The use of antibiotics in farming has decreased sharply in Europe, and antibiotic consumption in livestock is now proportionally lower than in humans, a new report by three European Union agencies has found.

The report, published by the European Food Safety Authority (EFSA), the European Medicines Agency (EMA) and the European Centre for Disease Prevention and Control (ECDC), includes data on antibiotic consumption (AMC) and development of antimicrobial resistance (AMR) in Europe for 2016-2018.

The significant drop in antibiotic use in monogastrics (animals like pigs and poultry that only have one stomach) and ruminants (animals like cattle, sheep and goats with four-compartment stomachs) suggests that the measures taken at country level to reduce the use of antibiotics such as polymyxins are proving to be effective.   

This, according to the report, “is a positive development, as polymyxins are also used in hospitals to treat patients infected with multidrug-resistant bacteria”.

“Combating antibiotic resistance remains a top priority for EMA and we will continue collecting veterinary antimicrobial consumption data to guide policy and research,” said Emer Cooke, EMA’s Executive Director.

The main aim of the report was to provide an integrated analysis of possible relationships between AMC in humans and farm animals and the occurrence of antimicrobial resistance in bacteria from humans and farmed animals. “This is the first time that the EU/ European Economic Area (EEA) population-weighted average AMC in humans overall exceeds AMC in food-producing animals when measured in mg/kg biomass,” states the report.

The data was collected from five different surveillance and monitoring networks coordinated by the agencies as part of ongoing clinical and epidemiological surveillance/monitoring and not specifically for the report. It covered the EU member States, Iceland, Norway and Switzerland.

The authors of the report found that human resistance to bacteria was associated with resistance in bacteria from food-producing animals which, in turn, was related to the animals’ antimicrobial consumption. The findings suggest the need to continue to promote the careful use of antimicrobial agents in terms of infection control and prevention in both humans and farmed animals.

“The high levels of AMC and AMR still being reported in bacterial isolates from both food-producing animals and humans from several countries show that these interventions should be reinforced.”​

The report called for detailed and comprehensive AMC data to allow for more refined analyses in relation to AMR data. It also states that the development of the mandatory monitoring of AMR in animals will provide even more robust datasets for analysis.

“AMC data should preferably be collected so that analysis for relevant sub-groups is possible. For example, AMC in the hospital sector versus the community for all EU/EEA countries, or AMC in animal categories that are likely to have characteristic treatment patterns, such as sows and sucklers, slaughter pigs, calves, dairy production, beef production, laying hens, broilers and turkeys.” 

Image Credits: Commons Wikimedia.

frontline workers
Nurses are on the frontline of the COVID-19 response.

In the wake of COVID-19, both the needs and the skills of frontline healthcare workers need to be made integral to the design of global mental health services, said experts at a Wednesday webinar, sponsored by the Geneva-based Global Self-Care Federation (GSCF).    

While mental health issues have come more to the forefront during the COVID pandemic, including among WHO member states, much still needs to be done to ensure that countries build strong systems of mental health services at community level, while also recognizing the mental health needs of health care workers themselves, said Dr Fahmy Hanna, of the WHO Department of Mental Health and Substance Abuse, speaking at the session.  

Involving frontline health workers in building awareness can also help destigmatize mental health conditions, he added, during the panel discussion on ‘COVID-19 and Frontline Workers’. Healthworkers, who have undergone trial by fire during the pandemic, are well-placed to share testimonies about their own experiences and challenges at the frontlines, he added, saying:  

“It is key and evidence-based that sharing and involving those who are affected by mental health conditions through campaigns is an effective tool to reduce stigma.” 

Nurses as Leaders: From Bedside to Boardroom

Nurse treating a child at a medical center in Baghdad, Iraq

Nurses, as skilled professionals at the cornerstone of primary health care systems, can become movers and shakers in building better mental health services – if only given the chance, added Dr Michelle Acorn of the International Council of Nurses (ICN). 

“Nurses are the life, blood, and stewards of the health system and should be recognized for what  they are,” she said. “[Nurses] are the glue and connectors holding the healthcare system together.” 

Underpaid, and overworked, nurses have a range of skills from “bedsides to the boardroom” that need to be recognized and harnessed more effectively in mental health services and support to health care workers and the communities that they serve, said Acorn.

Too often, however, nurses are often left out of policy debates and choices – preventing them from becoming fully and actively engaged in leadership, governance, and decision-making, especially in issues around gender and inclusivity in health service provision. 

“They do the work but they’re kept at arm’s length, around the periphery or fringes, not being fully enabled or empowered to maximize their contributions or knowledge to support mental health and deliver safe, competent care,” she said.   

The pandemic has also profoundly impacted the mental and physical health of nurses themselves, she added, despite the fact that COVID-19 highlighted how critical nurses and other frontline workers have been in leading pandemic response.  

Global Shortage of Nurses Exacerbated by Pandemic 

The largest shortages of nurses are seen in some parts of Latin America, Africa, and Southeast Asia

Additionally, the global nursing shortage, the result of rising rates of mental distress, poor working conditions, personal protective equipment shortages, and more, has been further exacerbated by the pandemic.

An expected six-million shortfall of nurses  is likely to increase by more than 4 million  nurses retiring by 2030, with this influx caused by the cumulative influence of mass trauma from COVID-19, said Acorn.

In addition over 115,00 health workers have died as a result of contracting COVID-19, according to the WHO.

Acorn called this a “complex form of trauma with devastating consequences” that will cause millions to leave the nursing profession.  

“Trauma is like an iceberg – you can maybe see above the ice but you don’t know what’s below that iceberg.” 

She advocated for increased investments in nursing. “Investing in nursing is not actually a cost; it’s an investment in our future.” 

Self-Care of Patients and Providers is Necessary 

The pandemic has also highlighted the importance of ”self-care”, as complementary to formalized medical care, and this goes for mental health as much as for other areas of health, like diet, exercise and sleep, the panel experts underlined.  

“We need greater recognition, and for people to jump on the bandwagon [to recognize the importance of self care],” said Director-General of GSCF Judy Stenmark. “We need to really work together to demonstrate the value of self-care, particularly in terms of mental health.” 

For healthcare workers, who have devoted most of their time to the frontline response of the pandemic, caring for patients and communities, in addition to the needs of their family, there’s little time for them to focus on their own wellbeing. 

“How much time do we actually truly devote and prioritize to self-care?” asked  Acorn. 

Those with family members who are on the front lines can support their loved ones through continued social contact, support, and empathy, encouraging positive coping mechanisms as opposed to negative ones during these stressful situations, said Hanna.

This can include supporting positive self-care approaches, like meditation and physical exercise, and discouraging negative habits, like tobacco use or alcohol abuse, he said, observing:  

“You cannot take care of others until you really take care of yourself.” 

WHO Expands Mental Health Action with Member States    

In the wake of the COVID crisis, the May meeting of the World Health Assembly, the WHO’s member state governing body, included a dedicated discussion on the “mass trauma” triggered by the pandemic, in which member states agreed to extend WHO’s 2013-2020 Mental Health Action plan for another decade – including a bold new set of global targets for 2030, Hanna said.

