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.

The World Health Organization (WHO) doesn’t fully know what is driving the latest monkeypox outbreaks; it doesn’t know the virus’ animal reservoir nor knows what the future holds for the disease.

A session at the 75th World Health Assembly that was aimed at enlightening member countries ended up highlighting the existence of knowledge gaps and uncertainties regarding the future of monkeypox virus disease that has now been reported in about 20 countries just 17 days after the UK reported its first case.

On 7 May 2022, the UK Health Security Agency (UKHSA) announced an individual was diagnosed with monkeypox in England. According to the agency, The patient had a recent travel history from Nigeria where they believed the patient contracted the infection before traveling to the UK. Seventeen days after the announcement, monkeypox was discussed at the World Health Assembly on a day that the UK reported its 71st case. Cases have also been reported in a number of countries in Europe and beyond.

According to the UKHSA, a notable proportion of the cases identified to date have been among people who are gay, bisexual and men who have sex with men. And despite further cases being detected, it said the risk to the UK population remains low.

“We are continuing to promptly identify further monkeypox cases in England through our extensive surveillance and contact tracing networks, our vigilant NHS services and thanks to people coming forward with symptoms,” said Dr Susan Hopkins, UKHSA’s Chief Medical Adviser.

Multiple transmissions

At a WHA75 Committee session on Tuesday, WHO executive director of Health Emergencies Programme, Dr Mike Ryan, described monkeypox as “an emerging zoonosis that has once again reached a species barrier, and is now transmitting in multiple countries but is a containable event nonetheless”.

Dr Sylvie Briand, WHO director for Global Infectious Hazard Preparedness, said the global health body has been monitoring the outbreak of the disease for several years, especially in a number of African countries in which it is endemic. 

“We have localized epidemics every year, sometimes they’re higher, sometimes they’re lower every year, but that’s why we’ve been monitoring the outbreak of this disease for several years,” she said. 

She added the WHO had always been concerned that monkeypox would replace variola virus (the virus that causes smallpox) which was eradicated in 1980 — three years after the last wild case was reported in 1977, among human populations.

For several years, she said monkeypox was exported by travellers, but the cases had remained extremely isolated and have not become major outbreaks in countries which imported the virus.

‘Current situation is not normal’

In sharp contrast to previous epidemiological trends for monkeypox, WHO described the current outlook of the disease as not normal with 131 confirmed and 106 suspected cases now reported in 19 countries between 7-23 May.

“We’re currently facing a very unusual situation. We haven’t seen this type of situation in previous years. In a few days, we’ve had a high number of cases in many countries and that raises a number of questions and it’s unusual,” she said.

The initial suspicion was a mutation in the virus genome, but WHO said while more data is still needed, initial genomic studies suggested the virus hasn’t changed or mutated. What is considered more likely is a change in the pattern of human behaviour and this could explain the numerous transmissions in different areas of the world.

She noted that after two and a half years of the Coronavirus pandemic where there were a number of restrictions on human contact and large events, the global health body is suspecting that individuals are now more interested in getting out to events. In the same vein, they may be taking advantage of the fact that COVID-19 restrictions have now been lifted. 

“That means that they’re having, for example, more human contact or there are larger assemblies of people together, which means that there has been a facilitated transmission of this disease,” she added.

Unknowns and uncertainties

WHO however admitted that the outbreaks are still plagued with several unknowns and uncertainties about the future. These include the extent of the current disease spread in non-endemic countries.

“Are we just seeing the very tip of the iceberg or have we already passed the spike in transmission communities?” Briand asked. She added that the animal reservoir of the monkeypox virus is still unknown.

According to her, more research is needed on the modes of transmission to better understand what has generated the current unusual situation. She however encouraged countries to increase the surveillance of monkeypox in order to know the levels of virus transmission and to understand the outbreak progression in countries.

She added that while there are available medical countermeasures, they are extremely limited in quantity and some of them are not yet fully licensed to be put on the market.

Going forward, the WHO recommends targeting containment of the disease in countries where monkeypox is non-endemic. 

“We believe that it is still containable. It is possible to cut the transmission chain by first of all increasing awareness, and early recognition in our populations. Also, detecting cases, enhancing clinical recognition of the disease to ensure early detection of cases and isolation of patients to make sure that these patients do not transmit to their countries or their loved ones,” Briand added.

Intensified surveillance through cluster investigation and contact tracing are also being recommended by the WHO to stop chain transmission while contacting sexual partners would ensure that there is no sexual transmission of the disease. 

Ryan added that the monkeypox outbreak is the latest in the cycle of disease emergence, amplification and dissemination that the entire world needs to face together.

