Ambassador Grata Endah Werdaningtyas, co-chair of the Working Group on Strengthening WHO Preparedness and Response to Health Emergencies

Now that the World Health Assembly Special Session has overwhelmingly resolved to negotiate a “pandemic accord”, the urgent work of producing a workable plan to tackle future pandemics begins.

This was the view of speakers – most of whom have been integrally involved in “pandemic accord” discussions – addressing an event convened by the Global Health Centre at the Graduate School of International and Development Studies (IHEID) and the United Nations Foundation on Friday.

Colin McIff, co-chair of the Working Group on Strengthening WHO Preparedness and Response to Health Emergencies (WGPR) that brokered the pandemic accord decision, said the two mandates of group were almost “in conflict”.

The first was to assess the International Health Regulations (IHR) that currently govern health emergencies, scanning them for gaps, and the second was to examine the benefits of setting up a WHO instrument on pandemic preparedness and response. 

“These were very challenging mandates,” said McIff, who is Deputy Director of Global Affairs at the US Department of Health and Human Services.

“What we did as a bureau [of the WGPR] very early on was agree that the only way to achieve progress was to keep them as integrated as possible.”

“It was necessary to look at the existing tools and and regulations like the IHR, before looking at a new instrument and to define what those gaps are,” said McIff. 

By the fourth WGPR meeting, the issue of equity was put squarely on the table by the Africa group, added McIff.

The WHASS showed that “there was consensus among Member States, both to take forward a new instrument and to take concrete meaningful steps to strengthen the IHR and to tackle some of these key issues like equity, like sample sharing, like One Health issues”, he added.

Colin McIff, co-chair of the Working Group on Strengthening WHO Preparedness and Response to Health Emergencies (WGPR)

Elusive issue of equity

Indonesia’s Ambassador Grata Endah Werdaningtyas, the other WGPR co-chair, said the pandemic treaty is “a little bit burdened by the hopes of a lot of member states in terms of finding the final solution of our problem”.

“The treaty itself is not a panacea. It has to work in coherent alignment with the existing mechanisms that we have, including the IHR,” she stressed. “The treaty will not stand on its own.”

Werdaningtyas conceded that inequity would not be solved by a new instrument but could be addressed by, for example, “building core capacity in terms of supply compliance and in terms of strengthening our health system”.

WGPR member Dr Malebogo Kebabonye said that WHO member states now had to define how a pandemic accord would work, says, adding that the working group would continue to operate until mid-2022 as it still had to conclude proposals on how to strengthen the IHR.

Pandemic focus, not panacea

Prof Ilona Kickbusch

Despite the WHO now referring to the new instrument as an “accord”, Professor Ilona Kickbusch, said she insisted on it being called a treaty.

She said clarity needed to be reached about its focus – and that it could not be about solving all the problems in global health over the past 75 years, as some seemed to think.

“There is no process of proclaiming a pandemic. If there is to be one, what would this trigger?” asked Kickbusch, chair of the Global Health Center’s International Advisory Board. 

She also said there was an urgent need for increased financing.

“My hair stands on end when I see the expectations on the WHO emergency programme [in comparison to] its budget.

Impatience is giving way to anger

Preeti Sudan, a member of the Independent Panel for Pandemic Preparedness and Response

However, speakers also expressed frustration that the final text of a pandemic accord would only be presented to the 2024 Wold Health Assembly.

“The pandemic is still raging, reinventing itself, throwing up new challenges. Financing is required urgently, the WHO needs to be strengthened. It needs independent financing. How do we do that?” asked Preeti Sudan, a member of the Independent Panel for Pandemic Preparedness and Response.

“Do we need do we then wait for 2024? How do we address issues of inequity? The situation is dynamic and extremely serious.”

Elhadj As Sy, Co-Chair of the WHO Global Preparedness Monitoring Board, also appealed for urgency.

“What we really have not really taken into account fully is the degree of impatience that is really growing among citizens and communities,” he said.

“That is translating into anger. And that is translating into mistrust and then we should not let that continue. Because then we will not only have a health problem or a pandemic to deal with but a much bigger societal and political issue that will threaten all our efforts.”

Elhadj As Sy, Co-Chair of the WHO Global Preparedness Monitoring Board
PAHO Director Carissa Etienne

Following the detection of the newest WHO COVID-19 variant of concern, Omicron, in Canada and Brazil, and most recently, the US, the Pan American Health Organization (PAHO) has urged countries to “redouble their surveillance efforts in the region, warning that it is likely that the new variant will likely be circulating in other parts of the Americas soon. 

Omicron was first identified in southern Africa late November. Concern has been raised over the fact that the variant has over 30 mutations in the spike protein, the site usually targeted by COVID-19 vaccines.

The first known US case of the variant was announced late Wednesday – a fully vaccinated person in California who returned to the country from South Africa on 22 November and tested positive seven days later. 

In addition, Canada has reported six cases of Omicron while Brazil has reported 2. Delta remains the predominant variant in the region. 

PAHO is currently working with health ministers in the region and will share guidance and updates on Omicron as it becomes available, said PAHO Director Carissa Etienne during a media briefing Wednesday. 

“Speed and transparency is most critical, but above all, we urge people to not be frightened.” 

PAHO officials also discouraged the spread of rumors surrounding the variant, and urged people to continue to get vaccinated. 

“There are many rumors saying, ‘This vaccine doesn’t work, that other vaccine doesn’t work [against Omicron]. But these are just rumors,” said PAHO’s Assistant Director Jarbas Barbosa.

“Within two to three weeks, we will have more valid, accurate information about the ability to neutralize the new variant with the antibodies generated by the vaccine, but until we have more information, we should continue vaccinations.” 

PAHO Assistant Director Jarbas Barbosa

COVID cases predominantly on the rise in the Americas 

Over 753,00 new COVID-19 infections and 13,000 COVID-related deaths were reported in the Americas in the past week, PAHO announced on Wednesday.

Cases in Canada and the United States remain steady but high. Infections and deaths have dropped by over 20% in Mexico.

Central America has seen a reduction in cases and deaths over the last week, with the exception of Panama. 

