World Health Summit
Dr Ricardo Baptista Leite, President and Founder of UNITE Parliamentarians, and Dr Tedros Adhanom Ghebreyesus sign MoU at the World Health Summit.

BERLIN – Donors pledged some $2.6 billion more in funding to the global polio eradication initiative (GPEI) as of the closing day of the World Health Summit – which saw its shares of highs and lows in its finale, much like the rest of the three-day event. 

On the plus side, the donations, which included a pledge of $1.2 billion by the Bill and Melinda Gates Foundation announced at the conference´s opening session Sunday, mean that the GPEI has come more than half way to meeting the funding target of US$4.8 billion set out in its 2022-2026 Strategy. 

And WHO´s Director General Dr Tedros Adhanom Ghebreyesus also signed a new memorandum of understanding with a global network of parliamentarians, UNITE. The network will collaborate with the global health agency to mobilize elected officials around the world in the campaign for a pandemic accord as well as other milestone global health aims. 

On the downside, a new WHO report released at the summit described the setbacks in women’s, children’s and adolescent health recorded during the pandemic – rolling back years of progress.  

And as with the Summit´s opening, marred by disruptions by climate protestor,  closing day saw its share of reputational woes – of an entirely different nature. 

Sexual assault charges levied at WHO staff member

As conference goers got set to push through the final day of the summit on Tuesday morning, news broke that a female attendee had reported being sexually assaulted by a WHO staff member the night before.

¨I was sexually assaulted tonight at the World Health Summit,” tweeted Rosie James, a British-Canadian medical doctor, who had filled her social media account up to that point with detailed coverage of conference events on topics ranging from HIV to women and migration.

¨This was not the first time in the global health sphere that this has occurred (for MANY of us). I will be reporting it. So disappointing and disheartening. We must do better ,¨ she said. 

WHO´s response was swift and public. Dr Tedros quickly issued a statement saying the WHO would have zero tolerance for any sexual misbehaviour, while senior WHO staff met with Ms James to collect her account of the incident.  

The alleged attacker was immediately sent packing to Geneva, where he will face a formal investigation, WHO sources later told Health Policy Watch.  

Others who said that they had witnessed the incident, also proffered support: ¨So sorry that this unacceptable behaviour happened @rosiejames96. You can count on myself and others who witnessed this happen for support, tweeted Brian Li Han Wong, a young health professional, who had just been appointed to a new WHO Youth Council.

Setbacks in women´s and children´s health also revealed 

The new WHO report, ¨Protect the Promise¨, released Tuesday, showed that women’s and children’s health has suffered globally as the impacts of conflict, the COVID-19 pandemic and climate change converge with devastating effects.

A child born in a low-income country still has an average life expectancy at birth of around 63 years, compared to 80 in a high-income country. This 17-year survival gap has changed little over recent years, the organization noted. In 2020, five million children died even before the age of 5, mostly from preventable or treatable causes. Meanwhile, most maternal, child, and adolescent deaths and stillbirths are concentrated in just two regions – sub-Saharan Africa and South Asia.

The UN analysis revealed more staggering figures:

  • More than 45 million children had acute malnutrition in 2020.  Nearly three-quarters of these children live in lower-middle-income countries. Some 149 million children were stunted in 2020, with Africa as the only region where the numbers of children affected by stunting increased over the past 20 years.
  • The six countries with the highest numbers of internally displaced persons – Afghanistan, the Democratic Republic of the Congo, Ethiopia, Sudan, the Syrian Arab Republic and Yemen – are also among the top 10 food insecure countries.
  • A woman in sub-Saharan Africa has around a 130 times higher risk of dying from causes relating to pregnancy or childbirth than a woman in Europe or North America. Coverage of antenatal care, skilled birth attendance, and postnatal care is far from reaching all women in low- and middle- income countries, leaving them at elevated risk of death and disability.
  • Millions of children and their families are experiencing poor physical and mental health from recent humanitarian disasters in Afghanistan, Ethiopia, Pakistan, Somalia, Ukraine and Yemen. In 2021, a record 89.3 million people worldwide were driven from their homes by war, violence, persecution, and human rights abuse.

Failure to address gaping inequalities

“Almost three years on from the onset of COVID-19, the pandemic’s long-term impact on the health and well-being of women, children and adolescents is becoming evident: their chances for healthy and productive lives have declined sharply,” said Tedros at the launch of the report in Berlin.  “As the world emerges from the pandemic, protecting and promoting the health of women, children and young people is essential for supporting and sustaining the global recovery.”

“The report advocates for countries to continue investing in health services, in all crises, and to re-imagine health systems that can truly reach every woman, child, and adolescent, no matter who they are or where they live,” added Helen Clark, former prime minister of New Zealand and the Board Chair of The Partnership for Maternal, Newborn & Child Health.

“The impacts of COVID-19, conflicts, and climate crises have raised the stakes for vulnerable communities, revealing the weaknesses and inequities in health care systems and reversing hard-won progress for women, children, and adolescents – but we are not powerless to change this,” said UNICEF Executive Catherine Russell.

Speed dating for consultants or meaningful dialogue?

Some critics complained that the summit was overloaded with too many events and talking heads – what some described as ¨speed dating for consultants.¨

On the other hand, the Summit, the first to be formally co-sponsored by WHO, also provided a new venue for more informal dialogue between WHO´s top echelons and diverse groups of civil society, including activists, students and the private sector – going well beyond the highly-scripted meetings of the annual World Health Assembly.

And as Tedros noted in his closing remarks, along with the funds raised for polio eradication, WHO also signed onto a number of new civil society collaborations at the Berlin event.

Those included a new agreement with the International Association of National Public Health Institutes to strengthen public health services, particularly for emergencies; a collaboration with a new tobacco cessation consortium, including private sector participants; and the memorandum of understanding agreed with UNITE, a network of global parliamentarians focused on global health.

Global Parliamentarians muster forces to fight for change 

Parliamentarians from six WHO regions speak about global health challenges at the World Health Summit event where WHO signed an MoU with UNITE.

Such collaboration offers WHO a new and valuable channel for reaching out beyond top national government officials to more diverse groups of elected politicians who control national budgets and develop legislative priorities. 

¨Together we will work together to advance universal access to health, sustainable finance for health strengthening, and strengthening the global health security architecture, especially the implementation of the international accord in countries,¨ said Tedros during a signing ceremony with Ricardo Baptista Leite, UNITE´s President and Founder. 

¨Nearly 20 years ago, I started working as a young medical doctor in an infectious diseases ward in Portugal, where I met patients who couldn´t make it to the hospital because they couldn´t afford public transportation and a man in his twenties who died [from HIV] without feeling a last hug and kiss from his loving ,¨ recalled UNITE president Baptista Leite in his remarks to Tedros.

¨When I was elected for the first time into the parliament, I felt that responsibility to be part of the fight for a more equitable society at home and abroad. And that is why, six years ago exactly at the World Health Summit in Berlin, I pitched an idea of creating a network of parliamentarians that would then become leaders for global health.¨

Image Credits: Fletcher/Health Policy Watch.

From left to right UNITE and IFGH parliamentarians: Neema Lugangira, Tanzania; Mariam Jashi, Georgia; Marie-Rose Nguini Effa, Cameroon; Andrew Ullmann, Germany; Gisela Scaglia, Argentina; Ayesha Mohammed ALMulla, United Arab Emirates.

BERLIN – If a new treaty that rewrites the global rules for pandemic response is really approved by the World Health Assembly by May 2024, as planned, that will still only be the beginning of the journey. 

The new international accord will still have to be ratified by a critical mass of WHO´s 194 member states in order to really become operational. And that means agreement over the treaty´s principles by the tens of thousands of elected politicians representing the very diverse, and oft-conflicting views of their constituencies about global health goals and priorities. 

With that in mind, a group of parliamentarians from about two dozen countries gathered under the auspices of the UNITE Global Parliamentarians Network for a panel discussion on the second day of the World Health Summit, to outline what they see as key ingredients in a successful pandemic recipe – one that could win support not only from global leaders but in countries the world over.  