“We are clearly making progress in our capacities to work together in the face of these emerging threats,” Ryan concluded.

An individual with Noma
An individual with Noma

A team of health professionals and Noma survivors called on the World Health Organization on Tuesday to list the deadly infection of the mouth and face as a neglected tropical disease (NTD) so that it can receive the attention it needs to be eradicated.

“We hope that we can bring global attention to this disease and work toward the elimination of Noma,” said Nigeria’s health minister Dr E. Osagie Ehanire. He was speaking at the Geneva Press Club ahead of a screening Wednesday evening of a new documentary film on Noma, Restoring Dignity by the filmmaker Claire Jeantet, followed by a panel discussion at the Geneva Graduate Institute’s Global Health Centre.

Noma is a progressive and usually fatal infection of the mouth and face that affects some 140,000 people a year – most in sub-Saharan Africa, predominantly young children between the ages of two and five years old, living in poverty. It has a 90% fatality rate.

Although the exact cause is still unknown, Noma is likely the result of a bacterial infection that attacks children who have weakened immune systems as the result of a previous illness, such as measles or tuberculosis.

“There is nothing that talks more about you than your face,” said Ehanire. “If your face is damaged, imagine the psychological and mental consequences.”

The 52-minute documentary film follows the stories of several Noma survivors from Nigeria who have also come to Geneva this week to stimulate awareness about the disease on the margins of the World Health Assembly.

For survivors – facial scars and stigma

Among them is Mulikat Okanlawon, an advocate and hygiene officer at the Noma Hospital in Sokoto, Nigeria, who shared her personal story about contracting the disease as a child. While around 90% of people who get Noma die, she survived.

“I recovered from the disease, but it left a deadly mark on my face, which stopped me from interacting with people and being a part of the community. I could not go out. I could not go anywhere. I could not even look at myself in the mirror like other children,” she said Tuesday. “I always cried… I often wished that I had not survived.”

Another survivor, Fidel Strub – now an advocate and president of Noma-Aid Switzerland – explained that Noma is not a disease a person gets as a child and then moves on. Recovery, he said, is a life-long fight and “takes a lot of energy, self-motivation” and money.

Noma survivor Fidel Strub

Dr Isah Shafi’u has been working at the Noma Hospital in Sokoto for the past decade and said he has treated around 2,000 patients with Noma. He described how children are brought to the hospital in a struggle between life and death and it is his job to bring them back to life.

“To bring back a smile to those children is really amazing,” he said. “It is the most wonderful feeling.”

“We do not want to leave anyone behind,” added Ehanire, noting that he had recruited several countries to co-sponsor a petition to WHO to include Noma on its list of NTDs.

More than 90% of the children who get Noma die

Noma is preventable, but only if there is early diagnosis and treatment, explained Dr Maria Guevara, International Medical Secretary for Médecins Sans Frontières (MSF). She said that good nutrition, proper oral hygiene and access to healthcare – including childhood vaccinations – all prevent Noma.

“More than 90% of the children who get Noma die in the first two weeks if they do not get the treatment they need,” Guevara stressed. While an estimated 140,000 children are infected with Noma each year, those statistics were last collected in the 1980s.

“The data has not been updated for more than 25 years, showing just how neglected the disease and its survivors are,” she added. “Neglect should not be the case for a disease that could be eliminated.

“I am here today to add my voice to the call for Noma to be listed as an NTD,” Guevara continued. “Let’s make it a disease of the past and no longer the face of poverty.”

Prof. Dr. Bertrand Piccard
Prof. Dr. Bertrand Piccard

Guevara’s words were echoed in closing by Prof. Dr. Bertrand Piccard, chairman of the Solar Impulse Foundation, in a video message.

“WHO needs to put Noma on the list of tropical neglected diseases,” he said. “If this does not happen, Noma will continue.”

He praised the hospitals and nonprofits working to raise awareness about and treat Noma, but said they will not succeed without WHO’s attention.

“Only WHO can do what we have not been able to do, only WHO – by putting Noma on the list of NTDs – can put a stop to this unacceptable situation in our world today.”

###

REMINDER: GETTING NOMA OUT OF NEGLECT

Film screening and panel discussion
25 May 2022, 15:00 – 16:30
Auditorium Ivan Pictet, Maison de la paix, Geneva
Learn more >>

Image Credits: Wikimedia Commons, Screenshot.

Björn Kümmel (left) and Dr Tedros (right) at a WHA event moderated by Folly Bah Thibault.

In a groundbreaking decision on financing reform, the World Health Assembly (WHA) resolved on Tuesday that half of the world body’s budget will be derived from members’ fees by 2030.

