Dr Tedros Adhanom Ghebreyesus speaks at the World Health Assembly’s closing session on Friday, 13 November.

BREAKING – World Health Organization Director-General, Dr Tedros Adhanom Ghebreyesus has proposed the creation of a Swiss-based global repository for sharing pathogen materials and clinical samples related to potential outbreak threats – allowing for the more rapid development of medical interventions. 

The COVID-19 pandemic has shown the urgent need for this kind of system, said Dr Tedros Adhanom Ghebreyesus in his closing remarks to the 73th World Health Assembly.  He alluded to the problems associated with existing WHO-sponsored frameworks for pathogen-sharing, which are based on bilateral agreements between countries, and have no centralized repository. 

“The pandemic has also shown that there is an urgent need for a globally agreed system for sharing pathological materials and clinical samples to facilitate the rapid development of medical countermeasures as global public goods. 

“It can’t be based on bilateral agreements. And it can’t take years to negotiate. 

“We are proposing a new approach that would include a repository for materials housed by WHO in secure Swiss facility; an agreement that sharing these materials in the facility is voluntary; that WHO can facilitate the transfer and use of materials; and a set of criteria under which WHO will distribute them.”

Dr Tedros said that Alain Berset, head of the Swiss Federal Office of Home Affairs [Public Health] had offered his support for the initiative, including a high-security  BSL certified laboratory (biosecurity level 4). The Health Minister of Thailand, Anutin Charnvirakul, and Italy’s Minister of Health, Roberto Speranza, have also come behind the concept, Dr Tedros said. 

Sharing of Samples is Critical to Rapid Response  – But Slow Under Current Arrangements 

Sharing of such biological samples is crucial for the rapid response to an emerging outbreak threat, leading to the faster development of diagnostic tools, medicines and eventually, vaccines. 

Current WHO-mediated arrangements are guided by bilateral Material Transfer Agreements (MTAs), a contract governing transfer of biological materials – that is relevant samples and data– between two countries or parties (e.g. laboratories).  The MTA also defines the rights of the provider and the recipient with respect to the materials and any derivatives.

The current WHO MTA formulas are part of the Organization’s broader Research and Development (R&D) Blueprint for Action to Prevent Epidemics blueprint.

WHO developed and published its first such R&D blueprint framework 2016, which was approved that year by the WHA, following the harsh experiences of the West African Ebola epidemic where a lack of such formalized frameworks hindered response. The Blueprint was updated  again in 2017, following another expert public consultation.

This Framework was scrutinized again as the COVID-19 pandemic was building steam – when WHO convened a major research meeting in Geneva in February 2020. 

The WHO-convened Global Research and Innovation Forum with scientists, researchers and public health experts followed on the heels of WHO’s initial declaration of  COVID-19 as a public health emergency at the end of January, 2020. 

The meeting, 11-12 February, yielded the first COVID-focused research and development blueprint to accelerate global research work on treatments and vaccines, which is part of the WHO’s broader global strategy and preparedness plan. 

At this meeting, the expert participants issued a set of recommendations for “immediate research actions”, saying that virus material, clinical samples and associated data should be “rapidly shared for immediate public health purposes, and that fair and equitable access to any medical products or innovations that are developed using the materials must be part of such sharing.”

Sources in Geneva told Health Policy Watch that while the Swiss Confederation has indeed agreed, in principle, to host such a repository – a more formal framework for the initiative still needs to be developed. If successful, however, such a facility could make a meaningful contribution to global health security, providing an important base for more rapid, initial investigation of emerging disease threats on neutral ground. Indeed, the concept dovetails well with the classic Swiss diplomatic positioning as a “trusted” and “neutral” partner – in the polarized world of global health diplomacy.

Image Credits: Health Policy Watch .

Limited education and employment capacity in LMICs means has encouraged health workers to move to high-income countries
Limited education and employment capacity in LMICs means has encouraged health workers to move to high-income countries. One in eight nurses globally are migrant nurses.

The migration of health professionals to high-income countries should not lead to a dearth of healthcare workers and services low- and middle-income countries (LMICs), the International Council of Nurses (ICN) has warned.

Speaking at the World Health Assembly (WHA), the council flagged that the global shortage of six million nurses, in tandem with the burden of the COVID-19 pandemic, would continue to drive health worker migration, leading nurses away from LMICs.

One in eight nurses globally are migrant nurses, according to WHO’s 2020 State of the World’s Nursing report, drawing comparison to the limited education and employment capacity in LMICs.

The global shortage of six million nurses continues to drive health worker migration
The global shortage of six million nurses continues to drive health worker migration.

To address this, the ICN said high-income countries must train enough nurses to become self-sufficient at a large scale.

It urged countries to implement a self-sufficiency indicator, presenting their reliance on foreign-trained nurses as a percentage. This would give policymakers insight into the extent of dependence on international nurse supply, it said, and would enable tracking and monitoring of their commitment to the global strategy of human resources for health.

The representative said: “The impact of COVID-19 on the nursing workforce will continue to increase the flow of nurses from low- to high-income countries. High-income countries must train enough nurses to become self-sufficient.”

UK Admits Dependence on Health Worker Migration

The United Kingdom is one of the world’s top destinations for emigrating health professionals.

Workers born abroad have constituted 50% of the increase in the country’s health and social care workforce across the last decade, according to a Nuffield Trust analysis published in December 2019. The analysis also revealed that people born outside of the UK account for nearly a quarter of all staff working in hospitals, and a fifth of all health and social care staff in the country.

The UK spokesperson at the World Health Assembly admitted that the UK’s National Health Service relies to a large extent on international health workers.

“By forging international partnerships, the UK will foster collective efforts across the world to address the global shortage of health workers and provide health workforce-related support and safeguards to countries with the most vulnerable health systems, enabling progress towards universal health coverage and sustainable development goals,” she told the assembly.

She added that in consultation with WHO, the UK has updated its code of practice for international improvement based on the latest advice, due to be published later this year.

Feeling the Weight of Health Workforce Inequality

Evidence points to a direct correlation between the size of a country’s health workforce and its health outcomes, with WHO estimating a projected global shortfall of 80 million health workers by 2030, mostly in LMICs.

A COVID-19 responder in Kenya learns how to properly equip protective gowns in Kenya. The country is experiencing a critical resource shortage during the pandemic.

COVID-19 has piled additional pressure on the healthcare systems in many countries losing health professionals to high-income countries.

This is an especially pressing issue in Kenya. In a 2016 study published in BJPsych International, researchers noted that one in five nurses trained in Kenya applies to emigrate. They also found that up to 40% of the country’s 600 medical graduates leave upon completing their internship every year.

Kenya’s spokesperson said the East African country’s healthcare system is faced with a shortage of critical human resources for health demands. Similar situations occur in many other African countries.

“We continue to experience challenges in managing human resources for health, such as severe shortages of essential workers, inability to attract and retain health workers, and even remuneration among workers,” she told the assembly.

Kenya also urged WHO to establish and regularly update the list of countries with critical health workforce challenges.

Transparency and Accountability

A representative from the United States asked WHO to put more pressure on Member States to report information on international recruitment of health professionals.

She said this would promote fair, equitable and ethical decision-making. She referred to Cuba, which had more than 30,000 doctors working in nearly 70 countries in 2019.

The US called for the investigation of any allegations by health personnel of human trafficking and slave labour conditions. If substantiated those responsible must be held accountable, she said.

Dr Jim Campbell, WHO’s Director of Health Workforce, noted that the global health body will work on the strategic directions on the code of practice, and address the implementation gap.

Image Credits: Tim Kubacki/Flick, UNICEF/Frank Dejongh, Twitter: WHOAFRO.

A scientist at Ethiopia’s National Influenza and Arbovirus Laboratory, in February, equipped to test for COVID-19.

Africa is set to establish a plan of preparedness and to compile influenza data sets with the World Health Organisation (WHO), to expand its surveillance of potential flu outbreaks.

