antimicrobial resistance test on bacteria in petri dish
Recent AMR successes include increased prominence in global discussion and a robustly funded discovery-stage and translational research but momentum and public communication have been long-standing issues.

The COVID-19 pandemic has underlined the need to dramatically step up the combat against drug-resistant bacteria, viruses and other pathogens. The world can’t afford to be caught again by surprise with the spread of a dangerous infectious disease for which there is no cure, a growing chorus of global health leaders are warning as the world observes World Antimicrobial Awareness Week (18 – 24 November).

“The antimicrobial resistance (AMR) agenda must move forward with renewed vigor and momentum in the global health space, one that can fit into a post COVID-19 narrative,” says Timothy Jinks, Head of the Drug Resistance Infections Program at Wellcome Trust.

Timothy Jinks, Head of Wellcome Trust’s Drug Resistant Infections Priority Program, speaking on Wellcome Trust’s “The Global Response to AMR” Report

He spoke as the Wellcome Trust released a new update on “The Global Response to AMR” that said concrete progress on attacking the root causes of AMR had been too slow and key priorities like water, sanitation, and hygiene (WASH) and infection prevention and control (IPC) have not been addressed.

To up the political ante, WHO will be launching Friday a new “One Health Global Leaders Group on Antimicrobial Resistance” (AMR) – led by Sheikh Hasina, Prime Minister of Bangladesh and Mia Mottley, Prime Minister of Barbados – whose mission will be to give the issue more visibility among other world leaders. The “One Health Global Leaders” initiative was first announced in August by the  WHO, the Food and Agriculture Organization (FAO) and the World Organization for Animal Health (OIE)- which are trying to work together more closely to curb both human and animal use of precious drugs – which is one of the key drivers of AMR.

“The world is in an arms race against antimicrobial resistance and we hope the new group will consider solutions on all fronts against AMR, including encouraging sustainable production of antimicrobials,” said Alba Tiley, the Global Director of the Sustainable Antibiotics Program at Centrient Pharmaceuticals, regarding the WHO initiative. Centrient, a generic pharma firm based in Rotterdam, Netherlands, is one of the few remaining antibiotic manufacturers in Europe. Their portfolio covers many medicines on the WHO Essential Medicines list including amoxicillin, penicillin and cephalosporins. 

“We need to make sure the very process of making these life-saving medicines does not contribute to antibiotics losing their effectiveness.”

Three Critical Gaps – Wellcome Trust Report

AMR already causes some 700,000 deaths annually. But if current trends are not reversed, that number could rise to 10 million per year by 2050, a special UN task force has warned.

As antimicrobial drugs lose their efficacy due to AMR, risks of prolonged hospital stays or additional surgical interventions increase substantially. AMR burdens health systems already struggling with cost inflation, and damages national economies from increasing illness and death that further hit health budgets. These health and economic burdens disproportionately fall on low and middle-income countries (LMICs). The Wellcome Trust report zeroes in on what it describes as three key gaps in global AMR response, that drive the risk of irreparable loss of valuable drugs.

  • Ambition has not translated into action. Though there has been a prominent increase of global discussion on AMR over the past three to four years, this has not translated into a broader implementation of initiatives, especially in LMICs, where AMR typically competes for political attention and resources with other public health topics.
  • The most critical drivers of AMR need to be prioritized. The ‘big tent’ approach of the AMR response to date has increased awareness among a broad range of stakeholders. However, AMR experts are concerned that the multifaceted nature of the issue, the complexity of its narrative, and the multitude of possible interventions are paralysing the community, preventing impactful action.
  • The AMR agenda was losing momentum before SARS-CoV-2 emerged. And now? Already in late 2019, a growing circle of experts perceived the AMR agenda as losing momentum, due in part to the complexities of communicating about the issue to the broader public. The COVID-19 pandemic has exacerbated those concerns.
The report notes that the COVID-19 pandemic has demonstrated how vital it is to conduct R&D to combat novel and drug-resistant viruses

New Opportunities – and Solutions

At the same time, now that politicians and the broad public have seen what damage an invisible virus can wreak, when no drug treatment exists, the time may be more ripe for warnings that this could happen again – very soon – if AMR trends aren’t vigorously addressed.

