for badminton, one of Indonesia’s most popular sports, and runs national football programmes for youth players. Djarum was also the main sponsor of Indonesia’s pro football league from 2005 to 2011 and purchased Italian football club Como 1907 in 2019.

Djarum’s history of football-related branding made the World Cup a unique opportunity. The company quickly moved to capitalise on fan enthusiasm around the tournament to market limited-edition World Cup cigarette packs featuring colourful designs created by local artists. The campaign appears to be a clear attempt to market to children as studies have found colourful packing increases youth susceptibility to smoking.

Through its affiliate brand Djarum Super Soccer, whose social media accounts share football news and highlights to over one million combined followers, the company promoted the “Soccerphoria” event series. These watch-party cum festivals unfolded across four major cities with a combined population of around 16.5 million, including the capital, Jakarta, and featured live World Cup matches, concerts, mural painting, and stalls selling branded clothes and other Djarum merchandise.

Special edition World Cup e-cigarettes advertised by GeekVape, the official partner of French club Paris Saint-Germain.

Danilla Riyadi and Jason Ranti, two popular Indonesian musicians who took part in the tobacco-branded festivities, have nearly two and a half million combined followers on Instagram alone.

Geekvape, the e-cigarette manufacturer and official partner of French football giant Paris Saint-Germain, also sold special edition World Cup e-cigarettes in Indonesia.

Indonesia is notorious for its lax approach to regulating tobacco and its marketing. The country is home to the second-largest cigarette market in the world and the third-highest number of smokers behind India and China.

Nearly two-thirds of men over the age of 15 and 19.2% of youth aged 13 to 15 (including 35.6% of boys) use tobacco. The government has been slow to reign in the country’s tobacco giants, and commitments to raise excise tax for tobacco products have so far failed to curb the explosion of smoking rates among its youth.

The advertising efforts of tobacco giant Djarum to market to young people through sports – and parallel government inaction – are likely to worsen the crisis.

Tobacco companies shift gears in India, matching global advertising trends

Advertisements by tobacco company-owned brands clearly display their logo over top of fast food advertisements.

In India’s tougher regulatory environment, tobacco companies pivoted to a new strategy to profit from the World Cup: marketing affiliate brands.

While there was no direct marketing for tobacco products related to the 2022 World Cup in India, Vital Strategies uncovered extensive advertising campaigns pushing ultra-processed food brands owned by tobacco giants. Some brands clearly displayed the tobacco company logo in the corner of images promoting crisps.

Tobacco advertising, promotion and sponsorship have a long history in India, notably in the highest levels of cricket, the country’s most popular sport, but the shift away from tobacco towards ultra-processed foods is in line with wider developments in football advertising around the world.

Ultra-processed foods and alcohol, like tobacco, are well-established risk factors for non-communicable diseases, yet they continue to be marketed ubiquitously across international football leagues and tournaments.

Budweiser and McDonald’s were the key sponsors for the 2022 World Cup, while Coca-Cola was an official partner. A viral ad by Pepsi featuring stars like Lionel Messi, Paul Pogba and Ronaldinho links Pepsi to footballing greatness.

Meanwhile, a study on the 2018 World Cup found that around 1,806 advertisements for alcohol and ultra-processed foods were played during just 13 matches on British television networks, making around 7.5 billion impressions.

The e-cigarette problem

E-cigarette advertisements are following in the footsteps of old-school cigarette branding.

Vital Strategies’ analysis observed that several online retailers used images of football players to promote e-cigarettes, often with World Cup-related promotions featuring pictures of football players alongside e-cigarette products and discounts.

One such post featured Guillermo Ochoa, the goalkeeper of the Mexican national team, holding an e-cigarette and exhaling smoke through his nose, with the caption “Vamos Mexico,” linking e-cigarettes with national pride and a beloved figure. Other promotions linked e-cigarette use with friendship and community, similar to how football is seen as a common interest that brings people together.

Tobacco advertising and sponsorships are not allowed in Mexico’s national football league, but e-cigarettes can still be advertised to Mexico’s 45 million Formula 1 fans at racing events like the Mexico Grand Prix.

The e-cigarette industry is estimated to grow to $46.9 billion in the United States alone by 2025. All major tobacco companies now own at least one e-cigarette brand.

Studies on the health effects of e-cigarettes and vapes are still in their early stages but have so far found them to be less dangerous than tobacco.

While major study by King’s College London found “drastically lower” levels of exposure to cancer and other toxicants in people who vape compared to smokers, the report’s lead author, Ann McNeill, said that “the evidence we reviewed indicates that vaping is very unlikely to be risk-free”.

However, said McNeill, professor of tobacco addiction at King’s College London, “smoking is uniquely deadly and will kill one in two regular sustained smokers”.

“We strongly discourage anyone who has never smoked from taking up vaping or smoking,” she said.

Regulators in the European Union and United Kingdom have already banned the advertising of e-cigarettes, but much of the world has yet to follow suit.

Image Credits: Republic of Korea, FIFA, Stillblowingsmoke.org.

Water
Thousands of delegates from over 170 countries gathered in New York this week for the first United Nations meeting on water security since 1977.