The UNITE network is also gearing up to provide formal inputs to the WHO member state Intergovernmental Negotiating Board (INB) negotiating the pandemic instrument.

In that role, they´re leading a working group of a dozen international parliamentary assemblies and networks, the  International Forum on Global Health, which convened in April to discusss the pandemic treaty, just ahead of the World Bank and IMF spring meetings. And they are set to sign an MoU with the World Health Organization on Tuesday, paving the way for more formal channels of collaboration with WHO on their work with parliamentarians. 

Ricardo Baptista Leite, UNITE founder and president, Portugal

¨We have a lot of work ahead of us and the role of parliamentarians is critical,¨ said Ricardo de Dr. Ricardo Baptist Leite, the Portuguese politician and medical doctor who is the head of UNITE, and a driving force behind the global health movement of elected officials.

¨We need to make sure that this pandemic treaty, convention, or legal agreement is not composed in corridors and then imposed on the people, but is actually something built from the people, for the people. 

¨I think this is huge opportunity for us to work together with the World Health Organization to achieve this ambitious goal.¨

Engaging political opponents, ensuring democratic freedoms

Mariam Jashi, former parliamentarian, Georgia describes the erosions in democracy during the pandemic.

The COVID pandemic saw basic freedoms eroded in many countries, observed Dr. Mariam Jashi, a former parliamentarian from Georgia.

Jashi was among the half dozen UNITE members from countries in Europe, Africa, Latin America and the Middle East who etched their vision of how to ensure the treaty´s acceptance and eventual ratification.

Topping that list was simple engagement of national politicians as partners, early on in the negotiating process.

The challenge of engaging elected politicians in the process is all the more urgent in light of sensitivities to political constituencies, who emerged from the crisis distrustful and burnt by the loss of basic freedoms during lockdowns, and of government more broadly. 

Status of democracy was eroded during pandemic

¨The status of democracy and human rights in over 80 countries deteriorated during the pandemic,¨ she said, citing research by the watchdog group Freedom House. ¨Many countries, especially in low and middle income countries have not engaged opposition political leaders or public health experts or different political parties in the discussions around the restriction measures.

¨Some of the measures were not evidenced based…And in the name of fighting the pandemic, we´ve seen different levels of political manipulation unfortunately. So we have to consider those challenges while designing the new global treaty for  pandemic, preparedness, prevention and response. And what could be the role of parliamentarians?¨ she asked. 

¨We can definitely bring discussion of the official negotiating draft to the parliaments. We have to facilitate non-partisan discussions around the treaty; we have to make sure that every party is represented during the dialogue and discussions. That  can bring better ownership.

Providing finance to implement the treaty will also be key – as the carrot that accompanies the stick of any tougher compliance measures on outbreak alert and responses.

¨We also have to ensure that we not only adopt a very comprehensive document, but  to really provide concrete tools and instruments to the countries to implement those regulations,¨ Jashi said. 

¨We can empower WHO,  and empower implementation of global health recommendations through linking international financial institutions´ funding to performance based assessments, of how they observe the Global Health regulations.¨

Build health literacy among politicians as well as health workers 

Neema Lugangira: need to build capacity among politicians to understand health concepts and terms.

Neema Lugangira, a Tanzanian member of parliament also cited the need to build more health literacy among elected politicians.

¨During the pandemic, a lot of (outreach) efforts and focus was geared to health professionals, but we forgot about the power that parliamentarians have to distort everything that health professionals say,¨ she observed.

¨So in this global pandemic treaty that is being proposed, we must be proactive in engaging parliamentarians in capacitating us to understand.

Lugangira described her own difficulties in coming to grips with new concepts and terms that were never explained:

¨I saw this as a weak point. As a politician, it’s not very easy to get a clear understanding of issues like mRNA and DNA vaccines.  And if you don´t get a clear understanding, then you will not communicate effectively to the people that you are leading. 

¨So in this global pandemic treaty that is being proposed, we have to be proactive with parliaments, engaging them and recognizing the importance of capacity building for parliamentarians – that parliamentarians are partners in the process.¨

Discuss with parliaments as well as with ministries

Typically, when WHO proposes new global health policies, ¨It’s very common that discussions will be with governments, meaning the respective ministries, but not necessarily parliament,¨ she pointed out.

¨And then all of a sudden, as parliamentarians, we are expected to use that document, to champion it, to  advocate for it –  but we were not involved in the process. 

¨So it’s very important ….to make sure that we are involved at the beginning of the process. – how can we now take this from a global level to our national parliaments?¨ 

A treaty – not a directive from the global north

Another issue of concern is the perception in low- and middle-income countries that the proposed legal accord will be designed largely to suit the needs of the global north.

Related to this, politicians and voices in the north have tended to emphasize a set of priorities centered around the need for more prompt outbreak alert, notification and responses. Conversely, politicians and advocates from developing countries stress the need for more equitable access to medicines and stronger health systems to both cope with emerging threats, and ensure better responses.

¨This is something that we have to be very candid about, and very careful about,¨ Lugangira warned. ¨because sometimes what works in Europe or in the US or in Canada, or in Australia, may not work in Africa. And what works in South Africa may not work in Tanzania,¨ 

¨The global treaty should include us, from the global south in the discussions. If this is not addressed, it can end up being a global north pandemic treaty that is then a directive for us from the global south.¨ 

Equity another key principle 

Key to that sense of balance is equity in access to not only healthcare and health products but also capacity to use them, Lugangira stressed.  She noted that in the early stages of the crisis, vaccine distribution by rich countries to poorer neighbors seemed to be mostly a fig leaf – ¨ticking a box¨  But as time passed, there was growing recognition in even the strongest economies that they could not buy their way out of the pandemic alone. 

¨We are in this together, and in a way I think God somehow made the global north realize that  if all systems are not strong enough, you’re not strong.

Ensuring adequate finance as well as ¨digital inclusion¨ of developing countries in a future accord is critical to creating a win-win scenario going forward. 

¨During the pandemic, there was a huge effort on making sure that, for instance, that we were recording the number of people being vaccinated. But for that to work effectively, we need digital inclusion. Linked to that, pandemic preparedness requires financing; to implement this global pandemic treaty requires financing. Will that financing be available? Or are we going to find ourselves again in the same situation of privilege versus non non privilege?¨

Nutrition, gender and the right to health 

Gisela Scaglia, Argentina, says gender equality needs to be embedded into a pandemic accord.

Panelists also stressed that recognizing the links between health, and broader social concerns  – from nutrition to gender equality – will also help pave the way to parliamentarians´ wider acceptance of any eventual treaty. 

¨Women and children were the most vulnerable populations during the pandemic,¨said Gisela Scaglia, a  former member of parliament in Argentina. Women suffered the consequences of isolation. They saw their rights restricted and  increased violence against them. Access to contraception was restricted. They suffered the consequences of a pandemic that deprives women of access to their routine medical checkups.

¨Nowadays we can see an increase of many non-transmissible diseases, such as breast cancer, because of the absence of checks for the two years or more,¨ Scaglia added, concluding that ¨We should include as a priority gender equality. 

¨Finally, we cannot face the next pandemic with restrictions on education,¨ she added. ¨In my country, for two years, the schools were closed.  The government tried to do virtual education, but it was a mess… The gap between people with connectivity and access to technology, and people without, was big. And this was a huge inequality.¨ 

Parliamentarians at the center of cross-sectoral processes 

The comments illustrate how linkage of the pandemic accord to broader concerns about well-being can ensure that politicians appreciate the benefits of a treaty, and align with its aims and goals, said Roland Göhde, of the German Health Alliance (GHA) which co-sponsored the session with UNITE. 

¨With all of their roles and responsibilities, parliamentarians are both at the center of the processes in very specific pillars that provide health care, justice, equity, economic support, education, and at the intersection, with overaps, areas of interconnection and interaction,¨he pointed out. 