Wellcome Trust’s key preventative measures for the next decade

The Wellcome Trust report etches out a way forward for the next decade. The plan of attack focuses not only on accelerating the pace of R&D for new drug therapies to replace those rendered impotent by drug resistant bugs, but also limiting abuse of drugs in use now. Among the key preventive measures, are:

Human consumption of antibiotics: Optimising human consumption of antimicrobials requires guaranteed access for those who need treatment – but adequate stewardship to limit overuse and abuse. This requires much stricter regulation of sales and use of classes of antibiotics and antiviral agents to which bacteria have developed, or are beginning to develop, resistance. In particular, greater restrictions on over-the-counter sales to the public – and more public awareness about the appropriate use of such drugs, is needed.

Antimicrobial use in animals: A response that is preventative that doesn’t focus purely on treatment requires a holistic perspective that includes other topics such as ensuring appropriate antimicrobial use in animals. There needs to be a more prudent use of drugs needed for humans in the livestock sector, which is one of the world’s largest consumers of antibiotics, particularly in the USA, Europe and other OECD countries.

Water, sanitation, and hygiene (WASH): Access to clean water and better management of sewage runoff both prevents infections, reducing the need for drugs in the first place,  as well as reducing untreated waste streams laced with antibiotics or other drug residues that act as reservoirs where drug resistant pathogens might breed.

Infection prevention and control (IPC): IPC measures in hospitals and communities reduce the need for antibiotics and their consumption.

Surveillance: Right now, only about one-third of countries gather data and report systematically on use of antimicrobial drugs.  Much more effective surveillance systems also are critical to understanding the problem, designing and implementing interventions, and assessing the effectiveness of the response, the report underlines.

Livestock applications of antibiotics in metric tons/year, among countries reporting use. (The Antibiotic Footprint)

Scaling up Research and Development for New Drugs

Research and development also needs to be scaled up dramatically, the report emphasizes. This has already begun to happen, with the establishment of a new Global Antibiotic Research and Development Partnership (GARDP), created by the World Health Organization (WHO) and Drugs for Neglected Diseases initiative (DNDi), which aims to drive more private and public investment into R&D to replenish the antibiotic drug pipeline. In July an AMR Action Fund of nearly $1 billion was also established by more than 20 leading biopharmaceutical companies, with a mission to bring 2-4 new antibiotics to patients by 2030.

In addition to that, the Wellcome report also underlines that in light of the COVID-19 pandemic – the source of which is a virus, not a bacteria – that R&D to combat new and drug-resistant strains of viruses, and other pathogens must also occur continuously and sustainably.

In addition, by preventing infection in humans and animals, vaccines play an important role in reducing antimicrobial consumption.

Can COVID be an Opportunity?

Despite the complexity of the issue, this week is seeing a flurry of activity that suggests the ripples of a broader awakening about AMR.

During Wellcome Trust’s panel on Wednesday, global leaders brought up AMR’s unique role in the face of the COVID-19 pandemic. 

COVID-19’s impact on the AMR global response

“So while COVID-19 is taking over the public health dialogue, it simultaneously has opportunities through this pandemic that we should strategize around. This is prevention’s moment; prevention has never been sexier,” says Lindsey Denny, a health advisor at Global Water 2020, and a global health practitioner with experience across Africa, Asia, and Latin America. Denny spoke to how the pandemic has generated a better understanding of public health principles such as WASH and the importance of PPE. “We can and should capitalize on advocating both to decision makers and to the broader public for WASH and IPC strategies.” 

Jyoti Jyoshi, Head of the South Asia Center for Disease Dynamics, Economics, and Policy, discussed the need for the AMR community to integrate itself more so into the global health sphere. “The AMR community should tie in with the large global health preparedness and systemic response agenda. Because we don’t live in isolation. Infections don’t need visas. It’s a flat wall – people travel just as microbials and chemicals like antibiotics do.” 

There was also a joint statement on the AMR threat issued today by very diverse group of actors, including: the International Alliance of Patient Organizations, the International Hospital Federation, the International Society for Quality in Health Care, and the International Federation of Pharmaceutical Manufacturers and Associations.