That will reduce the World Health Organization’s (WHO) massive reliance on donors. But there was less enthusiasm for revising the International Health Regulations (IHR).

The Assembly adopted in full the recommendations for financing reform made by the Sustainable Financing Working Group chaired by Germany’s Björn Kümmel, which also include proposals to increase the body’s efficiency.

“When it was approved, I have to admit I had a tear in my eye,” Kümmel told Health Policy Watch on Tuesday night. “I’ve been covering WHO for ten years and I always thought the financial situation was unsustainable.”

Kümmel, deputy head of the global health division at Germany’s Ministry of Health, said he was “told that it was un-doable” when he was asked to lead the process on financing reform a year and a half ago. “This is a success of multilateralism,” he said.

Incremental increases to member states’ fees (known as assessed contributions), starting with an increase to 20% in next year’s budget, is the group’s key recommendation. 

The WHO currently derives 84% of its budget from donors and voluntary contributions, making it beholden to donor priorities and inflexible funding that is earmarked for particular projects and cannot be redirected to health emergencies.

A task group of member states will be set up to work with the WHO Secretariat to strengthen the body’s “transparency, efficiency, accountability and compliance.”

The WHO is also mandated to investigate a replenishment model for additional funds.

Member states, particularly the US, have been adamant that if they are to pay more fees, they want financing reform that leads to a more efficient WHO.

Welcoming the decision, WHO Director-General Dr Tedros Adhanom Ghebreyesus said that it  “addresses head-on the decades-long challenge WHO has faced on predictable, flexible and sustainable funding”. 

“WHO’s current financing model has been identified by many experts as posing a risk to the integrity and independence of its work,” the WHO said in a statement on Tuesday night.

“WHO’s over-reliance on voluntary contributions, with a large proportion earmarked for specific areas of work,” it said, “results in an ongoing misalignment between organizational priorities and the ability to finance them.”

As financing reform gains support, IHR reform hits opposition

However, proposals to revise the IHR did not go so smoothly at the assembly on Tuesday.

The IHR are binding laws that govern countries’ obligations to report and respond to pathogens that could result in cross-border disease outbreaks public health emergencies.

The IHR were last revised in 2005 and the Independent Panel on Pandemic Preparedness and other bodies have pointed out a number of inadequacies in the light of COVID-19.

This has led to calls for the IHR to be revised, alongside the negotiation of an international pandemic instrument or treaty to better prepare the world for future pandemics.

But on Tuesday, a group of mainly African nations pushed back on both the process and substance contained in several proposals for revising the IHR.

Among the sticking points on financing reform were issues around national sovereignty and the speed raised in proposals before delegates at the WHA.

One proposal to shorten the process for effectively reforming the IHR was put forward by Australia, Bosnia and Herzegovina, Colombia, the EU Japan, Monaco, Korea, the UK and the US – and one with more far-reaching changes was offered by the US.

While the first one is more procedural, the US proposal would strengthen the WHO’s ability to gather and share information among nations with disease outbreaks that could put global public health at risk. 

But African nations led by Botswana voiced unease, dimming hopes for the one concrete action the Assembly might be expected to take on pandemic reform. 

The US proposal suggests 13 reforms including strict timetables for reporting outbreaks and introducing language on gene sequence sharing, forming a new compliance committee to monitor nations’ implementation, and authorizing expert teams to be sent to outbreak and contamination sites.

Holistic package

Iran also objected to the US proposal’s technical measures for changing IHR Article 59, saying Tehran “deems it premature to decide to reduce the time entry into force.” 

The US proposal would shorten the timeframe for amendments to take effect to one year, down from its current two-year period. That would also limit the time that member nations have to meet, analyze and raise objections.

“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. 

A US delegate said its proposals are meant to encourage a process that is “more agile and responsive to technological” considerations, and that “it is essential that states’ parties comply” because “there is no greater duty for governments” than to look after the public health of their citizens. 

A Danish diplomat, however, expressed a preference for more “targeted amendments,” while Norway’s envoy said “much can be done without altering the regulations, and there is an urgency in doing so.”

Singapore’s Health Minister Ong Ye Kung said overall the “foundation of our response is not lockdowns but vaccinations” in responding to pandemics.

The US in January submitted its draft WHA proposal for a series of pinpoint amendments to the 17-year-old IHR.

But final agreement on any IHR amendments is now likely to be put off until 2023, with resistance growing to any attempt to “fast track” the process of amending the IHR.

The Assembly had been expected to agree only to a process for making new IHR amendments by inviting all member states to propose their own reform proposals by the end of September.

Rightwing clamour

Meanwhile, outside the WHA there has been a clamour of rightwing opposition to reforms to the IHR and to a pandemic treaty on the basis that these will cede national sovereignty to the WHO.