At the first international conference on water security in five decades, governments, international organizations and civil society groups from over 170 countries committed to nearly 700 new initiatives to address a global water crisis that is causing record droughts, threatening food security, and threatening global supplies of drinking water. 

This week’s UN Water Conference is only the second of its kind. The last high-level meeting convened by the UN on water security was in Argentina in 1977.

The substance of the voluntary commitments in the conference’s outcome document – the Water Action Agenda – varies widely. They range from new investments in sanitation and hygiene services, to investments in desalination technologies, to transnational collaborations to preserve shared lakes, rivers, wetlands and aquifers.  

Around a quarter of commitments relate to water-related biodiversity preservation, health and hunger targets, while over half relate to climate change, according to preliminary data provided by UN Under-Secretary-General Li Junha at a press conference on Friday.

Putting water on the climate agenda

While no binding commitments were made, the Water Action Agenda made one thing crystal clear: water must be central to all future climate negotiations.

That must begin with COP28, scheduled to take place from November to December of this year in Dubai, said Henk Ovink, special envoy for international water affairs in The Netherlands, which co-hosted the conference along with Tajikistan. 

“We have to make sure that water will never be left out of any COP, be it the Convention on Biological Diversity or a climate COP,” Ovink said. “We see a [binding] pact for the future where water is core and central. This conference did not give us the mandate to do so, but we brought the world together to ensure that there is a follow-up.” 

Despite the fundamental impacts of climate change on water quality and access, it has so far been neglected in the climate agenda. COP27 in Sharm el-Sheikh was the first-time ever that water was mentioned in a high-level climate negotiation outcome document – and even then, it was only mentioned in the cover text. 

UN officials said they hope this week’s conference will be remembered as a turning point.  

“The past three days have proven that water truly unites the world,” Junha said. “From now on, water should be in every major global agenda for discussions among the member states.”

Li added that the framework set out in the Water Action Agenda will contribute to a series of high-level negotiations this year, where countries will have a chance to turn their voluntary  commitments into binding statements or resolutions. Those include the Sustainable Development Goals (SDG) Summit in September and COP28. 

“There is a direct connection between this conference and COP28,” Ovink said, adding that discussions about fixing water at the center of the COP28 agenda with United Arab Emirates representatives began even before last year’s meeting in Sharm-el Sheikh. 

States issue call for Special UN Envoy for water

Coinciding with this week’s event, some 149 member states called upon UN Secretary General Antonio Guterres to appoint a special envoy for water to oversee and coordinate international water security efforts.

Water, unlike biodiversity and the climate, does not have a dedicated forum in the UN. The call signaled the growing political will to solidify water’s position on the UN agenda.  

“We suddenly understood a strong request from the member states to appoint a special envoy for water,” Junha said. “I’m pretty sure that the Secretary-General will give very serious consideration to that.”

Demand for fresh water will outstrip supply by 40% within the decade

Water
Access to clean drinking water is a human right under international law. Today, women and children spend 200 million hours every day collecting water.

After years of inaction, a raft of reports published throughout the conference appear to have focused international attention around the growing urgency of water degradation, drought and depletion of resources.   

A new report by the Global Commission on the Economics of Water, published on day one of the conference, predicted that global demand for water will outstrip supply by 40% as early as 2030.

This shortfall could lead to between 1.7 billion and 2.4 billion people living in cities facing water scarcity within the next 30 years as population growth pushes urban demand for water up by an estimated 80%, according to the new UN World Water Development report published on the eve of the conference.

Another 10% of the world population lives in countries experiencing chronically “high or critical water stress”. 

“It is easy for some to think that water simply comes from the tap, but this limited perspective fails to acknowledge the vital ecosystems from which our water comes,” said Ibrahim Thiaw, UN Executive Secretary for the Convention to Combat Desertification. “When rivers run dry or become polluted, when groundwater is over-exploited, and when ecosystems are degraded, it is only then that we begin to understand the true value of water.”

Some 4 billion people worldwide experience water stress at least one month per year, according to UNICEF. Half of the world’s population could face water scarcity as early as 2025, the agency projects. 

Deaths increasing from lack of WASH services 

https://twitter.com/UNESCO/status/1639311361862778884?s=20

The United Nations University rang out another alarm bell: 2019 saw increased rates of mortality from the lack of access to water and sanitation services (WASH) in 164 countries compared with 2016 World Health Organization estimates. 

That follows years of mortality reductions from unsafe water and sanitation reported by the World Health Organization due to the gradual improvement of WASH services. 

Even as access to safe drinking water and sanitation have increased over the past decades, some 2 billion people still lack access to clean drinking water. Around 3.6 billion people – or 46% of the world’s population – still lack access to basic sanitation. 

Unsafe water and sanitation continue to cause over a million deaths from infectious diseases annually – far surpassing the 50,000 killed globally by natural disasters, the UNU report estimated.

“Far more people die from lack of access to water then die from lesser climate disasters,” said Dr Charlotte MacAlister, a senior researcher at the UNU, told the Associated Press. “I’m not saying that people aren’t dying, but far more people are dying from lack of safe water, safely managed water, and safely managed sanitation.”

