Dr Hiroki Nakatani joins in the applause after the resolution’s passage

Diplomats approve the complex process they will use to update the legally binding rules among nations for responding to global health emergencies like the coronavirus pandemic.

GENEVA – The 194-nation World Health Assembly approved a resolution on Friday that halves the two-year period for amendments to the International Health Regulations (IHR) to take effect down to just one year.

The move is part of a highly technical package of US-proposed measures that picked up support as the most practical way of kickstarting the reform process in pandemic response. Broad applause broke out just after one of the Assembly’s main committees adopted the resolution.

“I’m so excited,” said the committee’s president and veteran public health specialist Dr Hiroki Nakatani, “that we could adapt this very important resolution by consensus.”

Just before the respolution’s adoption, Colin McIff, deputy director of the US Department of Health and Human Services’ Office of Global Affairs, explained a series of technical changes that had been reached to ease passage of the resolution. Those included giving nations “additional time for consideration” – up to 10 months, rather than nine, to reject or voice reservations over any future amendments that would be adopted. Nations also would have up to 12 months – double the previous suggestion of six months – to ensure they implement any IHR amendments that newly enter into force of law.

A paragraph also was added, he said, that urges nations “to collaborate with each other in the provision or facilitation of technical cooperation and logistical support, particularly in the development, strengthening and maintenance of the public health capacities required under the International Health Regulations.”

Resolution reflects “our produtive work together”: Colin McIff, Deputy Director of the Office of Global Affairs at the U.S. Department of Health and Human Services.

The entire resolution reflects “our productive work together over the past several days here at the Health Assembly and reflects the consensus of member states,” said McIff. “We would like again to thank member States for working together on this historic effort to strengthen the IHRs.”

The Biden administration, supported by countries as diverse as Colombia and Thailand, has long contended that changes to IHR would complement, rather than be a substitute for a pandemic treaty. The changes to IHR would be targeted to topics already covered in the global health rules like procedures around outbreak notification, and could take effect within three years. A treaty would likely address a broader set of issues, but also take far longer to negotiate, approve and be ratified by individual member states.

IHR revisions urgently needed  

More than a year ago the Independent Panel on Pandemic Preparedness and Response concluded the IHR badly needed updating from the “analogue” to “digital” era of information sharing to ensure that WHO and its member nations more quickly react to global health risks. 

Under current IHR rules, for example, there is no clear deadline for countries to report suspected outbreaks to WHO or for WHO, in turn, to report them to member nations. In a recent wild poliovirus outbreak in Malawi, it took months for a report on it to be published.

While such concerns weren’t directly addressed by this Assembly, the decisions made this week set in motion a process for updating the vague and often indirect 2005-era IHR rules, while negotiations proceed over a broader pandemic treaty.

Earlier in the week, that procedurally-oriented resolution ran into unexpected resistance from some nations, including the African Group, which was concerned that changes might be introduced to the IHR without sufficient study or input.  

Working Group on IHR reform paved the way  

McIff told the committee that those concerns were addressed during intensive discussions as part of a Working Group that paved the way for the resolution’s adoption by consensus. One key breakthrough, diplomats said, was the Assembly’s approval late Tuesday of the companion WHA decision that sets in motion a two-year process for substantive rule changes that are the ultimate goal. 

The aim is to have a package of reforms ready for the World Health Assembly 77 in 2024 and for any new rules that are approved to take effect as of May 2025. The task of collecting and assessing nations’ proposals for amending the IHR will be managed by a new member state “Working Group on IHR reform (WGIHR)” that replaces the  “Working Group on Pandemic Reform” that operated over the past year.  

In tandem, WHO’s Director-General Dr Tedros Adhanom Ghebreyesus has been asked to convene an IHR expert review committee to provide more studied inputs into the WGIHR about the most needed and useful reforms.

According to the timeline agreed to on Tuesday, any and all member states may submit their proposals for revising the IHRs to the new WGIHR group by 30 September 2022. The WGIHR group will sift through the proposals and draft a report to be reviewed by the WHO Executive Board in January 2023. In parallel, the expert IHR Review Committee will make its own recommendations by then.  

“The rebranding of the WGPR to the WGIHR gives all member states an equal opportunity to put their ideas forward,” a senior US official, said of the process, in an interview with Health Policy Watch.

The fact that an IHR expert review committee will also provide input means that “there’s going to be a member state political component that’s backed up by an expert level review commissed by the DG,” the official said.

Interface with the pandemic convention negotiations 

One key concern has been the potential overlap of the IHR reform process and the parallel process already underway of negotiations on a potential new pandemic convention, treaty or other instrument – which can potentially address  a broader set of issues and concerns, such as medicines and vaccines equity and related to that, support for better emergency preparedness and response in low and middle-income countries.  

The negotiations on the pandemic instrument are already underway under the guidance of an Intergovernmental Negotiation Board (INB), mandated by a special session of the World Health Assembly in November 2021.

Diplomats hope that by the time the negotiations over IHR reform get underway in serious in early 2023, the INB will have made some progress – and specific pandemic reform issues can be allocated to one or the other of the processes without too much overlap.

The aim is to make the two processes complementary, the senior US official said, with the IHR revisions starting later, but also concluding more rapidly – while the pandemic convention or treaty process continues.

“There’s been very strong engagement with the African group, and also with the Europeans and others, a lot of back and forth around this discussion of should there be a treaty or an international instrument,” the official said.

That dialogue contributed to “a lot of consensus-building over the course of this year, starting with the Executive Board in January, which endorsed in Decision 150(3), the concept of targeted, limited [IHR] amendments, without opening up the whole IHR for renegotiation. So that’s what we’ve been building on, and that’s what was adopted.”

Timeline for moving ahead on IHR reform

According to the timeline set out in the the decision on Tuesday, any and all member states may submit their proposals for revising the IHRs to the new WGIHR group by 30 September 2022.

The WGIHR group will sift through the proposals and draft a report, to be reviewed by the WHO Executive Board in their meeting of in January 2023. 

In parallel, the expert IHR Review Committee of experts will also complete its work – and make recommendations by early 2023. 

The aim, the senior US official told Health Policy Watch, is to then “put all that into the mix, and then the member state negotiation process can really begin in earnest.”