More than ever before, political leadership needs to focus on systemic strategies from a holistic perspective,¨ Gohde added. ¨Exactly for this reason, the establishment in the international fora of global health, of a dedicated working group of 12 diverse parliamentary assemblies and networks worldwide, can only be seen and embraced as a truly very significant milestone.¨

Image Credits: Fletcher/Health Policy Watch, Fletcher/Health Policy Watch .

Germany’s health minister, Dr Karl Lauterbach and WHO’s Dr Mike Ryan

Amid criticism that the World Health Summit was ‘speed-dating for consultants’, panellists lamented a lack of practical plans to empower local service delivery

A more empowered World Health Organization (WHO), stronger health local systems and better surveillance are some of the weapons that will protect the world against future pandemics, according to panellists at the World Health Summit in Berlin.

“The WHO needs more powers to deal with pandemics. Isn’t there something ridiculous about the fact that the International Atomic Energy Agency can go into a war zone and inspect what’s happening in a nuclear power plant and WHO doesn’t have an absolute right to get visas to go to the site of any outbreak anywhere in the world?” said Helen Clark, the former prime minister of New Zealand and co-chair of the Independent Panel for Pandemic Preparedness and Response. 

She was referring to how China denied WHO-appointed experts access to the outbreak of the pandemic in Wuhan.

“The International Health Regulations need to be made fit for purpose and empowering the WHO on very practical issues like that,” said Clark, who also asserted that “it was not the WHO that failed the world. It is member states that failed the WHO.” 

No one had a plan

Germany’s health minister, Dr Karl Lauterbach, said that when his country assumed leadership of the G7, it was clear that no country had a plan on how to address pandemics. To get a better understanding of the gaps, he convened three informal meetings of scientists.

What emerged, said Lauterbach, were two key consensus points: first, “we are lacking a workforce which is better prepared to recognise a possible pandemic and to avoid that an outbreak becomes a pandemic” and second, a lack of surveillance to identify a pandemic Lauterbach appealed for everything to be geared towards addressing these two crucial needs – and training young people to “get them interested in pandemic control”. 

“We will either spiral upwards or spiral downwards. If we spiral downwards, we will have more climate change, and more pandemics because of climate change. We will have poorer primary health because of climate change and pandemics and we will have more wars because all of this is happening.”

‘Last mile of delivery is first mile of health security’

Dr Mike Ryan, WHO executive director of health emergencies,  agreed that “without data, you’re blind and without a workforce, you have no capacity to act”.

However, he added that “95% of people who survive natural disasters survive because their neighbours and their families dig them out from under a building or pull them out of the water”. 

“That’s exactly the same principle in epidemics. It is local, community-based surveillance, point-of-care diagnostics, the ability to understand there’s a problem in the community and the rapid provision of support to a community before an outbreak becomes a national or global event,” said Ryan.

The “last mile” of health care was also the “first mile of health security” – and often the weakest link.

Describing the health summit as “speed dating for global consultants”, Ryan said that things were very different at the country level where Ministries of Health were “usually underfunded, and the weakest ministry in government”.

“Then we come in with our vertical systems and we start pushing everyone: ‘you must do this and you must do that. We have decided this is best for you’. How paternalistic is that?” Ryan said, appealing for attention to “that principle of service to the people” – and humility.

South Sudan Minster of Health Elizabeth Chuei receiving a COVID-19 vaccine after delivery from COVAX.

‘Little white, northern cabals’

He also took aim at “many unelected individuals around the world who live in their little, white northern cabals who like to sit in rooms and decide what the future of global health is going to be”.

“The reality is 194 ministers of health come together every year in Geneva, and they set out under democratic principles, what are the policies for the world and we need to continue to invest in that,” said Ryan.

“We’re a flawed organisation. But we are radically transparent and we are open. Everything we do is on the table. Everything we do is out there for criticism. I wish it were the same for other entities and institutions.”

He also blamed any failures in the global vaccine delivery platform, COVAX, on “the greed of the north”, “the greed of pharmaceutical industry” and “self-interest in certain member states” that were not prepared to share.

“COVAX went against that trend, and COVAX tried in its best way to represent that need around the world,” said Ryan, adding that he and others often worked “26 hours a day” to address the pandemic and sometimes needed to be “peeled off the wales”.

Principles not plans

Professor Lawrence Gostin from Georgetown University in the US said there was a need for “better governance” of the WHO.

“We need to have more honesty and stewardship, transparency and openness, most important, inclusive participation, effective performance monitoring benchmarks, quality improvement, accountability, and the most important thing is equity,” said Gostin.

German health ministry official Björn Kümmel, who has driven the re-financing of the WHO as co-chair of the Intergovernmental Working Group on Sustainable Financing, said that his country would like to “enable WHO not only financially but also technically, potentially legally through new mechanisms in the IHR and obviously, the pandemic treaty, and politically also vis a vie other global health agencies or other actors who are engaging in global health”. 

However, Kummel conceded that “nobody seems to have a plan”.

Discussion was largely about “principles” – such as “better governance, trust, transparency, acceptance of criticism, [ensuring] the voice of civil society, equity, community intelligence systems.

“All the big words that were mentioned here, I think it’s clear that none of us seems to have the right plan.”

Image Credits: UNICEF.

pollution
Air pollution in Delhi, India.

New evidence that exposure to air pollution can potentially contribute to obesity in women has emerged from a study by the University of Michigan

“Women in their late 40s and early 50s exposed long-term to air pollution—specifically, higher levels of fine particles, nitrogen dioxide and ozone—saw increases in their body size and composition measures,” said Xin Wang, epidemiology research investigator at the University of Michigan School of Public Health and the study’s first author. 

By cross-referencing the residential addresses of the 1,654 US women participating in the study with hybrid air pollutant concentration estimates from 2000 to 2008, the data showed exposure to air pollution was linked with higher body fat, body mass index, and lower lean mass.

But it is not all bad news. The study found that while body fat increased by 4.5%, high levels of physical activity were an effective way to mitigate and offset the effects of air pollution exposure.

Pollution and obesity: a growing link 

With an unprecedented increase in body weight issues worldwide over the last decades, numerous studies have sought to understand the complex and varied causes of obesity – and this is not the first to explore the link to air pollution.

In 2019, researchers at the University of California at Santa Barbara published the first study estimating the causal effect of air pollution on body weight based on data from 13,226 adults in China from 1989-2011. 

This period of study is unique for its historical backdrop. Across the years of the study, China’s economic explosion contributed to a rise in fine particulate matter concentration by 70%. During this time, China’s average BMI increased by 11%, while overweight and obesity rates increased from 8.57% to 32.83% and 0.48% to 4.9% respectively.

“Our study suggests that the cost of air pollution on overweight and obesity is non-trivial,” the authors state. “Although the effect’s magnitude is smaller than studies focused on other economic [and socioeconomic] variables, it is in the same order of scale.”

The International Journal of Obesity also highlighted the potential effects of ambient air pollution on child obesity development but noted evidence is still scarce.

“Early life exposure to air pollution may be associated with a small increase in the risk of developing overweight and obesity in childhood, and this association may be exacerbated in the most deprived areas,” the journal notes. “Even these small associations are of potential global health importance.”

The most striking results came from a study conducted by the Lung Care Foundation and Pulmocare Research and Education in India. The results found that while 39.8% of the children in Dehli, one of the world’s most polluted cities, were obese or overweight, this was true for only 16.4% of children in Kottayam and Mysuru, cities with significantly better air quality.

As studies continue to deepen our understanding of the toxic effects of fine particulate matter (PM2.5) on human health, the silent threat posed by polluted air has revealed itself to be more multifaceted than previously known – and extremely deadly.  

With 99% of the global population breathing air beyond the World Health Organization’s recommended quality limits, an estimated nine million deaths are caused by modern air pollution sources every year. 

New evidence of the adverse effects of air pollution is emerging at a rapid clip, but despite the economic and health implications, progress on the policy front remains slow.

Image Credits: Ella Ivanescu/ Unsplash, Wikimedia Commons: Prami.ap90.