The world is also far off-track to meet the SDG goal of universal access to safe drinking water and sanitation, the 2023 Global Water Security Assessment said.

Globally, Africa was the only region to make progress in reducing WASH-related deaths between 2016 and 2019. But it continues to suffer from the lowest levels of access to safe sanitation services and drinking water overall. 

Nearly 31% of people across Africa’s 54 countries do not have access to basic water drinking services, and 82% live without access to proper sanitation. 

“Deaths due to inadequate WASH provision are preventable and should no longer occur anywhere in the 21st century,” UNU said. “This is unacceptable.”

Draining humanity’s ‘lifeblood’

The UN Secretary-General called on the world to “bring the water agenda to life”.

“We are draining humanity’s lifeblood through vampiric overconsumption and unsustainable use and evaporating it through global heating,” UN Secretary General Antionio Guterres told the conference. “Water is a human right — and a common development denominator to shape a better future.”

Without a “quantum-leap” in the actions being taken by member states to address the water crisis, Gutetres said, the world’s lifeblood may soon run dry. 

The commitments submitted to the Water Action Agenda will be vetted by the UN Department of Economic and Social Affairs (UNDESA) and other research institutes to assessthat countries can follow-through on their targets.

The results of the audit will be published at the high-level political forum hosted by UNDESA in July this year, laying the groundwork for future UN negotiations. 

Image Credits: UN, UNICEF, US Mission to the UN.

Lucica Ditiu, Executive Director Stop TB at the World TB Summit in Varanessi, India

After major setbacks during the pandemic, TB diagnosis and treatment appears to have rebounded with the number of undiagnosed TB-infections estimated at less than three million people in 2022- the lowest ever. 

That’s according to preliminary data released by the Stop TB Partnership, on Friday, World TB Day. 

“In 2022 the gap between the estimated number of people with TB and those diagnosed and treated was the lowest ever—with less than 3 million missing people with TB. This gap was 3.2 million in 2019, 4.3 million in 2020, and 4.2 million in 2021,” stated the Partnership in a press release coinciding with the One World TB Summit, in Varanessi India.

At the Summit, the Partnership also announced a new “high-level advocacy platform” to reinvigorate commitments to eliminate TB as a public health threat by 2030, in line with the Sustainable Development Goals.  

“We are making history because we are meeting here in India, which is the highest burden of TB but also the highest ambition to end TB,” declared Lucica Ditiu, executive director of the STOP TB Partnership at a press briefing in Varanessi. 

Along with India’s Minister of Health, Mansukh Mandaviya, the briefing included leading health officials from other countries that have pledged to lead the charge in the campaign, including Indonesia and Brazil as well as South Africa and Nigeria.   

“We are changing the narrative about TB. We are saying “Yes we can end TB!” declared Ditiu, in reference to the Summit’s theme, hearkening back to the “Yes We Can” campaign slogan that helped propel former Barack Obama to the US Presidency in 2008.  

“There are things that are happening in all of these amazing countries and beyond,” she added, citing, for India: “the fact that people receive, every month, direct cash for treatment, that people are paired with friends who support them through the treatment.” 

Working with communities, private sector, care providers to increase testing

We have been working closely with communities, private sector care providers and others to increase awareness about increased testing and reaching all those who are affected by TB,” said Mandaviya, at the press briefing.   

Added Dr Ethel Maciel, Brazil’s deputy minister of health,  “Poverty is very close to TB disease, so we should fight against this. The new government has a special plan to fight against hunger and poverty, as well as increasing social protections and respect for human dignity. We all know that high TB affects the most vulnerable, the most vulnerable get even more vulnerable from this disease. 

“All of the things we learned in the COVID pandemic, we can put towards eliminating TB.  Close collaboration, sharing knowledge. We can do much more when we are united, when we have transparency. Today is a day of hope – that we can end TB. 

Maxi Rein Rodonuwu, director general, disease prevention and control, Ministry of Health, Indonesia

Indonesia, with the world’s fourth largest burden of TB, also made significant progress in 2022. 

Almost three-quarters of the estimated TB caseload was diagnosed and treated, with the overall treatment success rate at 84%—the highest rates recorded for Indonesia. Key to the success of the National TB Program was the deployment of screening campaigns similar to what was used for COVID-19, said Maxi Rein Rondonuwu, Director General of Disease Prevention and Control at the Ministry of Health.

Coalition of leaders set to launch initiative at UN General Assembly 

Speaking at the TB Summit opening, Indian Prime Minister Narendra Modi appealed to the G20 group of industrialized nations to support TB elimination. India holds the presidency of the G-20 this year, with heads of state set to meet in September in New Delhi.  

“The theme of the G20 is a resolution for the shared future of the entire world,” said Modi. “India’s efforts are a new model for the global war on TB. People’s participation in the fight against TB is India’s big contribution. India is now working on the target of ending TB by the year 2025. I would like that more and more countries get the benefit of all campaigns, innovations and modern technology of India,” added the Prime Minister. 

Along with the heads of state of India and Brazil, the coalition set to lead the “Yes We Can” campaign also includes Indonesia, South Africa, and the newly elected President of Nigeria, Bola Tinubu. The ‘Coalition of Leaders’ will be formally launched during the United Nations (UN) General Assembly week in New York City in September 2023.