While the IHR negotiations will still take at least two years, not including the year for any new amendments to take force, there is a delicate balancing act that must be observed, the official said, referring to concerns that had emerged in talks with the African Group and other nations over the past week:

“We have to move with a sense of urgency and a sense of purpose. But frankly, these are also technically complex issues, relating to a lot of implementation challenges, not only in the executive branch, but legislative branches of governments.  So we have to give due consideration to the topics as well.” 

Nigeria objected to the inclusion of ‘sexual orientation, transgender and men who have sex with men’.

Despite significant compromises to a draft strategy on HIV, hepatitis B and STIs, conservative World Health Organization (WHO) member states used a debate at the World Health Assembly on Friday to object to the inclusion of such as “sexual orientation”, “sexuality” and “men who have sex with men”.

The objections were led by Nigeria, Egypt, Pakistan, Jordan and Saudi Arabia, who claimed that some of the sexual health and rights terms referred to in the Global Health Sector Strategies (GHSS) on HIV, viral hepatitis and sexually transmitted infections 2022-2030 – terms standard for many years in HIV treatment and care – was an affront to their culture.

This led to a delay in WHA approval of the GHSS – whose finalization also was delayed by disputes over references to comprehensive sexuality education and gender identity, despite the expiration of a previous strategy in 2021.

A last-minute compromise was proposed on Friday night by Saudi Arabia. This involves deleting the entire GHSS glossary and inserting two footnotes. One footnote would record that some countries have reservations about the term “sexual orientation”. The other would note objections to a reference to the International Technical Guidance on Sexuality Education.

But a number of member states said that they needed to first check with their principals before accepting the last-minute compromise. While none of the member states voiced objections to Saudi Arabia’s compromise, Monaco’s delegate expressed disquiet at the delay, which she said was unprecedented in her many years at the WHO.

The Africa region did not object to the text, with Namibia and Senegal expressing support for science-based approaches. Neither did Russia which is renowned for leading the anti-LGBTQ charge at international forums, but in this case described the GHSS text as “balanced”.

Saudi Arabia proposes a compromise.

Science-based policies

Earlier in the debate, Suriname on behalf of 56 countries including South Africa, Thailand, the UK and US, stressed that while consensus was important, health strategies had to be based on data and evidence.

“We recognise that achieving consensus at the World Health Assembly depends on compromise balancing national priorities and contexts with the global epidemiological context, but it is the WHO’s role to put forward normative guidance that follows and aligns with the most current science-based knowledge,” Suriname asserted.

“We must continually adjust and replace outdated or ineffective interventions with those that can reach key populations and vulnerable populations,” added Suriname. “Effective approaches must promote equity, gender equality, and protect and fulfil the human rights and dignity of all.”

Loyce Pace, Assistant Secretary for Global Affairs at the United States Department of Health and Human Services (HHS).

The US, represented by Loyce Pace, Assistent Secretary for Global Affairs at the US Department of Health and Human Services, praised the “comprehensive and transparent consultation process” that took place over the strategy throughout 2021 and 2022. 

“The US would like to underscore the important role WHO plays in developing strategies,” said Pace.

“These strategies are used widely across all regions to guide the provision of health services and interventions. To ensure the greatest impact they must be based on the most current science responding to the diverse needs of different populations, especially those who are excluded from health services due to stigma and discrimination.”

Pace added that “effective approaches must promote equity, gender equality, and protect and fulfil the human rights and dignity of all”. 

Concessions

She also pointed out that a number of concessions had been made to the GHSS in the interest of reaching consensus. 

“Important subjects central to addressing these diseases have been removed from the document or caveat, including comprehensive sexuality education, gender identity, gender-responsive approaches, intimate partner violence that’s not limited to heterosexual partnerships and gender-based violence,” said Pace.

“The current scientific evidence clearly supports the inclusion of these terms and effective strategies to address HIV, viral hepatitis and STIs,” said Pace, but added that the US “remain satisfied that the strategy is preserved the importance of core interventions and populations of focus”. 

France on behalf of the European Union (EU) noted that, “despite the scientific nature of the work on the strategy, some states are reluctant to recognise some realities on which this guidance is based, even though they could adapt them to their national situation”.

“We underscore the importance of ensuring universal access to complete education and good information on health connected with sex, your sexual health and complete sexual and reproductive health support,” added France.

Cultural objections

Among African nations, Nigeria was most vocal in its complaints about terminology used in the strategy documents.

“Spirited efforts were made by the delegation of Nigeria to engage the Secretariat where these concerns can be addressed. Nevertheless, and despite the demonstration of openness and best intentions by Nigeria, it is disappointing and most unfortunate that some of these terms and phrases – which are totally objectionable, and inimical to our cultural and social well being as a sovereign state – are still broadly reflected in the text,” said the Nigerian delegate.

“Nigeria hereby without ambivalence and or intended ambiguity, objects and dissociate itself from the following terms and phrases in the text: ‘sexual orientation, transgender, men who have sex with men’.”

Nigeria also objected to the reference to the International Technical Guidance on Sexuality Education and the definition of sexual health in the glossary.

“Let it be placed on record that Nigeria has not accepted these terms and phrases in the past. I will not accept them today,” he declared.

Jordan said that “some of the expressions and some of the language used in the text does not conform to the culture and tradition in our country and the countries of the region” and “remain unacceptable to us”. 

Pakistan objected to  “non-consensual terminologies about gender, sexual orientation, sexual rights, comprehensive sexuality education, among others”. 

Egypt, Indonesia, Bahrain and Bangladesh also raised objections.

Science not ideology

The International Federation of Medical Students Associations, International Federation on Ageing, International Planned Parenthood Federation, and Women in Global Health told the assembly that they “deeply regret the removal of terms like comprehensive sexuality education (CSE) and intimate partner violence (IPV) from the text”.

“We emphasise the need for WHO to adopt strategies that are evidence-based, rather than based on politics and ideology. The objective and functions of WHO as defined in its constitution are very clear. We call on the director-general of WHO to stand firm behind science and not ideology.”

Meanwhile, Cedric Nininahazwe, the advocacy manager of the Global Network of People Living with HIV, praised the new strategy, saying that it gave hope to communities.

 

Dr Tedros urges implementation of NCD policies.