The statement supports innovative partnerships of healthcare providers, patients and the business sector in tackling the growing AMR threat.

In an op-ed in Geneva Solutions, Neda Milevska, vice-chair of the International Alliance of Patients’ Organizations, says it is also the patient’s responsibility to become more aware about the need to prevent the abuse and overuse of antibiotics and other drugs.

She describes the approach as one that can also enhance patient empowerment, saying that so far, the power of patients has been ignored by policymakers in the battle against AMR, even though personal behaviour plays a major role: “Among patients today, there is widespread practice of self-treatment with antibiotics. This is stimulated even more so by the COVID-19 pandemic, as physicians have increasingly prescribed antibiotics to stave off increased illness, which feeds back into the loop of drug-resistance.

“It is always politically sensitive to mention that patients have some responsibility. But, no amounts of funding to develop new drugs or curb AMR now will work, if people at the grassroots continue to abuse their life-saving potential. The magnitude of people’s power is so great .. .and it can be destructive or productive.”

Image Credits: DFID – UK Department for International Development, Wellcome Trust, USAID Asia/Flickr, antibioticfootprint.net.

Contributing to human progress: open innovation for infectious diseases

Finding the right combination of open innovation – that is the free sharing of expertise, knowledge and data – and intellectual property (IP) that may drive private  investments in expensive new technologies, can be a difficult balancing act to attain.

But as the COVID-19 pandemic has underlined, it is more and more critical to etch that golden mean, in order to support successful collaborations between academia, industry and government entities and also make the end products widely accessible and affordable, said speakers at a Geneva Health Forum (GHF) during a session on the potential of Open Innovation to support R&D on infectious diseases on Monday. The forum brought together experts from both private and non-profit sectors.

Kelly Chibale, Neville Isdell Chair in African-centric Drug Discovery, University of Cape Town.

“During the early stages of scientific discoveries, the whole question of IP and data ownership can often become more complex than the actual science itself,” said Benjamin Perry, Senior Discovery Manager at the Drugs for Neglected Diseases Initiative (DNDi).

Even though IP and science share an intricate interface, IP remains an important aspect of attracting investments to new pharma ventures in Africa, said Kelly Chibale, the Neville Isdell Chair in African-centric Drug Discovery, University of Cape Town.

“In order to attract development partners, such as pharmaceutical companies for example, it is necessary to ensure the IP is secured because it gives the company the freedom to operate,” he said.

But Chibale also stressed the critical role that the government plays in R&D collaborations, saying that the partnership model that his MRC team uses also involves academia and industry in not-for-profit R&D product development.

In Research on Neglected Diseases IP Disputes Are Muted

At the Geneva-based Drugs for Neglected Diseases Initiative (DNDi), a Geneva-based health non-profit, the focus is on curing diseases that are prevalent among the world’s poorest populations and offer little promise of financial reward to innovators. So it is possible to get a new medicine all the way through the R&D pipeline and into the hands of  patients, without having to debate the issue of  intellectual property position, said Perry.

Benjamin Perry, Senior Discovery Manager at the Drugs for Neglected Diseases Initiative (DNDi).

Perry cited a project he runs, where chemistry students in 25 universities in different countries are working on the same project collaboratively, without the need for IP. These institutions include the University of Otago in New Zealand, University of Ghana and the University of Geneva in Switzerland as well as a couple of universities in the UK and the US.

“This has been enabled by the agreement that there will be no IP taken on this,” said Perry.

While some private sector companies still want to claim certain IP rights when they support certain aspects of DNDi’s research, the non-profit has formulas for arranging this, which also ensure up front that patients’ access to the final end-product at an affordable price will be guaranteed.

For its part, the collaboration between the World Intellectual Property Organisation (WIPO) with a number of organizations, is now helping advance early stage research on neglected tropical diseases, malaria and TB, through an initiative known as WIPO Research.

“What we do is we connect researchers with company scientists and leading pharmaceutical companies,” explained Charles Randolph, Head of Global Health at WIPO.

The initiative started 10 years ago, with about 30 academic research institutions. The network has  since grown to 150-plus institutions in 43 countries in six continents.