Cancer
More than 1,500 scientists, medical specialists, NGO and civil society representatives, ministers of health, high-level United Nations representatives and people living with, or affected by, cancer are expected this week at the World Cancer Congress 2022.

A lack of expertise in geriatric oncology means that cancer in older adults is often confused with other signs of ageing and diagnosed too late.  Dr Sonali Johnson sets out a blueprint for addressing this barrier – one of the many topics to be discussed at the World Cancer Congress, hosted by the Union for International Cancer Control in Geneva, 18-20 October.

Cancer is a disease for which older adults are particularly at risk as the cells of the body are more likely to turn cancerous as a person ages, primarily as a result of greater exposure to risk factors (though this exposure can be reduced by adopting early a healthy lifestyle). In 2020, over 50% of all cancer cases were among people aged over 65 – nearly 10 million out of a total of 19.3 million – and this proportion will grow further in the coming decades, with the fastest increase occurring in low and middle-income countries (LMICs).

The treatment of cancer is more complex for older adults with co-morbidities, requiring an integrated approach. Yet a lack of expertise in geriatric oncology at different levels of the health system means that cancer in older adults is often diagnosed late as early symptoms are sometimes considered to be signs of ageing. Cancer is more complicated and invasive to treat successfully when it is detected at a more advanced stage.

Age isn’t everything

IUCC
More than half of all people who have cancer are over 65 years old, and this number is predicted to rise as populations age globally. Yet, many health systems are not prepared to address the specific needs of this population.

Older adults are not a uniform group and age alone is a poor predictor of an individual’s health. They can have widely varying physical and mental health at a similar age, with the presence or not of co-morbidities. They may or may not have a strong social support network. They may have considerable or, on the contrary, very limited financial means. Each of these factors will shape if and how an older adult engages with the health system, therefore their preferences and needs should be individually assessed. 

To do so effectively, we need to improve our data on the prevalence of co-morbidities amongst adults aged over 65. Many health policies have been developed and implemented with partial information and in silos, addressing diseases separately. There is an opportunity here for cross-sectoral and multisectoral coordination and integrated approaches that lay the groundwork for patient-centred care.

There is also a need to train health staff in geriatric care to correct the misconceptions that often surround health and ageing – stereotypes, assumptions and prejudices that mask the diverse nature of older populations and the contributions of older adults to society.

Patient-centred care also means removing age limits in clinical trials and the inherent biases in research programmes to make them more inclusive. Currently, doctors and regulators may have little precise knowledge of how older adults react to certain treatments or how cancer medicines may interact with other medications they are taking, since these have not been tested.

Countering misperceptions that older adults themselves may have about clinical trials (e.g. fear of mistreatment, being used as a ‘guinea pig’) is also essential to improve access to services and research. Other limitations also need to be addressed, such as hearing or transportation difficulties.

Only if older adults are proportionately well represented in clinical trials and research can doctors have more insight into the efficiency and side effects of cancer treatments for people over 65.

Caring for older cancer patients is a surmountable challenge

Cancer
Estimated increase in cancer incidence and mortality (2020 data: Globocan / 2030 previsions: AIRC)

The Union for International Cancer Control (UICC) has made cancer and ageing a focus area of its work, supporting the advocacy efforts of UICC member organisations in LMICs working to improve access to cancer services and care for older adults

Initiatives in El Salvador, Guatemala, Kenya, Mongolia and Tajikistan have been set up in partnership with Sanofi, to improve the training of healthcare practitioners in geriatric care; include cancer and ageing strategies in national cancer control plans and universal healthcare packages; ensure cost-free access to cancer medicines for people aged over 65, and increase the availability of palliative care specifically tailored to the needs of older adults.

To improve cancer care for older adults at the international level, the International Society of Geriatric Oncology has developed the Top Priorities Initiative to identify global priorities for progress and development in geriatric oncology and translate these priorities into tangible actions.

The American Society of Clinical Oncology (ASCO) has issued recommendations for geriatric assessments, a tool to understand an older person’s physiological and socioeconomic situation to inform the most effective and appropriate course of care.

These are being adopted by several health systems, for instance in Chile, where the Arturo Lopez Perez Foundation (FALP) created an oncogeriatric unit to provide a comprehensive geriatric assessment of older adults with cancer.

Caring for older adults is not about prolonging life at all costs – and it is not an insurmountable challenge. Neither does it necessarily involve investing significantly in additional resources or diverting resources from other priorities.

It is, ultimately, about ensuring that the clinical expertise exists to identify the specific needs of older adults and offering them the same opportunities for diagnosis and treatment as other populations enjoy, in line with their wishes and particular situation.

Sonali Johnson is Head of Knowledge and Advocacy at the Union for International Cancer Control (UICC), which is hosting the World Cancer Congress in Geneva, 18-20 October.

Demonstrators outside the World Health Summit protest that lack of climate action during a speech by German Chancellor Olaf Scholz Sunday evening

BERLIN – The first World Health Summit co-sponsored by the World Health Organization (WHO) started off with a siren call to climate action – literally – as activists disrupted the ceremonial plenary attended by German Chancellor Olaf Scholz by repeatedly setting off fire alarms 

Outside the posh Hotel Berlin venue,  activists plastered the doors with scientific papers on climate change’s health and environment impacts while a handful staged a sit-in, as police cordoned off the area.

“How many scientific papers are pasted on this building where Olaf Scholz is speaking, telling about the climate crisis and the health crisis?” said one protestor in a post on the demonstration.  “How many things did we do before coming here?”  

Added another protester: “Governments, including the German one, have not defended the climate safe zone. Now there is no plausible way to limit global heating to below 1.5°C.”

Airport delays of Africa CDC Acting Director also provoke storm

Earlier, Africa Centre for Disease Control Acting Director, Dr Ahmed Ogwell, protested at being delayed by German border guards at Frankfurt airport. In a series of tweets, Ogwell said that he had been “mistreated” at Frankfurt Airport by immigration guards who “imagine I want to stay back illegally. My attendance of the @WorldHealthSmt is now in doubt. I’m happier & safer back home in Africa.”

The incident provoked a small storm on social media, including  US Assistant Secretary for Global Affairs, in the Department of Health and Human Services, Loyce Pace,

Pace, also in Berlin for the WHS event, offered an unusually personal description of the treatment she had also experienced as an African American diplomat at border crossings, including Frankfurt´s.  

There was no reference to the incident at the official opening Sunday evening, which Ogwell did not attend. Asked by Health Policy Watch for comment,  a WHS spokesperson confirmed that Ogwell had arrived in Berlin, adding: 

“We consider the situation of Dr Ogwell to be very concerning and we hope that the situation clears up quickly. Dr Ogwell’s voice and expertise, and that of the Africa CDC, are of the utmost importance and are essential to the World Health Summit,” the spokesperson said. 

“It is absolutely critical that all WHS 2022 participants from Africa and all other countries are treated with respect. …WHO and the World Health Summit are both dedicated to the well-being of all people, the key to achieving better health for all lies in collaboration and open dialogue. This is what WHS 2022 stands for.”

However, in the early hours of Monday morning, Ogwell confirmed on Twitter that he had returned home:

Meanwhile,  Yassen Tcholakov, attending the WHS on behalf of the World Medical Association,  suggested: “Maybe we should simply change where global conferences are held. If Europe and North America are unable to act as hosts maybe they shouldn’t be any longer.”

Most elaborate Summit to date 

German Chancellor Olaf Scholz addresses the World Health Summit

As the first WHS to be co-sponsored by the WHO, this year´s summit is the most elaborate to date, with several thousand participants in attendance, along with Pace, Germany´s Chancellor, and most of WHO’s senior staff from around the world on hand. 

Ironically, the African Union is also one of the co-sponsors of the three-day summit, with Senegal’s president Macky Sall, current chairperson of the African Union, offering a video-taped address.

Former Africa CDC director, Dr John Nkengasong, now the US Global AIDS coordinator, appeared in person where he was honoured at the opening ceremony as the recipient of an award for his global public health career of service.  

UN Secretary-General Antonio Guterres also addressed the opening plenary session, calling on participants to make more sustained investments in a healthier world. 