Rebounding from the pandemic 

About 1.1 million children and young adolescents aged under 15 years are diagnosed with TB every year, and over 225,000 of them lose their lives.

Last year’s rollback in undiagnosed TB cases came as high TB burden countries—including Brazil, Nigeria, India and Indonesia—increased the number of people diagnosed and enrolled on treatment, exceeding the numbers seen before the COVID-19 pandemic. 

Despite this progress, TB was once again the world’s biggest infectious disease killer in 2022 – the delayed effect of setbacks in diagnosis and treatment over three pandemic years. So 2023 remains a critical moment as the international community prepares for the second UN High Level Meeting (UNHLM) on TB, 22 September 2023 (UNHLM), on the margins of the UN General Assembly in New York City. 

“With the world regaining strength as the COVID-19 pandemic wanes, ending TB as a global health threat is a critically important goal,” said Ditiu. 

New innovations 

“We have new innovations now to help us save lives—new diagnostic tools, shorter, less toxic treatment regimens, and new digital tools—and when we add the political muscle that the UNHLM will gather to the many dedicated health care professionals already in the front lines, ending TB looks increasingly possible,” she added.

These innovations include:

  • Rapid molecular tests that can identify TB and resistance patterns in the bacteria;
  • Shorter treatment regiments, for drug-sensitive and drug-resistant infections;
  • New digital tools, such as AI enabled ultraportable X-ray systems for screening for TB; 
  • Vaccine candidates that have advanced to phase 3 clinical trials.

Globally, investments in TB research and development have started to climb, surpassing US$1 billion for the first time ever. 

TB advocates hope that the coming High Level Meeting will propel governments and other funders to attain the US$2 billion per year investment goal pledged by countries at the first High Level Meeting in 2018, with a roadmap for increasing funding to US $5 billion per annum as envisioned by the Global Plan to End TB. 

They cite new data that shows every US$1 invested in TB yields US$46 in benefits.

 “What we need is quite simple, given that TB kills 1.6 million people every year,” added Ditiu. “We need increased political commitments from all high TB burden countries, and significantly more financing so that we can meet new challenges and embark upon a much faster path to new vaccines. We know what it takes to end TB; we need to roll up our sleeves and make it happen.”

India’s model system 

Mansukh Mandaviya, Minister of Health, India, describes country’s advances in TB diagnosis and treatment.

India’s model system combines digital health tools, economic incentives,  and old fashioned social support systems with a facelift.  

A real-time TB information system called NIKSHAY, triggers direct cash transfers to TB patients who continue their treatments. In the last five years, using this system, US$260 million has been disbursed to nearly 8 million people with TB to support their nutrition, Indian officials say. 

“Under the Prime Minister’s TB Free India Campaign, launched in September 2022, nearly 1 million people with TB have received commitments from individuals in society who will support them through their treatment journey,” said Suvanand Sahu, the deputy executive director of the Stop TB Partnership. 

“This initiative is unique in the world and is a great intervention for TB awareness, stigma elimination, community ownership and crowdfunding.”

At the same time, responsibility for implementing the campaign has been decentralized to state, district and village levels, with awards given to recognize states and districts who are making rapid progress towards ending TB. 

“TB Champions” also are recognized for their contributions to end TB in their community. Currently more than 30,000 TB Champions are supporting the TB response in India.

“India is providing models to fight TB. Trace, Test, Track, Treat and Technology is the strategy we are implementing to end TB in India by 2025,” said Modi in his keynote address.  

India also ramping up generic production of improved TB treatment  

At a separate press briefing on Thursday, WHO said it was also extending a TB Flagship Initiative for another five years- as new, promising TB vaccines approach market approval stage. 

WHO will establish a TB Vaccine Acceleration Council to spur movement on promising vaccine candidates, said WHO Director General Dr Tedros Adhanom Ghebreyesus at the briefing. 

“The only TB vaccine developed to date, the BCG vaccine, is more than 100 years old, and does not adequately protect adolescents and adults, who account for most TB transmission,’ he said, adding the new Council would “facilitate the development, licensing and use of new TB vaccines.

WHO welcomes India’s removal of patent from TB drug bedaquiline

Tereza Kasaeva, WHO Assistant Director, and head of the global TB programme.

Speaking at the press briefing  Dr Tereza Kasaeva, WHO Assistant Director-General, said “we are very optimistic about having new vaccines. There are about 16 vaccine candidates in the pipeline and at least one of the vaccines at the Phase III clinical trial stage is showing efficacy at least 50%. 

BioNTech has also identified a promising mRNA TB vaccine candidate, with Phase 1 trials due to begin soon, she reported, adding:  “If it will go the right way, quite soon, we may have new, effective TB vaccines.  

Kasaeva also welcomed the Indian Patent Office’s rejection of Johnson & Johnson’s request to  extend the patent on a critically important TB drug, Bedaquiline, which is set to expire in July. 

The decision opens the way for generic manufacture of the TB drug at far reduced prices; the drug currently costs about US500 a year in India. As India is the world’s leading TB drug producer, generic manufacturer will increase the flow of cheaper generics to many other low and middle income countries.     