“Why [open innovation and open collaboration] in global health?” asked Thomas Spangenberg, Head, Global Health Drug Discovery at Merck, which co-sponsored the GHF session.

By dedicating resources to open research into neglected areas of infectious disease research, pharma companies fulfill an important corporate responsibility, he said.

“We believe that innovation occurs at the scientific interface. By collaborating, we can pull resources and make the model more sustainable,” he said.

Image Credits: Geneva Health Forum.

New guidelines detail how household spices and accessible medicines have been used across India’s population during the pandemic.

Use of Ayurvedic medicines, already on the rise worldwide, has soared even higher during the pandemic.

But few people may be aware that at least one country, India, actually has an entire ministry devoted to promoting use of these traditional remedies, that have been used for centuries: the Indian Ministry for Ayurveda, Yoga, Unani, Siddha, and Homeopathy (AYUSH).

Appearing at the Geneva Health Forum on Tuesday, India’s Minister for AYUSH, Shripad Yesso Naik, presented the ministry’s guidelines for using traditional treatments, like Ayurveda and Yoga, to build health and immunity against COVID-19.

The guidelines – which have been translated into 9 languages including English and Chinese – detail how household spices and accessible medicines have been used across India’s population, and were issued by the Indian Ministry for Ayurveda, Yoga, Unani, Siddha, and Homeopathy (AYUSH).

Yesso Naik, the Indian Minister for AYUSH, said: “India has shown the path to combat with COVID-19 by improving the general immunity – by using Yoga and other Indian traditional systems of medicine.”

He added: “An advisory has been issued about self care guidelines and preventative health measures for boosting immunity. For example, a nasal application of oil, herbal tea made up of spices commonly available in every household and Ayurvedic medicine like sanshamani vati and Chyawanprash.”

This follows WHO’s announcement last week that it will set up a Global Centre for Traditional Medicine in India.

Clinical Trials for AYUSH Must be ‘Rigorous’

Over the last few years, the Ministry of AYUSH has taken several measures to regulate the traditional medicine manufacturing industry, with a particular emphasis on researching the medical systems.

Since the beginning of the COVID-19 pandemic in India, the Ministry of AYUSH has been conducting research into AYUSH interventions, including releasing a protocol for clinical trials on AYUSH treatments.

Naik said that so far, soome 67 AYUSH clinical research studies have been undertaken in India that examine the use of AYUSH treatments to relieve symptoms of COVID-19, most of which  are near completion.”

The Indian government also issued an additional Post-COVID management protocol this September mostly with inputs from the AYUSH ministry, including recommendations of practicing Yoga and taking some other Ayurvedic medicines, that is said to improve immunity.

Dr Ritu Priya Mehrotra, Professor at the Centre of Social Medicine and Community Health, at Jawaharlal Nehru University, noted that the pandemic has created an “excellent opportunity to conduct some good studies related to AYUSH”.

She warned, however, that these studies accord value to traditional interventions for their medical potential, but still “need to be conducted rigorously” to see how they measure up scientifically. There has been widespread criticism in the Indian medical community over the promotion of traditional Indian remedies that have not undergone rigorous clinical trials and studies.

She also warned against the what she called “pharmaceuticalisation” of these traditional medicinal approaches: the idea that certain remedies, if proven to be effective, might be reduced only to medicinal formulations, ignoring the holistic principles that traditional medicine also emphasize with respect to the importance of healthy lifestyles, the practice of meditation and exercise such as yoga.

climate change effect on maize ears crop
A woman shows how her maize ears have dried in the drought stricken garden. A new report has shown that countries most affected by climate change receive only a fraction of available funding for climate change adaptation.

Climate change poses an even greater threat to public health than the COVID-19 pandemic – and needs to be treated with equal urgency, Jagan Chapagain, Secretary-General of the International Federation of the Red Cross and Red Crescent Societies (IFRC), told a virtual news conference on Tuesday.

He was speaking at Tuesday’s launch of the IFRC’s World Disasters Report 2020, which finds that a rising wave of extreme weather and climate-related events have killed more than 410,000 people over the past decade.

“Of course, the COVID is there, it’s in front of us, it is affecting our families, our friends, our relatives. It’s a very, very serious crisis the world is facing currently,” Chapagain said.