The global 2030 targets include calls for:

  • Mental health to be integrated into primary health care services by 80% of countries – and increased mental health service coverage by 50% of countries;
  • 80% of countries with at least two national mental health promotion and prevention programmes;
  • 80% of countries with a system for mental health and psychosocial preparedness for emergencies;
Examples of WHO mental health resources during COVID-19

In addition, WHO has developed a range of new tools for primary care and self-care responses.  Those include a new  WHO guidance for healthcare workers and other COVID-19 responders, which supports front-line workers in providing mental health and psychological ”first aid” as part of their emergency response. 

Other guides have been developed to address groups that are often overlooked by the mental health community, such as older adults and their caregivers. 

A children’s storybook has also been produced for children ages 6 – 11 years to help them cope with COVID-related stressors. 

The recently-launched report, ‘Guidance on community mental health service: promoting person-centered and rights-based approaches’, featured over two-dozen peer-reviewed examples of mental health services around the world that have developed high quality and cost-effective alternative models of care, anchored in communities. These systems, which exist in countries ranging from the United Kingdom, to Myanmar, Kenya, Zimbabwe and India, rely heavily on front-line workers as well as peer support systems, and avoid compulsory hospitalization and forced medication, whereever possible. 

Hanna highlighted Zimbabwe’s Friendship Bench, as just one example, which utilizes the expertise of lay volunteers, often older women, to support people in distress with problem-solving interventions, provided under the guidance of other front-line health workers.  As its name implices, Friendship Bench is “an actual wooden bench, placed in front of some of the healthcare facilities and building on local resources in local communities in Harare, Zimbabwe,” said  Hanna.

“The guide provides simple solutions [like the Friendship Bench] and many others, that can be used by countries to scale-up.”

Image Credits: Public Services International/Madelline Romero, International Labor Organization/Flickr, WHO, GSCF.

AstraZeneca’s Covishield is not recognised by the EU COVID vaccine certificate although its European equivalent, Vaxzevria, is.

Travellers who are fully vaccinated with vaccines authorised in the European Union (EU) “should” be allowed entry for non-essential travel – even if these vaccines were not “produced in facilities covered by the marketing authorisation in the EU”, a European Commission spokesperson for health, food safety and transport told Health Policy Watch on Wednesday.  

At the same time,  it remains up to individual EU member states to decide if they wish to interpret that European Council policy recommendation, adopted by EU member states on 20 May, so as to authorize entry to vaccinated recipients of the Indian-made Covishield vaccine, said the EC spokesperson, Stefan de Keersmaecker.

Covishield, the AstraZeneca vaccine produced by the Serum Institute of India, has the same biological composition as the European vaccine branded Vaxzevria.  However, unlike Vaxzevria, Covishield never received European Medicines Agency marketing approval since it is not being manufactured on the European continent. 

The EC spokesperson was speaking in response to Health Policy Watch’s recent report that the Indian-made “Covishield” vaccine would not be recognised by the EU digital COVID vaccination certificate, which launched on Thursday, 1 July.

“As set out in the Council Recommendation on the temporary restriction on non-essential travel to the EU, adopted by Member States on 20 May,  entry into the EU should be allowed to people fully vaccinated with one of the vaccines authorised in the EU. This does not mean that the vaccines has to be produced in facilities covered by the marketing authorisation in the EU,” Keersmaecker stated, adding that,  “Member States could also allow entry for people vaccinated with vaccines having completed the WHO Emergency Use Listing process.

Specifically with respect to Covishield, while it is “not authorised for placing on the market in the EU…. it has completed the WHO Emergency Use Listing process.,” he added. “On the basis of the relevant Council Recommendation on the temporary restriction on non-essential travel to the EU, Member States may allow travellers (without an essential reason) fully vaccinated with this vaccine to enter the EU.”

At the same time, he cautioned that while member states might take various approaches to recognizing vaccines administered, or vaccine certificates issued, outside of the EU, they are not required to do so as part of the new EU digital COIVD pass policies:

“Member States are, however, not required to issue certificates for a vaccine that is not authorised on their territory, ” he stated.

Clarification Comes After Week of Growing Protest In LMICs over EU Vaccine Pass Policies

The EU clarification comes after it emerged last week that Covishield, the only vaccine available in most African countries, would not be recognised by the EU digital COVID vaccination certificate as the European Medicines Agency had only authorised Vaxzevria – and not the Covidshield counterpart.

The new certificate aims to enable safe and free movement of people by providing proof that travellers have had COVID vaccinations, received a negative test result or recovered from the virus.

Earlier in the week, the African Union Commission and the Africa Centres for Disease Control and Prevention (Africa CDC) urged the EU Commission to include “vaccines deemed suitable for global rollout through the EU-supported COVAX facility”.

“The current applicability guidelines put at risk the equitable treatment of persons having received their vaccines in countries profiting from the EU-supported COVAX Facility, including the majority of the African Union (AU) member states,” they noted.

News of the EU’s exclusion of Covishield has also sparked concerns in various African countries that the Indian version of the vaccine is sub-standard, prompting vaccine hesitancy at a critical moment when the continent faces a major new wave of the virus – and scarce vaccines remain precious resources.

Member States Could Allow Vaccines with WHO Emergency Use Listing

In his responses, De Keersmaecker acknowledged that while “Covishield is not authorised for placing on the market in the EU”, it had been given Emergency Use Lising (EUL) by the World Health Organization (WHO) – which grants it a certain status.

“Member states could also allow entry for people vaccinated with vaccines having completed the WHO Emergency Use Listing process,” he noted.

He added that an EU Digital COVID certificate also is not an absolute prerequisite for non-essential EU travel – but rather “a practical tool that can facilitate travel in those cases where restrictions are lifted.”

In fact, EU member states have gradually been lifting their overall restrictions on non-essential travel at a varying pace – and with respect to a diversity of approaches to visitors from non-EU countries.  Those also may include recognition of certificates of COVID recovery alongside vaccines, as well as requirements for PCR tests, as conditions for entry.

While the new EU digital pass attempts to set out a more standardized system, that does not preclude recognizing certificates from other countries, should member states choose to do so, Keersmaecker said:

“Member states are free to accept the documentation issued in third countries for vaccination. These should contain information that at least allows [the country] to identify the person, the type of vaccine and the date of the administration of the vaccine,” he added.

Travellers from abroad who were fully vaccinated with an EU-authorised vaccine also could be issued with certificates “on a case by case basis”.

Over the coming weeks and months, the European Commission may also opt to adopt, on a country by country basis, “an equivalence decision for a third country COVID-19 certificate, which will then be considered as equivalent to EU Digital COVID certificates issued by member states”, said De Keersmaecker. 

“This is only possible when a third country’s certificates are interoperable with the digital COVID certificate technical standards,” he stressed.  He did not elaborate on which countries’  certificates had already been recognized as equivalent.  