While the World Health Assembly adopted a raft of roadmaps, strategies and resolutions to address non-communicable diseases (NCDs) on Friday, what was important was their implementation, said Dr Tedros Adhanom Ghebreyesus.

“It is impossible to overstate the importance of concerted action against non-communicable diseases, which account for 85% of all premature mortality in low and middle-income countries,” said Tedros,  Director-General of the World Health Organisation (WHO).

“The package of strategies, roadmaps, action plans, work plans and recommendations you’re about to adopt provide important evidence-based tools that could save many lives. But what matters is not adopting them, but implementing them. What happens in this room is important only in as much as it translates into concrete change,” Tedros challenged.

“The growing burden of NCDs highlights the many threats to health in the food people eat, the water they drink, the air they breathe and the conditions in which they live and work,” said Tedros.

While diabetes and obesity are rising globally, tobacco use has declined in 150 countries and 58 countries had policies to eliminate trans fat from food, he added.

“Tobacco use remains too, high physical activities too low and 99% of the world’s population raises air that exceeds WHO air quality limits,” he said.

“The great tragedy of NCDs is that many of these diseases are preventable and treatable when people have access to the services they need. That’s why it’s so crucial that all member states prioritise resources to integrate services for NCDs and their risk factors into primary health care as part of their journey towards universal health coverage.”

Huge treatment gap for epilepsy

Dr Zsuzsanna Jakab, WHO Deputy Director-General.

Dr Zsuzsanna Jakab, WHO Deputy Director-General, pointed out that more than 50 million people with epilepsy live in low and lower middle-income countries, but the treatment gap is over 75% in most low-income countries and 50% in most middle-income countries.

Jakab said that the neurological manifestations of COVID 19 infection had also highlighted the importance of addressing neurological conditions such as epilepsy.

“COVID-19 condition, disruption of services, medication inaccessibility, interruption in vaccination programmes and increased mental health issues have added to the burden of those with neurological disorders,” said Jakab, adding that the action plan represents an unprecedented opportunity to address the impact of neurological disorders.

“Meanwhile, the alcohol-attributable disease burden continues to be unacceptably high and there is a need to accelerate action on reducing the harmful use of alcohol,” she added.

Dr Ren Minghui, WHO Assistant Director-General of communicable and non-communicable diseases within universal health coverage, highlighted that disorders of the nervous systems are “the leading cause of disability-adjusted life course and the second leading cause of deaths globally”, accounting for 9 million deaths per year. 

“In addition, every 10 seconds a person died from alcohol-related causes.”

“People living with neurology disorders continue to experience stigma, discrimination and human rights violation,” he added.

With regard to alcohol, some member states had asked for guidance on how to protect alcohol policy from commercial interests and this would be provided by the WHO Secretariat, Minghui added.

monkeypox
Sylvie Briand fielding questions about COVID-19 cases in healthcare workers.

GENEVA — The monkeypox outbreak has spread to almost 200 cases reported by more than 20 nations outside of Africa, where the disease is endemic. But the epidemic can be contained through a quick response, World Health Organization (WHO) officials told a public briefing for member nations on Friday.

With few vaccines and drugs available globally to fight monkeypox, a zoonotic disease transmitted from animals, WHO officials proposed creating a stockpile to equitably share existing resources. They said there is no evidence the virus has changed but acknowledged many questions remain about how this epidemic emerged, and what role animal hosts played in tranmission.

Dr Sylvie Briand, WHO’s director of pandemic and epidemic diseases, said “it’s an unusual situation” because the first case was only reported on 7 May, and since then there have been a high number of cases among non-endemic countries. Most of the cases result in symptoms such as body aches, chills, fatigue and fever, but some people may also develop a rash and lesions on their face and hands that can then spread to other parts of the body.

Monkeypox endemic in nine countries

“We know that it’s endemic in a bit more than nine countries in Africa where we have seen outbreaks in the recent years. This virus is an autopox virus. It’s a virus from the same family as smallpox and also other cowpox viruses,” Briand said.

“What is important is just to see that this event is unusual,” she said. “Usually, we have no cases or very sporadic cases that are exported to non-endemic countries. But now we have more and more cases.”

Briand said WHO doesn’t know “if this unusual situation is due to a virus change. It doesn’t seem so, because the first sequencing of the virus shows that the strain is not different from the strains we can find in endemic countries, and it’s probably more due to a change in human behavior.”

“But we are also investigating this and trying to understand the origin of this sudden outbreak of monkeypox in non-endemic countries,” she continued. “There are so many uncertainties about the future and this disease, about the future, because we don’t know if this transmission will stop.”

Briand said WHO believes there is “a good window of opportunity to stop the transmission now” because of existing medical countermeasures, vaccines and therapeutics. “We are afraid that there will be spread in communities, but currently it’s very hard to assess this risk. We think that if we put in place the right measures now, we probably can contain this easily,” she said.

No need for mass monkeypox vaccination

Dr Rosamund Lewis, head of WHO’s smallpox department, said a vaccine for monkeypox has only been approved in the US and Canada, but there is no need for mass vaccinations because the virus is usually only transmitted only through skin-to-skin contact. But she suggested those few nations that have the vaccines could use them for vulnerable populations, such as health workers or families of patients.

“And as far as we know, smallpox countermeasures may be protective against monkeypox. But you can imagine that there’s not been time to do a lot of research, certainly nothing on smallpox in the last 40 years in terms of human studies, clinical trials and field studies,” Lewis said. “What we have been advised so far is that there is no need for mass vaccination, there is no need for large immunization campaigns.”

Dr Mike Ryan, WHO’s emergencies chief, said the global body will work with member nations on creating a stockpile to share the limited number of smallpox vaccines with other nations that lack the resources to purchase them.

“We would like to see a coordinated mechanism whereby countries can access vaccines and therapeutics through a mechanism that’s efficient, that’s fair, that’s equitable, but also recognizes that mass vaccination is not the target here,” he said.

“We’re talking about providing vaccines for a targeted vaccination campaign, for targeted therapeutics. So the volumes don’t necessarily need to be big, but every country may need access to a small amount of vaccine.”