But, he warned that “climate change will have a more significant medium and long term impact on the human life and on Earth… and unfortunately, there is no vaccine for climate change”.

The report finds that over the past decade, 83% of all disasters triggered by natural hazards were caused by extreme weather and climate-related events such as storms, floods and heatwaves. Together, these disasters have killed more than 410,000 people and affected 1.7 billion people. Meanwhile, efforts to tackle climate change are failing those people who are most at risk from its effects.  Those countries most affected by climate change receive only a fraction of the funding that is available for adapting to climate change, the report found.

At-Risk Populations Not Receiving Full Funding

The report shows that countries most affected by climate change receive only a fraction of the funding that is available for climate change adaptation, meaning the populations most at risk are not protected.

Analysis by the IFRC showed that none of the 20 countries most vulnerable to climate change were among those that received the most funding for adaptation.

People receive food assistance during the dry season in the Sahel. The region has suffered from extended droughts due to climate change.

Somalia, the most vulnerable country, ranked 71st for funding disbursements per person. Meanwhile, more than half of the countries categorised as highly vulnerable to climate change received less than $1 per person in climate adaptation funding, while two countries – the Central African Republic and North Korea – received none at all. Of the countries with the highest disbursement for climate adaptation, none had high or very high vulnerability scores.

“There is a certain amount of climate adaptation funding out there [which is] really needed in a lot of countries, but there are some particular countries that are particularly vulnerable, many of which are fragile, and they are getting left out,” said the report’s editor, Kirsten Hagon, in a press conference on Monday. “One of the things we would like to see happen with this report is to really push for an increased investment in those countries that are currently left behind.”

Given the steady increase in the number of climate and weather-related disasters, the failure to protect the people most vulnerable to climate change is alarming. According to the report, the average number of climate and weather-related disasters per decade has increased nearly 35 per cent since the 1990s.

No Vaccine for Climate Change

More than 100 disasters have taken place since the start of the pandemic in March this year, affecting more than 50 million people. Pandemic response and recovery are at the top of most governments’ agendas, but the IFRC are urging governments not to let the pandemic detract from making climate change a priority.

“We are slowly learning to deal with the pandemic…and once we have vaccines available, hopefully in the next two years, we should be able to largely manage the impact of the virus,” IFRC Secretary General Jagan Chapagain told Geneva Solutions. “But unfortunately there is no vaccine for climate change, and the depth and scale of the impact it is having and will have on the planet would be much more significant, and extremely difficult to reverse.”

Dead and dying animals at the Dambas, Arbajahan, Kenya, which has dried up due to successive years of very little rain.

Chapagain argues that the massive stimulus packages being developed around the world to respond to COVID-19 are an opportunity to “build forward better”, prioritising a green recovery that not only tackles the causes of climate change but also makes communities more resilient to future climate-related disasters.

“Broadly we have seen global solidarity around COVID-19, and there have been quite huge stimulus packages announced by different governments,” explained Chapagain. “It will really be a massive lost opportunity if governments and organisations do not use those massive stimulus packages in ways that are climate friendly, and that not only don’t do harm but actually strengthen recovery in a more green, inclusive, and adaptive manner. This is absolutely possible.”

Humanitarians Urged to Make Climate Change a Priority

The IFRC is also encouraging investment in early warning systems and anticipatory action to reduce risks and prevent disasters before they happen, calling on humanitarian organisations in particular to step-up their implementation of early action plans.

“Unfortunately, climate change has already happened, and it’s increasing the frequency and intensity of disasters, so of course we will have to continue to respond rapidly and at scale to save lives,” said Chapagain. He explained that many organisations have made progress towards facilitating anticipatory responses in recent years, but more can be done to invest in forecasting systems and encourage forecast-based financing.

The IFRC has also urged humanitarian organisations to ensure their work on the ground is sustainable and always keeps climate change in mind. The pandemic has highlighted the importance of local actors in humanitarian response, and made practices such as distributing cash rather than importing goods overseas more commonplace. Organisations should focus on putting resources in the hands of communities most affected by climate change and supporting their efforts to adapt and build resilience against future shocks.