The European Council and European Parliament adopted the COVID digital certificate policy on 20 May, with the issuance of certificates on a systematic, EU-wide basis beginning this week. Countries have six weeks to phase in the system. Some 15 EU member states have already done so. They include Austria, Belgium, Bulgaria, Croatia, Czech Republic, Denmark, Estonia, Germany, Greece, Latvia, Lithuania, Luxembourg, Poland, Portugal and Spain. They are joined by Iceland, one of the four European Economic Area member states also eligible for the scheme. . 

The certificates are available as a smartphone app, or on paper. For EU/EEA residents, the certificate includes a QR code with the necessary data showing vaccination, PCR test, or recovery status, as well as a digital signature. Along with that, citizens or residents of third countries that have been vaccinated with one of the four EMA-approved vaccines, can use the vaccine cerficates to make non-essential trips to EU countries, according to the new EU-wide policies.  The EMA approved vaccines include:  Pfizer/BioNTech, Moderna, Johnson & Johnson, along with AstraZeneca’s Vaxzevria version.   

In contrast, WHO has granted emergency use listing to four other vaccines that are not on the EMA list. Those include AstraZeneca’s Covishield and SK-Bio versions, produced in India and the Republic of Korea respectively, along with the Chinese made, Sinopharm and Sinovac vaccines.

 

-Updated 1 July, 2021

Evidence of the existence of malaria in China has been found carved into bones from the Shang Yin era estimated to be 3000 years old – yet on Wednesday, the country beat this thousands-year-old scourge by getting certified “malaria-free” by the World Health Organization (WHO).

WHO Director-General Dr Tedros Adhanom Ghebreyesus, said China’s success was “hard-earned and came only after decades of targeted and sustained action”. 

At its zenith in the 1940s, malaria affected an estimated 90% of the Chinese population with 30 million cases and 300,000 deaths annually, according to a report from Harvard University.

China established a National Malaria Control Programme in 1955, and q2 years later, it launched the “523 Project” – a nationwide research programme aimed at finding new treatments for malaria, according to the WHO – in 1967. 

“This effort, involving more than 500 scientists from 60 institutions, led to the discovery in the 1970s of artemisinin – the core compound of artemisinin-based combination therapies (ACTs), the most effective antimalarial drugs available today,” the WHO added.

Professor Tu Youyou of the Academy of Traditional Chinese Medicine, who isolated artemisinin in 1971, was awarded the Nobel Prize for Physiology or Medicine in 2015 for her discovery. 

Thinking ‘Outside the Box’

“Over many decades, China’s ability to think outside the box served the country well in its own response to malaria, and also had a significant ripple effect globally,” notes Dr Pedro Alonso, Director of the WHO Global Malaria Programme.

“The government and its people were always searching for new and innovative ways to accelerate the pace of progress towards elimination.”

Aside from discovering artemisinin, China was one of the first countries in the world to extensively test the use of insecticide-treated bed nets to preventi malaria during the 1980s – well before nets were recommended by WHO for malaria control.  

In 2010, the country resolved to end malaria within a decade, and 13 ministries – including the health, education, finance, research and science, development, public security, the army, police, commerce, industry, information technology, media and tourism sectors – joined forces to do so.

It adopted a “1-3-7” strategy – a one-day deadline for health facilities to report a malaria diagnosis; confirmation of the case by the end of day three, and take measures to prevent its spread within seven days.

“By the end of 1990, the number of malaria cases in China had plummeted to 117 000, and deaths were reduced by 95%,” said the WHO.

“With support from the Global Fund to Fight AIDS, Tuberculosis and Malaria, beginning in 2003, China stepped up training, staffing, laboratory equipment, medicines and mosquito control, an effort that led to a further reduction in cases; within 10 years, the number of cases had fallen to about 5000 annually.”

In 2020, China applied for an official WHO certification of malaria elimination in after four years of zero cases, and members of the independent Malaria Elimination Certification Panel visited the country last month to verify the country’s malaria-free status and progamme to prevent re-establishment of the disease, according to the WHO.

China has undertaken to assist African countries to eliminate malaria, and it has signed agreements with Burkina Faso, Cameroon, Cote d’Ivoire, Sierra Leone, Tanzania, and Zambia to set up Institutional-based Networks of Cooperation between Africa and China on Malaria (INCAM). 

 

Shoppers mob malls in Geneva, Switzerland after restaurants and stores reopened on 6 June 2020 – following nearly two months of lockdown.

After a rocky second wave with COVID-19, Switzerland has turned a corner and is witnessing a decline in cases and deaths and the easing of restrictions, opening the country for tourism and large events. 

Switzerland has been praised for its response early in COVID-19 and for its economic policy throughout the pandemic. 

“Switzerland has navigated the pandemic well. COVID-19 has had major social and economic impacts, but an early, strong, and sustained health and economic policy response helped contain the contraction of activity,” said the International Monetary Fund (IMF) in a statement released last week. 

A total  of 702,746 COVID cases and 10,347 deaths have been recorded since the beginning of the pandemic, numbers proportionately comparable to neighbouring countries. 

During the first wave in late March 2020, Switzerland benefited from witnessing and learning from the catastrophic impact the pandemic had on northern Italy. Switzerland’s health system had three weeks to reorganize hospitals, expand the intensive care unit (ICU) capacity, and adopt procedures that made ICU admission criteria stricter, which eased pressure on the health system. 

“It’s really remarkable what they did, and because they were able to do that, we did not suffer a completely overwhelming situation of the type that was seen in north Italy in March 2020 in Switzerland,” said Samia Hurst-Majno, a member of the Swiss National COVID-19 Science Task Force, at a virtual symposium organized by the Swiss Tropical and Public Health Institute on Tuesday. 

Second Wave Brought Rise in Cases, Deaths, and Mistrust of Health Authorities

Despite Switzerland’s success in curbing cases and deaths in the early days of the pandemic, the government took a different approach during the second wave in mid-October 2020. 

COVID-19 restrictions in Switzerland were more lenient during the second wave, compared to the first. Instead of quickly imposing far reaching restrictions, the focus was placed on reducing the burden on the health system. 

This was done by delaying thousands of non-urgent medical interventions and raising the threshold for admissions for non-COVID patients. 

Other countries in the region, by contrast, tended to impose more stringent policies, including school and workplace closures, stay-at-home requirements, restrictions on public gatherings, and travel bans. 

“Public health is a difficult task in a federal country,” said Hurst-Majno. 

Switzerland’s decentralized decision-making during the second wave led to wide variations in the measures implemented and inconsistent messages coming from cantonal governments. 

The second wave was also characterized by a rise in conspiracy theories about COVID-19 and a decline in trust in authorities. 

A study conducted between June and July 2020 in Fribourg, Geneva, and Vaud found that among the 1,518 respondents, 32.6% believed that the virus had escaped from a laboratory in China and over 40% considered lifestyle responsible for the emergence of the virus. 

Individuals who held conspiracy beliefs were less likely to follow public health recommendations, thus facilitating the spread of the virus. 