The African region has also called for the integration of influenza surveillance into an all-inclusive infectious disease surveillance system, and for the creation of a necessary mechanism for contributory finance that can make vaccines and control measures affordable and equitable.

Dr Chikwe Ihekweazu, Director General of the Nigeria Center for Disease Control (NCDC), told the World Health Assembly (WHA): “We notice the challenges with influenza preparedness as well as the consequences that recurring pandemics have on health, economies and society – particularly on vulnerable countries with weak health systems, now exacerbated by the COVID-19 pandemic.”

Establishing a plan of preparedness with the Secretariat would “help expand and reinforce the surveillance and diagnostic capacity of the African region in case of influenza outbreaks,” he said.

He also asked WHO to continue to stockpile vaccines in anticipation of influenza outbreaks, so as to support the region’s ongoing plan to expand sentinel sites next year.

Could the Northern Hemisphere Avoid Flu Season?

In the early weeks of the COVID-19 pandemic, WHO and health stakeholders noted that COVID-19 could worsen the seasonal influenza outbreaks around the world.

“Every year, there are up to 3.5 million severe cases of seasonal influenza worldwide, and up to 650,000 respiratory-related deaths,” WHO stated. “Every hospital bed occupied by a patient with COVID-19 is a bed that is unavailable for someone else with another condition or disease, such as influenza.”

As of November, however, trends are less clear.

On the one hand, over the spring and summer, the southern hemisphere registered a sharp drop in flu cases compared to previous years – attributed to COVID-19 restrictions and guidance like social distancing and hand washing.

At the same time, given the unpredictable course of the pandemic, public health officials have warned countries in the north not to let up their guard.

“We cannot assume the same will be true in the northern hemisphere flu season,” WHO stated. “The co-circulation of influenza and COVID-19 may present challenges for health systems and health facilities, since both diseases present with many similar symptoms.”

WHO said it is working with countries to take a holistic approach to the preparedness, prevention, control and treatment of all respiratory diseases, including influenza and COVID-19.

“Many of the same measures that are effective in preventing COVID-19 are also effective for preventing influenza, including physical distancing, hand hygiene, covering coughs, ventilation and masks,” said WHO Director-General, Dr Tedros Adhanom Ghebreyesus.

WHO Must Make Sure Africa’s Record-Low Cholera Cases Are Not Undone by COVID-19

African countries, including Zambia, Nigeria and South Sudan, reported an average 59% decrease in the number of cholera cases between 2017 and 2018, as the broader African region experienced its lowest number of cases in the 21st Century. COVID-19’s impact on vaccination campaigns, however, threatens to drive cases back up.

Dr Chikwe Ihekweazu says influenza outbreaks in Africa require improved surveillance
Dr Chikwe Ihekweazu, DG of Nigeria’s NCDC, spoke on behalf of the African region at the WHA on Wednesday.

Despite the successes so far earned by global initiatives – like the Global Task Force on Cholera Control’s 2030 roadmap which aims to reduce cholera deaths by 90% using evidence-based best practices – Ihekweazu noted the urgent need for additional work to ensure these milestones are consolidated.

“We emphasize that despite a significant downward trend in cholera transmission, more effort is needed to sustain the results achieved, especially during this period of the COVID-19 pandemic,” Ihekweazu said.

He also called for support for a privatization of epidemiological and laboratory surveillance, and a multi sectoral approach to strengthening health systems: a sentiment mirrored by a separate committee at the WHA.

Dr Ibrahima Socé Fall, WHO’s Assistant Director-General for Emergencies Response, noted that there was a 64% reduction in cholera deaths between 2019 and 2018 in the African region, and he drew attention to Nigeria and Sudan’s requests for continued investment in laboratory capacity and community engagement.

He said: “We are continuing to work on this with our partners. There are still a number of challenges despite this progress that we’ve made.”

Dr Socé Fall noted that many African countries, including Cameroon, Uganda and Mozambique, are now resuming their vaccination campaigns following COVID closures, with others resuming preventive campaigns. In 2019, the region distributed 23 million oral cholera vaccines.

“We are also seeing preventive campaigns in Zambia, Tanzania and other countries,” he said. “We would encourage countries not to cancel these campaigns.

“COVID-19 measures have been implemented and it is important that we continue to do this to save lives.”

Image Credits: WHO AFRO/Otto B., WHO / WH.

A bavy is given a polio vaccine
A new oral vaccine that is expected to have a substantially lower risk of generating vaccine-derived poliovirus is expetced to roll out in Janaury.

Despite the big success this year in the eradication of wild poliovirus in the African region, the COVID-19 crisis has seen a temporary interruption of polio vaccine programmes. This has led to a rise in vaccine-derived polio cases which, are more likely to occur when vaccine coverage is weaker, WHO and African Region health officials told World Health Assembly (WHA) member states in a wide-ranging review of WHO’s massive two-decade polio eradication effort.

The prospect of a forthcoming COVID-19 vaccine, meanwhile, underlines the important role the programme can play, WHO’s Dr Michel Zaffran, director of the Polio Eradication Programme, said at the WHA session. He specified that adapting national polio eradication teams to COVID-19 prevention and eventually immunization was critical.

“Since July … polio immunization campaigns have resumed under strict infection control protocols in endemic impoverished countries,” he noted, adding that “polio staff have rapidly pivoted to support COVID-response activities, helping with disease surveillance, contact tracing, and educating communities on physical distancing and hygiene.”

Zaffran warned, however, that inadequate vaccine coverage in areas at risk of outbreak mean that “risks are high”.

A map indicating the disparity in polio immunization in Africa.

“Last week, UNICEF and WHO issued a global call,” he said, “for the international community to ensure that the financial resources needed to respond to outbreaks are made available.”

WHO’s Sylvie Briand confirmed that WHO is looking at options to ensure the continued cross-fertilizing between polio eradication and the COVID battle.

She said: “We know that innovative partnerships, mechanisms and platforms, developed through the ACT Accelerator can be leveraged for long term investment in pandemic preparedness, including the research, development and availability of innovative influenza pharmaceutical products.

“So … learning from the COVID-19 crisis, we are looking at options to ensure the continent continues cross-fertilising between programmes.”

“There is an opportunity to link the transition of polio-funded assets with COVID-19 recovery efforts to build back better,” said a representative of the UN Foundation, one of the partners in the polio eradication effort.

Integrating Polio Programmes with National Health Systems

Over the longer term, better integration of polio programmes with national health systems remains a key priority, donor states have emphasized.

“Polio programmes have become cornerstones of the national health system, including their response to COVID 19. It is essential that we progress on integration of the project assets into the national health programmes and have polio vaccines integrated,” said Germany’s WHA representative.

The wide-ranging conversation followed WHO’s presentation to member states of a progress report on its eradication effort. A parallel WHO report covers polio “transition planning” – shifting polio staff and resources into broader Ministry of Health vaccines and primary health care activities.

The Global Polio Eradication Initiative (GPEI) is one of the WHO’s and the world’s largest single global health efforts, with a separate budget of US$4.2 billion, that employs teams embedded in the national health systems of countries in Africa, the Eastern Mediterranean region, and the Western Pacific (Asia). Gavi, the Vaccine Alliance has contributed more than US$180 million to the GPEI, and has pledged an estimated US$800 million in support of inactivated polio vaccines (IPV), as part of GPEI’s Polio Endgame Strategy.

The number of polio cases has dropped significantly, but the COVID pandemic threatens this progress.
Polio Programmes: From Downsizing to Repurposing

Only a couple of years ago, the main corridor conversation inside WHO was how to dramatically downsize the polio programme – including termination or transition of polio team members to other positions – as eradication goals were progressively met.

Now, talk has pivoted to a conversation about how to repurpose those same programmes and teams to help deliver COVID-19 vaccines when these become available – a new and equally momentous task.

Along with that, donors and countries are talking about the importance of better, long-term “integration” of the vertically-designed, donor-driven polio programme into countries’ broader immunization plans and national health systems.