In South America, cases in the Southern Cone region have increased steadily over the last several weeks, while in the Andean region and Brazil, cases have plateaued. 

Meanwhile, in the Caribbean, cases are on the rise in the Cayman Islands and Anguilla.  

Etienne highlighted the need for countries to sustain public health measures to limit the transmission of the virus.

“This pandemic is dynamic and the decisions we make about upholding preventive measures and expanding access to vaccines will influence how far this virus spreads.”

Vaccine inequity prolongs pandemic 

In light of fears surrounding Omicron, PAHO reiterated how vaccine inequity would continue to prolong the pandemic.

 “The more COVID-19 circulates, the more opportunities the virus has to mutate and change,” said Etienne. 

Only 54% of people in Latin America and the Caribbean have been fully vaccinated against COVID-19. 

Though the WHO had established a target for countries to reach at least 40% of their population vaccinated by the end of 2021, only 20 countries in the Americas have reached the overshot that goal, while 15 countries in the region still have less than 40% vaccinated.

The vaccine inequity is evident in the region – four countries have more than 70% of their populations vaccinated, but two countries still have not reached even 20% in the Americas – Jamaica and Haiti .

Haiti has less than 1% of its people fully vaccinated against COVID-19, while Nicaragua has 17%. Both countries had failed to reach the original goal of vaccinating at least 10% of their people back in September. 

“While progress is being made, there is still a persistence of a situation of inequality and inequity in access,” Barbosa noted. 

Increased access to antiretroviral therapy still needed 

To commemorate World AIDS Day, 1 December, PAHO officials called for increased access to vital treatments such as antiretroviral therapy (ARV), by combating the still-existing discrimination and stigma in health care, as well as the disruptions in services due to COVID-19. 

“Expanding access [to HIV treatment] is only possible if we combat the persistent stigma and discrimination that keep health services out of reach from too many men who have sex with men, transgender women, and sex workers across our region,” said Etienne. 

For people living with HIV, proper ARVs can help keep their disease in check and avoid infection. However, this requires consistent access to these life-saving drugs.

Even before the pandemic, just 65% of people living with HIV were receiving antiretroviral therapy. But the pandemic has caused more countries to report partial disruptions in services.

But while the region is falling behind on the 2030 target to reduce new HIV infections and eliminate AIDS-related deaths, significant progress  has been made with new treatments for people living with AIDS. 

In order to reach the 2030 target, Etienne emphasized the need for a human-rights approach to addressing the AIDS pandemic.

“Our AIDS-elimination responses must reflect the cultural and sexual diversity, gender equality, and human rights, with active participation from communities most affected.” 

Image Credits: PAHO.

SA launches a COVID-19 vaccination drive in schools on Thursday as the country enters a fourth wave of infection amid the highly infectious Omicron.

CAPE TOWN – While much is still unknown about Omicron, the new COVID-19 variant, South African health officials are “optimistic” that the current vaccines will continue to offer protection against severe illness and death.

Speaking from Gauteng province, South Africa’s economic hub and the place where Omicron was first sequenced, Dr Mary Kawonga told a media briefing on Thursday that “analysis is continuing but we are optimistic”.

Hospitalisations are lower than at a similar point in the province’s previous COVID-19 wave, which was driven by the Delta variant, said Kawonga, a public medicine specialist who made a presentation on behalf of the Gauteng Premier’s COVID-19 advisory group. 

Gauteng is currently the epicentre of South Africa’s fourth COVID-19 wave and scientists have shown that the current infections are being driven by Omicron, not Delta as in the previous wave.

During the Delta third wave, vaccinations were not widely available whereas currently 42% of South Africa’s adult population is now vaccinated.

Based on current figures, statisticians predict that Gauteng will record less than half the hospitalizations of the previous wave when this (fourth) wave peaks, likely in two weeks’ time –  an estimated 4000 hospitalisations in comparison to 9,500 previously.

Currently, most of those hospitalised are people under the age of 39, a group that has lower vaccination rates than older people. 

In addition, deaths were “significantly lower”, reported Kawonga.

Highly infectious

However, the rate of infection appears significantly faster than Delta, with Gauteng cases increasing by over 20% per day. By 22 November, the Reproduction number (R) had increased to 2.33 with 12,5% of tests being positive for the week ending 27 November – a whopping 261% increase compared to the previous week.

Johannesburg – the biggest city in the province – recorded 155 COVID-19 cases in the first week of November but this had shot up to 3,595 cases two weeks later.

Cases are starting to rise rapidly in the rest of the country too, and late Thursday South Africa reported 11,535 new COVID-19 cases, an increase of 368% from last week, and a case positivity rate of 22,4%.

Reinfection does not offer protection

Aside from the rapid transmission rate, scientists are also concerned that previous infection from COVID-19 does not appear to offer protection from Omicron infection.

“Many [South Africans] have had previous COVID infection and we believe that previous infection does not provide them protection from infection due to Omicron,” Professor Anne von Gottberg, told a media briefing on Thursday called by the World Health Organization’s (WHO) Africa region.

Von Gottberg, a microbiologist from South Africa’s National Institute for Communicable Diseases, said that this was in contrast to during the Delta-driven third wave when those previously infected had been protected from reinfection.

‘“We believe that vaccines will still, however, protect against severe disease. Vaccines have always held out to protect against serious disease, hospitalisations and death,” she added.

Ghana and Nigeria identify Omicron

Dr John Nkengasong, Director of the Africa CDC

In the past few days, Omicron has been identified in Ghana and Nigeria, aside from Botswana and South Africa, according to Dr John Nkengasong, Executive Director of the Africa Centre for Disease Control (CDC). Over 23 countries worldwide have also found the variant, the WHO reported on Wednesday.

But WHO Africa virologist Dr Nicksy Gumede-Moeletsi reports that only half of African States have the capacity to do their own genome sequencing which would enable them to identify the variant. 

However, only southern Africa and to a lesser extent, the north of the continent, are experiencing significant case increases.

“In the past week (22 – 28 November 2021), a total of 52,300 new cases were reported in Africa. This is a 105% increase from the previous week,” said Nkengasong. “The highest proportion of new cases is from the Southern region, which accounts for 63% of new cases.”