COVID Exacerbated Social Divides

The pandemic has also exacerbated existing socioeconomic divisions, exerting different stresses, threats, and possibilities for populations. Some have been able to work remotely, protected from the virus and from job loss, while others were at risk of losing their income and were further marginalized by COVID-19. 

Gender disparity was also seen, with men having a higher mortality rate and women suffering more from social and economic consequences. 

“It is not surprising that these divisions should arise in the face of a pandemic,” said Hurst-Majno.

Samia Hurst-Majno, Director of the Institute for Ethics, History, and Humanities at the University of Geneva and member of the Swiss National COVID-19 Science Task Force.

“Seeing these distinctions is not really a Swiss specialty and this has had an unsurprising consequence…[that] data are lacking,” said Hurst-Majno.

A preprint study from May found that wealthier citizens were more likely to get tested, less likely to receive a positive test, be hospitalized, or die from SARS-CoV2. 

Recent Positive Trends in Cases and Behavior

Despite the rise in misinformation and vaccine hesitancy in Switzerland, Hurst-Majno highlighted the positive, compliant behavior of the majority of the population. 

“I have been consistently impressed by the response of the population,” she said. “Most people have handled themselves extraordinarily well.”

Most impressive was that over the Christmas holiday, the majority of individuals complied with the recommendations communicated by the Federal Office of Public Health and gathered in small numbers in cautious ways. 

This resulted in no uptick in cases. 

Cases have been on a continuous downward trajectory since mid-April, coinciding with the acceleration in the vaccination campaign. Some 32% of the population are fully vaccinated.

As of 26 June, individuals from a third country who are fully vaccinated can enter Switzerland for tourism, masks will no longer be required outside, and large events of up to 10,000 people can take place with a certificate showing vaccination, recovery from COVID, or a negative test. 

It remains to be seen how Switzerland will fare as restrictions and government stringency decline.

Image Credits: S. Lustig Vijay/HP-Watch, Swiss TPH.

Kenya has secured $130 million in funding from the World Bank to buy COVID-19 vaccines and help boost the country’s vaccination drive, the Bank announced on Tuesday.

The funding comes as the Kenyan government starts to administer the second dose of AstraZeneca vaccines to citizens, amid an upsurge of infections across 13 counties in the western region of the country.

As of Monday, the East African country had recorded 182, 883 COVID-19 infections and 3, 612 deaths.

World Bank Country Director for Kenya, Keith Hansen, said the “upfront financing for the acquisition of COVID-19 vaccines will enable the government to expand access to more Kenyans free of cost”.

It will enable the country to procure more vaccines via the African Vaccine Acquisition Task Team (AVATT) initiative and COVAX, the global vaccine-sharing facility.

“This additional financing comes at a critical time when the Government of Kenya is making concerted efforts to contain the rising cases of COVID-19 infections and accelerate the deployment of vaccines to a wider population,” said Hansen. 

Part of the funds will go to boosting Kenya’s cold chain storage capacity, including establishing 25 county vaccine stores, strengthening the capacity of 36 sub-county stores, and equipping 1,177 health facilities with vaccine storage equipment. It will also be used for vaccine safety surveillance, training for health workers, and advocacy and communications activities to encourage COVID-19 vaccine uptake.

“With the increased support for a rapid COVID-19 response, the World Bank is offering the government a flexible approach to select a portfolio of vaccines that best suits local capacities, timings of delivery, and vaccine approvals,” said Jane Chuma, World Bank Senior Health Economist.

In April last year, Kenya received another World Bank loan for Covid-19 tests, isolation and quarantine centres and the purchase of personal protective gear for health workers. 

Vaccination Drive Intensifies As 13 Counties Declared COVID-19 Hotspots

So far, 1,293,004 doses of AstraZeneca vaccines have been administered with vaccination efforts being boosted by a donation of 360,000 doses from the Danish government early last week, according to the Ministry of Health.

A further consignment of 180,000 doses is expected in the coming weeks from COVAX, the global vaccine-sharing facility,  as well as a donation from the US.

Susan Mochache, Principal Secretary in the Ministry of Health, acknowledged that the vaccine donation from Denmark came at a critical time when the country was only left with 5000 doses in total. 

Administration of the second dose comes in the wake of an upsurge of infections across 13 counties in the western region of the country. 

The counties of Bomet, Bungoma, Busia, Homa-Bay, Kakamega, Kericho, Kisii, Kisumu, Migori, Nyamira, Siaya, Trans Nzoia, and Vihiga have been declared hotspots by the Cabinet Secretary of Health, resulting in a dusk-to-dawn curfew from 7pm to 4am.

According to the Ministry of Health, the 13 counties account for 60% of the total caseload in the country and a positivity rate of 21%, which is way above the 9% national average over the last two weeks.

Even though movement in and out of these counties was not banned, Cabinet Secretary for Health Mutahi Kagwe said it is “strongly discouraged.”

Funeral gatherings have been restricted to less than 50 people and burials are now supposed to take place within 72 hours following a death. Wedding gatherings are now restricted to 30 attendees. Employees have been urged to work from home and places of worship will remain closed for the next 30 days. These measures are meant to curb the spread of the virus in these counties and beyond.

The aviation sector is unlikely to recover before 2024, as new variants, stringent quarantines and costly COVID-19 tests continue to confound international travel – but airline officials have appealed for global cooperation to simplify travel requirements.

In 2020, the global aviation industry lost about $430 billion, according to Kamil Alawadi, the International Air Transport Association (IATA) Vice President for Africa and the Middle East. 

While domestic travel in the region has returned to 2019 levels, international travel is yet to recover and it may not fully do so until 2024 unless urgent actions are taken to remove the bottlenecks and regulations that include travel passes, vaccine passports, and conflicting and confusing policies on testing and quarantine.

“The recovery of international travel is very slow because of friction between borders. And looking at the situation today, I think the losses will stop or will reduce to an acceptable level by 2023,” Alawadi said. 

According to him, the airlines will only generally start to generate positive revenues and cover previous losses by the year 2024 unless things change dramatically. 

Costly Multiple Testing 

Following the resumption of international flights in Africa, Adewale Yusuf, Chief Executive Officer of TalentQL, an African talent recruitment company, travelled from Lagos, Nigeria to Kigali in Rwanda.

He told Health Policy Watch that, before leaving Nigeria, he spent NGN50,000 (over $120) on a PCR COVID-19 test and on arrival in Kigali, he paid for another COVID test ($50) in addition to incurring the cost of the mandatory hotel room for isolation until his COVID test result was available. 

Before leaving Rwanda, Yusuf had to pay for another COVID test as the Nigerian government requires every passenger arriving in the country to present a negative test.

Alawadi described this development as a major stumbling block in the aviation industry’s path to recovery.

For a single trip, travellers can spend up to $500 for COVID-19 tests alone, said Yusuf. Moreover, he said the quarantine requirement by several countries is discouraging people from travelling the most.