De facto, polio teams are already deeply involved in national health services delivery of a much broader array of vaccines – including the 3-in-1 Td/IPV vaccine (protecting against tetanus, diphtheria and polio).

But until the COVID-19 pandemic, the relevance of the polio programme to vaccine services more broadly was not well understood.

Now that COVID has made this more obvious, the challenge of supporting and funding the institutional rea-lignment of resources remains. With this support in place, national ministries and immunization programmes can staff and fully budget for tasks being fulfilled by the polio programme, as part of primary health care systems.

New Low Risk Oral Vaccine Rollout Urged

A new oral vaccine that is expected to have a substantially lower risk of generating vaccine-derived poliovirus (VDPV) cases was also announced to replace a predecessor that had been used until 2016. The new vaccine is expected to be rolled out, beginning in January 2021 and will be deployed under emergency use.

While oral polio vaccines (OPV) are generally safe and effective, on rare occasions the live poliovirus component can cause infection.

But since 2016, when the earlier OPV was withdrawn, some 49 outbreaks of a genetically distinct circulating VDPV have been reported in 21 countries, including in Africa and the Eastern Mediterranean and Western Pacific Regions.

“Unfortunately, 2020 has seen a dramatic increase in outbreaks of circulating VDPV in Africa and Asia,” said Dr Zaffran. Commenting on the deployment of the new vaccine, he added: “This must be complemented by existing tools, including efforts to strengthen routine immunisation with a second dose of IP.”

Increasing Risk of VDPVs in Migrants to Polio-Free Countries

Several countries – including those certified polio-free – reported an increased risk of polio infection in vulnerable populations, caused by COVID-impeded vaccination campaigns.

Malaysia is a country that was declared polio-free in 2000, however it warned that delays in vaccination campaigns pose a risk to newborns and migrants. The representative said that the GPEI and international organisations need to assist countries to “address the issues of highly-mobile, cross-border populations.”

A representative from Iran cited a “growing concern due to illegal immigration” with neighbouring countries. Wild polioviruses still exist in Afghanistan, which sits along Iran’s eastern border, and experienced an outbreak of VDPV type 2 earlier this year.

The Malaysia representative also said: “Undocumented migrants are at an even greater risk of missing not only routine immunisation, but also polio vaccination campaigns. Efforts to address these marginalised populations will benefit polio control.”

Image Credits: UNICEF Ethiopia/Mulugeta Ayene 2018, WHO.

A doctor checks an x-ray of the lungs of a hospitalised boy with COVID-19.

What if every household in the world could diagnose coronavirus-triggered pneumonia from their home with a cheap handheld device?

We are not at this stage yet. But the Swiss-made Pneumoscope, an intelligent stethoscope that can diagnose pneumonia in seven minutes, is bringing this dream closer to reality, says Benissa Mohamed-Rida from the Pneumoscope initiative.

The device is one among a series of new portable and low-cost innovations that will be featured at the Geneva Health Forum which opens Monday, 16-18 November.

Why is This Important?

The three-day Forum brings together Swiss and European expertise with that of researchers and practitioners from low- and middle-income countries (LMICs) to explore problems on the cutting edge of global health, as well as innovative solutions.

While an overarching theme of the first-ever virtual of the Forum will naturally be COVID-19, the conference is covering a wide range of other topics – from big picture themes such as climate change and decolonising global health to nuts-and-bolts approaches to tackling cervical cancer or neglected tropical diseases.

The event is co-sponsored by the Geneva University Hospitals and the University of Geneva, in collaboration with Geneva International, WHO, UNAIDs and UNITAR.  It is expected to draw some 1,600 participants from 80 countries worldwide.

In addition, some 120 new health technologies will be showcased at a special GHF Innovation Fair, including the Pneumoscope. People registered to the GHF will be able to visit the online “exhibit” spaces at certain times every day to meet with the innovators and chat with them about their products.

A Pneumonia Diagnosis in Just Seven Minutes

The current Pneumoscope prototype can diagnose in just seven minutes common forms of pneumonia, one of the leading causes of death for children under five in low-income countries.  Although this diagnosis isn’t sufficiently fine-tuned [yet] to identify only COVID-19, it’s a hint at the direction such new technologies are heading.

“In times of a pandemic, public health professionals are on the lookout for cost-effective strategies to promote diagnosis and disease prevention, not only in low-resource settings,” notes Mohamed-Rida, a Paris-based medical doctor who is working with the Swiss-based Pneumoscope Initiative. “If we can be precise in the laterality of pneumonia, there is no need to do an x-ray, so insurance companies will want to pay for the Pneumoscope, even in high-income countries.”

The Pneumoscope Initiative is being led by Geneva University Hospitals and the University of Geneva, in collaboration with the Swiss Ecole Polytechnique Federale Lausanne (EPFL) and Terre des Hommes, a global NGO.

The Smart Scope, an Indian invention that can detect cervical cancer in under 10 minutes.

Among the many other innovations on display will be the Indian-designed Smart Scope, an award-winning portable device that can detect cervical cancer, the second largest killer of women in India after breast cancer.

They are just two examples of the many low-cost health technologies that are emerging out of the “reverse innovation” spirit of entrepreneurs looking to turn resource scarcity into a virtue.

Such devices are potential deal breakers in LMICs, where a lack of more sophisticated x-ray and laboratory infrastructure and trained healthcare workers, means that many preventable diseases, including pneumonia and cervical cancer, slip past our radar.

How Does it Work? Think Shazam

Just like a song that can be recognised through apps like Shazam, respiratory diseases also have their own acoustic “signature”. And they can be recognised by artificial intelligence (AI), with the help of a smartphone or tablet, at a surprisingly high accuracy.

Working from this principle, the Pneumoscope can tease apart a healthy lung from a diseased one at a sensitivity of almost 100%, according to a preliminary case-control study that compared children under 5 years of age with pneumonia to healthy children.

In comparison to commonly used tools to diagnose pneumonia like the WHO/UNICEF case management algorithm, the Pneumoscope is twice as accurate, says Mohammed-Rida. Currently, the algorithm developed by UNICEF/WHO misses every second child with pneumonia, which is ‘simply not good enough’, he adds.

But there’s more. The Pneumoscope can also tease apart viral pneumonia from bacterial pneumonia almost 90% of the time.

That means that it could help address another important issue – unnecessary prescription of antibiotics. In low-income countries, given the scarcity of effective diagnostics, antibiotics are often prescribed when a child is sick with pneumonia – even though they may have a viral infection – and this contributes over time to drug resistance.

In addition, the device can potentially diagnose severe bouts of asthma, the leading chronic disease in children that affects almost 340 million people worldwide. Preliminary results are ‘quite promising’, says Mohammed-Rida, noting that the Pneumoscope picks up asthma’s acoustic signatures 90% of the time, according to preliminary trials that are still unpublished.

The device is currently being field tested in Burkina Faso, Morocco, Brazil, Cameroon and Senegal.

Not a Rolex

The Pneumoscope is designed to withstand a range of extreme conditions, including deserts with scorching temperatures as hot as 50 °C, as well as humid environments and rain.

“The Pneumoscope can’t be a Rolex,” says Mohamed-Rida. “It has to withstand extreme conditions, especially heat and humidity, as well as sand, which clogs up electronics and renders them unusable.”

Although its price remains to be determined, its cost-effectiveness ratio is likely to be “quite interesting”, says Mohammed-Rida. The group is working to manufacture it locally in LMICs through 3D printing.

Reverse Innovation

Because it doesn’t need lots of technical training to use, it’s particularly well-suited for LMICs, where pneumonia is five times more common than in rich countries.

But there may be appetite for the Pneumoscope in high-income countries as well, especially during the pandemic, says Mohammed-Rida. Precisely because such devices save time and money – and may even be more accurate – they often infiltrate upward into more affluent countries – a process some call “reverse innovation.”

Notably, since the Pneumosocope can also detect which side of the lungs is infected, more formally known as the ‘laterality of disease’. it may be able to overcome the need for pricey x-rays.