The Northern region had reported a 25% increase in cases, while there were small upticks in the Eastern (8%), Western (3%) and Central (1%) regions.

Dr Richard Mihigo, WHO Africa’s co-ordinator of immunisation, said that the global body was ready to help member states and was currently helping Botswana to increase its oxygen capacity.

WHO officials reiterated that the travel bans imposed on a number of African countries in the wake of Omicron’s identification were “unfair” and would deter other countries from reporting variants as required by the International Health Regulations. South Africa reports losing $63-million in tourist bookings since the variant was announced.

Image Credits: Gauteng Department of Health.

Standing ovation at special World Health Assembly session that decides to negotiate a new pandemic accord

The World Health Assembly Special Session (WHASS) closed on Wednesday with a standing ovation as virtually all 194 Member States committed to negotiating a new global accord to guide the response to future global pandemics.

The World Health Organization’s (WHO) Director-General, Dr Tedros Adhanom Ghebreyesus, described the decision as “cause for celebration, and cause for hope, which we will need”.

While Dr Tedros warned that “there are still differences of opinion about what a new accord could or should contain”, delegates had “proven to each other and the world that differences can be overcome, and common ground can be found”.

“A convention, agreement or any other international instrument will not solve every problem, but it will provide the overarching framework to foster greater international cooperation and provide a platform for strengthening global health security,” Dr Tedros told a later press briefing.

WHO Assistant-Director-General for Health Emergencies and International Health Regulations (IHR), Dr Jaouad Mahjour, said what had emerged from over 300 recommendations was that the new pandemic would rest on four major pillars.

He identified these as governance and leadership; financing of preparedness; global mechanisms that can be activated during the crisis, and finally, equity, including equitable and timely access to goods.

WHO legal advisor Steven Solomon added that negotiating any global agreement was “complicated”. 

“What is important is that there be a transparent, inclusive and consensus-driven process among Member States to work it out,” added Solomon.

Driven by ‘almost complete consensus’

WHA Vice-Presidents Professor Benjamin Hounkpatin (Benin) and Dr Hanan Al Kuwari (Qatar)

WHASS vice-president, Qatar’s Dr Hanan Al Kuwari, praised the “near complete consensus on the path we must take”.

This path involves:

  • The WHO convening the first meeting of the intergovernmental negotiating body (INB) by 1 March 2022
  • A draft global agreement by July 2022
  • The second INB meeting by August 2022
  • Discussion of the draft agreement at the WHA in May 2023
  • Adoption of the agreement at the 2024 WHA.

However, other issues will also impact on the negotiation process. These include the working group on sustainable finance for the WHO, a proposal for a pandemic standing committee of the WHO executive board, and the call to strengthen both the WHO and the International Health Regulations (IHR) before the next World Health Assembly.

Chile’s Frank Tressler and Australia’s Sally Mansfield, the countries that chaired the informal member state negotiations that thrashed out the decision, were also upbeat about the outcome.

“Today was have taken the first step in the process that calls upon all of us to work together,” Tressler told the assembly. “Pandemics recognise no borders. It is therefore very important that we have a consensus among Member States and equity must be at the centre of our new international instrument.”

“The text before us is the product of extensive discussions, of frank exchanges and of compromises, but above all, it represents a shared commitment to an ambitious, coordinated whole-of-government and whole-of-society effort to strengthen pandemic prevention, preparedness and response,” said Mansfield. 

Australia’s Sally Mansfield

Mansfield also credited the hard work of the “Bureau” of six countries that guided a months-long review by a Working Group of member states examining the International Health Regulations (IHR) needs and gaps, headed by the US and Indonesia, for having “laid the groundwork” for the decision.

As reported earlier by Health Policy Watch, Colin McIff,  deputy director of the office of global affairs in the US Department of Health and Human Services, had been positive about the potential advantages a new treaty could offer in  light of the failings of the existing IHR legal framework.  

Speaking on behalf of the 43 Member Countries that made up the Group of Friends of the Pandemic Treaty, Costa Rica described the WHASS decision as a “turning point”.

“The challenge of distributing vaccines throughout the world, and the slow reaction to the crisis, must be dealt with at the highest level and lead to a timely, coherent and coordinated response from all member states,” said Costa Rica. 

The Group of Friends facilitated informal negotiations on the pandemic “treaty” – now being referred to as a convention, instrument and agreement – that led to speedier agreement on the current decision, and could play a similar role in the new discussions outside of the formal INB.

Why the speed, ask civil society groups

However, a group of civil society organisations have questioned the speed of the negotiations.

“The mechanics of the current treaty proposal have been enacted at full speed without a serious assessment of the reasons why the implementation of the current binding arrangement on health emergencies – the 2005 International Health Regulations – have been so broadly neglected and disregarded by all countries in the world.

“What’s the real advantage of starting a negotiation on the same topic again?” asked Nicoletta Dentico, Head of Global Health Justice Program, Society for International Development (SID) and G2H2 co-chair in a press release.

Alexandra in Johannesburg during a COVID-related lockdown. Millions of South Africans have lost their jobs during the pandemic.

CAPE TOWN – The Omicron-related travel bans imposed on southern Africa are costing the economically fragile region millions of dollars every day – and countries that introduced them did not follow the process laid out in the International Health Regulations (IHR) adopted by the World Health (WHO) Organization in 2005.

A snap survey of over 600 tourism and hospitality operators in South Africa found that they have lost over $63-million in cancelled bookings since last Thursday when the new COVID-19 variant was announced.

“If the travel bans remain in place, based on the cancellations to date, respondents would lose 78% of their previously expected business levels for the period December to March. This would support in order of 205 000 jobs annually,” according to a statement issued this week by the Federated Hospitality Association of Southern Africa and tourism body SATSA.

Enver Duminy, CEO of Cape Town Tourism, said that the city alone was losing an estimated $15million every day in cancelled bookings since the announcement of Omicron.

Over two million South Africans have already lost their jobs during the COVID-19 pandemic, and 34.4% of all adults were now officially unemployed – the highest recorded level ever, Statistics South Africa announced on Tuesday.