“We’ve done a number of surveys. Our last survey showed that 84% of the passengers will not fly if quarantine is in place. Additionally, it is unclear today, in many cases, for the average passenger to know what is needed when he travels from A to B. When does he do the PCR test, what sort of certification is needed and so on,” Alawadi said.

To address the issue of testing for travellers within Africa, the Africa Union’s Digital Vaccination Platform, Trusted Travel, was launched to try to simplify the verification of public health documentation for travellers during exit and entry across borders. 

However, countries within Africa have been reluctant to fully adopt the service, choosing instead to institute their own protocols that often compel travellers to pay for tests at each point-of-entry.

Travel passes and passports

To ensure the aviation industry fully begins to recover from the impact of COVID-19, Alawadi said more restrictions need to be removed – although the opposite is happening as countries limit travel to contain the spread of the Delta variant, according to Health Policy Watch.

“The removal of travel barriers is a big key to recovery. Right now, what is standing in the way of passengers traveling are the restrictions placed by governments,” Alawadi added.

One of the travel barriers that IATA is concerned about is the introduction of vaccine passports. The European Union’s COVID Digital Green Pass officially goes into effect 1 July. Even though its goal is to ease travel to Europe for vaccinated and recovered passengers, Health Policy Watch recently reported that it does not recognise the most widely administered vaccine in Africa, the version of AstraZeneca manufactured by the Serum Institute of India.

This policy could have a negative impact on Africa’s fragile aviation sector, which lost over $7.7 billion in 2020 alone, with massive job losses and millions more jobs threatened by uncertainties and slow return to normal.

“There are eight airlines that filed for bankruptcy in Africa due to COVID-19 and we do not want to see that continuing in 2021,” Alwadi said.

Regarding the EU Green Pass, Alawadi said the aviation industry was not in support of discrimination in the space that only favors individuals that have been vaccinated.

“We can’t have a situation where only people who have been vaccinated are able to travel internationally,” he noted.

However, he urged countries across the world to accept WHO-approved vaccines to ensure greater consistency and foster trust between governments and travellers.

Even though countries in the EU are going ahead with the vaccination passport policy, the World Health Organization (WHO) has noted that making proof of vaccination a prerequisite for travel may deepen inequities while the vaccines continue to be in such short supply.

“Decisions on vaccine passports are taken at the national level, in line with each country’s unique epidemiological, political, social and economic contexts. At the same time, they require coordination between countries, airlines and interoperable systems,” said WHO Regional Director for Africa, Dr Matshidiso Moeti.

Collaborative work to Harmonise Travel Passes

IATA has called on the global community to collaborate to ease travel bottlenecks by streamlining processes and harmonising the numerous passes.

“The focus should be collaborative work with all the stakeholders, including governments, to support the aviation industry (especially in Africa) and prevent any further damage, closure of airlines or the supporting players like the catering companies,” he said.

Willie Walsh, IATA’s Director General, has noted that the international travel metrics will improve when the world’s largest air travel markets, Australia, China, the UK, Japan, and Canada, fully open up. But for now, they remain essentially closed with no clear plans to guide a reopening. 

“Data should help these and other countries to introduce targeted policies that keep populations safe while moving towards a normality in the world with COVID-19 for some time to come,” Walsh said.

Image Credits: Paul Adepoju.

Countries (in blue) where the Delta variant has been verified (US CDC)

Countries as diverse as Russia, Portugal, South Africa and Sydney have imposed new lockdown regulations as they attempt to control the spread of Delta, the SARS-CoV-2 variant that is more deadly and infectious than any other variant.

By last Friday, the World Health Organization (WHO) reported that the Delta (B.1.617.2) variant had been detected in at least 85 countries, describing it as the “fastest and fittest” variant, likely to dominate all others in time.

The WHO also urged everyone – including those who are fully vaccinated – to continue to wear masks in the face of Delta, which was responsible for the devastating wave of COVID-19 cases in India in early May where the country recorded over 400,000 cases per day.  The WHO advice has prompted renewed debate over mask policies in countries like the United States, where the US Centres for Disease Control had recently stated that fully vaccinated people no longer needed to wear masks indoors or outside.  Even Israel, which had driven COVID cases down to nearly zero with one of the highest vaccination rates in the world, has now reinstated mask requirements for indoors spaces and mass gatherings – in the face of a Delta-driven virus resurgence.  

In Russia’s capital, meanwhile, unvaccinated Muscovites have been told to work from home and observe tighter restrictions on movement and social gatherings, as the city’s mayor told the public that Delta now accounts for over 90% of the city’s new COVID-19 cases.

South Africa moved to a Level Four lockdown on Monday, bringing a tighter curfew, the closure of sit-down restaurants, and a ban on alcohol sales for two weeks. The country has been battling a third wave, which is surging in its economic heartland – Gauteng province – which by Sunday accounted for over half the country’s 158,998 active cases. Leisure travel in and out of the province has also been restricted for two weeks.

Over the past weekend, only those who had been vaccinated or could show a negative COVID-19 test were allowed to enter or leave Portugal’s capital, Lisbon. Last Thursday, the city recorded its highest case number since February – 1556 new cases – and authorities said that 70% of these were from the new variant.

Sydney residents have been ordered to stay at home for two weeks since last Saturday (26 June) and entering or leaving the city is prohibited except for a few exceptions. New South Wales reported 130 active cases by Sunday.

Taiwan tightened border controls from 27 June, making a 14-day quarantine mandatory for all travellers. Those from seven high-risk countries – Brazil, India, the UK, Peru, Israel, Indonesia, and Bangladesh – face free quarantine in government facilities while all other travellers need to quarantine in group quarantine facilities at their own expense, according to the Taiwanese Ministry of Foreign Affairs.

The proportion of Delta cases in the US has risen exponentially in the past month and now account for almost 10% of cases, with the highest prevalence in Missouri where almost 30% of cases are due to Delta, according to the US Centers for Disease Control (CDC).

In May, 4,7% of California’s cases were from the Delta variant but this had jumped to 14.5% of cases by 21 June, according to the California Department of Public Health.

Delta Variant Associated With Higher Risk of Hospitalisation

A report on COVID-19 hospitalisations in Scotland published in The Lancet, reported that there had been twice as many hospitalisations in people infected with the Delta variant in comparison to the Alpha variant.

“Based on the available evidence, the SARS-CoV-2 Delta (B.1.617.2) variant of concern (VOC) is 40-60% more transmissible than the Alpha (Β.1.1.7) VOC and may be associated with higher risk of hospitalisation,” according to a risk assessment published by the European Centre for Disease Prevention and Control last week.

“Furthermore, there is evidence that those who have only received the first dose of a two-dose vaccination course are less well protected against infection with the Delta variant than against other variants, regardless of the vaccine type. However, full vaccination provides nearly equivalent protection against the Delta variant,” it added.

A risk assessment for Delta published last Friday by the UK government noted that  

“there are now analyses from England and Scotland supporting a reduction in vaccine effectiveness for Delta compared to Alpha against symptomatic infection” which were “more pronounced after one dose”. 