The pharma company had sought to extend the patent, originally granted in 2008, until 2027, under a slightly new formulation – a tactic described as “evergreening” to prolong a patent’s lifespan. 

“As you know, Janssen Pharmaceuticals [a J&J subsidiary] has a monopoly over Bedaquiline, one of the most effective drugs for the treatment of drug resistant TB,” Kasaeva said. “And this monopoly will continue until July 20, 2023. The generic manufacturers are quite ready to enter the market with quality-assured tablets of Bedaquiline. So that’s why from that point of view, we are considering this news as positive.”

Image Credits: Stop TB Partnership, Stop TB Partnership.

 

Health clinic destroyed by cyclone Freddy, which made a double landing on the southern coast of Africa in the past month.

More than 300 health facilities have been destroyed or flooded in Madagascar, Malawi and Mozambique in the wake of Cyclone Freddy, WHO estimates.

That has left hundreds of communities without adequate access to health services even as the cyclone’s double whammy of devastation has raised public health risks including the increased spread of cholera, malaria, COVID-19, and as malnutrition, WHO African Region officials said at a press briefing on Thursday.  

In Mozambique alone, the number of cholera cases more than doubled over the past week from 1023 to 2374 new cases recorded as of 20 March.

Malawi, which has been battling its worst-ever cholera outbreak, fared somewhat better despite all odds.  It continued to record a decline in cases, with new infections dropping to a total of 1424 for the week ending 20 March as compared with 1956 the previous week. That decline came even as a second wave of Cyclone Freddy-linked flooding and infrastructure damage was still sweeping the country. 

The fierce Indian Ocean storm, dubbed the longest and most devastating to hit the Southern coast of Africa, made landfall on the continent’s southern coast for a second time in a month in mid-March, leaving more than 220 people dead so far.   

Dr Charles Mwansambo, Secretary of Health, Malawi

Speaking at the WHO African Region briefing, Dr Charles Mwansambo, Secretary of Health, Malawi, said that 14 districts had experienced floods and mudslides since the disaster began with torrential rains between the 11th and 13th of March.

“That’s almost half the country because Malawi has 28 districts. And due to that severity, our president declared a state of disaster in the 14 affected districts,” Mwansambo told journalists. 

According to Mwansambo, while there is an ongoing search for missing persons, more than 500,000 people have been internally displaced in the country, some of whom are being housed at 576 established camps. 

“We knew this cyclone was coming but we didn’t imagine that it would be of this magnitude,” he said.

Meanwhile, WHO African Regional Director Matshidiso Moeti noted that with a double landfall in less than a month, the impact of Cyclone Freddy is immense and deepfelt. 

“While we work to understand the full extent of the devastation, our priority is to ensure that affected communities and families receive health assistance for immediate needs as well as to limit the risks of water-borne diseases and other infections spreading,” she said.

Image Credits: NASA Worldview, WHO .

Tanzanian health workers being trained to tackle with the Marburg outbreak.

The World Health Organization (WHO) hopes to be able to fast-track the testing of various Marburg candidate vaccines following outbreaks of this rare and deadly viral haemorrhagic fever in Tanzania and Equatorial Guinea.

“WHO is leading an effort to evaluate candidate vaccines and therapeutics in the context of the outbreak,” WHO Director General Dr Tedros Adhanom Ghebreyesus told a media briefing on Thursday.

“The developers are on board the clinical trial protocols are ready. The experts and donors are ready. Once the national government and the researchers give the green light,” he added.

Four or five candidate vaccines already have doses ready for human trials, WHO’s Dr Ana Maria Restrepo told a media briefing.

Restrepo, who heads the WHO’s R&D Blueprint team, said that a Marburg consortium had been working together since the Equatorial Guinea outbreak had been confirmed in January.

“We are working through a platform that is cooperative that involves all the regulatory and ethics committees in Africa,” stressed Restrepo.

There are 28 potential candidate vaccines for Marburg, according to WHO R&D Blueprint. The virus is from the same family as Ebola and has an 88% fatality rate.

“Marburg belongs to the same family of viruses as Ebola, causes similar symptoms, transmits between humans the same way and like Ebola, has a very high fatality ratio,” warned Tedros.

“In the meantime, we’re not defenceless. Careful contact tracing isolation and supportive care are powerful tools to prevent transmission and save lives.”

Tanzania reports first-ever outbreak

Meanwhile, Tedros said that Tanzania had confirmed eight cases, including five deaths, by testing samples at a WHO-supported mobile laboratory set up last year “to prepare for viral haemorrhagic fever outbreaks, including Ebola and Marburg”.

National responders, WHO and the US Centers for Disease Control and Prevention (CDC)  “have been deployed to the affected region to carry out further investigations, monitor contacts and provide clinical care,” added Tedros.

A week ago, Tanzanian health authorities initiated a frantic search for the cause of the mysterious disease that had claimed several lives in the country. 

Five of the eight cases, including a health worker, have died and the remaining three are receiving treatment. A total of 161 contacts have been identified and are being monitored.

Tanzania Chief Medical Officer Tumaini Nagu said multiple isolation units to help monitor and isolate people displaying symptoms are now operational. 