Last month, the UK – South Africa’s biggest tourism partner – finally removed South Africa from its red list, while the US did so on 8 November.  International bookings followed and the tourism sector expected to make a modest recovery over the Christmas period – until the identification of Omicron.

Internal Health Regulations require scientific reasons

Botswana’s Ambassador to the UN in Geneva, Dr Athaliah Molokomme

Botswana’s Ambassador to the UN in Geneva, Dr Athaliah Lesiba Molokomme, told Wednesday’s closing session of the World Health Assembly special session that the travel bans were a violation of the very International Health Regulations (IHR) that many member states had urged the assembly to strengthen this week.

Speaking on behalf of the 47 African WHO Member States, Molokomme called for the immediate lifting of the travel restrictions imposed on southern African countries.

“We remain deeply concerned and disappointed by the lack of upholding of collective action, shared responsibility and solidarity. In a globalised and highly interconnected world, locking out a whole sub-region is dangerous and is neither effective nor sustainable,” said Molokomme.

Furthermore, she said that the countries that had jumped to restrict travel – 56 of them, according to the WHO – had not followed the process laid down in the IHR, the only global legally binding rules relating to health emergencies. 

“Member states are required to implement the recommendations in line with the International Health Regulations of 2005 and are supposed to inform the WHO of the travel measures and further provide the scientific and public health rationale when informing the WHO,” Molokomme pointed out. 

According to Article 43 of the IHR, any member state that implements health measures which “significantly interfere with international traffic shall provide to WHO the public health rationale and relevant scientific information for it”. 

WHO needs to be given public health and scientific rationale

The WHO has to be informed “within 48 hours of implementation, of such measures and their health rationale unless these are covered by a temporary or standing recommendation”. 

Significant interference is defined as “refusal of entry or departure of international travellers, baggage, cargo, containers, conveyances, goods, and the like, or their delay, for more than 24 hours”. 

Once a Member State has informed the WHO of its action, the global body “may request that the State Party concerned to reconsider the application of the measures”.

Ironically, this week’s World Health Assembly special session was dedicated solely to the need for negotiations for a new “convention, agreement or other international instrument on pandemic prevention, preparedness and response” – as most Member States deem the IHR to be inadequate.

Vulnerable are advised to postpone travel

Late Tuesday, the WHO issued an “advice on international traffic” in light of Omicron, advising people who are unwell, not fully vaccinated or recovered from previous SARS-CoV-2 infection and are “at increased risk of developing severe disease and dying” to postpone travel to areas with community transmission.

This includes “people aged 60 years or older or those with comorbidities that present increased risk of severe COVID-19 (eg heart disease, cancer and diabetes)”

However, the WHO stressed that “blanket travel bans will not prevent the international spread, and they place a heavy burden on lives and livelihoods”.

The WHO commended South Africa and Botswana for their surveillance and the speed and transparency with which they notified and shared information with the WHO Secretariat on the Omicron variant in accordance with IHR. 

“WHO calls on all countries to follow the IHR and to show global solidarity in rapid and transparent information sharing and in a joint response to Omicron (as with all other variants), leveraging collective efforts to advance scientific understanding and sharing the benefits of applying newly acquired scientific knowledge and tools”.

It appealed to countries to “apply an evidence-informed and risk-based approach when implementing travel measures in accordance with the IHR, including the latest Temporary Recommendations issued by the WHO Director-General on 26 October”.

 

Image Credits: Flickr: IMF Photo/James Oatway.

South African protestors call for universal access to antiretroviral treatment.

Pandemics exacerbate and thrive on inequity. They find the fissures in our societies and deepen them. As a result, the poorest and most marginalized always suffer the most.  

We have seen this with HIV and we are seeing it again with COVID-19. Rich countries are starting booster vaccination campaigns while most people in poor countries are without even a first dose. But as we mark World AIDS Day, we must also acknowledge that inequities exist within countries as much as between countries.  

Since the first cases of AIDS were reported 40 years ago, the world has made huge progress in the fight against HIV. In countries where the Global Fund invests, AIDS-related deaths have dropped by 65% since we were founded 20 years ago. Globally, more than 27.5 million HIV-positive people are on lifesaving antiretroviral therapy (ARVs).

Yet in many countries, persistent inequities have proved a formidable barrier to accelerating progress against the virus. In such countries, new HIV infections are concentrated amongst those made vulnerable by human rights or gender-related inequities. 

People in communities that are stigmatized or criminalized, and thus cannot access essential services to protect them from HIV, can be up to 25 to 35 times more likely to acquire HIV infection than the general population. In sub-Saharan Africa, adolescent girls and young women face an array of gender-related barriers that predispose them to HIV: six in seven new HIV infections among adolescents aged 15 to 19 years in the region occur among girls.

Most vulnerable are most exposed

COVID-19 has exposed the most vulnerable and marginalized communities to even greater risks, as lockdowns and restrictions to curb the new pandemic hindered access to lifesaving HIV treatment, tests, care and prevention services.

In the fight against HIV, we now face a new reality: we were off track even before the pandemic, and COVID-19 has pushed us further off track. What got us this far will take us no further.

To accelerate progress – and reach the even more ambitious global HIV targets for 2025 – we will need to invest more and invest more smartly. We must be even more precise and differentiated in devising and delivering prevention and treatment approaches for communities most at risk. Achieving this entails empowering communities themselves to play an even greater role in designing and implementing interventions.

For prevention, we are advancing the concept of “Precision HIV Prevention” to ensure we get maximum impact from the scarce resources that are available. 

That means we’re supporting countries to focus efforts on locations where HIV is most prevalent and on people with the greatest HIV prevention needs so they have the tools, knowledge and power to protect themselves. 

For treatment, we are supporting innovative and cost-effective models of drug and care delivery that make services more accessible, which is critical for getting people on ARVs early and improving retention and viral suppression. Such practices include multi-month dispensing of ARVs – now recognized as a best practice for increasing adherence to treatment. 

A variety of antiretroviral drugs used to treat HIV infection.

Human rights and gender barriers

We also need to be even more determined in tackling the human rights and gender-related barriers that prevent the people most at risk from accessing the services they need. 