Ryan said such vaccines would be distributed on the basis of need, not the ability to pay, and a number of countries already “have very wisely invested in stockpiles in case of smallpox” and could make available vaccines and therapeutics that are licensed for monkeypox.

“We will and are and will be working with those countries to see if we can make good on many informal arrangements over the years for the sharing of those products,” he said. “And we would very much thank those countries who do have stockpiles, who have engaged with us previously over the years, and are engaging with us right now to try and find solutions for this issue.”

Image Credits: WHO.

Albert Bourla, CEO of Pfizer.

Pfizer will provide all of its current and future patent-protected medicines and vaccines available in the United States and the European Union on a not-for-profit basis to 45 lower-income countries where some 1.5 billion people live.

However, critics have questioned whether the announcement has been timed to undermine a possible waiver on intellectual property for COVID-19 vaccines due to be discussed at the World Trade Organization (WTO) next month.

The Pfizer initiative, an ‘Accord for a Healthier World’, was announced at the World Economic Forum in Davos on Wednesday.

Under the Accord, Pfizer said it would initially provide 23 medicines and vaccines that treat infectious diseases, certain cancers, and rare and inflammatory diseases. 

Making these medicines and vaccines more readily available has the potential to treat non-communicable and infectious diseases that claim the lives of nearly one million people each year in these countries and chronic diseases that significantly impact quality of life for at least half a million more. 

Rwanda, Ghana, Malawi, Senegal and Uganda are the first five countries to commit to join the Accord. Health officials in these countries will help identify and resolve hurdles beyond supply to inform the roll-out in all 45 lower-income countries.

“As we learned in the global COVID-19 vaccine rollout, supply is only the first step to helping patients. We will work closely with global health leaders to make improvements in diagnosis, education, infrastructure, storage and more. Only when all the obstacles are overcome can we end healthcare inequities and deliver for all patients,” said Pfizer Chairman and Chief Executive Officer Albert Bourla.

The Accord countries include 27 of the world´s lowest-income countries as well as 18 lower-middle-income countries that have transitioned from low to lower-middle-income classification in the last ten years. 

Distraction from TRIPS waiver?

However, Julia Kosgei, policy advisor to the People’s Vaccine Alliance, described the accord as an attempt by Pfizer to improve its reputation.

“It’s right that some countries will not have to pay Pfizer’s rip-off prices for certain vaccines and treatments. But Pfizer is once again gate-keeping who can and can’t manufacture and access these lifesaving vaccines and medicines. Many lower-middle and middle-income countries will continue to pay through the nose for lifesaving drugs they can’t afford,” said Kosgei.

“We are weeks away from an important vote on pharma intellectual property at the World Trade Organization [TRIPS waiver]. And Pfizer has calculated that this move will ease the heat generated by its appalling conduct over the last two years.”

Meanwhile, James Love of Knowledge Ecology International (KEI) said that while the deal drew attention to the need for expanded access to medicines, “there are so many questions about what the initiative really is and is not”. 

He also questioned the timing of the announcement.

“What I would like to see would be: all the agreements and program details made public; an independent evaluation of what constitutes a ‘non-profit’ price, and annual, truly independent and transparent evaluations of what actually happens,” said Love.

“For most companies, these announcements are primarily offered to serve public relations objectives with very little follow-through, very little transparency and no evaluations on what actually happens.”  

Cancer Coalition

Meanwhile, the Access to Oncology Medicines (ATOM) coalition was launched this week, and announced that AstraZeneca, BeiGene, Bristol Myers Squibb, Gilead Sciences, Novartis, Roche, Sanofi and Teva had joined the partnership to improve access to essential cancer medicines in poorer nations.

 

Image Credits: Flickr – World Economic Forum.

World Health Assembly Thursday 26 May just after votes on competing resolutions on the health crisis in Ukraine.

The World Health Assembly on Thursday approved a resolution condemning Russia’s invasion of Ukraine by 88 votes to 12 – but the 53 abstentions reflected the discomfort of many member states with a debate that polarised the global health body. 

Russia’s counter-resolution only garnered 15 votes including those of Belarus, Burundi and Eritrea, with 66 countries voting against – but this time, a massive 70 countries abstained.

Most African nations abstained during both votes, as did many Middle Eastern nations, India and Pakistan. Some indicated discomfort with voting on a political issues, while others alluded to support received from Russia during COVID-19.

Most of Europe, the United States, Oceania and many Latin American countries supported the Ukrainian-backed resolution, which condemns “in the strongest terms, Russian Federation’s military aggression against Ukraine, including attacks on health care facilities”.

Unlike most of the African region, Ghana also supported the resolution, which also expresses “grave concerns over the ongoing health emergency in Ukraine and refugee receiving and hosting countries, triggered by the Russian Federation’s aggression against Ukraine”  and  calls for an increase in contributions to the WHO Emergency Appeal for Ukraine.

The  Russian-sponsored resolution, backed by Syria, omits any reference to who began the war or Russia’s attacks on health facilities. But it called for the rules of war to be respected around medical and humanitarian relief, and safe passage of medical supplies and personnel, along with support for WHO emergency relief efforts.

Ukraine delegation describes vote as a victory 

Ukraine
Ukraine´s representative to the UN Mission in Geneva, Ambassador Yevheniia Filipenko just after vote tally on WHA resolution condemning Russia´s invasion of Ukraine.

As much as the vote itself, the diverse reactions to the dual resolutions underlined the sharply divided perceptions over the war, and the role of WHO in responding to politically-laden conflicts between its member states.

The United Kingdom, one of the Ukraine resolution´s co-sponsors, described it as a vote ¨against war, against the lies, for peace and for health.¨ 

The US Mission to the UN in Geneva’s Ambassador Bathsheba Nell Crocker noted that “not even maternity hospitals have been spared” by Russia’s onslaught in Ukraine. “And the devastation is not limited to Ukraine. Impacts are being felt across the world. What is the impact of this war if not a health crisis?” she added.

Speaking just after the count was tallied, Ukraine´s representative to the UN Mission in Geneva, Ambassador Yevheniia Filipenko, representative thanked the WHA saying, ¨This is exactly the document which Ukraine was expecting from the World Health Organization to comprehensively address the health emergency caused by the Russian Federation. 