“The government is closely monitoring the situation and taking appropriate measures to contain the disease,” Nagu told Health Policy Watch.

Tanzania Chief Medical Officer Tumaini Nagu

Lack of capacity

Equatorial Guinea has struggled to identify cases because of a lack of laboratory capacity but had confirmed nine cases with a further 20 probable cases. 

The first case from the eastern province of Kié-Ntem was confirmed in early February by the Institute Pasteur in Senegal. Two other people from Kié-Ntem province were diagnosed by a mobile laboratory at the Regional Hospital of Ebibeyin. 

A month later another case was identified in Litoral province in the western part of the country that was epidemiologically linked to a confirmed case in Kié-Ntem, while cases have also been confirmed in Centro Sur province.

The wide geographic distribution of cases and uncertain epidemiological links between cases “suggests the potential for undetected community spread of the virus”, according to WHO.

The provinces that share international borders with Cameroon and Gabon, and the WHO is working with those countries identify any potential cases, Tedros confirmed.

Dr Ahmed Ogwell Ouma, Acting Director of the Africa Centres for Disease Control.

At the Africa CDC press briefing on Thursday, acting director Dr Ahmed Ouma, said the center is providing Equatorial Guinea with needed technical support, infrastructural development and capacity building required to test for Marburg virus disease. 

“The government is responsible for the testing and to release those results to us,” he said, adding that the turnaround time for result is currently five days and this is being improved upon by the authorities and partners.

“The capacity is still being built,” he said. “The main lab is still not fully functional. We are finalizing calibration this week. And that main lab should be up and running in a few days as soon as the calibration and capacity building is done. And I think before the middle of next week when all that has been completed, they should be up and running. And that will make it easier to do more samples and [will be] a little bit faster.”

Meanwhile, health authorities are expecting genomic analysis results soon to see whether there is any connection between the outbreaks in Equatorial Guinea and Tanzania.

Dr Matshidiso Moeti, WHO Regional Director for Africa, said that gene sequencing analyses are being conducted in both countries to reveal any possible connections for both outbreaks. “We know that the world is interconnected in many ways, [but] the likelihood is not that high,” Moeti told journalists.

“The confirmation of these new cases is a critical signal to scale up response efforts to quickly stop the chain of transmission and avert a potential large-scale outbreak and loss of life,” said Moeti. “Marburg is highly virulent but can be effectively controlled and halted by promptly deploying a broad range of outbreak response measures.”

At the Africa CDC press briefing on Thursday, acting director Dr Ahmed Ouma, said the center is providing Equatorial Guinea with needed technical support, infrastructural development and capacity building needed to test for Marburg virus disease. 

“The government is responsible for the testing and to release those results to us,” he said, adding that the turnaround time for result is currently five days and this is being improved upon by the authorities and partners.

“The capacity is still being built,” he said. “The main lab is still not fully functional. We are finalizing calibration this week. And that main lab should be up and running in a few days as soon as the calibration and capacity building is done. And I think before the middle of next week when all that has been completed, they should be up and running. And that will make it easier to do more samples and [will be] a little bit faster.”

Image Credits: Muhidin Issa Michuzi.

Uganda’s Speaker of Parliament, Anita Among, during the passing of the Act.

The United Nations (UN) High Commissioner for Human Rights Volker Türk has called on Uganda’s President Yoweri Museveni not to promulgate the Anti-Homosexuality Act his country’s Parliament passed on Tuesday night.

Describing the Act as “probably among the worst of its kind in the world”, Türk said that, “if signed into law by the president, it will render lesbian, gay and bisexual people in Uganda criminals simply for existing, for being who they are”. 

Meanwhile, US Secretary of State Antony Blinken said that the Act would “undermine fundamental human rights of all Ugandans and could reverse gains in the fight against HIV/AIDS”, and urged the Ugandan government to “strongly reconsider the implementation of this legislation”.

The Act introduces “the offence of homosexuality”, with a potential life sentence for a same-sex “sexual act”. It also criminalises a person who “holds out as a lesbian, gay, transgender, a queer or any other sexual or gender identity that is contrary to the binary categories of male and female”.

It also proposes the death penalty for “aggravated homosexuality”, including sex acts with children, disabled people or those drugged against their will, or committed by people living with HIV. 

Landlords face prison sentences for renting premises to homosexuals, journalists face 20-year sentences for “promoting homosexuality” and even lawyers may face fines for representing gay clients.

The Act was proposed by Asuman Basalirwa from Bugiri and had the near-unanimous support of MPs.

Ugandan gay activist Frank Mugisha, told Reuters that if the Act becomes law, he will challenge it in court on grounds that it was unconstitutional and violated various international treaties to which Uganda is a signatory. 

However, Mugisha also said that he feared mob violence and the mass arrest of LGBTQ people, adding that his community would be too afraid to seek treatment at health centres and warned of the mental health damage, including an increased risk of suicide.

“The Bill confuses consensual and non-consensual relations – the former should never be criminalized, whereas the latter require evidence-based measures to end sexual violence in all its forms – including against children, no matter the gender or sexual orientation of the perpetrator. This bill will be a massive distraction from taking the necessary action to end sexual violence,” the UN High Commissioner said.