Key and vulnerable populations, including adolescent girls and young women, gay men and other men who have sex with men, people who use drugs and transgender people, face a daunting array of barriers arising from stigma, discrimination and criminalization. Unless we address these through a rights-based approach, we will not defeat HIV.

These imperatives are central to the Global Fund’s new strategy, approved by our Board last month. Putting people and communities at the center, this strategy puts even greater emphasis on equity, human rights and gender equality, and on reinforcing the role and voice for communities living with and affected by HIV.

The strategy also commits the Global Fund to investing in people-centered, integrated systems for health, including community systems. 

Without diluting our focus on saving lives and reducing infections, we will be more deliberate in leveraging the synergies between the fight against HIV and interventions to combat other pathogens, so as to serve people better and improve the resilience and sustainability of our interventions.

For example, in many countries we already invest in integrated programs for HIV and tuberculosis, but now there is a need to manage the interaction with COVID-19 as well. High throughput molecular diagnostic instruments installed for viral load testing are now being utilized for COVID-19 testing; testing people for both HIV and COVID-19 fights both pandemics at once. 

People living with HIV who are not virally suppressed are more likely to be severely affected by COVID-19, so it is all the more important to provide them with ARVs and protect them from the new virus.

Again and again, we have seen the poorest and most marginalized suffer the most from the most dangerous infectious diseases. We must take an approach that recognizes this cruel reality. 

HIV was the last big pandemic to strike humanity, and while we have made great progress, we have not yet defeated it. COVID-19 poses another huge challenge, particularly to communities most at risk from HIV. We must fight both pandemics, and beat both, and do so in a way that tackles the inequities they exploit and deepen.

Peter Sands is the Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria. 

 

 

 

 

 

 

 

Image Credits: Louis George 2011 , Louis George 2011 , NIAID.

WHA collage
Collage of delegates presenting Member State positions at the WHA special session on Tuesday.

While the vast majority of World Health Organization (WHO) member states expressed support for a negotiated pandemic “instrument” at Tuesday’s World Health Assembly special session (WHASS), many also urged the strengthening of the International Health Regulations (IHR) – currently the only existing legal framework to address pandemics.

Singapore, Thailand, Zambia, and Colombia were among those that supported the strengthening of the IHR alongside a new pandemic instrument.

Colombia said that a pandemic instrument could be linked to the IHR, and called for the IHR to be strengthened “through amendments and effective bodies, which will allow better implementation mechanisms”.

Zambia called for “focused adjustments to the identified weaknesses’ alongside the development of a new legally binding international instrument”. 

However, Dr Ahmed Al-Mandhari, director of the WHO Eastern Mediterranean Region (EMRO), said that while the IHR were important, they were not sufficient to address future pandemics.

Meanwhile, the Netherlands cautioned that a legally binding pandemic treaty was not a “panacea” for pandemics and that much more needed to be done to prevent pandemics. 

For Japan, universal healthcare has to be a key principle of any pandemic treaty to ensure “no one is left behind”.

Fiji drew attention to the fact that there is “no comprehensive framework within the WHO that governs pathogens, including emerging diseases of zoonotic origin”, and called for this to be addressed alongside numerous calls for a “One Health” approach to future pandemics.

India, on behalf of the South East Asia region, called for any new instrument to address the development and distribution of medicines, “research and development, intellectual property, technology transfer, and scaling of local and regional manufacturing capacities during emergencies”.

Risk of lengthy negotiations

The agreement to set up an intergovernmental negotiating body to strengthen pandemic prevention, preparedness and response” has been co-sponsored by 114 of the 194 members.

However, the new instrument – variously called a treaty, convention and agreement – is likely to take at least 18 months of negotiations to come into existence. The best-case scenario for a “pandemic treaty” agreement is by mid- 2023.

Thiru Balasubramaniam, Knowledge Ecology International’s (KEI) Geneva representative, acknowledged that the proposed negotiations “are not a quick fix to the current pandemic, but they offer a much more comprehensive and potentially useful response going forward, including for the next pandemics”. 

But a report prepared by the WHA working group presented to the assembly by Tedros, acknowledged the possibility of drawn-out negotiations.

“The risks include lengthy time frames for negotiating new instruments or deadlock due to negotiation, as well as insufficient resource and time commitments resulting from intergovernmental negotiations,” the report acknowledged.

Balasubramaniam said that the negotiators “will be looking to see how they can address the many policy failures that have accompanied the current pandemic responses, and to create a better global framework for cooperation, including the sharing of technology and the financing of measures to prepare for and respond to pandemics”. 

“The initial plan is to negotiate the details in a two-year time-span, commencing in March 2022 and ending in May 2024. The WHA decision cites Article 19 of the WHO constitution, a rare and important effort to attain the highest legal status to an agreement,” he added.

Civil society appeals for solidarity

Addressing the WHA on Monday, WHO Director-General Dr Tedros Adhanom Ghebreyesus said that the governance of global health security was “complex, fragmented and has failed to ensure effective collective action and equitable access to vaccines and other tools”.

A wide range of civil society observers addressed Tuesday’s session, and most appealed for a well-funded, nimble body that was based on solidarity and equity.

The International Federation of Red Cross and Red Crescent said the COVID-19 response had been “hugely impaired by gaps in global cooperation and inequities”, and any new  treaty must include “a firm commitment to equity, including equitable access to health services, and care and resources such as “vaccines, data, diagnostics, treatment and PPE”.

Dr Seth Berkley, CEO of the global vaccine facility, Gavi, appealed for more attention to be paid to strengthening countries’ routine immunisation programmes and primary healthcare systems.

Berkeley outlined a five-point approach, including a “truly global response, as infectious diseases need to be simultaneously controlled all across the world” and “agile contingency financing”.

Reminding the WHA that at least 115,000 health workers had died of COVID-19, the International Council of Nurses stressed that any instrument had to ensure the protection of workers in the sector.

Medecins Sans Frontieres and the South Centre stressed a community-based approach to addressing pandemics that involved the people most affected.

The WHA concludes on Wednesday when it is expected to endorse the decision to negotiate a new instrument.