“This could save overwhelmed healthcare systems tremendous amounts of money,” says Mohammed-Rida.

Image Credits: Keystone / EPA / Emanuele Valeri, Periwinkle Technologies.

Melinda Gates tells Paris Peace Forum that broad global access to COVID-19 vaccines is criticlal to  recovery

A series of new COVID-19 drug and vaccine funding commitments worth just over US$300 million were announced on Thursday by the Gates Foundation, France and the European Commission – amidst a quickening pace of anticipation that at least one, if not two, COVID-19 vaccines may soon become available. 

Appearing at the Paris Peace Forum, Melinda Gates announced a new $US 70 million contribution by the Bill and Melinda Gates Foundation to vaccine research and the ACT Accelerator’s COVAX facility. The WHO co-sponsored ACT Accelerator aims to ensure the worldwide distribution of forthcoming COVID vaccines, along with drugs and tests, to countries that can least afford to purchase them. 

“In this pandemic there is no difference in helping yourself and helping others,” said Gates. “But its not enough to have the right values, we have to put enough money behind our values,” said Gates.

She spoke at the Paris Peace Forum shortly after WHO published an urgent appeal for US $4.579 in immediate financing to the Accelerator’s various arms of support – which aim to cover worldwide procurement of not only vaccines, but also COVID-19 tests, treatments – and required health systems capacity.  Some $US 28 billion will be needed over the course of 2021, WHO warned, in a detailed investment case, published just hours before the Paris Peace Forum event. 

‘Urgent’ finance asks for COVID-19 drugs, diagnostics, vaccines and related health system capacity, published by WHO on 12 November 2020

Gates appeared at the Paris Peace Forum high-level event along with French President Emmanuel Macron, Norwegian Prime Minister Erna Solberg, European Commission President Ursula Von der Leyen, and Dr Tedros Adhanom Ghebreyesus, head of the World Health Organization.  Both the French President and the Von der Leyen also pledged another €100 million Euros each to the Act Accelerator vaccines, tests and treatments initiative. 

Macron also called upon global leaders to adopt an “Act-A Charter” to ensure that “regulatory and policies making COVID-19 products available for all people…if part of the planet is not safe, the entire planet will remain under threat,” he said.

Added von der Leyen, “If we have a COVID19 vaccine, we should have a common approach to give a fair share to everyone so the most vulnerable groups, the frontline workers and the healthcare workers are the ones that get it first.”

Macron’s proposal for a Charter was applauded by WHO’s Dr Tedros who said: “WHO welcomes the ACT-A Charter, which outlines the core principles of equity and fair allocation that align this landmark effort to ensure vaccines, diagnostics and therapeutics are allocated fairly as ‘global public goods’ and not private commodities.”

Meanwhile, however, Norway’s Solberg stressed that, “money talks” and what is needed is $US4.5 billion immediately – as well $US28 billion over the course of 2021 in order to fully fund all four pillars of the Act Accelerator’s activities.

She was referring to the new WHO “investment case” outlining “Urgent Priorities and Financing Requirements” for the ACT Accelerator initiative.  Solberg and other panelists pointed out that the monies, while significant, are small in comparison to the economic costs of a continuing pandemic.  

The Act Accelerator’s $US 28.3 billion ask includes: $US 5.3 billion for COVID tests;  $US 6.1 billion for drugs and other therapeutics; $US 7.8 billion for vaccines; and $US 9.1 billion for upgrading health systems to make it all happen, states the investment case.

Act Accelerator Therapeutics Pillar
ACT Accelerator Vaccine Pillar
Act Accelerator Diagnostics Pillar
Act Accelerator Health Systems Pillar

The Access to COVID-19 (Act) Accelerator is a collaboration  between WHO and the GAVI Vaccine Alliance, the Global Fund, Gates Foundation, The Wellcome Trust, FIND diagnostics, Unitaid and the Oslo-based Coalition for Epidemic Preparedness Innovations (CEPI). It is acting on four pillars – that aim to ensure worldwide access to COVID drugs, vaccines, tests and health services.

“Our goal is to accelerate the development of COVID vaccines and ensure people in all countries get rapid and equitable access regardless of their ability to pay, said Seth Berkley, CEO of GAVI, also speaking about the Accelerator at the Paris Peace Forum.

Generic Drug Manufacturers Pledge To Collaborate With Medicines Patent Pool 

Meanwhile, a coalition of 18 of the world’s largest generic drug manufacturers pledged to work with the Geneva-based non-profit Medicines Patent Pool (MPP) to expedite delivery of the latest COVID-19 drug solutions, including monoclonal antibodies to low- and middle-income countries.  

“We strongly believe that collaboration is the only way we can make it past this pandemic. Each of us stands ready to contribute to the fight against COVID-19 through our technical expertise and longstanding experience in manufacturing and distribution of quality-assured medicines,” states the pledge, signed by the leading generics manufacturers such as Adcock Ingram, Celltrion, Sun Pharma, Natco and others. 

“This unprecedented cooperation from companies that are typically competitors represents a breakthrough in our efforts to level the playing field for access to drugs that will be crucial to controlling and defeating this pandemic,” said Charles Gore, Executive Director of MPP, in a press release. “These are companies with an excellent track record of working with originators to ensure generic versions of their innovations meet high standards for quality—while answering the need for more affordable, accessible therapies.”

Gore noted that collectively the 18 companies that have so far joined the  “open pledge”  have the capacity to deliver huge amounts of conventional drugs, technically known as “small molecules” in industry parlance.  They also have a growing capacity to produce cutting-edge “biologics,” or drugs based on the chemistry of living, biological compounds. Promising COVID-19 biologics include monoclonal antibodies targeting COVID-19 that are currently in clinical trials, and have shown potential for either treating or prevent viral infections such as COVID-10. However, their cost and manufacturing capacity pose substantial barriers to deploying them globally. 

Gore said he hopes the pledge by such a respected group of generic industry players to produce large volumes of high-quality COVID-19 treatments will encourage firms now developing either new or re-purposed therapies to negotiate agreements allowing rapid access to those in need. This can be either through licensing of their intellectual property, or where licences are not needed, facilitating ways to scale up manufacturing capacity to meet the high demands.

Charles Gore, Executive Director, Medicines Patent Pool

MPP was created in 2010 by the global health initiative Unitaid to negotiate license agreements for the generic manufacture of patented drug products of critical importance to health-care systems in low and middle income countries – vastly easing the process for generic drug manufacturers.  Beginning with HIV and Hepatitis C drugs, MPP’s mandate had recently expanded to include other treatments, most recently COVID-19 therapeutics. 

World Health Assembly Sees Debate on WTO Patent Waiver Proposals – Affirmation by Pharma of “Equitable Access”

In a separate statement, the International Federation of Pharmaceutical Manufacturers and Associations and the International Generic and Biosimilar Medicines Association, declared their “shared commitment to equitable acccess to COVID-19 medicines and vaccines” – adding that the pandemic has also highlighted the “importance of ensuring adequate resources are spent to build stronger, more resilient health systems that can cope with complex health challenges.”

The statement, coincided with this week’s World Health Assembly, which saw a wide-ranging discussion of the COVID-19 pandemic, including fears expressed by low- and middle-income WHO member states that their countries could be left out of the COVID-19 vaccine sweepstakes – as rich countries snap up huge pre-order supplies of those products most likely to come first to market.

To address those concerns, South Africa and India have already jointly proposed an IP “waiver” at the World Trade Organization on patents, copyrights and trade secrets for COVID-related health products – covering not only drugs, tests and vaccines, but also hospital supplies like respirator and protective gear.   The “waiver” proposal has, however, so far failed to make headway against rich countries’ objections. And the proposal was subject to considerable pushback again at this week’s WHA from high-income countries, including the United States and the United Kingdom.