“This resolution sends a clear signal to the Russian Federation, stop your war against Ukraine, stop attacks on health facilities, respect international humanitarian and human rights law. 

“In voting down Russia´s draft, the World Health Assembly confirms that the responsibility for the health crisis in Ukraine rests exclusively with the Russian Federation… It is only through collective efforts that we will be able to address the health emergency in Ukraine and elsewhere in the world, in realizing the vision of health for peace and peace for health,” Filipenko concluded in remarks greeted by a round of applause from WHA delegates.

“We cannot ignore the abstentions but it´s good that we got 88 votes against and only 15 opposed,” Laremenko Oleksii, a member of the Ukraine delegation, told Health Policy Watch, adding that he believed the resolution would also boost donations to WHO´s  emergency aid effort. 

“It’s about depriving [Russia] of a platform for their propaganda,” another Ukrainian delegate to the Assembly added. 

Ongoing dialogue

Kenya’s delegate appealed for ongoing dialogue, while abstaining in both votes.

However, a number of leading developing countries, including Brazil and China, expressed concern that the WHO was being “politicised” and forced into “taking sides” over the war raging in Europe.

“WHO is not the right place for us to discuss” the war in Ukraine, China’s envoy asserted.

Kenya, which abstained on both votes, called for the “cessation of hostilities, and condemns all attacks on health care which are clear violations of international humanitarian law and human rights”. It also called for “continued dialogue and concerted efforts of all players within the multilateral setting”.

“We have observed with extreme distress how the war has had a ripple effect across the world, and we remain deeply concerned about the escalating food, energy and financial crisis, which has particularly dramatic impacts on developing countries,” added Kenya, raising a fear haunting most African countries.

Most countries, including those abstaining, expressed support for the efforts of the WHO to provide humanitarian health assistance to Ukraine and its neighbours assisting refugees. 

Ukraine and Russia exchange harsh words

Deputy Ambassador Alexander Alimov from the Russian UN Mission in Geneva called the Ukrainian resolution is “politicized,” “one-sided,” and “biased.”

“They are trying to transform WHO into a forum for score-settling and political debates,” he said of proponents of the competing resolution. By contrast, he said, Russia’s resolution “is constructive, it is not politicized, and it seeks to bring about the most rapid resolution to this crisis.”

But Crocker countered that: ¨This isn´t about politicization¨ adding that ¨Russia is asking you to look away” from the reality of the war’s impacts.

Before the vote, Filipenko, blasted Russia’s resolution as diplomatic double speak: “This is not just shamefully dishonest. It is also a cynical attempt to dupe this assembly. We urge you not to fall for this subterfuge,” she said.

The politically charged vote in the global health body comes at a pivotal moment in the grinding war in the Ukraine, with Russia now concentrating troops and firepower in the country´s eastern Donbas region. Full conquest of the Donbas is now the most immediate target for Moscow, keen to show some kind of decisive victory after abandoning its earlier aim of a quick and easy conquest of the capital Kiev, and overthrow of President Volodymyr Zelensky.

Elaine Ruth Fletcher contributed to this story.

Image Credits: Health Policy Watch .

World Health Assembly on Thursday morning, as member states launch debate over Russia’s invasion of Ukraine.

GENEVA –Russia’s war in Ukraine grabbed centre stage at the World Health Assembly Thursday as delegates prepared to take up competing draft resolutions on Ukraine’s health emergency: one denouncing Russia and supported by Turkey, Ukraine, the United States and all European Union members except for Hungary; the other co-sponsored only by Russia and Syria.

Although the resolutions – which address health conditions in Ukraine and neighbouring refugee-hosting countries – were only due to come to the Assembly’s floor in the afternoon, delegates began trading charges over the war in the morning while discussing a World Health Organization report on the Ukraine emergency as well as a broader report from WHO’s Independent Oversight & Advisory Committee of the Health Emergency Programme (IOAC) on the agency’s responses to global emergencies. 

Ukranian backed resolution calls for immediate halt to attacks on health facilities

Mapping of the co-sponsors of the Ukraine-backed and Russian resolution on Russia’s invasion of Ukraine in the World Health Assembly. The Russian city-enclave of Kaliningrad, sandwiched between Poland and Lithuania is also etched in red on the maa.

The Ukrainian-backed resolution condemns “in the strongest terms, Russian Federation’s military aggression against Ukraine, including attacks on health care facilities.”

It further expresses “grave concerns over the ongoing health emergency in Ukraine and refugee receiving and hosting countries, triggered by the Russian Federation’s aggression against Ukraine.”  And it causes for an increase in contributions to the WHO Emergency Appeal for Ukraine. 

Co-sponsors include Albania, Andorra, Australia, Austria, Belgium, Bosnia and Herzegovina, Bulgaria, Canada, Colombia, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Georgia, Germany, Greece, Guatemala, Iceland, Ireland, Italy, Japan, Latvia, Lithuania, Luxemburg, Malta, Moldova, Montenegro, Netherlands, New Zealand, North Macedonia, Norway, Peru, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Turkey, United Kingdom and United States.

The competing Russian-sponsored resolution, backed by Syria, omits any reference to who began the war or Russia’s attacks on health facilities. But it calls for the rules of war around medical and humanitarian relief, safe passage of medical supplies and personnel to be respected, and support for WHO emergency relief efforts.

Ukraine describes “catastrophic health crisis”

Ukraine’s UN Geneva Mission First Secretary Taras Popelniuk said Russia’s invasion on February 24 is causing a “catastrophic health crisis” that extends well beyond the many deaths, injuries and trauma inflicted on civilians. He cited damage to hundreds of health care facilities and services, causing disruptions in acute and chronic treatments, less access to medicine and added mental health burdens “so huge that they need additional assessment.”

He said that over 100 health facilities had been destroyed and 500 damaged.

As the delegates spoke, the latest figures from the Office of the United Nations High Commissioner for Human Rights (OHCHR) showed 8,628 civilian casualties were recorded in Ukraine, including 3,974 killed and 4,654 injured. Among those, 259 children were killed and 402 children were injured. OHCHR said it believes the actual figures are considerably higher.

Already in April, WHO reported the “grim milestone” of 103 verified attacks aimed at health care providers since the start of the war – attacks that killed 73 people and injured 51 others. Of those attacks, 89 directed against health facilities and 13 targeted ambulances and other health transport providers.