This has been voiced by conservative leaders including Fox News’s Tucker Carlson, US former congresswoman Michele Bachmann, and Christine Anderson, a Member of the European Parliament from the German right-wing, anti-immigrant Alternative für Deutschland.

Some of the claims appear to be part of an overall disinformation campaign against the WHO by anti-vaxxers.

That was demonstrated by a petition against the IHR changes signed by a number of prominent anti-COVID-19 vaccine conspiracy theorists.

However, the WHO does not have the power to enforce or police the IHR – which was violated by a number of member states during the current pandemic.

Meanwhile, negotiations on a pandemic instrument or treaty only started this year with a proposal on its form only likely at next year’s WHA at the earliest.

Tedros
Djibouti Health Minister and World Health Assembly President Dr Ahmed Robleh Abdilleh and WHO Director-General Dr Tedros Adhanom Ghebreyesus sign a new contract for the second term

World Health Organization (WHO) Director-General Dr Tedros Adhanom Ghebreyesus has been re-elected unopposed to spend another five years at the helm of the UN health agency, after receiving the World Health Assembly’s overwhelming endorsement as a health diplomat fluent in war and a pandemic.

Tedros, a former Ethiopian health minister and the first African to lead WHO, ran unopposed for a second term. He was re-elected in a secret ballot vote in accord with Assembly procedures that required at least two-thirds of its 194 member nations to endorse him. A key donor nation, the United States, expressed support in February.

Although it initially appeared that all regions had endorsed his nomination, an indignant Ethiopia berated Botswana after it had delivered a message of support for Tedros on behalf of the Africa region. Neither Ethiopia nor Eritrea support Tedros as he has been outspoken about their blockage of Tigray, his home territory in Ethiopia. After Tedros’s re-election, Botswana then delivered a message of support on behalf of 45 African states – not 47.

Tedros began his first five-year term on July 1, 2017, and since 2020 he has been the public face of the world’s response to the COVID-19 pandemic, including its delays and failures at vaccine equity. 

Immediately after the secret ballot vote, which lasted without explanation for a couple hours longer than had been scheduled, Tedros entered the Assembly hall to a rock star’s welcome, surrounded by delegates, well-wishers and photographers on his way to the podium. 

“The Health Assembly has just decided to appoint you,” Djibouti Health Minister and World Health Assembly President Dr Ahmed Robleh Abdilleh said. “In congratulating you, the Health Assembly fully acknowledges the challenges ahead of you.” Immediately afterward, Tedros took a brief oath of office and, also in front of the Assembly, signed a new contract that runs from 16 August, 2022 to 15 August, 2027.

“This is overwhelming. I’m really grateful and very humbled for your confidence and trust. It was not just today. During my nomination, all regions have nominated me,” he told the Assembly. “This is for the whole team.” Tedros laid out his previously established main priorities for his second term, ranging from primary care to pandemic preparedness to accountability. 

He became teary-eyed recalling being a seven-year-old boy living in Ethiopia in a poor family when his younger brother died of a disease later suspected to be measles, a preventable condition, and it could have just as easily been him. 

“So I hope peace will come,” he said. “Let peace and understanding be the antidote to war.”

Dr Tedros visited Kyiv in Ukraine earlier this month.

Vaccine equity

He has repeatedly called out wealthy nations for taking first dibs on most of the world’s vaccine supplies, leaving poorer nations years behind in getting their first shots. Amid the media focus on Ukraine, he has kept reminding people of the suffering in Afghanistan, Syria, Tigray, Yemen and other conflict zones. 

Throughout his first term, the 57-year-old Tedros projected empathy. In his opening remarks to the Assembly, he spoke of his visits to see first-hand the effects of conflict.

“In both Yemen and Ukraine, and in other countries I have visited in between during my first term, I saw the profound consequences of conflict for health systems and the people they serve. More even than pandemics, war shakes and shatters the foundations on which previously stable societies stood,” Tedros said.

“And it leaves psychological scars that can take years or decades to heal. For me, this is not hypothetical or abstract; it’s real, and it’s personal. I am a child of war,” he recalled. 

“The sound of gunfire and shells whistling through the air; the smell of smoke after they struck; tracer bullets in the night sky; the fear; the pain; the loss – these things have stayed with me throughout my life, because I was in the middle of war when I was very young.  … Not only a child of war, but following me throughout. But my story is not unique.”

He also has been harshly criticized for his agency’s dealings with China soon after COVID-19 was first discovered, and for early statements against mask-wearing. And, under his tenure, WHO has also been criticized for failing to hold its staff accountable for sexual abuse and other misconduct.