Meanwhile, WHO has tried to promote a “third way” including a C-Tap initiative that would mimic the successful Medicines Patent Pool approach, but for a wider array of COVID-19 products, particularly vaccines.  So far, however, that WHO-led effort does not seem to have gained much ground. That appeared even more evident on Thursday in the news that MPP is now building an alliance with generic drug manufacturers to negotiate patent pooling deals over key COVID drugs – in a format that is more predictable and familiar to industry partners.

Overall, the trends have frustrated medicines access advocates who protest the notion that public monies will be spent to buy pharma products that were also financed, in part, by public “Lofty rhetoric on global public goods and solidarity in the COVID-19 response has not been matched by concrete action on the sharing of know-how and intellectual property rights to facilitate deep technology transfer,” said Knowledge Ecology International’s representative, Thiru Balasubramaniam, during the WHA debate. At the minimum, he said public funders of COVID-19 R&D, such as governments and philanthropies should “use their financial leverage to enable the sharing of know-how, cell lines and rights in data and patents, for COVID-19 related technologies.”

Along with tried-and-true MPP approaches, the mood at the Paris Peace Forum made it clear that European leaders are trying to cut a path forward in the marketplace to ensure universal access to whatever the world needs to recover from COVID-19.

Rather than upending the established legal order at WTO or anywhere else, the approach is to leverage huge loans and donations to buy cutting-edge vaccines, drugs and tests as they come to market – but in coordinated, large scale deals that would at least be more affordable.

And that, may be the other bottom line of the US$28 billion Ask.

 

Image Credits: Paris Peace Forum , WHO , WHO , WHOI , MPP.

WHO Financing by Regional Major Office

Despite nearly two years of internal restructuring, WHO’s budget at its Geneva headquarters is still twice the amount spent in all 54 countries of the Organization’s African Region, said the African bloc of stated at Wednesday’s World Health Assembly. 

Speaking on behalf of the African bloc, Seychelles noted that the most recent WHO financial report highlights the continued trend of disproportionate spending in its Geneva headquarters in comparison to the Organization’s six regional offices and nearly 100 country offices. 

Under a “transformation” plan announced by Director General Tedros Adhanom Ghebreyesus in 2019 WHO Regional and Country offices, which are maintained in the countries of most low- and middle-income WHO member states, are supposed to be assuming a greater leadership role – with more resources allocated to their needs. 

But as of end 2020, more of the $US3.7 million annual budget is still being spent at WHO headquarters than anywhere else — including Africa, where WHO teams desperately need more funds to tackle problems associated with the continent’s high disease burden and systemically weak national health systems. 

“Apportionment of funds to Headquarters remains higher than other regions,” said the Seychelles representative, speaking on behalf of the African bloc during a review of WHO’s 2020-21 biennial budget. “It is twice higher than apportionment to Africa which has weak health systems and burdens. There is the need to shift resources from WHO HQ to where the health issues are, and more can be achieved,” the spokesperson concluded. 

Rich Countries Call for Greater Investment in Primary Health Care and NCDs 

Meanwhile, countries ranging from Japan to China and Norway have enjoined the WHO to commit more resources to the prioritisation of universal health coverage and combating the non-communicable diseases – which are a growing problem in poor as well as rich countries today.

Japan’s delegate noted that efforts should be made towards ensuring that finance and health ministers of member countries are able to collaborate in order to ensure mutual understanding of national and global health financing priorities, especially in countries that are struggling to meet their financial commitments to the WHO.

For the WHO, Japan also urged the global health body to strengthen accountability and enshrine transparency more deeply into its operations. It also called for an independent assessment to ascertain resources were being deployed and used in the most efficient way. 

The delegate for the People’s Republic of China added that funding gaps exist in non-communicable diseases and such gaps will only be closed when member countries of the WHO pay their contributions on time.

LMIC Member States Decry Negative Impact of COVID-19 on their Ability to Contribute to WHO

Although WHO’s leadership has also called upon member states to step up to the bat with larger and more predictable funding, Member States said they are already having a hard time paying the current annual assessments to WHO – as a result of the pandemic’s economic fallout. 

Argentina cited COVID-19 as reason for its delay in paying annual assessed fees to WHO – but pledged to fulfill its commitments. 

“We are making our payment. We’ve made partial contributions for 2019 and we hope to meet pending balances,” the country’s representative said. 

Wars and civil conflicts have also compounded pandemic problems for some countries. Libya’s delegate, for instance, pointed to the suspension of oil extraction activities, the country’s major source of revenue generation. 

“Hostilities have halted oil production but we are working with Tunisia to work out an arrangement. By the end of 2020, we hope to have resumed oil production again and we are asking for global solidarity,” Libya’s representative said. 

Funding Shortfalls Constrain Operations 

Funding for the WHO has been a recurring topic at the World Health Assembly. 

In his opening remarks on Monday, Dr Tedros said that WHO’s member states need to step up to the bat. 

Dr Tedros Adhanom Ghebreyesus, WHO Director General.

Right now, regular  “assessed contributions” comprise only 20% of the organization’s budget, and that is a diminishing proportion. The bulk of the money comes from additional voluntary funding provided by countries and other donors. But ‘earmarking’ of those funds often constrains WHO’s ability to spend money according to its own defined priorities. .   

“Predictable and sustainable funding remains one of the fundamental challenges for the future success of this Organization. For WHO to do its job, we must address the shocking and expanding imbalance between assessed contributions and voluntary, largely earmarked funds,” the DG said.

Over the past decade, Dr Tedros said, the world’s expectations of WHO have grown dramatically, but the organisation’s budget has barely grown at all. Those expectations, he said, will only continue to increase in the wake of the COVID-19 pandemic.

“Our annual budget is equivalent to what the world spends on tobacco products every single day. If the world can send that much money up in smoke every day on products that maim and kill, surely it can find the funds – and the political will – to invest in promoting and protecting the health of the world’s people,” the DG added.

Too Dependent on Handful of Donors 

Tedros also has admitted that WHO is too dependent on a handful of large donors, and there is need to broaden the donor base overall. 

WHO funding by fund type and contributor

 

To that end, he last year announced the creation of the WHO Foundation. The Foundation can draw funds directly from the private sector and individual donors – something that WHO’s strict conflict-of-interest rules generally prevent.   

However less than a year after those moves were put in motion, the COVID-19 pandemic hit – vividly illustrating the shortcomings between expectations and delivery of the WHO’s emergency response in a number of arenas.  

Particularly evident was the slow scientific response to urgent issues like whether the virus was airborne or not, whether masks were useful, and whether or not travel restrictions would help curb the spreading pandemic. 

While some of the delays may have been due to the conservative nature of WHO – which simply re-issued the same kind of travel and public hygiene advice that had been a standard for other epidemics – it was also blamed on a lack of in-house scientific know-how.  

In July, an announcement by the US Administration that it would withdraw its funding – which comprises some 15% of the Organization’s operations, including a significant proportion of resources that go to the African Region and the WHO Health Emergencies Programme. 

The shock has prompted a rethinking among European donors, led by Germany, about how to improve WHO’s budget and make it more sustainable over time. 

Speaking Monday at the resumed 73rd WHA, on behalf of the European Union, German health minister Jens Spahn said the COVID-19 pandemic had highlighted “a gap between WHO‘s 194 member states’ expectations and requests vis-à-vis the organization and its de facto capacities to fulfill them.” 

Jens Spahn, Federal Minister of Health, Germany, speaking at the WHA.
Pockets of Poverty 

While there is a drive to bolster scientific staff and expertise presumably at headquarters in the wake of the pandemic, the underfunded WHO regional and country offices of the low and middle-income countries are also a big donor concern. 

At a WHA debate over the budget, extending over Tuesday and Wednesday, another German WHA delegate  acknowledged the “pockets of poverty” that are often seen in specific programmes or WHO offices. 

Each year, again and again … with a déjà vu we see pockets of poverty — so specific programs that have not received adequate funding,” the official said of the assembly. “Within the last 10 years, many options have been explored in order to change the situation but the financing challenge has not been properly addressed.” 