France’s U.N. Ambassador in Geneva Jérôme Bonnafont said Russia, one of the five permanent, veto-wielding members of the powerful 15-nation UN Security Council, was “clearly violating” the principles of the UN Charter. The opposition to Russia’s invasion of Ukraine – and its proposed resolution – was widespread among Europe’s delegates, particularly ones with shared borders.

“Let’s be honest. What we are witnessing in Ukraine is genocide,” said Poland’s U.N. Ambassador Zbigniew Czech. “This draft is only a cynical attempt to complicate our work.”

WHO Emergencies work will be strengthed by more stable finance

While many delegates veered into the emotional Ukraine crisis, others also took time to focus on the broader issues WHO is facing in strengthening its own health emergencies response.

That is the focus of the report of the IOAC committee, chaired by Felicity Harvey, which describes the challenges faced internally by the global health agency in its emergency response.

“The World Health Emergency program continues to be overstretched and understaffed,” said Germany’s Bjorn Kummel, summing up key conclusions of the IOAC review.  “The HR management with high level of short term contracts is a concern and must be adequately addressed. Given the circumstances the program does a great job despite occasional unacceptable derailing moments such as in the DRC,” he added, referring to the ongoing investigation of sexual misconduct and abuse by WHO staff and consultants during the 2018-2020 Ebola crisis.

He also pointed out to mental health challenges faced by staff, noting that “The IOC speaks of intolerable level of toxicity and incivility on social media against WHO and its staff members and we appreciate that the IOAC is drawing attention to this issue.

“Many of the problems resigned from the chronic underfunding. We fully agree with the IOAC that the solutions formulated by the Working Group on Sustainable Financing will be the single most important contribution to the improvement of the program,” Kummel concluded referring to the successful passage Tuesday of a new WHA resolution that would increase fixed member state contributions to 50% of WHO’s core budget by 2029-30 in an effort to stabilise budget planning.

“Not surprisingly, Germany believes that WHO should play a central role not only in the global health architecture for pandemic preparedness and response, but also the discussions on this topic,” Kummel added, referring to a recent WHO White Paper on global health institutional reform. Related to that, he stressed that WHO needs to play a “central role” in the new FIF (Financial Intermediary Fund) for emergency relief that has been proposed by global health leaders, to be hosted at the World Bank.

Image Credits: John Heilprin , Konrad Adenauer Stiftung .

An advertisement from the Healthy Caribbean Alliance advocating front-of-package warning labels.

Barbados recently imposed a 20% tax on sugary drinks, while Mexico, Chile and Uruguay, have introduced warning labels on food packaging to curb unhealthy eating – a key driver of obesity, diabetes and other non-communicable diseases (NCDs).

Mexico also has restricted the marketing of junk food to children, including sports sponsorships as it battles one of the highest rates of obesity in the world.

But interference from industries that produce unhealthy ultra-processed food and sugary drinks is undermining countries’ efforts to control food, according to speakers at a side event on curbing NCDs through healthier diets at the World Health Assembly in Geneva.

Ian Gooding-Edghill, the Barbados Minister of Health and Wellness, told the event his country had first imposed a 10% tax on sugary drinks, but that had only reduced consumption by 4.3%.

 “This was, in our opinion, far from what was required to have a significant impact,” said Gooding-Edghill, whose country now has one of the highest taxation rates in the world.

“The prevalence of diabetes is approximately 18% of the country and the obesity prevalence rate for those persons who are 25 years and older, is 33.8%.”

The Caribbean region, which imports a lot of packaged goods, is also tackling warning labels as a region.

Ian Gooding-Edghill, the Barbados Minister of Health and Wellness

Junk food kills more than tobacco

Jordan’s Princess Dina Mired, who is the NCD Ambassador for Vital Strategies, told the gathering that “junk food now claims more lives than tobacco”.

“In the decades since ultra-processed foods appeared on supermarket shelves, they have been aggressively promoted and marketed around the world, displacing traditional and healthier foods and diets,” she added.

“There is even some debate about whether ultra-processed foods can be called food at all. They do not resemble anything you can prepare in a kitchen. Made from ingredients that use industrial processes, these harmful products are appealing as they are preserved, packaged, convenient and ready to eat,” said Princess Dina.

“Ultra-processed products are exposing billions of people to a higher risk of Type 2 diabetes, heart disease, stroke and obesity. Obesity has nearly tripled since 1975— today, 2 billion people are overweight or obese.”

She criticised the World Health Organization’s (WHO) “best buys” to address NCDs for not going far enough in regard to “making the link between rising NCD rates and ultra-processed foods”.

Vital Strategies’ Nandita Murukutla

Meanwhile, Nandita Murukutla, vice-president of global policy and research at Vital Strategies, said that industry interference was preventing countries from acting against ultra-processed food and drink.

She highlighted a paper that was published in The Lancet in 2021 that found only a third of the WHO’s recommended policies to address NCDs were being implemented by member states. 

“Policies on tobacco control, except for graphic health warnings, junk foods and alcohol marketing were among the least well implemented,” said Murukutla, adding that “conflict of interest and industry interference, were the chief contributors in delays in implementation”. Latin America has one of the highest obesity rates in the world, and ultra-processed beverages are often more accessible than clean water or fresh food and other healthy options. 

Simon Barquera, executive director of the Nutrition and Health Research Center at Mexico’s National Institute of Public Health.

Simon Barquera, executive director of the Nutrition and Health Research Center at Mexico’s National Institute of Public Health, said that more than 80% of deaths in Mexico are due to NCDs. 

“More than 100,000 deaths every year are due to diabetes, and more than 40,000 deaths per year are a consequence of a sugar, sugary drink consumption,” added Barquera.

“And we’re one of the countries with the highest ultra-processed food consumption.”

Mexico has been trying to “modify” this food environment for more than 20 years, but “it has been very hard”, he acknowledged. 

“The soda tax took us 14 years of developing evidence and doing attempts at the Congress with the President in the Ministry of Health. The front-of-pack labels took us about 11 years.”

Mexico had successfully curbed marketing to children through an alliance of civil society, academia and government officials. But much of this marketing was now digital – which made international collaboration essential, said Barquera.