“Iterated analysis continues to show vaccine effectiveness against Delta is high after 2 doses. Current evidence suggests that [vaccine efficacy] against hospitalisation is maintained,” it added.

Europe CDC Warns Against Summer Relaxation as Africa Scrambles for Vaccines

Delta is the predominant variant in the UK and is driving a surge in cases there, and the European Centre for Disease Prevention and Control predicted that Delta would account for 90% of cases in the European Union by the end of August.

“Modelling scenarios indicate that any relaxation over the summer months of the stringency of non-pharmaceutical measures that were in place in the EU/EEA in early June could lead to a fast and significant increase in daily cases in all age groups, with an associated increase in hospitalisations, and deaths, potentially reaching the same levels of the autumn of 2020 if no additional measure are taken,” it warned, urging faster vaccination of vulnerable groups.

However, mass vaccinations are still out of the reach of many African countries that are dependent on the WHO-lead global vaccine access platform, COVAX, which has run out of vaccines for distribution.

Cases continue to surge in southern and East Africa, with Delta suspected to be driving cases in Uganda, Zimbabwe and Zambia, as well as South Africa which confirmed last Sunday that Delta was driving its third wave.

Spread of the Delta variant in South Africa

Meanwhile, a more dangerous mutation of the variant,  Delta Plus,  is driving cases in the Indian state of Maharashtra, causing the state to tighten up on restrictions there. All malls and auditoriums were closed from Monday.

Delta Plus is more transmissible than Delta, according to the Indian health ministry. Public Health England issued a briefing on Delta Plus last Friday noting that 41 cases had been detected in the UK.

Image Credits: US CDC, Department of Health, University of KwaZulu-Natal.

João Aguiar Machado, Ambassador, Permanent Representative of the European Union to the World Trade Organization.

As World Trade Organization (WTO) members continue to negotiate on ways to streamline and adapt intellectual property rules in the response to the COVID-19 pandemic, we bring you this interview with the European Union’s ambassador to the WTO, João Aguiar Machado. He discusses the different strands in the EU’s overall strategy on trade and health at the WTO in the context of this health emergency. Later this week (30 June), members head to an informal TRIPS Council meeting to discuss South Africa-India’s TRIPS Waiver proposal and elements of the EU’s alternate proposal.

Priti Patnaik: Can you explain how the three different suggestions articulated by the EU, in its communication to the WTO General Council (4 June), will come together? These include: a WTO framework on trade and health, the draft Declaration on Trade and Health and a proposal on the approach to compulsory licensing.

João Aguiar Machado: We all agree that the common global objective in this pandemic is equitable access to COVID-19 vaccines and treatments. It is certainly a top priority for the European Union (EU). We already see incredible progress in the total global production of COVID-19 vaccines with more than 10 billion doses due to be produced by the end of 2021. For comparison, the total global output of all vaccines before COVID-19 was only 5 billion doses. However, further ramping up the production and, most importantly, ensuring equitable distribution of COVID-19 vaccines, remain very essential priorities in the fight against time in this pandemic.

Setting up and ramping up the production of vaccines is a highly complex process which requires adequate facilities, trained personnel, know-how, raw materials and other inputs. It is a complex issue that cannot be solved by one simple solution. The overall strategy is not only within the WTO. The WHO, other organisations, institutions and initiatives –such as the [WHO and GAVI co-sponsored] COVAX Facility – are working on these solutions. Members of the WTO must collectively find ways to address the current delays and shortages in vaccine production to the extent that is possible in the WTO framework.

We have essentially two strands of work in the WTO: on the one hand, the proposal from a number of like-minded members (Ottawa Group) for a Trade and Health Initiative. On the other hand, the specific debate on intellectual property issues related to the proposal by India, South Africa and others to waive the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) and the recent EU proposal on optimising the use of licencing flexibilities provided in the TRIPS agreement. It is now time to work on all of these issues with urgency for a final comprehensive solution on health.

More concretely, the co-sponsors of the Ottawa group Declaration on Trade and Health are discussing, in particular, trade facilitation and production expansion through collaboration. As the vaccine production scale-up is related also to a smooth functioning of the supply chain, the EU proposed that this aspect is also discussed in the context of the Declaration on Trade and Health. The intention is to revise the current draft Declaration and to incorporate elements of the EU’s Communication to the WTO General Council. At the same time, the intellectual property strand is being dealt with in the TRIPS Council. Our objective is that these strands of work form a basis for a general understanding on health in the WTO General Council, at the upcoming WTO 12th Ministerial Conference.

PP: The EU proposal to the TRIPS Council has focused a lot on compulsory licensing. What is the EU’s position on other aspects of  the South Africa-India proposal including on copyrights and trade secrets as barriers to equitable access?

Machado: The EU proposes to the WTO a comprehensive approach addressing trade issues related to the actual bottlenecks that affect the manufacturing speed and the fair supply of vaccines and medicines in the current pandemic. The component on compulsory licensing as proposed for discussion at the TRIPS Council is thus only one element of this comprehensive approach. We consider that intellectual property plays an important role as an enabler that contributes to our overall objective of ramping up production of COVID-19 vaccines and medicines. However, it is not and should not be a barrier to achieve this objective. We have been clear that in a global emergency like this pandemic, if voluntary licensing fails, compulsory licensing is a legitimate tool to scale up production. This is why we propose to clarify and simplify the use of compulsory licensing in times of a pandemic.

If we examine how intellectual property can enable the production of vaccines or medicines, the focus is primarily on patents. We believe that a debate on the entire intellectual property system will only delay urgently needed action. Moreover, the intellectual property framework is already a system of checks and balances. There are relevant exceptions that could be used with regard to every intellectual property right, be it copyright, design or protection of undisclosed data. Moreover, we must be realistic as to what can be achieved with the proposed lifting of the Members’ obligations under the TRIPS Agreement. For example, in case of trade secrets, waiving Article 39 does not grant access to companies’ confidential information. It only removes certain minimum remedies against a misappropriation of that information.

PP: The proposal by the EU recognises the “urgent challenge” to ensure a rapid and equitable roll out of vaccines and therapeutics – but the proposal does not mention diagnostics. Can you elaborate why this is so?

Machado: The ongoing discussions concern the whole spectrum of essential medical goods, diagnostics tools being one of them, even if the EU Communication to the WTO focuses specifically on vaccines and therapeutics. The availability of safe and effective COVID-19 vaccines and therapeutics is now the main global priority that needs to be addressed urgently.

Diagnostic tools of course remain important for containing the pandemic. When we speak about “medicines” in the EU proposal to the TRIPS Council as regards the facilitation of compulsory licences, diagnostics as well as therapeutics fall under that term. We are looking forward to discussing the EU proposal with other WTO members and will certainly be open to clarifying the text as necessary.

PP: Some critics are of the view that the EU communication at the WTO is more driven by protectionist industrial policy than motivations to safeguard public health. How would you respond to that?