Rise in anti-LGBTQ activity

“Not only does it conflict with Uganda’s own constitutional provisions stipulating equality and non-discrimination for all – it also runs counter to the country’s international legal obligations on human rights and political commitments on sustainable development, and actively puts people­’s rights, health and safety at grave risk,” he added.

There has been a rise in homophobic sentiments, particularly among politicians and religious leaders in Uganda and neighbouring Kenya over the past few months

The OHCHR said that,  according to a report from a civil society group, in February alone more than 110 LGBTQI+ people “reported incidents, including arrests, sexual violence, evictions and public stripping”.

“Let us be clear: this is not about ‘values’. Promoting violence and discrimination against people for who they are and who they love is wrong and any disingenuous attempts to justify this on the basis of ‘values’ should be called out and condemned,” Türk said.

Meanwhile, UNAIDS has warned that, if the Act becomes law, it will curtail “the human rights of people living with HIV and some of the most vulnerable people of Uganda to access life-saving services”. 

“If enacted, this law will undermine Uganda’s efforts to end AIDS by 2030, by violating fundamental human rights including the right to health and the very right to life,” said UNAIDS East and Southern Africa Director Anne Githuku-Shongwe.  

“Research in sub-Saharan Africa shows that, in countries which criminalize homosexuality, HIV prevalence is five times higher among men who have sex with men than it is in countries without such laws,” said UNAIDS, calling on Museveni not to enact the Bill as it will  “cost lives and it will drive up new HIV infections”. 

“The harmful Act stands in marked contrast to a positive wave of decriminalization taking place in Africa and across the world, in which harmful punitive colonial legislation is being removed in country after country. Decriminalisation saves lives and benefits everyone.”

Describing the Act as “an extreme violation of human rights”, International AIDS Society (IAS) warned that it “threatens to reverse the country’s progress in the HIV response”. “Criminalizing LGBTQ+ people is wholly incompatible with an effective HIV response,” said the IAS.

In opposition to HIV response

“While Uganda has made considerable gains in reducing the impact of HIV, gay men and other men who have sex with men, trans people and sex workers continue to be less likely than the general population to access HIV treatment, prevention and care services and will be further threatened by this legislation.

“In 2021, key populations (gay men and other men who have sex with men, people who inject drugs, trans people, and sex workers) and their sexual partners accounted for 51% of new HIV acquisitions in central, eastern, southern and western Africa. This underscores the urgent need for governments in the region to work with, not against, communities most vulnerable to HIV.”

The IAS also noted that the Act is also “completely in opposition to President Museveni’s stated support for the HIV response. UNAIDS and others lauded the President when he launched The Presidential Fast-track Initiative on ending HIV & AIDS in Uganda by 2030, the first such initiative globally.”

A partly submerged house in Nsanje in Malawi after Cyclone Freddy.

Submerged houses, collapsed buildings, uprooted trees and floating household items are what remains of Mtemangawa Village in Nsanje district, located in southern Malawi, bordering Mozambique.

This is where one of the longest-lasting storms in the southern hemisphere, Tropical Cyclone Freddy, entered Malawi on March 12, 2023. 

Home to about 300 000 people, Nsanje is Malawi’s poorest district. Some 81% of its population is ranked as poor and 56% as ultra-poor, meaning that they live on less than one US dollar a day.

“Rising water levels were noticed around 2pm on Monday, 13 March,” recalls resident Laika Kawela. “We ignored it. Our area is usually like that during the rainy season. But by 6pm, water spread all over our entire village. Luckily, we ran to higher ground carrying only the nearest basic things.”

Kawela only managed to save her family and her mobile phone. All her belongings, including her and her husband’s HIV antiretroviral (ARV) drugs, were washed away.

“For close to a week, we have missed our medication. We have been disconnected from many things, including medical services,” laments Kawela.

Kawela’s family is amongst the 660 families seeking temporary shelter at Kapalokonje camp. They have survived on anything they could in the past week as a truck full of relief food only arrived on Tuesday, a week after their displacement.

“We have been squeezing ourselves into the few surviving structures nearby for a week as we waited for aid. We had two tents mounted at this camp yesterday. Food prices in the district have more than doubled and many of us cannot afford it. We have been starving,” she tells Health Policy Watch.

Her main worry is how she can pick up her life again: “My house is not habitable. It will require a lot of maintenance. This applies to many people here. Where are we going to start from? Other than life, I don’t have anything else.” 

Kawela is one of the estimated half a million people who have been displaced by Cyclone Freddy in the country’s 15 affected districts. Her situation is a reflection of what many people living with HIV are facing after being displaced by the disaster. 

According to the Coalition of Women Living with HIV (COWLA), over 250 women living with HIV in the affected districts are disconnected from treatment.

A collapsed house in Nsanje in Malawi after Cyclone Freddy.

Collapsed system

Public health experts say that the cyclone came at an unexpected time and it has had a severe impact on people’s health. Services have been disrupted by damaged roads and bridges, and there is an acute shortage of staff as some health workers have also been displaced and lost property. Many local health centres have lost some or all their supplies, leading to a critical shortage of supplies in these facilities.