Trump challenges

Perhaps his stiffest challenge came from former US President Donald Trump, who withdrew the US from the WHO after numerous broadsides about the body’s capabilities – a decision that was swiftly reversed by President Joe Biden.

As the ninth director-general of WHO, Tedros is the only one since the agency’s creation in 1948 to not hold a medical degree. Instead, he has a doctorate in philosophy. 

In his second term, Tedros will continue to have to deal with the global response to the pandemic and new health threats such as monkeypox and hepatitis. He said he had been humbled by the Executive Board’s decision to nominate him for a second term, and, as he reflected on the past five years, realized they have been “bookended” by two visits to war zones.

 

“I made my first trip as Director-General to Yemen in July 2017, a country which was, and remains, mired in civil war. While I was there, I met a mother and her malnourished child who had travelled for hours to reach the health centre I was visiting in Sana’a,” he recalled. 

“Then two weeks ago, I was in Ukraine, visiting bombed hospitals and meeting health workers. I visited a reception center for refugees in Poland, where I met another mother, from the Mariupol area, who told me that when the shelling began, her young daughter was very scared. … I met people who have lost loved ones; lost their homes; lost their sense of security – and yet somehow, have not lost hope.”

 

 

Image Credits: WHO.

Bjorn Kummel

Björn Kümmel, chair of the World Health Organization’s (WHO) working group on sustainable financing, wants to complete two marathons this year: an actual road race in Berlin – and the adoption of proposals to improve the WHO’s financing at the World Health Assembly (WHA) currently in session.

For 18 months, Germany’s Kümmel has steered discussions aimed at reforming the WHO’s finances as chair of the working group on sustainable financing. 

Only around 16% of the WHO budget is predictable, derived from member states’ fees, called “assessed contributions”. The other 84% comes from grants and voluntary contributions from members, skewing the global body’s programmes and making it hard to respond with speed and flexibility to health emergencies.

‘Severe risk’

“This situation has put WHO at severe risk, including its independence, its integrity, its agility and certainly also it’s mandated role to be the world’s leading and coordinating authority in global health,” Kümmel told the WHA’s meeting of Committee A on Monday.

He was reporting on the consensus reached by the working group last month on a package of measures, including that 50% of the WHO’s budget should come from assessed contributions by 2030, starting with an increase to 20% by next year’s WHA.

This is not a technical issue but a “gamechanger”, Kümmel told the committee. 

“It was clear for the working group that what we were discussing is nothing less than the future role of the WHO and global health and even beyond. Namely, the question, what kind of global health architecture do we envisage: a less fragmented, better coordinated, more efficient and truly inclusive global health governance with a fundamentally strengthened WHO at the centre as the enabled, leading and coordinating authority.”

 

WHO staff tied up with grant management

Earlier in the day, WHO Africa director Dr Matshidiso Moeti told a WHA roundtable meeting on WHO financing that the global body was managing around 3,000 grants.

“Many of our staff members are spending a disproportionate amount of their time processing these grants,” said Moeti. 

In addition, said Moeti, Africa was seen by donors as being “overwhelmed by communicable diseases” and this has resulted in a lack of funds for non-communicable diseases.

WHO Regional Director for Africa Dr Matshidiso Moeti.

If there was more flexibility in funding, the WHO could “address the health systems needs of the countries for preparedness, for providing essential health care services, for being resilient when we have to encounter such a problem as the pandemic we’re experiencing now”, she added.

She compared WHO’s funding model to that of “an average African country, which is highly dependent on donor funding” and “structured in this very vertical fragmented manner”.

This was inefficient, and made countries vulnerable rather than resilient to a pandemic, she said, appealing to member countries to support the changes being proposed by the working group.

Supporting her in the session, WHO Director-General Dr Tedros Adhanom Ghebreyesus said that it was “not about the money” as the WHO had received significant donations during the pandemic – but rather the flexibility to spend the money where it was most needed.

‘Constructive multilateralism’

Describing the process of reaching consensus in the working group as “constructive multilateralism”, Kummel told the WHA committee that “any substantive AC increase would need to be supported by concrete steps to ensure that agility of the WHO, therefore the working group on sustainable financing also recommends the establishment of an agile member states task group”.

This was well-received by member states, with unanimous support for the financial reforms – to the relief of Kummel who described the process as “a marathon run” at the roundtable event before the committee.

“But it was a good run because we ran as a team, and we are still running as a team. There are two things on my to-do list for this year. The one is the Berlin marathon that is in September. The other one is to get this over the finish line and we will have the chance to get this over the finish line, most likely this afternoon,” he told the roundtable.