 

WHA special session meets in Geneva in a hybrid format

A special session of the World Health Assembly is under way this week with just one item under consideration – Pandemic Treaty.

Will a pandemic treaty be able to help address deficiencies in global solidarity, and improve access to essential lifesaving medicines, vaccines, and tools?

The short answer is no. Not without the political will to hold corporations to account with the same vigour the treaty hopes to hold errant countries to account. And, not without the willingness to adequately resource and distribute capacities, away from rich countries to poorer countries and regions of the world.

The instrument that currently enables global public health responses to transnational spreads of infectious diseases is the International Health Regulations (IHR). There is a growing acknowledgement that the IHR, adopted in 1969 and revised in 2005 following the SARS outbreak, needs further revision and expansion of scope to include pandemics and zoonotic spillovers, guarantee just and equitable responses, and strengthen the ability of the World Health Organisation (WHO) to monitor, investigate, and work with national governments. A new proposal for an international treaty on pandemics is now on the table, championed by Germany, the  European Union and the United Kingdom, and as of last night, with the cautious support of roughly 100 other nations.

Timing of treaty critical with Omicron and vaccine inequity

Obviously, the timing is important. COVID-19 cases are still on the rise. Omicron – the new variant of concern – has been now detected in 11 countries. The WHO predicts 500,000 deaths in Europe alone by March. In spite of vaccine availability, Europe is struggling to increase full coverage of vaccines above 70%. Past weeks have seen street protests in Austria, Belgium, Croatia, Italy, and the Netherlands. This is therefore a sad and telling marker of egregious inequity — rich countries are ramping up boosters while millions in poor (and rich) countries are yet to receive their first shots.

These catastrophic failures in global cooperation and solidarity cannot be attributed to limitations in global frameworks and agreements alone.

Rich countries lacking ‘political will’ to share necessary resources

Demonstrators outside of the European Parliament just before a vote on a controversial proposal to waive IP related to COVID vaccines and treatments

What is clearly lacking is the political will to share essential resources and tools by rich countries. The DG of the WHO has said that the world cannot afford to wait until the pandemic is over to start planning for the next one. As we stare at another year of rising infections and deaths, we seem resigned to the reality of vaccine inequity and more deaths in this pandemic.

We know why people in poor countries have no access. A TRIPS Waiver proposal before the World Trade Organisation (WTO), officially backed by 63, and supported by 100 other countries, is being blocked, mainly by the EU, UK, Norway, Switzerland, and other countries that propose the pandemic treaty.

This proposal calls for a temporary waiver on intellectual property (IP) rights for all essential medical technologies including vaccines, transparency in regulatory information related to its development, lifting any and all forms of IP and their enforcement through any dispute settlement mechanisms, and sufficient duration for the production and supply of these technologies necessary to overcome the pandemic. This switch and bait tactic — diverting attention away from their lack of support for the waiver by proposing a new treaty — reeks of bad faith.

A TRIPS waiver will urgently allow medicines, vaccines and other essential tools be produced more widely, increasing access. A recent New York Times report outlines the capacity that exists around the world to immediately start the production of quality mRNA vaccines that will not only increase vaccination coverage but also guard against new variants.

Shift from protectionism of big pharma to sovereignty for poor countries over essential medicines

Countries such as India have grappled with exporting vaccines to Europe and the US, while failing to vaccinate their own citizens.

At the heart of a free-market ideology adhered to by rich countries, lies a protectionist tendency. Patent laws have allowed Big Pharma to build monopolies and reap immense profits while they are willing to let millions remain unvaccinated. Even in the time of an extreme health emergency, rich countries are unwilling to put people before profits. Furthermore, companies have secured maximum protection from countries seeking vaccines, against any liability through secretive and abusive agreements. The governance capture of public agenda by the private and influential philanthropists is complete.

It is important that we learn the right lessons from this pandemic before we rush into a new treaty. Even with the best of intentions, IHR, or any treaty for that matter, will only go so far if capacities, and all of the resources needed to implement recommendations do not exist in countries.

Any future frameworks or treaties must therefore resist corporate interests and ensure distributed capacities in a manner that poor countries and regions have sovereignty over essential medicines, materials, and supply chains. The colonizing impulse to centralize control over agenda, response, and supply chains must be resisted. A positive instance of distributed capacity, in the aftermath of the 2013-2016 Ebola outbreak in West Africa, is the creation of the Africa CDC in 2017. On the other hand, the creation of the WHO Health Emergencies Programme in 2016, is an instance of a centralizing initiative that also distracts from WHO’s essential norm-setting functions in global health, further weakening its role as an impartial actor.

Decolonization of global health requires de-imperialization for ‘pandemic insurance’

The need for country-led supply-chain sovereignty comes at a time when public health practitioners and scholars are increasingly vocal about the need for decolonization of global health. Successful decolonization requires, a conscious de-imperialization. It is not just about letting go of power and control but an intentional and deliberate recognition and transfer of knowledge and capacities. Decolonized and distributed capacities will also serve as a sort of ‘pandemic insurance’ in the future when global solidarity is lacking or non-existent.

A fundamental shift in mindsets is required to successfully counter a pandemic. Because no amount of treaty-making will cover the fact that we see people, especially in poor countries, as expendable and not deserving of protection. We now live in a multipolar world with rising nationalism and trenchant inequalities. Global solidarity requires that we share pains as well as gains. It is imperative that we privilege lives over profits, privilege equity over nationalism, and privilege social justice over corporate monopolies. This further requires that we see people in poor countries as not deserving of charity but as those with a right to human and health security. And importantly, not just within national borders but globally.

The IHR needs to be strengthened. Perhaps we need a treaty. But countries that oppose the TRIPS waiver need to demonstrate that they are willing to put public health before corporate interests. Unanimous support for a TRIPS waiver is the required show of good faith needed for further engagement on a pandemic treaty, for sceptical nations and hesitant civil society groups. WTO Ministers should no longer use COVID-19 transmission as an excuse to delay decisions that could help bring the pandemic to a halt.

Dr. Unni Karunakara, Senior Fellow – Global Health Justice Partnership, Yale Law School.