“The previous cyclones (Ana and Gombe) severely damaged our water, sanitation and hygiene infrastructure along with shelters, all of which exacerbated the current cholera outbreak,” said Dr Titus Divala, a public health expert.

“I can’t even begin to imagine how and when we will be able to get out of this. Considering the poor shelter, scabies and many other communicable diseases will also increase. It’s going to be painful. Authorities and their development partners need to act quickly,” Divala predicts.

Satellite image of Cyclone Freddy before it hit Mozambique on 10 March.

Roads washed away

According to the Ministry of Health (MoH), Nsanje has been disconnected from health facilities as roads have been washed away.

Even before the cyclone, Malawi’s health sector had been struggling to deal with the most prolonged cholera outbreak in a decade. The outbreak started last March and has claimed 1,686 lives.

MoH spokesperson, Adrian Chikumbe says the fight against cholera has been affected by the cyclone in some places.

“Patients are failing to go to facilities either because the facilities are affected or roads are impassable,” Chikumbe told Health Policy Watch.

A report from the ministry and the Public Health Institute of Malawi report warned that Cyclone Freddy has contributed to the breakdown of water and sanitation facilities, leading to contaminated water sources and collapsed latrines.

“Congregate settings like camps are a fertile ground for disease outbreaks,” they warn.

However, the MoH has trained volunteers and Health Surveillance Assistants (community health workers) to monitor the camps amid ongoing assessments in the affected areas, the report, which was issued on Monday, adds.

Professor Adamson Muula, Head of Community and Environmental Health at Kamuzu University of Health Sciences, notes that living with friends, relatives or strangers at the camp is a nightmare for survivors – even in countries that are used to managing displaced individuals.

“The schools, churches and other places, which have turned into shelters, are not designed to cater for displaced individuals. The schools are created to offer services to children and adolescents for classes. They are not meant to house adults. Many of the survivors don’t know when they will leave these shelters. We also need to be aware that there are psychological ramifications which must be attended to,” Muula said.

Pregnant women, people with chronic medical conditions including high blood pressure and heart diseases, and those on ARVs, are particularly at risk, he warns.

“Those on tuberculosis and HIV treatment, their medication and health records have been lost. All these people are in camps now or staying in strange environments. The system has been compromised and we need to intervene before things become worse,” he said.

However, Muula observed that the current tragedy is largely man-made: “This is not the time to blame one another. But as the dust settles, there is a great need for soul-searching and an honest discussion about how to prevent future losses of life. No doubt, these cyclones will continue to come, more frequently.”

More extreme weather events

Malawi President Lazarus Chakwera declared a state of disaster on 13 March 13, and 14 days of national mourning from 15 March. The death toll on Wednesday stood at 507 deaths, with 1,332 people injured, according to the Department of Disaster Management Affairs.

Last Monday, United Nations Secretary-General, Antonio Guterres warned that, unless countries dramatically scale up their efforts to counter the climate crisis, the world faces a global disaster as the planet is “nearing the point of no return”.

Global emissions of carbon dioxide and other greenhouse gases keep increasing, largely because of the burning of fossil fuels, deforestation, and intensive agriculture, said Guterres at the launch of the sixth synthesis report of the Intergovernmental Panel on Climate Change (IPCC).

“Emissions should be decreasing by now and will need to be cut by almost half by 2030 if warming is to be limited to 1.5°C,” the report warns, referring to the temperature target adopted by most countries in the Paris Agreement in 2015.

Herbert Mwalukomo, Executive Director for the Centre for Environmental Policy and Advocacy, said that Malawi should expect more extreme weather events.

“The global community must wake up. The piecemeal solutions to climate change will not help. The UN report is very clear that the pace and scale of what has been done so far and current plans are not sufficient,” said Mwalukomo.

“Developed countries must shift away from carbon energy in their own countries now if they care about climate change. No amount of preparedness will help if emissions continue to rise.”.

Mwalukomo said that the most immediate policy action is to enact a national Disaster Risk Management Bill. 

“Cabinet, the Ministry of Justice and the Department of Disaster Management Affairs must do the needful to ensure that the Bill is tabled in the current sitting of Parliament. The Bill is not a magic bullet, but it will go long way to ensure that Malawi has a legal framework for preparedness, effective response and recovery from disasters,” he said.

“As citizens, we have to invest in our own preparedness. We cannot continue building and living in areas that are prone to flooding. It is a suicide mission. We also have to pay attention to early warning messages provided by the Department of Meteorological services,” he said.

Dodma says the world has for some time known that it is in a climate crisis and the department is putting in place adaptation plans including early warning system, anticipatory plans and bringing back the environment.

Charles Kalemba, Commissioner for Disaster Management Affairs, said that “disasters will continue to happen, it’s not a new thing. We are prepared for anything that may come in future”.

The department’s main strategy to reduce the impact of future disasters, he added, was encouraging people to relocate from flood-prone areas through local councils that need to find suitable safe places for the citizenry.

“We have asked councils to be aggressive in enforcing laws on illegal settlements especially those settling at the foot of mountains. They need to relocate these people, especially in Blantyre where such residents were hard hit,” Kalemba said.

Image Credits: NASA Worldview, Josephine Chinele.