“As we have seen during COVID-19, the local actors are very capable of responding,” said Chapagain. “I think recognising that, investing in them, and really empowering the local response makes a huge, huge difference.”

Health Policy Watch Watch is collaborating with Geneva Solutions, a new non-profit Geneva platform for constructive journalism covering International Geneva.

Image Credits: Pablo Tosco/Oxfam, EC/ECHO/Anouk Delafortrie, Brendan Cox / Oxfam.

The test, which is currently available on prescription use only, can provide results within 30 minutes.

The U.S. Food and Drug Administration has issued an emergency use authorization (EUA) for the first COVID-19 diagnostic test for self-testing at home and that provides rapid results. The Lucira COVID-19 All-In-One Test Kit is a molecular-based single use test that is intended to detect the novel coronavirus SARS-CoV-2 that causes COVID-19.

“While COVID-19 diagnostic tests have been authorized for at-home collection, this is the first that can be fully self-administered and provide results at home. This new testing option is an important diagnostic advancement to address the pandemic and reduce the public burden of disease transmission,” said FDA Commissioner Stephen M. Hahn, M.D. in a press release on Tuesday. “Today’s action underscores the FDA’s ongoing commitment to expand access to COVID-19 testing.”

“Today’s authorization for a complete at-home test is a significant step toward FDA’s nationwide response to COVID-19. A test that can be fully administered entirely outside of a lab or healthcare setting has always been a major priority for the FDA to address the pandemic. Now, more Americans who may have COVID-19 will be able to take immediate action, based on their results, to protect themselves and those around them,” said Jeff Shuren, M.D., J.D., director of FDA’s Center for Devices and Radiological Health. “We look forward to proactively working with test developers to support the availability of more at-home test options.”  Link to the FDA press release here.

 

Image Credits: Flickr: Prachatai.

Healthcare worker in the COVID-19 intensive care unit in San Salvatore Hospital in Pesaro, Italy in March.

The world’s 27 million nurses and midwives – who comprise 60% of the health workforce – are not only excluded from the health system’s corridors of power, but also have faced new levels of censure and reprisal during the COVID-19 pandemic when they protested dangerous or abusive working conditions, said expert panel members at the Geneva Health Forum on Monday.

Along with the widespread shortages of personal protective equipment (PPE) that put many nurses lives at risk and led to at least 20,000 deaths, the pandemic period has seen the suspension of labour laws in some countries, increased discrimination against healthcare workers, and employers’ restrictions or censorship of nurses who dared to speak about their working conditions. 

Speaking on the panel ‘The Year of the Nurse and Midwife 2020 – A Catalyst for Change’ on Monday, Soosmita Sinha, President of the Health Law Institute, said: “There were cases globally, and especially in the US, where … nurses could not talk to social media, nurses could not talk to government organizations. There were repercussions from employers.”

Soosmita Sinha, President of the Health Law Institute, at the Geneva Health Forum session on Monday.

In an interview with Bloomberg News in March, Ruth Schubert, a spokesperson for the Washington State Nurses Association, observed that “hospitals are muzzling nurses and other health-care workers in an attempt to preserve their image”, threatening to fire employees if they talked to the media without authorization or publicized their working conditions.  

Two states in the US, Colorado and Virginia, expanded whistleblower protections to apply to these circumstances and allow nurses to report issues to their employers, social media, and other organizations. Other states enacted laws enabling healthcare workers to bring their own PPE if the hospital had a shortage.

“We’ve heard reports of nurses having to work long hours, not being able to take vacations, working when they’re sick … how is it compromising patient safety? If nurses are not safe, can patients really be safe in that environment? Aren’t we actually making them vectors of COVID to pass on to the next person?” posed Sinha. 

Healthcare workers form between 2% and 3% of the population in most countries, yet data has shown that the healthcare worker COVID-19 infection rate is 10-14%. Of the 54 million total COVID-19 infections globally, some 5 million could be healthcare workers. 

Nurses Needed in Leadership Positions and Decision Making Bodies

The panelists reviewed WHO’s first-ever State of the World’s Nursing Report released in April, which highlighted the unrecognized contributions of nurses to health systems and called for new policy measures and investments to strengthen the nursing workforce.