“Companies don’t like tweets that are international, exposing what these multinational companies are doing in our countries.”

The event was organised by NCD Alliance, Vital Strategies, World Obesity Federation, and the Ministry of Health and Wellness of Barbados.

Loyce Pace, Assistant Secretary for Global Affairs at the United States Department of Health and Human Services (HHS).

GENEVA – Despite pushback Monday from many WHO member states, including the 47-member ‘Africa Group’, Loyce Pace, US Assistant Secretary for Global Affairs at the Department of Health and Human Services remains “hopeful we may reach consensus” on reforming international health emergency rules at the World Health Assembly this week. 

The proposal backed by Australia, Colombia, the European Union, the United Kingdom, Japan and the United States, is perhaps the only concrete measure that the WHA can take in its current session to address the international rulebook for emergencies that largely failed the world in the COVID-19 pandemic – and was described by the widely-acclaimed Independent Panel review  as an “analogue” system in a digital age. 

While a much broader reform proposal backed only by the US also is technically on the table, it is the much narrower, process-based resolution,  A75/A/CONF./7, that has the only real chance of passage this year.  

Responding to a question from Health Policy Watch at a small media briefing Wednesday at the US Mission to the UN in Geneva, Pace spoke with diplomatic tact about the resistance that has been encountered to making any changes in the rules: 

“It’s obvious each country or government has a prerogative to express any concerns or reservations at any time, and it’s our job to listen, frankly.” 

But she added, “We are hopeful, I am hopeful we will reach consensus…. It is our hope…   to at least be able to move forward on this process point.” 

Process for changing a process 

WHA75 is meeting at the Palais des Nations, Geneva.

Under the process proposed by A75/A/CONF./7, countries would submit and negotiate proposals for more substantive IHR amendments over the coming two years.  An amendment to Article 59 of the IHR, would also create an abridged one-year framework in which any future amendments would actually take force – as compared to the two-year time frame that now exists.  

“It’s really how we just get that ball rolling, and ensuring that we have some method whereby we can at least bring into force these various amendments at a faster pace,” said Pace of the issue at stake.

Time frame for IHR changes too tight? 

Botswana, on behalf of the African group, expressed reservations over a US-backed initiative to expedite the process for amending the International Health Reservations, on Tuesday, 24 May

But ostensibly modest moves to expedite the timeline for future changes in the IHR ran into resistance in an initial debate on Tuesday, led by China and Iran, which complained that the time-frame for making amendments was too tight – although any process begun now would still take until 2025 to complete. 

While those objections may have been expected in light of the current state of geopolitical tensions, reservations by the WHA’s Africa bloc of 47 states took the resolution’s co-sponsors more by surprise.   

Led by Botswana, African countries expressed concerns about the nature of more substantive amendments lying in wait down the road – should they open the door to changes now.

“The amendments need to be considered as a holistic package,” Botswana’s Moses Keetile, a deputy permanent secretary in its health ministry, said on behalf of the African delegation to the Assembly. 

Admittedly the proposal tabled by the US early in 2022 sets out a more ambitious agenda for very substantive IHR revisions. Those include much clearer and tougher time frames for countries to report to WHO on suspected outbreaks as well language about responsibilities to rapidly share the “gene sequences” of pathogens, when available.  

Country comfort with pace of change 

But establishing tighter time frames for reporting on outbreaks could be difficult for low- and middle-income countries with few resources to muster for reporting at all, some African member states complained at Monday’s session. 

And there is a complex, brewing controversy over rules that would mandate sharing of the DNA sequences of new or emerging pathogens – which some low- and middle-income countries feel should be accompanied by guarantees that they would receive certain “benefits” from medicines or vaccines developed as a result.  

In the interest of transparency, the US has been forthright about the kinds of changes it would ultimately like to see in the IHR rules, Pace said.

However, she added that Washington is also keen to build a consensus with the African group and others uncertain about how next to proceed.   

“I think what we are keeping an ear out for is countries’ comfort with the pace at which things are happening and understanding of the scope of what is included in amendments,” she said.

“I think the President’s been clear about our commitment to international cooperation and dialogues…doing so with not only a sense of leadership but a sense of humility.  We’re still working to ensure that everyone is comfortable with where we are, and that we can move forward and that the very least on this process issue.”

Pace added that the US was “open to any sort of questions or conversations” and that “conversations have been ongoing, which I think is a good sign in terms of us reaching some consensus this week”.

“If it doesn’t happen this week, we’re not going to stop, we’re going to keep working to that end,” she added.

Need to keep up momentum even as pandemic urgency wanes

At the same time, there is still momentum for reforming emergency rules right now, and beyond that, discussing a broader pandemic convention or legal instrument, which could be lost if the discussion drags on, and the memory of the recent crisis fades.  

“You get to another phase of COVID or even get beyond COVID, hopefully, and it might be very hard to get this on the agenda or as high up on the agenda, as we put it off,” Pace said. 

“And so countries have really commented on the importance or the value of putting it on the agenda, keeping it on the agenda… not just in principle we should look at the IHRs, but practically, here’s some specific pragmatic changes we can make. In a way that can make a difference right now.

“Everyone acknowledges that this has been a nightmare that we’ve lived through, but if we don’t do anything about it, then what are we here for ultimately? 

“So that’s really our goal with this Article [IHR Article 59]. And I think that other countries … understand that as well and share that goal, which is you have to be taking steps, meaningful steps, tangible steps to demonstrate to our countries that … when we come together, we truly are taking action and we really are making progress.”

IHR not about sovereignty 

Pace also rebutted the claims being made in some US media channels as well as in some circles abroad – that a stronger set of global health emergency rules mean a loss of sovereignty for the US or any other nation.

Whether such claims originate in ”valid confusion or deliberate disinformation”, global inaction could put more lives at risk, she stressed.     

“The IHRs are not about sovereignty. They’re about public health. And they’re about ensuring that we all do – countries around the world, member states of WHO and WHO itself, do everything we can to protect the global community from anything like this ever again,” she said. .

“We’ve had over a million Americans who have lost their lives. Over 6 million people around the world lost their lives. WHO estimates even more than 15 million associated deaths with those are real numbers. And they’re real people,” Pace said.  