Dr. Unni Karunakara was International President of Médecins Sans Frontières / Doctors Without Borders (MSF) from 2010-2013. He has been a humanitarian worker and a public health professional for more than two decades, with extensive experience in the delivery of health care to populations affected by conflict, disasters, epidemics, and neglect in Africa, Asia, and the Americas. He was Medical Director of the MSF’s Campaign for Access to Essential Medicines (2005-2007) and co-founded VIVO, an organisation that works toward overcoming and preventing traumatic stress and its consequences.

Dr Karunakara is an Assistant Clinical Professor at Yale School of Public Health and a Visiting Professor at Manipal University, India. In addition, he has held various academic and research fellowships at universities in South Africa, Zimbabwe, Uganda, Germany and the United Kingdom, focusing on the demography of forced migration and the delivery of health care to neglected populations affected by conflict, disasters and epidemics. Karunakara also served as the Deputy Director of Health of Columbia’s University’s Earth Institute, Millennium Villages Project (2008-2010), and was Assistant Clinical Professor at the Mailman School of Public Health (2008-2017),

Image Credits: Giacomo Carra/Unsplash, @Right2Cure , Flickr – New York National Guard, Rob van Uchelen.

WHA special session meets in Geneva in a first-ever hybrid format since the start of the COVID-19 pandemic – with about three dozen of the WHO’s 194 member states sending in-person representatives.

In a first face-to-face meeting in Geneva since the start of the COVID-19 pandemic, the World Health Organization’s 194 member states appeared set to adopt a landmark decision to negotiate a new treaty or framework convention governing pandemic response, dubbed “Our World Together”, and with over 100 countries now declaring co-sponsorship.  

But from the start of talks at Monday’s World Health Assembly (WHA) Special Session, it was clear that countries still have very different ideas of how this new legal instrument will take shape – and the role it would play alongside the 2005-era International Health Regulations – that now govern pandemic response, but which critics say has been too weak, ineffective, incomplete, and out-of-date for the current crisis. 

Notably, among the dozens of countries that took the floor both in person and remotely at the hybrid session, China sounded the most “treaty hesitant” affirming that “China supports amending the international health legal system with the IHR at its core.”

Speaking from Beijing, China’s WHA representative Shen Hongbing stressed that there was a “”wide divergence of views on how to move forward on a concrete path.” 

But he said that the country would agree to revisions to “integrate universality, equity, one health and whole of government approaches into the amendments of the IHR.”

He added that the IHR would remain “the most critical legal document in global health governance for the present and in the near future.” 

Indeed, as any new treaty instrument would only come before the WHA for approval in 2024, according to the draft decision, it will not be an immediate solution to the COVID-19 pandemic – but rather a preparation for the next one. 

United States sounding bullish

Colin McIff, co-chair of the Working Group on Emergency Preparedness and Response that met over the past six months, concluding with a recommendation to move ahead with negotiations over a pandemic treaty,

In comparison, the United States, which had been treaty skeptic until very recently, was now sounding almost bullish on the potential advantages a new treaty could offer – light of the failings of the existing IHR legal framework.  

Colin McIff,  deputy director of the office of global affairs in the US Department of Health and Human Services and co-chair along with Indonesia the “Bureau” of six countries that guided a months-long review of IHR needs and gaps, cited a long litany of weaknesses in the existing IHR rules. Those range from a lack of “networks, mechanisms and incentives for sharing pathogens’ genetic information, to “proper incentives and benefits to support more equitable health emergency preparedness and response,” he said. 

Other gaps identified in the review by the WHA Working Group on WHO emergency preparedness and response “that could be addressed by a new instrument” included the lack of compliance with, and accountability to IHR obligations, McIff said noting that: “The IHR has a dispute resolution provision, it remains unused to date.” 

European’s also see more stable WHO as treaty outcome 

Jens Spahn, outgoing German Health Minister

Lack of sustainable finance for WHO was yet another shortcoming cited by McIff and a number of other WHA representatives, including Germany’s outgoing Health Minister, Jens Spahn.  

Along with European Council President Charles Michel, Germany’s Spahn has been one of the most active supporters of a pandemic treaty from the early days of proposals made by Chilean president Pinera. 

In what he described as one of his last public appearances before the formal departure of outgoing German Chancellor Angela Merkel, Spahn acknowledged the many obstacles that still lie ahead to winning broad WHA approval on the shape of a new treaty instrument – and whether the new treaty, or convention, would wind up becoming the superstructure umbrella or merely a weak complement of the existing IHRs.

“True, there are still some questions remaining regarding such a legally-binding instrument under Art. 19 of WHO’s Constitution.  However it is clear the benefits significantly outweigh all potential disadvantages,” said Spahn. 

A new WHA Executive Board standing committee on health emergencies?

Olivier Véran, France’s Minister of Health and Social Solidarity

During the day-long debates,  Austria and France also called for the establishment of a health emergencies standing committee of WHA Executive Board member states. Such an EB committee could be activated immediately in the case of a WHO declaration of a global health emergency, they said. 

Said France’s Minister of Health and Social Solidarity, Oliver Véran, the initiative to create a standing committee, which would come before the next EB meeting in January, aims to: “strengthen governance on health emergencies.”   

Such an EB Committee could in fact help facilitate closer WHO and WHA coordination over rapidly emerging disease threats – ensuring better communication and coordination – along with earlier informal dialogue between member states.

That kind of dialogue was found to be seriously wanting in the early days of the COVID pandemic, by a number of review boards. And in fact, the WHA Executive Board, which is charged with providing close member state oversight of WHO, was not convened for months following WHO’s declaration of an international Public Health Emergency (PHEIC).   

Africa supports treaty and denounces travel restrictions imposed on southern Africa in wake of Omicron variant discovery

African nations swung as a bloc behind the treaty initiative – but also denounced the widespread travel bans and restrictions imposed on South Africa and other southern African nations as a result of the recent identification of the Omicron variant.

While WHO has repeatedly decried the use of travel restrictions as an ineffective means of limiting infection spread, most countries have ignored that advice – as well as the IHR rules that similarly call for countries to avoid travel bans as a means of infection control. Blanket travel restrictions are “not based on science, they smack of racism and xenophonia and must end immediately if other countries are to be encouraged to follow South Africa’s example” in rapidly reporting COVID variants like said Ghana’s delegate to the WHA session. 