The WHA will vote on a resolution based on the working group’s decision later in the week.

Image Credits: WHO.

France at the WHA75.

France led the call for a more integrated approach to ameliorating the global burdens of non-communicable diseases at the World Health Assembly (WHA) on Monday, appealing for climate change and environmental issues to be factored into the global response.

Speaking on behalf of some countries in the European Union at Monday’s WHA75 committee session to discuss the follow-up to the political declaration of the third high-level meeting on the prevention and control of NCDs, France said that NCDs were increasing and affecting more and more people of all ages around the world, in particular, the most vulnerable. 

“NCDs already place a large burden on future generations as well as the budgets of states. We must have efficient programs based on an integrated health approach,” the government of France told the WHA committee session.

It called for urgent action, financing and mobilization of stakeholders to be facilitated by the global coordination mechanism. While describing WHO’s roadmap as a basis to work on, it also called for the inclusion of climate change and environmental factors which it described as being of determining importance for NCDs.


Decrying the impacts of the COVID-19 pandemic on global and local initiatives to address NCDs, France said the interruption of prevention and treatment over the course of the pandemic has led to greater inequalities in health.

France then highlighted the importance of improved pandemic preparedness in order to intensify the efforts against NCDs. This, it said, should include promoting patient-focused health education; and policies that prioritize early detection, diagnostics and better treatment in the framework of continued treatment.

Shift to primary health 

In his opening address at WHA75, WHO DG revealed that over the past five years, the global health body has supported 36 countries to integrate services to prevent, detect and treat NCDs into primary health care programmes. He added that health systems are being reorientated towards primary health care as the foundation of universal health coverage.

He revealed that 90% of essential health services can be delivered through primary health care. And investing in primary health care could increase global life expectancy by as much as 6.7 years by 2030.

“We need a radical shift to accelerate progress towards universal health coverage, with a significant increase in investments in primary health care in all countries – high, middle, low income. We have seen globally that the weakness is in primary health care,” the Director-General said.

France agrees. It told the assembly that primary healthcare needs to be strengthened to be able to give people the means to better control their health and in containing the risk factors of NCDs such as the effects of alcohol, tobacco and other addictive substances, diets and sedentary lifestyles.

“Countries rely on the support of WHO and it’s essential that the preparedness and response to NCDs is also part of all emergency responses in order to allow essential healthcare services to be provided in a multi-sectoral way,” it added.

Insights from the war against diabetes 

Diabetes is one of the NCDs that its control could have far-reaching impacts on the global NCDs agenda considering its association with other health conditions and socioeconomic impacts. 

In January 2022, WHO Executive Board proposed several global targets including diagnosing 80% of people with diabetes, 80% of people with diagnosed diabetes have good control of glycaemia, 80% of people with diagnosed diabetes have good control of blood pressure, 60% of people with diabetes of 40 years or older receive statins, and 100% of people with type 1 diabetes have access to affordable insulin treatment (including devices for insulin delivery, such as syringes and needles) and blood glucose self-monitoring.

National diabetes policies and guidelines in Kenya, Mali and South Africa. Source: MSF Access Campaign.

But Dr Helen Bygrave, Chronic Diseases Advisor for Medicins Sans Frontieres (MSF) Access Campaign said while setting global targets for response is strongly supported, more investments will be required, especially in the areas of monitoring and surveillance.

“In countries where MSF works, we have witnessed the challenges faced by people with diabetes receiving care in the public health system, who often don’t have access to the bundle of insulin, medical supplies required to inject it, and tools to monitor their blood glucose levels. It is imperative that countries consider this ‘diabetes bundle’ and its price, when forecasting, budgeting and procuring,” Bygrave stated.

Pandemic
WHO DG Tedros Adhanom Ghebreyesus at 75th WHA

GENEVA – The world is still not ready to handle pandemics despite all of the international efforts to improve health care in recent years, Dr Tedros Adhanom Ghebreyesus warned in a wide-ranging opening address to the World Health Assembly’s 194 member nations.

The World Health Organization must respond to dozens of global emergencies — cyclones, volcanoes, earthquakes, outbreaks, wars – while handling the COVID-19 pandemic, and it created a new hub for pandemic and epidemic intelligence in Berlin earlier this year.

And yet it is not enough because “it’s clear that the world was – and remains — unprepared for a pandemic,” Tedros said. “The pandemic is far from over. And even as we continue to fight it, we face the task of restoring essential health services, with 90% of member states reporting disruption to one or more essential health services.”

More optimistically, Tedros said the world’s needs “remain daunting and complex. But none of these challenges are insurmountable. For every challenge, there are solutions. If there is a will, there is a way.”