“And what we tried to do in a bureaucratic way, certainly, but in an important way, is to really show up with solutions to that problem – because we never should have been in a situation where we’ve lost so many to this.“

“ I think what happens when we see everything from… valid confusion to deliberate disinformation, is an undermining of those efforts to save lives in the future. And that’s never where we want to be. 

“What it is we are here to do is to protect all Americans and global citizens.” 

 

Director-General Dr Tedros Adhanom Ghebreyesus addresses the agency’s failings on sexual exploitation and abuse by WHO staff and contractors

GENEVA – Faced with a chorus of demands for accountability from member nations, Dr Tedros Adhanom Ghebreyesus again pledged greater efforts by the World Health Organization’s (WHO) leadership to eliminate sexual exploitation and abuse by its staff and contractors at the World Health Assembly on Wednesday. 

The discussion followed the recent publication of a letter sent to Tedros in March 2022 by three UN Special Rapporteurs regarding the “inadequate response” by the WHO to allegations of sexual exploitation and abuses during the Ebola response in the Democratic Republic of the Congo (DRC) from August 2018 to June 2020.

A number of weaknesses may have “prevented a fair and thorough investigation of crimes of sexual harassment, exploitation, and abuse” and “weakened the accountability for these crimes allowing perpetrators of these crimes to go unpunished”, according to the letter signed by Rapporteurs on violence against women, the right to the highest attainable standard of physical and mental health, and the Working Group on discrimination against women and girls, Reem Alsalem, Tlaleng Mofokeng, and Melissa Upreti.

The Rapporteurs also criticised the WHO for failing to explain how it would ensure criminal accountability for any sexual abuse committed by WHO personnel, beyond stating its existing policy of “referring cases that constitute a crime to national authorities for criminal investigation”, and committing to providing “support for legal action through the UN and national stakeholders”.

The Rapporteurs, who had information about 125 women, girls and men, also said the WHO had not adequately protected the identities of those abused.

An independent commission set up by the WHO found that 83 emergency responders in the DRC’s 2018-2020 Ebola outbreak, including 21 WHO employees and consultants, had raped nine women and likely abused dozens of women and men, obtaining sex in exchange for promises of jobs.

Member states want more action

During a discussion on the issue at the WHA on Wednesday, the African region represented by Cameroon, called on the WHO to establish a sub-committee within its health emergency programme “to consider how the organization’s current policies and procedures on prevention of and response to sexual exploitation and abuse and harassment could be improved”. 

The Africa group also welcomed the appointment of a regional coordinator on the prevention of sexual exploitation, abuse and harassment, who started work in March 2022 and called for adequate funds “to ensure capacity”.  

Meanwhile, the Geneva Group of Friends to Eliminate Sexual Harassment, made up of 56 member states and the EU, noted with concern that the Rapporteurs’ correspondence “was made public only this week”. Netherlands, on behalf of the group, called for regular updates from the WHO leadership and ongoing exchanges between the WHO and other UN organisations to strengthen the “zero tolerance” approach for sexual exploitation, abuse and sexual harassment. 

Netherlands, speaking on behalf of Geneva Group of Friends to Eliminate Sexual Harassment.

Norway also referred to the Rapporteurs’ concerns and said that these needed to be reflected in WHO’s management response plans.

“We stress the importance of providing the UN Office of Internal Oversight Services (OIOS) with unhindered access to all information and staff throughout its investigations,” said Norway.

Waiting for UN  investigation

In a response to the Special Rapporteur, dated 20 May, WHO said that the investigation of the allegations currently underway by the UN’s OIOS need to be completed before it takes further action against any of the WHO staff or former staff alleged to have committed the sexual exploitation and harassment. 

“All investigations related to the 10th Ebola outbreak in the Democratic Republic of the Congo are investigated by UN OIOS, not WHO,” said the WHO in an eight-point response to the Rapporteurs signed by Gaya Gamhewage, WHO’s director of prevention and response to sexual misconduct.   

It added that any criminal charges filed with the DRC government authorities would have to be filed with the consent of the victims – and so far that hadn’t been received. 

“WHO takes a victim- and survivor-centred approach and prioritizes their protection, wishes and needs. This requires obtaining consent from the survivor to share their personal information. As this has not yet been received, WHO has asked UN Investigators to seek such consent.” 

Speaking to Health Policy Watch, outside of the chambers, Gamhewage added that WHO had also offered 25 women in the DRC who were victims of abuse financial support for any cases that they wished to pursue in local courts there. 

‘Long. long way to go’

“We appreciate the attention you have given this,” Dr Tedros said in soft tones to delegates seated in one of the 194-nation World Health Assembly’s round chambers.

He acknowledged the criticism of bureaucratic delays, multi-year backlogs in investigations and concerns about the quality of WHO’s work, acknowledging that “we have a long, long way to go”.

Despite the hurdles, Tedros sought to highlight some progress WHO has made in creating a culture of zero tolerance for sexual abuse, exploitation and harassment. This includes holding weekly meetings, discussing possible actions and taking steps to put greater focus on prevention and care for the victims and survivors. 

He said WHO is sensitive to complaints about its investigation backlogs — and delays in delivering justice.

“And they are right, because some of the investigations have taken two years, three years, four years, five years, even more. I know some of the investigations that came after seven or eight years. So that’s why the backlog is now being finished,” he said, adding that WHO set a new 120-day deadline for all such investigations to be completed. 

“This is the first time we’re trying it in the UN system and we see advantages to it because it brings accountability,” Tedros said. “Of course, there are some concerns from some colleagues about the quality of it. But I assure you that quality will not be compromised, because quality will be at the centre.”

However, it took Tedros more than two months to respond to the Rapporteurs’ letter. In the WHO reply of 20 May, Tedros apologized for the delay, which he blamed on an “administrative error.” 

He assured Alsalem nonetheless that he feels a “profound, personal commitment to addressing the issues of sexual exploitation and abuse, and violence and discrimination against women and girls in all its forms.”

Also responding to the Rapporteurs in the WHO letter, Gamhewage said that the UN system is still working to find agreement on how best to focus its efforts around victims and survivors.

“I want to assure you that we are working with women-led organizations trusted by communities to support victims, but also to get their voices into the strategy that we’re developing,” she said.