But another problem, said the delegate, is that information provided by WHO, which informs WHA members’ debate, is “often not adequately grounded on a thorough analysis. We are discussing earmarked versus flexible, predictable versus non-predictable funding. But we never discuss what the consequences and implications are for WHO to perform.”

As a way forward, Germany has now proposed placing an item on sustainable financing on the agenda of the January 2021 WHO Executive Board – the next meeting of WHO’s 33-member governing body. The “ask” from donors is that WHO provide a coherent account here of its  current financial state – and how it affects its capacity to deliver, and what realistic needs it has – as well as alternatives for expanding the overall pool of donors – and money.

 

Image Credits: WHO, WHO.

Hypertension, an NCD that can be prevented through monitoring and early diagnosis

Norway will contribute an additional 133 million USD (1.2 billion NOK) to reduce the burden of non-communicable diseases (NCDs) in low-income countries from 2020 to 2024, the Ministry of International Development announced today. 

The announcement comes in the wake of last year’s path-blazing strategy for how to tackle the growing NCD burden in LMICs, “Better Health, Better Life”. The strategy was the first by an  international donor country to address health risks that are an increasing factor in deaths and disease in poor countries – where poor diets and degraded, unhealthy environments combine with a lack of access to standard NCD prevention and treatments. More than 15 million people under the age of 70 die every year from NCDs, with most of those under-70 deaths in low- and middle-income countries where people have less access to treatment.

Despite the growing burden, most donor assistance to developing countries remains focused on infectious diseases, including vaccine preventable diseases. While those risks can’t be discounted either, too many health programmes are often organized “vertically” so that even basic NCD services, like cervical cancer screening, are ignored. The intricate link between NCDs and infectious diseases has also become more apparent during the COVID-19 pandemic –  where NCD conditions increase the risk of becoming seriously ill or dying from the SARS-CoV-2 virus. 

“Norway is the first donor country with a strategy focusing on NCD-action in developing countries. I hope other donor countries will follow,” said Dag-Inge Ulstein. “There is a huge need for funding. Despite the enormous death burden in low- and middle- income countries, NCD efforts only receive between one and two per cent of all global health-related development aid. The funding gap comes with a consequence, and too often the victims are the most vulnerable.” 

World Health Assembly Discussion on Healthier Lives and Wellbeing 

The announcement coincides with discussions at the World Health Assembly gathering of its member states on a third pillar of the WHO’s strategy that aims to promote – Healthier Lives and Wellbeing. 

However, those discussions covering strategies for healthy ageing, food safety and nutrition… also are at risk of being eclipsed by the highly-politicized debates over the COVID-19 pandemic response and WHO reform.  

“We applaud Norway for prioritising NCD prevention and control within its poverty alleviation and sustainable social development priorities,” says Katie Dain, CEO of the NCD Alliance, in responding to the announcement.

 “Norway is walking the talk on the Sustainable Development Goals and has recognised the urgency for action on the global tsunami of NCDs. It is setting an important precedent for other OECD countries to follow.”  

Nina Renshaw, NCD Alliance Policy and Advocacy Director also adds: “Financing has long been the Achilles heel of the NCD response. The emphasis on ensuring sustainable financing for NCD prevention and control is particularly welcome. 

“We’ve been hearing throughout this week’s World Health Assembly that countries have the will to achieve Universal Health Coverage, (UHC) but need to mobilise the means, in increasingly challenging financial circumstances. That Norway is offering countries support to develop sustainable financing models and calling on other donors to join in to act on NCDs as a major cause of poverty, is a strong signal for others to invest.”

NCDs, including heart disease and hypertension, cancers, lung disease, diabetes, and mental health disorders cause more than 70% of all deaths worldwide. This means that far more people die from non-communicable diseases than from infectious diseases such as malaria, tuberculosis, polio, HIV/AIDS, and Ebola. And in developing countries, NCDs are a large and growing proportion of the disease burden. 

‘Worldwide, 41 million people die each year as a result of respiratory disease, cancer, cardiovascular disease, diabetes, mental disorders and other non-communicable diseases. This cannot continue,” said Ulstein when the Norwegian NCD strategy was first launched a year ago in Oslo.  

A 2019 panel at the launch of Norway’s new NCD-focused development strategy. (left-right) Maria Neira, WHO; Omnia El Omrani, (IFMSA); Mamka Anyona, UNICEF; Tiy Chung, CCA Coalition; Andrea Winkler, Centre for Global Health, the University of Oslo; Katie Dain, NCD Alliance.

“The NCD crisis has been ongoing for several decades. The death toll is rising year by year. NCDs are often chronic diseases, resulting in high health costs for individuals, families and societies. As is often the case, people in vulnerable situations bear the heaviest burden,” said Ulstein. 

And moreover, 86% of “premature” NCD-related deaths occur in low- and middle-income countries, where there is lack of awareness about prevention, and lack of access to diagnosis and treatment. These deaths will cost $7 trillion in economic losses over the next two decades.

Currently about 1-2% of global health-related assistance goes towards combating NCDs, or around $US 611 million. Bilateral donors (national governments or their development agencies) are the dominant source of funding in global health, but have been relatively absent in the field of NCDs until recently. 

Between 2010-2015, non-governmental organizations (NGOs) collectively provided more than twice as much aid for NCDs than bilateral donors, and considerably more than multilateral organizations such as the World Bank and the WHO. 

LMICs have been left to respond to increasing burdens of NCDs with their own scarce resources. Large-scale global efforts have the potential to save millions of lives and contribute to healthier populations and economic growth in LMICs. 

The Norwegian assistance will help fund activities around its three-point strategy: Strengthening primary health care; prevention targeting leading risk factors for NCDs, such as air pollution, tobacco and alcohol consumption, as well as unhealthy diets; and strengthening health information systems and other global public goods for health. 

Strengthening Primary Healthcare Services 

At the primary healthcare level, many NCD interventions can be delivered effectively and affordably, benefiting patients and savings for health systems. This can include checks for hypertension, diabetes, prevention of cervical cancer with HPV vaccination, as well as capacity for prevention and early diagnosis and treatment of mental health disorders in primary health services. Norway will support strengthening health services so that primary health care services are well-equipped to support NCD prevention, early diagnosis, and treatment.

Knowing your blood pressure supports NCD prevention, diagnosis, and early treatment.
Prevention Targeting Risk Factors for NCDs

Norway will support countries requesting assistance to improve taxation and regulation and regulation of products that are harmful to health through its Tax for Development Programme (Skatt for utvikling). These measures can be effectively used to discourage consumption of health-harmful products such as tobacco, alcohol, and sugary drinks. Pollution taxes and regulations can encourage shifts to clean energy and transport. All these are key risk factors that contribute to NCDs. 

Unhealthy, unregulated food is one risk factor for NCDs

Strengthening Health Systems 

The aim is to aid countries in developing better health information systems to improve access to health data critical for early stage NCD diagnosis treatment, supporting NCD-related health norms and standards, and will improve access to medical equipment and medication, especially in areas hit by crises and conflict. 

Together, these three points support the WHO Sustainable Development Goals (SDG) of reducing premature deaths from NCDs (SDG 3.4) by one-third by 2030 and Universal Health Coverage (SDG 3.8), and includes targets of reducing deaths from air pollution, strengthening tobacco control, and preventing harmful use of alcohol. 

Image Credits: icd 10/Flickr, Stine Loe Jenssen, John Campbell/Flickr, Sven Petersen/Flickr.

A map tracking rates of breast feeding globally, following the WHA discussion on breast milk substitutes
Global scorecard tracks rates of infants under 6 months who are exclusively breastfed, by country, with red as the lowest rate and green reflecting countries with 60% or more exclusive breast-feeding for under 6 infants. Grey indicates no information available.

Breast milk substitutes, long decried by global health specialists, are making new inroads into the markets of poor countries during the COVID-19 pandemic – including through new and more effective modes of digital marketing.