His opening speech on the second day of the Assembly began with a look back at the UN health agency’s past five years, during which Tedros’ first term as director-general has been marked by “many calls for WHO to change,” he noted, in its work methods and culture.

“And there is no question that more change is needed,” said Tedros, who is widely expected to be appointed to a second five-year term. “Allow me now to look forward to where I believe we need to go in the next five years. … We are calling on every government to put the health of its people at the center of its plans for development and growth.”

Tedros said the pandemic shows not only why the world needs WHO but also why it needs to be “stronger, empowered and sustainably financed.” To that end, he welcomed a working group’s recommendation to raise assessed contributions to 50% of the core budget over the next decade. These fixed contributions only comprise 17% of WHO’s budget, leaving it to a few rich countries and philanthropies to voluntarily cover most of WHO’s costs.

“You elected me five short years ago, with an ambitious agenda for universal health coverage; health emergencies; women’s, children’s and adolescents’ health; the health impacts of climate and environmental change; and a transformed WHO,” he noted, adding those priorities evolved into the five-year plan for achieving its “triple billion” targets that the Assembly adopted in 2018.

They aim by 2023 to help 1 billion more people benefit from universal health coverage; 1 billion more people be better protected from health emergencies; and 1 billion more people enjoy better health and well-being.

Pandemics progress still slow

“Progress isn’t always fast or easy to measure. But in ways small and large, seen and unseen, I am proud to say that this organization is making a difference. Let me start with our efforts to see 1 billion people enjoying better health and well-being,” he said. “Our projection is that we will almost reach this target by 2023, but progress is only about one quarter of what is required to reach the relevant SDG [Sustainable Development Goals] targets.”

For examples of other global health progress, Tedros also pointed to declining tobacco use, less industrially-produced trans fat in the global food supply and more excise taxes on at least one health-harming product, such as tobacco, alcohol or sugary drinks.

He also cited new WHO limits for air quality “based on mounting evidence of the harms to health of air pollution at even lower concentrations than previously thought” and new WHO health guidelines or tools that 71 countries are using to respond to violence against women.

But on the universal health coverage goal, he said, the world is “far behind, and progress is less than one quarter of what is required” to reach the target.

“Even before the pandemic, we estimated that only 270 million more people would be covered by 2023, a shortfall of 730 million people against the target of 1 billion,” said Tedros. “Disruptions to health services during the pandemic have sent us backwards, and we estimate the shortfall could reach 840 million.”

But there has been a 29% global increase in the number of health workers between 2013 and 2020, he noted, in contrast to previous projections for a global shortage of 18 million health workers by 2030. “That projected shortage has now shrunk to 15 million but it is still a massive shortage,” he added.

Tedros said that in the past five years there has been “significant progress in expanding access to medicines and other essential health products” – such as 53 prequalified vaccines, 50 in-vitro diagnostics and 288 medicines, including new therapies for HIV, hepatitis, TB, malaria, NTDs and COVID-19 – and two prequalified biosimilar cancer medicines along with a pilot program to prequalify human insulin.

Since the start of the pandemic in March 2020, WHO approved emergency use listings for 12 COVID-19 vaccines and 28 in-vitro diagnostics. And within 15 days of those vaccine listings, he said, 101 countries were “illustrating the weight that these countries place on WHO’s stamp of approval” through their own regulatory authorizations of those vaccines.

He said the UN target on hepatitis B — part of the U.N.’s 17 SDGs that contain 169 targets – has been met, and since 2015 the number of people who got treatment for hepatitis C increased ninefold to 9.4 million, reversing the trend of increasing mortality for the first time. And for the first time, the world has a malaria vaccine, enabling more than 1 million children in Ghana, Kenya and Malawi to receive at least one of 4 doses recommended for them from 5 months of age. Each year more than 260,000 African children under five die of malaria.

And on non-communicable diseases, he said, WHO helped 36 countries over the past five years to integrate services to prevent, detect and treat NCDs – one or more chronic conditions, like obesity, heart or kidney disease, or cardiovascular diseases – into primary health care programs, and supported 25 countries with rehabilitation services. WHO also helped 31 more countries to integrate mental health services into primary health care. “Child survival has improved dramatically over the past 20 years,” he said, “although 54 countries are off track to meet the SDG child survival targets.”

Ukraine
Djibouti Health Minister and World Health Assembly President Dr Ahmed Robleh Abdilleh in action on Monday

GENEVA – Russia’s attacks on healthcare facilities amid its war in Ukraine took center stage on the first full day of the World Health Assembly (WHA), where 46 mostly European nations including Turkey, Ukraine, and the United States proposed a draft resolution “condemning in the strongest terms” Russia’s invasion and the attacks on health facilities, calling on all 194 of the World Health Organization’s (WHO) member nations to “maintain or increase support for the UN-led response” to the war in Europe.