“Wealthier countries and international financial institutions need to support developing countries to make these crucial investments,” said Guterres in a pre-recorded address to the gathering.   

The climate crisis also received a nod from the high-level speakers, with Sol noting the ¨interdependence, between climate change, food crisis and public health.¨

“We should take one message from the protestors…It is an emergency,” said Axel Pries, WHS president at the close of the ceremony.

WHO takes global health to a new level 

WHO´s Dr Tedros Adhanom Ghebreyesus calls on countries to take global health to a new level.

WHO´s Director-General Dr Tedros Adhanom Ghebreyesus called upon world leaders to “take global health to a new level” in a three-pronged approach that would include approving a new pandemic accord; developing new tools to finance and respond to global health crises, and; taking a more preventive approach to health, including by embedding health promotion and disease prevention into areas ranging from urban transport design to finance.  

Tedros also denounced critics of the proposed new pandemic accord.  Those naysayers include some conservative American media celebrities who have tried to claim that a pandemic agreement would lead to an erosion of sovereignty: 

“The claim by some that this accord is an infringement of national sovereignty is quite simply wrong,” Tedros said. 

¨It will not give WHO any powers to do anything without the express permission of sovereign nation-states. If nations can negotiate treaties against threats of our own making, like nuclear, chemical and biological weapons, tobacco, and climate change, then surely it makes sense for countries to agree on a common approach to a common threat that we did not fully create and cannot fully control – a threat that comes from our relationship with nature itself.¨

COVID-19 and Ukraine undermined have undermined decades of progress

Fire alarms set off by climate protestors disrupted the ceremonial opening of the World Health Summit.

Together, the COVID-19 crisis and Russia´s invasion of Ukraine have undermined decades of progress in global health, said Sandra Gallina, the European Commission´s director general of health and food safety.

But looking out at the plenary room packed with over 1200 participants, including hundreds of others in overflow rooms, she added: ¨I have never seen such a crowd for health. We must require robust international rules, including a pandemic agreement. We are stretching our hands out to others to join us in this effort to  deliver a more equitable global health order.¨ 

From diagnostics to air pollution – WHS agenda is ambitious

Rosamund Ado-Kissi-Debrah speaks about the 2013 death of her daughter, Ella, from air pollution at a session on communicating about environment and health at the World Health Summit.

Already in the first day of the conference, the agenda´s menu was huge reflecting perhaps a pent-up appetite for the kinds of thematic debates that cannot as easily take place in the halls of WHO’s governing body, the World Health Assembly, where governments not global health experts set more of the tone.  

Workshops and seminar sessions ranged from the more upstream topics, such as the architecture of pandemic response, to the more familiar ground of  HIV/AIDS, air pollution, and on down to the nitty-gritty of improved diagnostics. 

While COVID has drawn tremendous attention to the importance of equitable access to vaccines and treatments, access to fast-changing technologies remains deeply pockmarked with inequalities, And that poses problems for future outbreak response, said Bill Rodriguez, executive director of the Geneva-based Foundation for Innovative New Diagnostics (FIND). 

Many health systems have yet to ensure access to reliable tests at ¨point of care¨, including self-testing for billions of people around the world, Rodriguez said at a session co-organized by the Konrad Adenauer Foundation and the German Health Federation. 

¨It’s about using tests in your daily life (protecting families and relatives),¨ Rodriguez emphasized.

Another high-profile session, a “Ports to Arms Approach to Access” discussed the successes and shortcomings of the Access to Tools Accelerator (ACT-A) – and whether a ¨supercharged¨ ACT-A could still play a role in future pandemic response.  

The ACT-A initiative, much vaunted by WHO at the start of the pandemic as a truly multilateral effort to ensure equity, has become a focus of debate between those who still tout its achievements and critics who say it was birthed with a paternalistic taint, which ultimately failed to ensure faster and fairer distribution of vaccines, treatments and tests across the developing world.   

Polio eradication gets major Gates Foundation commitment

Longstanding challenges such as polio eradication also got a boost. Notably, the Bill and Melinda Gates Foundation pledged some $1.35 billion to the Global Polio Eradication Initiative, which has seen serious setbacks ranging from new outbreaks of wild polio virus in Pakistan and Africa to a rash of vaccine-derived polio cases extending from New York to Jerusalem. 

The Gates Foundation announcement, following a commitment from Germany for $35 million to polio, was, however, an ironic reminder of the continued distortions in the public health finance landscape,

Despite the ambitious new vision embodied in the World Bank´s new Financial Intermediary Fund (FIF), the scale of the Gates Foundation commitment, as compared to that of Germany, was also a striking reminder that the world´s largest foundations and philanthropies are still carry an outsized load, as compared to governments, when it comes to global health finance,  

¨A reminder of who calls the shots in public health,¨ tweeted one WHS participant, Katri Bertram, acerbically, with the hashtag, #Followthemoney.

https://twitter.com/KatriBertram/status/1581695368987045888

 

Image Credits: Elaine Fletcher/Health Policy Watch , @nicoledepaula, Elaine Ruth Fletcher .

Vaccine deliveries by the global COVAX facility.

Midway through last year, the head of the Africa Vaccine Acquisition Task Team, Strive Masiyiwa, angrily accused the global COVID-19 vaccine acquisition platform, COVAX, of misleading African countries about its ability to procure vaccines for them.

Masiyiwa’s bitter remarks came after months of Africans watching Europeans and North Americans being vaccinated against COVID-19 while no vaccines were available for them – even if their governments had the money to pay for them.

By the end of last year, a special meeting of the World Health Assembly had resolved to set up an intergovernmental negotiating body (INB) to negotiate an accord to guide future pandemics, and all member states agreed that it needed to be based on equity. The INB is expected to submit a draft accord to be negotiated at the 77th World Health Assembly in 2024.

This week, an independent evaluation of the Access to COVID-19 Tools Accelerator (ACT-A), COVAX’s parent body concluded that “a different model for pandemic response will be needed in future”.

The review – which combined interviews with over 100 key informants, a survey and a review of documents – comes as the World Health Organization’s (WHO) INB is preparing a “zero draft” to kick off negotiations on the pandemic accord. 

The ACT-A comprised three pillars – diagnostics, therapeutics, vaccines (COVAX) and a fourth cross-cutting pillar, the Health Systems and Response Connector (HSRC), which was viewed as a flop. 

COVAX ‘too ambitious’

Interestingly, the review’s main criticism of COVAX is that its global scope as the key vaccine-purchasing agent for the world was “too ambitious” and that a “more targeted approach” would have been more useful. 

This observation is based on the failure of high-income countries to go through COVAX to buy its vaccines, meaning that COVAX was “unable to play the market shaping role it first envisioned”. 

The crux of any successful pandemic accord will be to ensure that wealthy countries don’t hoard all the available diagnostics, therapeutics and vaccines to fight the next killer pathogen – an almost impossible task.

Instead of expecting wealthy countries to subject their procurement to a global body, it might be more effective for a future pandemic body to “focus on a smaller set of lowest-income countries”, according to the review.

Despite the criticisms, COVAX’s performance in improving access to COVID-19 vaccines in the 92 Advanced Market Commitment (AMC) countries was ranked 7.5 out of 10, the highest survey rating.

By 15 September, it had delivered 1.72 billion doses although massive vaccine inequalities persist. 

Barbados receives 33,600 doses of COVID-19 vaccines, its first shipment through the COVAX facility, in April 2021

Unsuitable operating model

Almost two-thirds of respondents thought that ACT-A’s operating model should not be replicated, citing problems including “insufficient accountability, limited meaningful engagement of low- and middle-income countries (LMIC) and regional bodies, and an insufficient focus on delivery”.

Prioritising speed and using existing global health agencies to respond to the pandemic had “compromised accountability and transparency”, according to the review. 

“Insufficient manufacturing capacity, unhelpful member state responses to COVID-19, and issues around ‘last mile’ implementation were the three factors that had the biggest impact on ACT-A’s ability to deliver on its targets,” according to survey respondents. 