“We need to hear and see and be advised by nursing leadership voices at all levels through our health systems,” said Howard Catton, CEO of the International Council of Nurses. “It would bring this nursing perspective into the heart of decision making about how service is delivered and also into political decision making as well.” 

Howard Catton, CEO of the International Council of Nurses, at the Geneva Health Forum session on the Year of the Nurse and Midwife.

The ability of nurses to influence policies is essential because “they understand the reality on the ground,” Sinha said. Nurses account for 60% of the health workforce and provide 90% of primary health care.

“It is absolutely necessary to have nurses in all the decision making bodies, to have nurses in the COVID management taskforce, to have a government chief nurse, to have the voices and the views of nurses everywhere and to have influence … and not just to be used for managing crises,” said Roswitha Koch Heepen, senior member of the Swiss Nurses Association. 

Nurses have played a vital role on the frontlines of combating the pandemic and they will be essential in global vaccination efforts for COVID-19. Globally, nurses administer and lead the majority of vaccination programs, and they are crucial to a safe and efficient rollout of a COVID-19 vaccine – alongside pharmacists and refrigerated truck drivers. They have largely been left out of vaccination discussions, however. 

“Where is the nursing voice in terms of the big policy decisions? Where is the nursing voice in terms of managing the mass vaccination response?” said Catton. 

The State of the World’s Nursing Report highlighted the need to create at least 6 million nursing jobs by 2030, primarily in low- and middle-income countries. Elisabeth Iro, WHO Chief Nursing Officer, highlighted that without this increase “the ability to adequately respond to the COVID-19 pandemic or similar crises in the future is compromised and would jeopardize our collective ability to achieve Universal Health Coverage targets”.

“If you don’t have a nurse in place or a pharmacist to give that vaccination, it doesn’t matter how much of the vaccination we have or how we got to that point,” said Sinha.

The Geneva Health Forum runs from 16-18 November. Follow Health Policy Watch’s coverage here and on Twitter.

Image Credits: Alberto Giuliani, Geneva Health Forum.

Panellists argued that the outcomes of digital technology implementation has highlighted key deficiencies and oversights in health systems.

A panel of experts have called for cautious, strategic and realistic approaches in rolling digital tools out to ensure that patients remain a priority.

Speaking at the Geneva Health Forum on Tuesday, panellists noted that while the expectations for digital health are high, stakeholders need to be aware that digital health tools alone will not solve the world’s global health crisis, and that collaboration is needed to maximise potential.

David Stewart, associate director of the International Council of Nurses (ICN), argued that the differences in the outcomes of digital health implementation in various countries and settings “shine light on major gaps and deficiencies within health systems and digital health strategies”.

David Stewart, associate director of the International Council of Nurses (ICN)

In the context of the COVID-19 pandemic, for instance, digital health applications can help track the disease better among patients and healthcare workers, but asked: “Do we have the mechanisms to resource these effectively, and the governance and regulations to support?”

“We are fully aware that we do not adequately capture the number of health professionals that are currently contracting COVID-19,” Stewart said, referring to the widespread assumption that the 20,000 health worker deaths from COVID that have been recorded is a huge under-estimate. “This is particularly relevant when you consider that hospitals and health services are meant to be safe places in which care can be delivered safely, so that people can enjoy quality outcomes.”

Kaspar Wyss, Deputy Director at the Swiss Tropical and Public Health Institute, took this sentiment further, saying that despite the growing number of digital health applications, real potential has often fallen short.

“We have seen a lot of interest, a lot of promises, a lot of new avenues related to digital health, in areas like asthma treatment, smoking cessation, or diagnostics of cancer,” he said. “But there are obviously downsides — ethical issues, legal issues. Sometimes promises were much higher than what was delivered in the end.”

The digital universe can also work against health workers, Stewart also said. Nurses, for instance, who comprise 60% of the overall health workforce have, new levels of censure and reprisal, when they complained on social media about abusive working conditions during the pandemic.

 

Health workers deaths due to COVID-19 in Africa, Asia and Europe by August, the first 6 months of the pandemic.
Digital Innovation is Key but Achieving UHC Requires More Work

Even so, the health sector is better positioned than ever to implement digital processes, said Maguette Thioro Ndong, Technical Advisor, Digital Health Solutions for the Digital Square of PATH, a Geneva-based global health non-profit that pioneers innovative health technologies.