The resolution emerged from WHO’s Regional Committee for Europe, which adopted it at a special session on 10 May. It calls on WHO’s Regional Director for Europe to consider temporarily closing Russia’s regional office and suspending all regional meetings in Russia, including technical and expert meetings. 

It also urges Russia “to fully respect and protect all medical personnel and humanitarian personnel exclusively engaged in medical duties, their means of transport and equipment” and to show “respect for and protection of the sick and wounded, including civilians, health and humanitarian aid workers, healthcare systems consistent with the Geneva Conventions and their additional protocols, and with broader international humanitarian law.”

The resolution also urges all WHO member nations to “adhere to international humanitarian law, international human rights law, and WHO norms and standards; to allow and facilitate safe, rapid and unhindered access to populations in need of assistance by staff deployed by the World Health Organization on the ground, and by all other medical and humanitarian personnel; [and] to ensure the free flow of essential medicines, medical equipment and other health technologies in all conflict and non-conflict areas.”

Ukraine war scarier than a pandemic

Ukraine’s First Lady, Olena Zelenska, told the Assembly that Ukraine and WHO have had years of “fruitful relations” and, at least until recently, nothing could have been scarier than a pandemic.

“But it turned out differently. Russia’s war has shown horrors we could not have imagined,” she said by videoconference. “WHO is committed to protecting the most crucial human rights – to life and health. Now they are both being violated in Ukraine. No Ukrainian, neither adults nor children, can be sure that they will wake up tomorrow, that a missile will not fly into their house. Doctors cannot be sure that their ambulances will not be bombed on the way to a patient.”

On the same day, her husband, President Volodymyr Zelensky, spoke by videoconference to the World Economic Forum in Davos and called for help to come “as fast as possible” to arm Ukraine for victory and help rebuild the country after the war.

The draft resolution put forward by Ukraine was co-sponsored by 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, Luxembourg, Malta, Moldova, Montenegro, Netherlands, New Zealand, North Macedonia, Norway, Peru, Poland, Portugal, Romania, Slovakia, Slovenia, Spain, Sweden, Turkey, United Kingdom and United States.

Russia appeals for ‘non-politicized’ discussion

Among the holdouts from the co-sponsor list were Hungary – the only one missing from the 27-nation EU bloc – along with Israel and Switzerland.

Russia won some scattered applause in the Assembly when one of its diplomats urged colleagues not to allow WHO to become “politicized” – in keeping with the nations’ social media posts. 

Russia’s Mission in Geneva tweeted that “Russia looks forward to forging common solutions to the pressing global health challenges. We expect non-politicized, constructive and consensual deliverables of #WHA75, moving us towards a healthier planet.”

Separately, a Russian diplomat at Russia’ Mission in Geneva said he was resigning his position because he was ashamed of his government’s invasion of Ukraine. In a letter posted on his LinkedIn account, Boris Bondarev, a counselor for arms control, disarmament, nonproliferation and export control, said he resigned on Monday.

“Long overdue, but today I resign from civil service. Enough is enough,” he began. “For twenty years of my diplomatic career I have seen different turns of our foreign policy, but never have I been so ashamed of my country as on February 24 of this year. The aggressive war unleashed by [Russian President Vladimir] Putin against Ukraine, and in fact against the entire Western world, is not only a crime against the Ukrainian people, but also, perhaps, the most serious crime against the people of Russia, with a bold letter Z crossing out all hopes and prospects for a prosperous free society in our country.”

“Those who conceived this war want only one thing – to remain in power forever, live in pompous tasteless palaces, sail on yachts comparable in tonnage and cost to the entire Russian Navy, enjoying unlimited power and complete impunity,” he continued. “To achieve that they are willing to sacrifice as many lives as it takes. Thousands of Russians and Ukrainians have already died just for this.”

As the Assembly got underway, WHO said it verified 30 additional attacks on health care facilities in Ukraine. As of Monday, it said, 75 deaths and 59 injuries can be traced to 248 verified attacks on health care facilities in Ukraine from February 24, the day that Russia invaded, until May 19.

“It is a true catastrophe for millions of people. The World Health Assembly needs to discuss this,” Germany’s Health Minister Dr Karl Wilhelm Lauterbach urged colleagues.

“I call on everyone to support the resolution presented by Ukraine to this assembly.” Norway’s Health Minister Ingvild Kjerkol said her nation strongly supports Ukraine and WHO has a strong role to play in helping maintain peace. When nations stand together, she said, they are stronger and “that is what this time calls for.”