Guidelines for distributing and donating such substitutes to households facing hunger and malnourishment due to the economic fallout of COVID-19 lockdowns, are urgently needed, a number of member states told members of the World Health Assembly (WHA) meeting in a virtual session on maternal and child nutrition on Tuesday.

Nearly a dozen countries, including Kenya, Zambia and the United States, drew attention to the need for WHO and other global health organizations to address the marketing, distribution and recommendations for breast milk substitutes in a more uniform manner.

“Inappropriate promotional foods for infants and young children has been a big challenge in the fight against malnutrition in countries such as Zambia, particularly with the many advances in marketing strategies using various technologies,” said the country’s representative to the WHA.

Digital marketing makes it difficult for countries to ensure that mothers are not unduly targeted by ads promoting substitutes, further complicating authorities’ ability to control the reach of manufacturers.

“Zambia, for instance, despite recording a decline in most childhood forms of malnutrition has experienced a decline in infants exclusively breastfed in their first six months from 73% in 2013, to 17% in 2018.

“At the same time, the country has seen an increase in nutrition-related non-communicable diseases, which could in part, be attributable to inappropriate feeding of infants and young children as a result of advertising.”

Breastfeeding outcome in Zambia according to WHO
The rate of breastfeeding in Zambia, compared to the region and globally.

The Zambian representative said that clear guidelines are needed on how to address donations of breast milk supplements during the COVID-19 pandemic.

WHO says countries should monitor the marketing of such substitutes, which often undermine breastfeeding and normalise artificial feeding, more strictly.

The recommendation is part of a draft WHO report on the comprehensive implementation plan on maternal, infant and young child nutrition.

The draft report states: “The widespread use of digital marketing strategies for the promotion of breastmilk substitutes is a cause of growing concern.

“Modern marketing methods that were still unknown when the International Code for Marketing Breastmilk Substitutes was first adopted, are now used regularly to reach young women and their families with messages that normalize artificial feeding and undermine breastfeeding.”

It also said: “Tactics such as industry-sponsored online social groups, individually-targeted Facebook advertisements, paid blogs and vlogs, online magazines, and discounted Internet sales are used increasingly.”

Missing the WHO Targets

The report finds that an estimated 41% of infants aged under 6 months were exclusively breastfed, based on the latest survey estimates for 2013-2018. The World Health Assembly has set a target to increase this global rate to at least 50% of nursing infants by 2025.

The US representative at the WHA spoke on the issues of breast milk substitute marketing.

48 countries have exclusive breastfeeding rates higher than 50%, while 51 countries have rates below it. Of 73 countries with sufficient data to estimate current trends, 34 are on track to reach the proposed target by 2025. 16 countries present insufficient progress, while 23 either present no improvement or are worsening.

The draft report also said: “WHO Guidance on ending the inappropriate promotion of foods for infants and young children recommends that companies marketing foods … should not sponsor meetings for health professionals. Despite that guidance, 38% of national paediatric associations continue to receive funding for their conferences from the manufacturers of breastmilk substitutes.”

A US representative asked the WHO Secretariat to provide clarity on its data collection, however. She said that transparency is important in preparing a comprehensive report to understand the scope and impact of digital marketing strategies which may not be in accordance with the International Code for marketing of breast milk substitutes.

“In the interest of good governance, it is important to ensure that the Secretariat clearly defines the scope and resources necessary to provide a comprehensive report and member state guidelines,” the representative stated.

Global Perception Versus Local Reality

While stressing their support for WHO’s Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition: Biennial Report, a sharp contrast existed between the issues raised by developing countries compared with their developed counterparts. While developed countries suggested that their local laws have provisions to deal with the various issues mentioned in the report, developing countries stressed the need for WHO to further increase its support for member countries.

In its submission, Israel described the issue of maternal, infant and young child nutrition as crucial to global health. It then pledged its support to WHO which it also commended the various policy documents and guidelines that the global health authority had put forward regarding the COVID-19 pandemic.

The moderator at the session.

Kenya – one of two African countries that commented – localised the burdens of nutrition especially for their citizens. Kenya’s representative said the country has been making “difficult progress” in promoting maternal infant and young child nutrition. While describing the country’s breast milk substitute act of 2012, the country’s spokesperson said the government has been able to secure legislative provisions for breastfeeding-friendliness at the workplace in Kenya.

“There is also the development of national guidelines for healthy diets and physical activity. In addition, we have integrated food and nutrition content in our current school curriculum,” the spokesperson stated.

But in spite of the progress made, several challenges remain and they have been exacerbated by the COVID-19 pandemic in Kenya, disproportionately affecting young children and older persons.

“We therefore invite WHO to support member states to monitor and document the impact of COVID-19 on food security, nutrition status and to develop measures to mitigate the negative impact on nutrition,” the representative said.

“We also note with concern the findings that in the absence of a substantial scaleup, it is likely that the 2025 targets will not be met,” the UK said. “This is now even more of a challenge. Given the direct, indirect impacts of COVID-19, the Japan 2021 Nutritions for Growth Summit will come at a critical time.”

The United Kingdom urged the WHO Secretariat to promote engagement between WHO country offices and member state governments to support them to use published commitment guidelines to develop concrete policy and financial commitments that can catalyze progress towards the global nutrition targets.

Image Credits: WHO, WHO / UNICEF Global Breastfeeding Collective, WHO / UNICEF Global Breastfeeding Collective, WHO.

Air pollution above India
Smoke covering Punjab, Delhi, Uttar Pradesh and Madhya Pradesh, as captured by Nasa’s Visible Infrared Imaging Radiometer Suite.

DELHI, India – As north India reels under ‘severe’ levels of air pollution for the fourth day in a row, the government has appointed a former Petroleum Ministry bureaucrat to chair a new national Commission For Air Quality – hastily set up by a presidential decree just 10 days ago.

Dr M.M. Kutty, former head of India’s Ministry of Petroleum and Natural Gas, took over as chair of the new Commission on Friday, a day when official monitors reported PM2.5 levels in Delhi as high as 953, almost 100 times more polluted than WHO’s guidelines for 24-hour particulate pollution levels.

Delhi and adjoining areas are now regularly seeing PM2.5 cross 500 micrograms per cubic metre – more than 50 times the WHO-recommended 24-hour standards – as seasonal crop stubble fires continue to burn in neighboring rural states of Punjab, Haryana, Rajasthan and Uttar Pradesh.

NASA researcher Dr Pawan Gupta tweeted on Monday that there have been more fires in Punjab in the last two months, than any other September and October in 9 years, with the exception of 2016.

Adding to the pollution mix are seasonal weather conditions -falling temperature and stagnant winds – and open wood or biomass-burning fires to heat homes. Things could get even worse in coming days and weeks if Delhi’s residents also begin setting off firecrackers that are a traditional part of the late autumn festival of lights, Diwali.

New Ordinance For An Old Problem?

The new commission actually does something significant in terms of Indian law. It replaces the 22-year-old Supreme Court-empowered Environment Pollution (Prevention and Control) Authority (EPCA), with a formal government body responsible to the central government of Prime Minister Narendra Modi.

As such, it represents the most explicit action yet by Modi to address the threat of India’s air pollution to public health – even though the Prime Minister continues to avoid the issue in his public statements.

India’s Prime Minister Narendra Modi

Although air quality experts have welcomed the creation of the new Commission, they said that the notable lack of government urgency to act in the face of another mounting air pollution crisis remains disappointing.

“A new commission, with full-time members, representation from the Centre and states, and dedicated staff is a step in the right direction,” Shibani Ghosh, public interest lawyer and Fellow at the Centre of Policy Research, told Health Policy Watch. “It could address concerns of intermittent focus on air quality, institutional capacity constraints and lack of bureaucratic coordination.”

“What the ordinance has done is replace the EPCA and the multiple other task forces with a single new commission with full-time staff, representatives from the central and state governments and significant powers,” explained Dr Santosh Harish, who specialises in energy and environment policy and air quality governance. “This could help address some of the issues in bureaucratic coordination across agencies in this region.