Botswana, whose scientists collaborated with South Africa in the discovery of the variant, stressed that travel restrictions had been imposed by Europe and the United States “solely due to our agility and transparency in reporting the COVID19 variant.

Those moves are particularly unfair, asserted Botswana’s delegate at the WHA, since COVID infection rates had been declining in Botswana over the past three months, 80% of variant infections were imported and “all patients reporting mild to moderate symptoms”. 

The ironies are even more pronounced, since African countries have faced an uphill battle to access and pay for sufficient volumes of vaccines to curtail infection spread – which is the fundamental cause of variants. In countries like Zambia, only 4% of the population is fully vaccinated. And while vaccination rates in Botswana and South Africa are now approaching 28-37%, that is still far below rates in Europe, Asia and the Americas.

 

unaids
UNAIDS Executive Director Winnie Byanyima

Ahead of World AIDS Day, 1 December, UNAIDS has warned that the world could face 7.7 million AIDS-related deaths over the next 10 years if leaders fail to tackle inequalities exacerbated by COVID-19. 

If transformative measures needed to end HIV/AIDS are not taken, the world will also remain dangerously unprepared for pandemics to come, said the agency.

The warning comes with a new UNAIDS report – Unequal, unprepared, under threat: why bold action against inequalities is needed to end AIDS, stop COVID-19 and prepare for future pandemics, launched today. 

“This is a pandemic that we are not in control of,” said UNAIDS Executive Director Winnie Byanyima, during a Monday press launch of the report.

“We cannot be forced to choose between ending the AIDS pandemic today and preparing for the pandemics of tomorrow. The only successful approach will achieve both. As of now, we are not on track to achieve either.”

In order to be on track to ending the AIDS pandemic and prevent future ones, the report calls for increased investments and shifts in laws and policies to end inequalities that drive pandemics forward. 

AIDS progress undermined by 1.5 million new HIV infections in 2020

While some countries, such as Rwanda, have made remarkable progress against AIDS, demonstrating that these ending AIDS is feasible, new HIV infections are not falling fast enough globally to stop the pandemic. The year 2020 saw 1.5 million new HIV infections globally, with increasing rates of infection in some countries. 

Infections notably follow lines of inequality, with six out of every seven new HIV infections among adolescents in sub-Saharan Africa occurring among adolescent girls.

Men who have sex with men, sex workers and people who use drugs also face a 25 – 35 times greater risk of acquiring HIV worldwide. 

‘Startling Opportunism’ of COVID-19 impacted HIV prevention services

Paul Farmer of AIDS-nonprofit Partners in Health

COVID-19 continues to undercut the AIDS response in many places with “startling opportunism”, said Paul Farmer of AIDS-nonprofit Partners in Health at the press briefing:

“Pathogens ranging from HIV to the virus behind COVID-19 invade the cracks and fissures in our society with startling opportunism.” 

During the first year of the pandemic, 2020, the pace of HIV testing declined almost uniformly – fewer people living with HIV pursued treatmen, in 40 out of 50 countries reporting to UNAIDS.

HIV prevention services were also impacted, with 65% of 130 countries surveyed experiencing disruptions in harm reduction services for people who use drugs in 2020.

Rwanda and Haiti – integrating COVID measures into HIV programs

There have been some gains in the fight against AIDS, despite disruptions experienced by COVID-19, with Farmer citing Rwanda and Haiti as examples of countries with HIV platforms that not only had effective HIV prevention strategies, but also sought to integrate HIV prevention and treatment into COVID response measures, and vice versa.

“Rwanda is the symbol of hope that we should look for.”

Rwanda was one of seven countries in eastern and southern Africa where 2,500 HIV treatment sites, serving 1.8 million people living with HIV, dispensed greater amounts of drugs to cover longer periods of treatments, and established social distancing and other preventative measures at clinic.

In six of seven of these countries, these measures actually reduced the percentage of patients who experienced treatment interruptions.

Haiti’s HIV program, while highly regarded, and at the forefront of efforts to integrate prevention care online, has been placed under siege by natural disasters, civil violence, and chronic political crisis worsened by the assassination of Haitain president Jovenel Moïse in July.

But despite drawbacks, Farmer noted that what “Haiti is doing is marking World AIDS Day – to keep the fight going.”

“Our teams, in rural Haiti and across the world, have routinely shown that with comprehensive care delivery, robust forms of accompaniment and social support and a larger dose of social justice, disparities in HIV outcomes can be rapidly narrowed, and health systems swiftly strengthened. We shouldn’t settle for anything less.”

Despite setbacks during the pandemic, a report released earlier in the year by UNAIDS also suggested that over the course of the past decade, dozens of countries have, in fact met or exceeded the ambitious targets set by the UN General Assembly towards a goal of ending AIDS by 2030, with evidence showing that targets were not just aspirational, but achievable.

Human-rights based approach center of global AIDS strategy, outlines UNAIDS report

Helen Clark, Co-Chair of the Independent Panel for Pandemic Preparedness and Response

The new report from UNAIDS outlines the critical elements of a Global AIDS strategy that must be urgently implemented in order to halt the AIDS pandemic, and strengthen global pandemic prevention, preparedness, and response. 

The measures needed to tackle inequalities include: community-led and people-centered infrastructure; equitable access to medicines, vaccines and health technologies; human rights that build trust; elevating essential workers and providing them with the necessary resources and tools; and people-centered data systems that highlight inequalities. 

In remarks at the report launch, Helen Clark, former co-chair of the Independent Panel for Pandemic Preparedness and Response, reiterated the need for a human-rights based approach to HIV/AIDS prevention and treatment. She said that she hopes  governments heed the message of the report, by “following through with deed, not words.” 

“We can only win the fight against AIDS and other pandemics if we put health and human rights at the center and if we are bold enough to end inequalities that drive pandemics,” said Clark. 

Image Credits: UNAIDS/Twitter, UNAIDS/Twitter, UNAIDS/Twitter.