Civil society organisations and academics listed the lack of technology transfers and the management of intellectual property as the most significant challenges. 

“Going forward, a new platform should be established that involves all key R&D partnerships and coordinates R&D across product types and diseases,” the review recommends.

Three-quarters of survey respondents supported joint resource mobilisation instead of uncoordinated fundraising.  ACT-A raised $23.5 billion, two-thirds for COVAX, but fundraising was too slow, and respondents supported a pandemic advance commitment facility with access to credit. 

The World Bank has already heeded this, and last month it set up the Financial Intermediary Fund (FIF) for Pandemic Prevention, Preparedness and Response (PPR) to “provide a dedicated stream of additional, long-term financing to strengthen PPR capabilities in low- and middle-income countries and address critical gaps through investments and technical support at the national, regional, and global levels”. 

The lack of manufacturing capacity, and weak country health systems are key challenges to address before the next pandemic. 

High-level political leadership

Finally, the review advocates for the creation of a high-level political body to keep pandemic preparedness and response high on the global agenda, track overall progress and provide high-level political guidance. 

Previously, the Independent Panel for Pandemic Preparedness and Response (IPPPR) proposed that a council for pandemic preparedness, made up of senior political leaders, be established under the United Nations General Assembly.

Meanwhile, WHO suggested establishing a Global Health Emergency Council and a Committee on Health Emergencies of the World Health Assembly.

ACT-A was guided by a facilitation council chaired by Norway and South Africa, but the co-chairs lacked global clout and spent a lot of energy appealing to world leaders of wealthy countries to share their pandemic products with others.

Image Credits: Gavi , @CEPI , PMO Barbados.

Dr Mariangelo Simao, WHO Assistant Director General for Access to Medicines, Vaccines and Pharmaceuticals

The Indian government has halted the Maiden Pharmaceuticals plant that produced the cough and cold syrups that WHO says were tainted with toxic chemicals – possibly linked to the recent deaths of some 66 children in The Gambia.

A senior WHO official confirmed that Indian government health authorities had shut down the plant after WHO shared data showing that samples of four syrup formulations, produced by the firm and tested by the global health agency, contained diethylene glycol and/or ethylene glycol, which are toxic to humans.

Speaking at a WHO press briefing on Wednesday, WHO’s Mariangela Simao said that WHO had requested the suspension of production at the Haryana-based facility, following tests at a Swiss and French reference laboratories, which confirmed the contamination in the four syrup formulations.

“WHO did recommend to the drug control controller in India to suspend the manufacturing in the plants that were involved in this incident, and we hear that this has been done and that the production is suspended,” Simao said.

India media reported that the government shut down the plant after WHO shared the formal laboratory results (Certificate of Analysis) with Indian authorities. The government has announced the creation of an expert to further analyse the CoAs provided by WHO, and conduct a state investigation into the reported contamination.

WHO first issued alert on 5 October

WHO alert of contamination found in four Maiden Pharmaceuticals products – issued first on 5 October 2022

WHO first issued an alert about the tainted products on 5 October, stating that laboratory analysis of the medicines which were exported to The Gambia “confirms they contain unacceptable amounts of diethylene glycol and ethylene glycol as contaminants.

“To date, these four products have been identified in The Gambia, but may have been distributed, through informal markets, to other countries or regions,” the global health agency reported.

Speaking to reporters a day later, WHO’s Director General Dr Tedros Adhanom Ghebreyesus said the four cold and cough syrups produced by the firm “have been potentially linked with acute kidney injuries and 66 deaths among children.

“The loss of these young lives is beyond heartbreaking for their families,” the WHO director-general added, saying that the agency was investigating further “with the company and regulatory authorities in India.”

WHO tested the tainted medicines for contamination in Swiss and French laboratories

The Gambian Health Ministry has been investigating an unusual cluster of childhood deaths from acute kidney failure since July. In late September, health authorities concluded that tainted paracetamol or promethazine cold or cough syrups were the most probable cause of deaths in at least some of the cases. The ministry had also investigated high E-coli bacteria levels, due to recent flooding and sewage exposures, as another possible cause.

Following the initial laboratory analysis of the medications in The Gambia, which turned up the chemical contamination, WHO obtained samples of the formulations that had been administered to children who were were hospitalized, and sent them for testing in WHO reference laboratories, Simao said at Wednesday’s briefing,

“23 different samples were sent to our reference labs. One of them is in Switzerland in France,” said Simao. “And then we had unfortunate findings of the four pediatric formulations that had contaminations.

Two products are very old formulations

Two products of the products tested are also “very old” cough and cold formulations, which have known contamination risks in the production cycle, Simao also noted.

“They have been involved in other contaminations that led to serious health problems and deaths since 1930,” Simao added. “It’s a very well known history of diethylene glycol we call it DEG, and ethylene glycol we call it EG – they should never be in anything that human beings ingest.”

There is now “a very in-depth investigation of these deaths by the government of The Gambia, by international partners including WHO, who are supporting the investigation,” she said.

But separate from the investigation into the precise cause of the children’s deaths, “once we detect these products [DEG and EG] in a medicine or something that people will ingest… they should be banned from the market.

“WHO has procedures and one of them is the global medical alert that aims to inform national regulatory authorities when we notice problems with a product, and to also inform the public.

“And also we have to raise the alert in terms of [the possibility that] this product may be circulated in other countries. The information we received from the drug controller in India was that dispatches were manufacturer exclusive for the danger but we don’t rule out the possibility that through unregulated markets that it has reached other countries.”

She noted that several other countries in the African region have in turn issued their own alerts “and are proactively doing surveillance, trying to identify if these products are in the market.”

Meanwhile, she said, WHO is “working very closely with the Indian authorities for the full investigation into the manufacturing process itself and the ways this product reached the market.”

Specifics of WHO warning

The four Maiden Pharmaceutical products specifically called out in the WHO alert include:  Promethazine Oral Solution, Kofexmalin Baby Cough Syrup, Makoff Baby Cough Syrup and Magrip N Cold Syrup.

“To date, the stated manufacturer has not provided guarantees to WHO on the safety and quality of these products,” WHO said adding, “Diethylene glycol and ethylene glycol are toxic to humans when consumed and can prove fatal.

“Toxic effects can include abdominal pain, vomiting, diarrhoea, inability to pass urine, headache, altered mental state, and acute kidney injury which may lead to death. All batches of these products should be considered unsafe until they can be analyzed by the relevant National Regulatory Authorities. The substandard products referenced in this alert are unsafe and their use, especially in children, may result in serious injury or death.”

Substandard medicines a major problem in Africa

Substandard medicines are a widespread problem in Africa and parts of South-East Asia.  According to one recent estimate, in some parts of Africa, up to 70% of medicines may be either fake or substandard.

There are widespread hopes that the pending establishment of the Africa Medicines Agency (AMA) could help counter this longstanding trend by harmonizing drug regulatory review and approvals across the continent – thereby strengthening the capacity of poorly-resourced countries to supervise its medicines markets.

So far, some 33 of the African Union’s 55 member states have either signed and/or ratified the treaty on the African Medicines Agency. Just this week, South Africa’s cabinet announced it would submit the treaty to its parliament for ratification. The Gambia is one of the 22 countries to have neither signed nor ratified the agreement.  See related AMA coverage here,

African Medicines Agency Countdown

 

Image Credits: WHO, World Health Organization .

(From L-R) Olivier Dessibourg (moderator), Arnaldo Correia de Medeiros, Soumya Swaminathan, Jeremy Farrar and Scott O’Neill, at the GESDA Summit session Wednesday on Wolbachia control of dengue disease.

A nature-based solution that could help reduce the rising global burden of disease from dengue fever is looming on the research horizon. But more studies are needed before the World Health Organization could recommend a broad scale-up of the approach, WHO’s chief scientist said on Wednesday.  

WHO Chief Scientist Soumya Swaminathan summed up her conclusions on the research to date into Wolbachia bacteria as a dengue control tool at a panel event hosted by the Geneva Science and Diplomacy Anticipation Summit. The 2022 GESDA Global Summit is taking place this week from Wednesday to Friday.  