“However, all the major actions needed for improved air quality – tackling industrial or power plant emissions more effectively, finding a long-term solution to stubble burning, improving waste management – involve increased political willingness to impose costs on polluters. Neither the ordinance or the commission seem to solve that problem,” he added.

Quality Of Commission Members Will Be Decisive

In the absence of greater leadership from the prime minister, what will be critical to the effectiveness of this 18-member commission is the dynamism and accountability of its appointed members.

Alongside Kutty, other members are a mix of retired and serving bureaucrats and non-profits, with few technocrats or scientific experts on the new panel. This leads environmentalists to worry that the new commission may end up as yet another body of file-pushing officials.

Young people in Delhi demand action against air pollution
A long-standing issue: young protesters from the Democratic Youth Federation Of India, Delhi state, demand action against air pollution.

Those named so far include: Arvind Nautiyal, a mid-level Joint Secretary in the Ministry of Environment; Dr K J Ramesh, former head of the Indian Meteorological Department; Professor Mukesh Khare of Indian Institute of Technology-Delhi; Dr Ajay Mathur of The Energy Research Institute and Ashish Dhawan of the Air Pollution Action Group as NGO representatives.

The new commission also includes representatives from Punjab, Haryana, Uttar Pradesh and Rajasthan – which contribute to the seasonal air pollution with their crop-burning practices.

But other key stakeholders, like the Health Ministry, the Agriculture Ministry, the Rural Development Ministry and the Labour Ministry all seem to have been left out, at least for the moment.

It remains to be seen how the new commission might set measurable, time-bound goals and outcomes that could make a difference in the air pollution emissions – as well as being accountable to such targets.

If tackled systematically, these would include urban and rural measures, from shifting energy and transport policies to cleaner modes and sources to weaning farmers off of rice subsidies that leave crop residues which are easiest burned – to other, more nutritious indigenous grains and legumes that could be composted or managed more sustainably.

“A lot depends on how this commission will get constituted and the rules that are issued to enable its function,” Ghosh commented. She added: “Unless competing interests are heard and decided in a deliberative manner and the Commission is held accountable to ambitious but achievable targets for improved air quality, not much will change on the ground.”

Supreme Court Declares: No Smog in Delhi – Easier Said Than Done

Modi’s announcement of the new air quality commission followed weeks of Supreme Court pressures on his government in September and October. His government promulgated an Ordinance (which acts as law when Parliament is not in session) that brought this commission into existence via a gazette notification.

A view of Humayun's Tomb in New Delhi at various points during the air pollution season
A view of Humayun’s Tomb in New Delhi at various points during the ‘pollution season’.

The gazette notification – all five chapters and 26 sections of it – is fairly detailed and was likely in the works for some time.

The move to act, observers say, could have been prompted by any number of factors besides the Supreme Court. Those may have included US President Donald Trump’s denunciation of India’s “filthy air” in a pre-election debate, or growing public awareness of the health impacts of poor air quality, particularly during the pandemic. The gazette itself acknowledges that the number of petitions and litigations on environmental issues is skyrocketing across India’s judicial system.

On Friday, the country’s Supreme Court continued to be active on the issue. It directed the federal government to ensure that there is no smog in Delhi and neighboring areas following heightened alarm over the health hazard it poses during the coronavirus crisis, Bar and Bench reported.

The judges were responding to senior advocate Vikas Singh, representing one of the petitioners in court, who said the condition in Delhi was akin to a “public health emergency” and that “drastic measures need to be taken” to tackle the air pollution.

Environment Pollution Control Authority Dissolved by New Law

The Supreme-Court EPCA, which operated for 22 years, has meanwhile been dissolved with the publication of the new law.

The Government’s legal notification creating the new commission stated: “It is now considered necessary to have a statutory authority with appropriate powers and charged with the duty of taking comprehensive measures to tackle air pollution on a war footing and powers to coordinate with relevant states and the central government.

“The quality of air remains a cause of concern on account of the absence of a statutory mechanism for vigorous implementation of measures put in place.”

The government notice said the new body represents a “self-regulated, democratically monitored mechanism for tackling air pollution” that will lead to better “coordination, research, identification and resolution of problems surrounding the air quality index”. It is hoped this will do away with “limited and ad hoc measures.”

The commission will be empowered to direct orders to control air pollution and take cognizance of complaints. It will also have the authority to set new parameters for curbing emissions, as well as levying fines to violators. Pollution offences can invite a jail term of up to 5 years and penalties of up to $135,000, Section 14 of the new notification states.

Law Conceived Hastily – Commission Lacks Statutory Powers

Other questions revolve around why the new ordinance was so hurriedly issued by government fiat, rather than as a bill to be voted on by both houses when Parliament was in session.

“The haste in setting up this commission without any scope for public comment does not bode well for the professed objectives of increased public participation mentioned multiple times in the preambular text in the ordinance,” Harish said. “This is a missed opportunity at thinking through how to operationalise airshed level management.”

Delhi’s skyline, chronically obscured in late winter by heavy air pollution.

Experts are also annoyed at the way air pollution is being treated as a problem only in Delhi and its surrounding areas. Ritwick Dutta, an environmental lawyer, said:

“Unless the Central Government sets up similar committees in other polluted regions of the Country, it violates the right to equality under Article 14 of the Constitution and discriminates against those who are not in the NCR. Clearly, there are equally if not more polluted regions which are beyond the NCR.”

“There is disproportionate representation from agencies and ministries which are responsible for the problem,” Dutta said. “As it is currently constituted, the new Commission is neither a representative nor independent body to deal with the issue of air pollution.”

Dutta added: “The Commission has been given power similar to the one conferred on EPCA. EPCA in its 22 years rarely exercised its statutory powers and had become an advisory body to the Supreme Court. The same situation is likely to take place with regard to the new Commission.”

Still Missing – Accountability to Measurable Goals

What happens if air quality remains at the current hazardous levels in the Indo-Gangetic Plains by next winter, or even the year after?

“We certainly don’t want to be stuck with another EPCA-like authority for the next 22 years which will be as ineffective in bringing down pollution on the public payroll,” said Anita Bhargava, co-founder of Care for Air, a clean air non-profit.

In short, while on paper it might seem as if the Commission is empowered with legal and financial resources – its real power and its own accountability to measurable goals remains to be seen.

Bhargava added: “Any responsible government should already have been at work to find some real solutions to this gigantic problem that is causing more disease, disability and death than war, terror and several communicable and non-communicable diseases put together.”

There are solutions. The problem of massive stubble burning can be solved by zero-till farming. There are new rapid composting technologies, like the Pusa decomposer. Farmers should be discouraged from growing the wrong crop in the wrong state at the wrong time of the year – like water-intensive rice in water-scarce northern states such as Punjab.

But in light of the legacy so far, environmentalists fear that the commision may lack the real authority to act, and could still end up becoming yet another body adding to an already long list: “Between the Supreme Court, EPCA, National Green Tribunal (NGT), Central Pollution Control Board (CPCB) and State Pollution Control Board (SPCB) no one is clear as to what needs to be done,” Ritwick Dutta said.

Until the creation of this Commission, only the Indian judiciary has made any significant attempt at tackling the problem of pollution, whether through banning fireworks or crop-stubble burning, or the well-intentioned but misdirected order to install smog towers, a clear case of judicial overreach. But it isn’t really the job of judges to make public policy and enforce laws. It is the job of legislators and the executive.

“We still need to see measurable goals set, and timebound, real outcomes from this Commission. And of course, transparency and accountability,” Bhargav summarised.

Jyoti Pande Lavakare is the author of “Breathing Here is Injurious to your Health: The Human Cost of Air Pollution” published by Hachette and available on pre-order.

Image Credits: Pawan Gupta, Mike Bloomberg, DYFI Delhi Twitter, Chetan Bhattacharji / Care for Air, Wikimedia Commons: Prami.ap90.