Machado: On the contrary, the EU’s commitment to the global efforts of equitable access to vaccines and therapeutics against COVID-19 cannot be put in doubt. Just to recall that the EU is a leader when it comes to deliveries of effective vaccines to the rest of the world. By now, over 350 million [COVID vaccine] doses have been exported out of the EU to the rest of the world. This equals around half of the production in the EU. We are also a major contributor to the COVAX Facility.

As already noted, the WTO can and must contribute to delivering equitable access to vaccines and medicines in this pandemic, but this complex issue needs to be addressed comprehensively. This is the reason for the EU communication. It seeks to be as concrete as possible and identify which actions should be taken. The EU proposal is very much driven by the need to ensure equity in the distribution of vaccines. While the production of COVID-19 vaccines has been increasing significantly, their distribution across the regions of the world remains unbalanced. The WTO can certainly act and ensure that this objective is unimpeded by trade barriers.

PP: How will the EU reconcile its opposition to the TRIPS waiver proposal led by South Africa and India, with the support for this proposal by the European Parliament?

Machado: The Commission has carefully analysed the resolution of the European Parliament (EP). The resolution reflects a mix of positions expressed in the EP. The Commission is in full agreement with the EP that intellectual property is an enabler rather than a barrier to vaccines availability.

The Commission also shares the view of the EP that the proposal for an indefinite waiver as proposed in the WTO would pose a significant risk to innovation and research. At the same time, the EP calls on the Commission to support text-based negotiations for a temporary waiver of the TRIPS Agreement that aims to enhance global access to affordable COVID-19-related medical products.

The Commission has engaged in all strands of work and continues to be engaged in the text-based process that has been launched in the TRIPS Council. The EU proposal submitted to the TRIPS Council on 21 June 2021 is a significant step in that direction and a constructive contribution to the debate, as underlined by several other WTO Members. While the TRIPS waiver proposal and the EU proposal represent different approaches, they seek to address the same issue of the availability of COVID-19 vaccines and medicines.

PP: How will the 1 billion dose vaccine donations announced by the G7 affect the negotiations at the WTO? Will it ease the public and civil society pressures for a sweeping waiver of IP?

Machado: Indeed, total G7 commitments since the start of the pandemic provide for a total of over 2 billion vaccine doses, with the commitments made since February 2021, including the last meeting in Carbis Bay, providing for 1 billion doses over the next year. To that, we should add the pledges of Pfizer/BioNtech, Moderna and Johnson & Johnson to provide 1.3 billion does of vaccines to low- and medium-income countries at cost or at lower prices respectively by the end of 2021. We should not forget the EU’s massive financing of the COVAX Facility to help deliver vaccines where they are most needed. Finally, we have predictions of the manufacturing capacity reaching around 10 billion doses by the end of 2021. These are all causes for cautious optimism and indications that our efforts are paying off. Of course that does not mean that we should not try to produce more – and hence our proposal to the WTO on how to increase production, ensure well-functioning supply chains, etc.

At the same time, we must also look at the future. The crisis has demonstrated the importance of diversifying and enhancing the resilience of global value chains. This is why the EU and its Member States – or “Team Europe” – committed to supporting the vaccine production in non-EU countries. The crisis opened up a window of opportunity for Africa and Europe. During the G20 Global Health Summit in May 2021, President von der Leyen announced a Team Europe initiative on manufacturing and access to vaccines, medicines and health technologies in Africa. Through this initiative, Team Europe will help create an enabling environment for local vaccine manufacturing in Africa and tackle both supply and demand side barriers. It will serve to complement existing efforts. As a first step, the initiative will be backed by €1 billion from the EU budget and European development finance institutions, such as the European Investment Bank.

PP: What, in the view of the EU, would be the cornerstones of a compromise as far as the waiver proposal is concerned? Will it be the compulsory licensing approach as suggested by the EU?

Machado: The EU is engaging in the text-based process constructively to find a way forward in this discussion on the role of intellectual property in enhancing access to affordable COVID-19 vaccines and medicines. The objective is to proceed with concrete, pragmatic short and medium term solutions to enhance universal access to COVID-19 vaccines and medicines at affordable prices.

We would like to emphasize again that the EU considers that only a multi-pronged approach addressing the identified bottlenecks such as limited manufacturing capacity and access to raw materials can bring about a real change. Intellectual property is only a part, and not the key part, of the solution.

The EU is ready to continue discussing the revised TRIPS waiver proposal although we are not convinced that the broad waiver as proposed is the best immediate response to the reach the objective of the widest and timely distribution of COVID-19 vaccines that the world urgently needs. This is why the EU included in this discussion a different and more targeted approach focusing on facilitating the use of compulsory licensing, in other words how the flexibilities in TRIPS can be used to waive certain protections.

This approach can bring legal certainty to Members that are ready to produce COVID-19 vaccines and medicines on the basis of compulsory licences, and to those that would be interested to import those. WTO Members should try to progress on this approach because it can bring solutions quickly. We hope that we will be able to convince Members that our approach, including the components that will be addressed in the [WTO] General Council, represents the best way for an effective and pragmatic short-term response to the crisis.

Adapted from the article first published in Geneva Health Files by Priti Patnaik, GHF founder and publisher.

Image Credits: International Monetary Fund/Ernesto Benavides.

Dr Tedros Adhanom Ghebreyesus, WHO Director-General.

Artificial intelligence (AI) has the potential to strengthen the delivery of healthcare and move the world closer towards universal health coverage, but ethical considerations and human rights must be central to the design, development, and deployment of AI technologies, according to a new report released on Monday.

The World Health Organization’s (WHO) Ethics and Governance of Artificial Intelligence for Health report, the world’s first global report on the use of AI in health, is the result of two years of consultations conducted by a panel of 20 international interdisciplinary experts in ethics, digital technology, law, human rights, and health.

“Like many new technologies, artificial intelligence holds enormous potential for improving health,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General, at the launch of the report on Monday. “This important new report provides a valuable guide for countries on how to maximize the benefits of AI, while minimizing its risks and avoiding its pitfalls.” 

“I hope this report will help countries to harness the power of artificial intelligence while minimizing the risk for a healthier, safer, and fairer future,” Tedros added. 

AI refers to the ability of algorithms encoded in technology to learn from data to perform automated tasks and is an exploding area of science that is being used in numerous disciplines. 

AI is “poised to strengthen healthcare, health research, drug development, improved diagnosis of infectious diseases, including COVID, as we are now seeing, and public health surveillance,” said Professor Partha Majumder, co-chair of the WHO Expert Group on Ethics and Governance of AI for Health and founder of the National Institute of Biomedical Genomics in India.

Professor Partha Majumder, co-chair of the WHO Expert Group on Ethics and Governance of AI for Health and founder of the National Institute of Biomedical Genomics in India.

The COVID-19 pandemic accelerated the willingness to use and invest in innovations, including AI, to address disease outbreaks and curb the spread of pandemics. 

“The key lesson from the pandemic is the important role technology plays in surveillance, disease detection, and treatment,” said Dr E. Osagie Ehanire, Nigeria’s Minister of Health. “[The pandemic] also highlights the potentially enormous value of digital health in improving care and outcomes.”