Source: https://ourworldindata.org/grapher/dengue-incidence

“Safety is quite the primary thing for us…making the recommendation is one thing and using and applying it is another. Of course, the WHO’s role is to provide evidence-based guidelines in as timely a fashion as possible, but if there isn’t good evidence backing it, the [WHO] guideline developing group does not feel comfortable,” Swaminathan said.

The discussion on Wolbachia at a session on Controlling Vector-transmitted Infectious Diseases was among a number of future health strategies showcased at the three-day summit, which drew together some 1200 scientists, diplomats and other expert participants from around the world. 

This year’s agenda also includes discussions around the future potential for artificial intelligence, organoids and other synthetic biology approaches to address disease pathology and pave the way for new disease control solutions, from organ transplants to mood disorders.  

Science that makes no sense today, may make sense tomorrow

Sir Jeremy Farrar, director of Wellcome Trust, at the GESDA session

“Science that makes no sense today may make sense tomorrow,” said Sir Jeremy Farrar, the director of Wellcome Trust, who appeared with Swaminathan at the vector control control panel on the opening day of the GESDA conference. 

Farrar  described the work on Wolbachia, led by  Dr Scott O’Neill, founder of the World Mosquito Programme as the kind of pathfinding research that GESDA aims to identify and amplify – accelerating the long journey to real-world results.

 “GESDA wasn’t in existence when Scott (O’Neill) started his work. But if it had been, this would be a case study as to why GESDA was important,” Farrar said.  “It was in the last century when this work started, with basic science invested over years and years. It was high risk, it was difficult..no one could see where it was going…It made no sense.” 

A potentially sustainable solution to dengue that took decades to develop

Over the past two decades, the number of dengue cases reported to WHO has increased ten-fold. While estimates of the true rate of infections varies wildly, data by the Institute of Health Metrics and Evaluation (IHME) estimates a burden of more than 50 million cases a year, concentrated in South-East Asia.

Research on the Wolbachia’s potential as a control tool began in the 1980s. But the bacteria’s ability to compete with, and thus curtail, dengue virus transmission in Aedes mosquitoes only came to light around 2009. The experimental technology involves the injection of Wolbachia bacteria into female Aedes mosquitoes. Within the mosquito, the bacteria competes with dengue virus, Zika and other dangerous mosquito-borne diseases, curbing the mosquito’s potential to transmit those viruses to human beings. 

The female mosquitoes also continue to transmit the beneficial Wolbachia bacteria from one generation to the next within their eggs. Although not normally found in Aedes aegypti mosquitoes, Wolbachia is found in some 50% of insects in the world, and thus considered safe for humans and the environment, according to the researchers.  

First release in Australia in 2011

Scott O’Neill, founder of the World Mosquito Program and leading Wolbachia innovator

In 2011, O’Neill and his team based at Monash University released the first set of Wolbachia-infected Aedes mosquitoes into the wild in Cairns, Australia. The results were astonishing; dengue transmisison was reduced by 98%. 

Since then, the strategy has been tested systematically in two sites in Brazil, including Rio de Janeiro, three cities in Colombia, Indonesia and Vietnam. 

A study on the Indonesian trial that took place in Yogyakarta on the island of Java, was published in 2021 in the New England Journal of Medicine. Some 42-months post release, dispersion of the Wolbachia bacteria between March and December 2017 led to an 80% reduction in  dengue virus rates across 12 geographic clusters in the city of half a million people.  

Speaking about the trials in the panel discussion, O’Neill also stressed the climate resilience of the strategy, which is a growing concern in a warming world. 

“We found in some locations, extreme temperatures can be problematic and have been documented. Is that going to be a huge problem for the technology?” O’Neill asked.

“I don’t think so because it is not constant temperatures that cause the problem. It is the really blazing hot sun of around 45ºC that causes the problem. That’s usually when we get into more temperate areas…” he said, noting that in tropical areas where the dengue disease burden is the highest, the temperatures are more constant. 

Also piloted in Colombia and Brazil 

Professor Scott O’Neill presents the combined results of trials on Wolbachia control of dengue disease in four countries, at the GESDA Summit session Wednesday.

A pilot in three cities in Colombia, including Medellin, reduced dengue incidence by a whopping 94-97% 20-45 months post-release, Scott said in his presentation. Conversely, the trial in Rio de Janeiro has yielded the weakest results so far, with a 44% reduction in dengue incidence four years after the mosquitoes were released.

Even so, Arnaldo Correia de Medeiros, the Brazilian state undersecretary of health managing a pilot in Rio, stressed the government’s commitment to continue its investment in the Wolbachia method, on which it has already spent over $3 million. 

The trials also required significant outreach – sensitizing communities where the Wolbachia-infected mosquitoes were released not to kill mosquitoes infected with the beneficial bacteria, Medeiros observed.  

“It is important to educate the communities that they do not have to kill these mosquitoes because they are not the bad ones, they are the good ones,” Medeiros said, describing the meetings that were held with health workers and the public “so that they understand that  we are going to release the mosquitoes, and after that we are going to monitor, collect data and do the studies.”

In this dimension as well as others, the multi-country trials already have generated valuable insights critical to broader, real-world use of the strategy: “We need to understand how many lessons we have learnt when we think about [scaling up to] the world,” he said.    

WHO: Still need more solid and diversified evidence  

WHO Chief Scientist Soumya Swaminathan at the GESDA session

The technology has been on WHO’s radar for many years, and its Vector Control Advisory Group (VCAG) has been working closely with Dr O’Neill’s team for some time, Swaminathan said.  

Only last month, WHO concluded a year-long  public consultation on the design of a “Target Product Profile” that would help standardize the widespread use of the bacteria. 

Even so, WHO still needs more evidence on the strategy’s safety and efficacy to make a full WHO endorsement, in the form of a new WHO guideline for policymakers, said Swaminathan, at the panel event.

“Especially in a situation like this where the behaviour of a vector could vary from year to year, depending on the climatic conditions… there are many factors that might actually affect the results of an intervention study,” Swaminathan observed.

“For vector control it is not enough to show that there is a change in the vector behaviour, but it is important to show that there is some epidemiological change in the disease,” she stressed.  

“It also has to be cost-effective, it has to be equitable; we look at many factors before the WHO Guideline group actually recommends (a health innovation).”

And there is no fixed timeline for reaching that endpoint, the chief scientist acknowledged, noting that WHO guidelines development can take years.  

Drawing parallels between the agency’s actions during the Covid-19 pandemic where  emergency decisions were taken too rapidly, with insufficient evidence, and then later had to be corrected, Swaminathan added: 

“Science is interesting, but it also needs to have a public health impact.”

Big up front investments can pay off  

Widespread deployment of the technology would involve heavy up front costs, O’Neill acknowledged. 

However, he underlined that  such investments can also offer large returns. “To implement technology is expensive at the front end and it pays back over time.”

For instance, while Brazil so far has spent $3 million deploying Wolbachia-infected Aedes mosquitoes, to date, the savings in averted social and medical costs have amounted to over $24 million, according to data collected by O’Neill’s team – even at the 44% rate of efficacy demonstrated locally. 

Source: World Mosquito Program

Funding agencies and philanthropies need to look at such benefits-to-costs ratios when making decisions about investments – prioritising choices that will ultimately have the greatest  impact on the ground, Farrar added, echoing O’Neill’s remarks.  

Meanwhile, effective public health action against dengue virus, which has become a kind of poster child disease in many developing cities, could set a precedent for many other important innovations that can benefit health, Farrar emphasized.  

Notably, dengue-infected mosquitoes breed and thrive in crowded informal settlements and urban slums full of standing water and waste sites. As a result, the same forces of driving dengue also impact disease control more generally, and public health, through multiple pathways – from poor housing to the lack of effective water, waste and sanitation systems. 

“Dengue is something which is a harbinger of bigger things that are changing the world like climate, urbanisation, trade and travel…I think to get dengue right will set a precedent for how we get a number of things right,” said Farrar.  