As innovation and development of AI continues, it could allow medical providers to make faster and more accurate diagnoses, enhancing the capabilities of health systems. 

The future of public health will increasingly become digital, with the development of technologies that “bring both promise and opportunities, but also challenges and ethical questions,” said Dr Soumya Swaminathan, WHO Chief Scientist. 

Applications of AI in Health 

In high-income countries, the use of AI has already begun to transform health systems through the prevention, diagnosis, and treatment of diseases.

Currently, AI is being used for radiological diagnosis in oncology, such as colonoscopy, mammography, and brain imaging. In addition, AI algorithms based on RNA and DNA sequence data are used to guide immunotherapy cancer treatment.

AI technologies are also being piloted for the detection, management, treatment, and care of patients with tuberculosis (TB) and those living in areas with rampant TB. 

Predictive AI systems were able to identify the risk of birth asphyxia, a condition where a newborn doesn’t get enough oxygen before or during birth, with the use of imaging technology during the labor process, according to the report. 

In Singapore, a national programme was established in 2017 to develop and support the country’s AI ecosystem, focusing on healthcare innovation. AI-driven solutions are being used to address high cholesterol, high blood pressure, and diabetes, which are prevalent in Singapore. 

Predictive modelling is used to identify those at the highest risk of developing chronic diseases for early intervention programs. The goal in using AI is to slow the progression of diseases, reduce complications in patients, and lower healthcare costs. 

Low- and middle-income countries (LMICs) have the most to gain from the transformation to health systems brought by AI, as it could fill gaps in health care delivery and services. 

Numerous LMICs face chronic shortages of health workers, a high burden of diseases, and large underserved populations. AI could provide healthcare workers with assistance in diagnostics and speed up the analysis of X-rays and pathology slides, if there is a lack of health specialists. 

A pilot programme of AI-based tools is underway in India, Kenya, Malawi, Rwanda, South Africa and Zambia to screen for cervical cancer. LMICs could also use AI to manage HIC antiretroviral therapy by predicting resistance to the drugs and helping health workers to optimize the therapy, according to WHO’s report.

Ethical Challenges of Using AI in Health Systems

While AI tools and technologies will likely play an important role in improving patient outcomes, strengthening health systems, and driving progress towards universal health coverage, several ethical challenges could emerge. 

“In as much as AI offers enormous advantages to healthcare delivery systems, there remain significant challenges and gaps in the adoption, scale up and integration into health systems,” said Dr Ehanire. 

Dr E. Osagie Ehanire, Nigeria’s Minister of Health.

“Like all new technology, artificial intelligence holds enormous potential for improving the health of millions of people around the world, but like all technology, it can also be misused and cause harm,” said Dr Tedros. 

“Artificial intelligence raises potential ethical concerns, including equitable access to technologies, data protection, and liability,” he added. 

The use of limited, low-quality, or non-representative data in AI could deepen disparities in health as predictive algorithms based on inadequate data could result in racial or ethnic bias. 

Biases based on race, ethnicity, age, or gender that are encoded into AI algorithms can be detrimental to the equitable provision of and access to healthcare services. Many data sets used to train AI models exclude women, ethnic minorities, older people, rural communities, and disadvantaged groups. 

Discrimination in health systems will be captured by machine-learning models, making their recommendations inaccurate for populations excluded from the data. 

“Machine learning technologies have been shown to harm our right to equality and non-discrimination,” said Agnès Callamard, Secretary General of Amnesty International. “There is a substantive and growing body of evidence showing that these machine learning systems have discriminatory impacts and contribute to discriminatory practices.”

Potential to exacerbate disparities

The quality and availability of data may not be adequate in LMICs, resulting in algorithms with inaccurate performances. 

In addition, it is unclear whether AI trained for use in one context can be used accurately and safely in another geographical region. 

Investments will be needed to improve the collection of data in resource-poor settings and to ensure sufficient data on vulnerable and marginalized populations. 

If AI technologies are not deployed carefully, they could exacerbate disparities in health care, cause the over-medicalization of individuals, and cause stress and stigmatization of individuals or communities, according to the report. 

Issues of equity and access could be raised through the exacerbation of the existing digital divide, which refers to the uneven distribution of access to or use of information and communication technologies, such as broadband or smartphones. 

Some 1.2 billion women in LMICs don’t use or have access to mobile internet services and the infrastructure to operate digital technologies may be limited in many countries. 

Employing AI could further marginalize those who lack access to health services and they could be left behind by healthcare systems. 

Another major ethical issue is cybersecurity and data protection. AI technologies, which hold patient health data, could be the target of malicious attacks, putting individuals’ privacy at risk.

With the involvement of the private sector in designing AI systems, concerns are raised over where data is coming from, how it is being stored, how it is being used, and who has access to it. 

To combat the ethical issues that emerge through the use of AI, transparency must be prioritized, with independent oversight and public participation in the design and use of AI in healthcare, said experts at a WHO briefing on Monday.  

AI systems have to be designed to reflect the socio-economic and racial diversity in the relevant health care setting and must be accompanied by training of healthcare workers in digital literacy. 

Principles and Recommendations for use of AI

In an effort to limit the risks and maximize the benefits of AI systems, the expert group developed six principles as a basis for AI governance in the domain of health:

  • Protecting human autonomy;
  • Promoting human wellbeing and safety and the public interest;
  • Ensuring transparency, explainability, and intelligibility;
  • Fostering responsibility and accountability;
  • Ensuring inclusiveness and equity; and
  • Promoting AI that is responsive and sustainable.

The report detailed 47 recommendations to a range of stakeholders to encourage the ethical and transparent design of AI technologies to enhance clinical decision making, mitigate workforce shortages, and increase efficiencies in health service delivery. 

“The need for international comprehensive guidance on the use of artificial intelligence for health, in accordance with ethical norms, cannot be overstated,” said Callamard. 

“There needs to be a framework that addresses some of the ethical issues, the legal issues, as well as other societal challenges, including not creating another digital divide,” said Swaminathan.

Dr Soumya Swaminathan, WHO Chief Scientist.

The recommendations called on the private sector to design AI systems with the accuracy to improve the capacity of health systems; governments to require the use of impact assessments of AI technologies; companies to adhere to national and international regulations on the development and use of AI for health systems; and governments to support the global governance of AI for health. 

“To harness the promise of artificial intelligence for health, human rights cannot be an afterthought,” said Callamard.

“Success is only possible if we collectively and deliberately place ethics and human rights at the center of the design, deployment, and use of AI technologies for health,” said Dr John Reeder, Director of WHO’s TDR, the Special Programme for Research and Training in Tropical Diseases. 

The report was created as a living document, with the opportunity to update it as research emerges on AI and as the field evolves. 

In the coming weeks and months, WHO will focus on developing an implementation plan for the report, holding mission briefings for member states to advise them on the enactment of the recommendations. 

“We should all work together so that artificial intelligence for health becomes a panacea for most of the world and…[it] can be used to meaningfully make universal health coverage a reality,” said Majumder. 

Image Credits: WHO.