Speaking more broadly, public health practitioners and decision-makers need to develop their own capacity to anticipate and take up new public health technologies in a rapidly changing world:

“Technology is coming and let’s think ahead of how we may use it in the communities. We shouldn’t be thinking of tomorrow but five, 10 and 15 years ahead. Because, at least some of it, we can predict,” Farrar said.  

Also at GESDA: Other futuristic solutions  

Along with the session on vector control, this year’s GESDA summit is featuring a number of other futuristic technologies that could positively impact the understanding of the human body and eventually disease control solutions and public health outcomes. Organoids, synthetic biology, artificial intelligence, data and computational science, brain miniaturisation and brain signal detection all have a place in this year’s agenda. 

  • Defining Health Usage Frameworks for Organoids: Organoids are 3D cell cultures that have the potential to transform the realms of organ transplantation, disease pathologies and drug development. However, the technology is not without its own set of challenges and questions around ethics. 
  • Synthetic Biology: Towards New Geopolitical and Economic Frontiers: Apart from having a potential similar to organoids, synthetic biology also encompasses the power to disrupt the global order and disturb world peace. A public plenary to explore the various implications of advanced technology like this is on the schedule. 
  • Deciphering the role that artificial intelligence (AI) can play in decoding the human immunome, thus opening doors for exploring newer health diagnostics and therapeutics is also on the cards at this year’s summit. 
  • Data and computational systems. These are increasingly being leveraged to enhance the human understanding of climate cycles, population dynamics and their management.
  • Brain miniaturisation and brain signal detection – These technological advancements help humans better decipher neurological patterns and thus address pathologies related to mood regulation and memory. While the concepts have generated a lot of interest and investments in the research community, the GESDA session also looks at policy implications.

Image Credits: Megha Kaveri/Health Policy Watch, Megha Kaveri/Health Policy Watch , World Mosquito Program .

A Ugandan health worker disinfects the boots of colleagues in an Ebola treatment zone. In the absence of an effective vaccine for the Sudan Ebola virus strain, strict sanitation, patient isolation and contact tracing are the sole measures available to fight the outbreak.

The spread of a cholera outbreak to an overcrowded Haitian prison, of Ebola virus to Uganda’s capital city of Kampala, and increased incidence of malaria, dengue, measles and cholera in flood-swamped Pakistan were among the long list of health emergencies needing urgent attention and investments – as compared to the trillions being invested right now in military conflicts around the world, said WHO’s Director General on Wednesday. 

“We are deeply concerned about the outbreak of cholera in the capital Port au Prince and surrounding towns…The surveillance mechanism set up by the Haitian government with the support of WHO and other partners is operating under extremely difficult circumstances as the affected areas are very insecure and controlled by gangs,” said Tedros, speaking at a WHO press briefing Wednesday. “In Uganda, so far there are 54 confirmed and 20 probable cases, with 39 deaths [from Ebola virus]… 

“In Pakistan,  I said last week that many more people than died in the floods could die from diseases in coming weeks… now there is a malaria outbreak in two districts while the incidence of cholera, dengue, measles and diphtheria is also increasing in flood affected areas. But so far international support has not been at a scale or speed needed. 

“Trillions of dollars are being poured into fighting wars around the world.  We continue to ask international donors to invest in saving lives.” 

Cholera in Haiti – security the major barrier to controlling outbreak 

Dr Tedros Adhanom Ghebreyesus speaking at a WHO press conference on Wednesday 12 October.

In terms of the Haitian cholera outbreak – the threat that the deadly disease could spiral further out of control is high, both Tedros and other global health advocates have said, given the severe overcrowding of the country’s prisons, fuel shortages, and continued lawlessness. 

Officially, only 18 deaths have been confirmed nationwide, along with 200+ hospitalizations, since last week’s announcement of the country’s first cholera deaths in three years, according to the Associated Press.

However under-reporting is likely given the civil insecurity that is prevailing.

“The surveillance mechanism set up by the Haitian government with the support of WHO and other partners is operating under extremely difficult circumstances,” Tedros said at the WHO press briefing. “The affected areas are very insecure and controlled by gangs, which makes it very difficult to collect samples and information of cases and deaths.

“In addition, fuel shortages are making it harder to help workers to get to work, causing health facilities to close and disrupting access to services for people who live in some of the most deprived communities,” he added.  

Writing in The Nation, a group of global health experts said that as many as 80 people may have already died of the deadly disease in Haiti’s notoriously overcrowded National Penitentiary over the past week. 

And hundreds more prisoners could die in coming days, warned the experts, led by Partners in Health’s Loune Viaud. They appealed to Haitian authorities to organize a mass prisoner release to ease overcrowding and to international donors for urgent investments in vaccines, medicines, clean water and sanitation.  

“WHO is working with the Ministry of Health and our partners to coordinate the response, including for surveillance, case management, water and sanitation, vaccination and community engagement. But to bring this outbreak under control, we need secure access to the affected areas,” he concluded.  

A senior US official, Brian Nicols, was due to fly to Haiti Wednesday on an official visit, while a State Department spokesman said that Washington is also reviewing an urgent Haitian request for help, including intervention by foreign troops to quell the civil violence, the Associated Press reported. 

In 2010, some 10,000 people died in Haiti’s first cholera outbreak, the worst in recent global health history.  That outbreak was eventually traced to a sewage leak from a base of U.N. peacekeepers, who had been brought there to help after an earthquake earlier in the year. 

Ebola – no vaccines, challenges on ground with community engagement 

Meanwhile, speaking from Uganda, WHO’s Health Emergencies expert Mike Ryan said he had “confidence” in the government handling of the Ebola outbreak – the largest seen there in years.  

However, observers pointed to the fact that the spread of the deadly virus to a major city was a worrisome sign – following a similar pattern seen in the 2014-2016 West African outbreak that left over 11,000 people dead. 

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The shift of infections to a major city like Kampala is particularly worrisome for public health experts since there is as yet no approved vaccine for the Sudan strain of the virus, the one to have struck Uganda this time.  In comparison, the recent outbreaks in neighboring Democratic Republic of Congo, caused by the Zaire Ebola virus strain, have been quickly squashed by ring vaccination efforts using new vaccines developed since 2016. 

“As with Covid-19, the race is now on to find an effective vaccine: there are two potential candidates from GSK and Oxford, and clinical trials are being launched in the middle of this outbreak,” said global health expert Devi Sridhar, writing in The Guardian.

Emergency meeting of regional health ministers convened over outbreak

The area of southwestern Uganda, which has been the epicenter of the outbreak, is also a concern, located at a major trade crossroads.

“Cases were first detected in the Mubende district among people living around a goldmine. Gold traders are highly mobile, particularly along the busy highway that runs between Kampala, a densely populated and globally connected capital of 1.68 million people, and the Democratic Republic of the Congo to the west,” she noted. 

With no vaccine tools available, public health workers have been forced to rely upon non-pharmaceutical measures, including isolation of infected patients, careful infection control, safe burials and the like.  

On the positive side, the turnaround time for Ebola virus diagnosis has been sharply reduced from 48 to just 4-6 hours, said Ryan. Similarly, people with symptoms of Ebola are presenting themselves at clinics earlier  – but still not fast enough. 

Ministers of health from Uganda and eight neighboring countires also held an emergency meeting Wednesday to agree on a series of joint control measures – to prevent the onward spread of the virus beyond Uganda’s borders – which is regarded as a high risk.

Community engagement in the areas affected remains a problem, he noted, with some people still heavily reliant on traditional medicine – and resistant to undertaking safe burial practices – which forbid family members from gathering closely around and handling the body of a loved one who has died. 

“I think it’s fair to say that the Ugandan government is completely activated,” said Ryan. “But we  need more alerts, we need better infection prevention and control in private and public facilities. 

“We need to really embrace the concept of true community engagement – so that the communities are seeing benefits in the process.”

Image Credits: Photo: Anna Dubuis / DFID, WHO African Region.