“Ongoing digitalization and the introduction of new technology are already breaking down boundaries and creating patient-centered healthcare systems,” she said.

She cited telehealth and mobile health as services that allow healthcare professionals to communicate with, refer and potentially treat patients remotely – and more flexibly.

To achieve the ambitious goals for digital health, Ndong said it would require transformative thinkers to go beyond existing market structures to change the way digital health technologies and innovation are acquired and scaled.

“They will help us to better match the pace of digital health funding and implementation to the pace of technological evolution,” Ndong said.

But effectively innovating within the health sector would require more than just digital advancements and new technologies, argued Riccardo Lampariello, Terre des Hommes’ Head of Health Program.

Riccardo Lampariello, Terre des Hommes’ Head of Health Program.

He drew on experience from the deployment of the Integrated e-Diagnostic Approach (IeDA) in Burkina Faso, West Africa. The tool, which helps healthcare workers make a clinical diagnosis, has been deployed in 70% of primary health centers in Burkina Faso where it is being used for around 200,000 consultations every month.

The government of Burkina Faso is expected to take over the service by the end of 2020, and the system is now also being deployed in Niger and Mali.

“While digital health is necessary to reach universal health coverage (UHC), it is not sufficient to achieve UHC alone,” he said.

He emphasised several factors surrounding digital technologies which can limit – often severely – patient outcomes: namely sustainability and cost, along with health workers’ unwillingness or inability to use the technology applications.

These factors must play a part in designing implementation or response measures, he argued.

Keeping Patients at the Centre of Health Sector Innovation

Unlike in other global sectors, implementation of digital technology in health work must be more focused on patients than profit, argued Bernardo Mariano, Director of WHO’s Department of Digital Health and Innovation.

Bernardo Mariano, Director of WHO’s Department of Digital Health and Innovation.

Referencing the Global Strategy on Digital Health, approved by WHO Member States during the 73rd World Health Assembly in November, he said the ambitious WHO strategy aims to lay the foundation for the future of digital health and achieve transformation of the health sector similarly to how it has revolutionised the finance and banking sector.

“These sectors are quite advanced in their transformation. Government, social media and media in general are also quite advanced in their digital transformation. We want to see the digital transformation of the health care sector to be much better than all these other sectors,” Mariano said.

But unlike the finance and media sectors, where efforts have been geared primarily towards achieving profitability, Mariano stressed that it is essential that all stakeholders are working to ensure that digitalization of the health sector does not result in the loss of the people-centric element of healthcare.

“People centric elements in the ecosystem will deliver those health benefits we want to see delivered at every level,” Mariano said.

Image Credits: Geneva Health Forum, Amnesty International.

Dr. Sally Agallo Kwenda, survivor of cervical cancer

In the early 2000’s, when Kenyan doctor Sally Agallo Kwenda was diagnosed with cervical cancer, it was a big shock given she was not experiencing any pain or symptoms.

A bigger shock, however, was her husband’s decision to walk out on her. He claimed that he could not live with a woman who could not give him babies. 

Sally’s testimony is a sobering reminder of the devastation cervical cancer brings, even though it is almost entirely preventable and potentially curable, noted the World Health Organization’s Dr Tedros Adhanom Ghebreyesus on Monday.

She spoke along with nearly a dozen other cancer survivors from around the world at the historic launch of the WHO‘s Global Strategy to Accelerate the Elimination of Cervical Cancer.  It marked the first time ever that the world has committed to eliminating a cancerous disease – and an especially neglected one that kills a whopping 300,000 women every year. 

Coinciding with the launch, countries around the world, beginning with Japan and Australia, began lighting up landmark monuments in the color teal and blue, in a worldwide display of unity to eliminate cervical cancer once and for all. 

Princess Dina Mired of Jordan

Princess Dina Mired of Jordan, along with the first ladies of South Africa and Rwanda also appeared for the launch at a high level panel, alongside WHO’s Director General as well as officials of Unitaid, GAVI, the Vaccine Alliance, The Global Fund and others.

“Today is the day we tell cervical cancer, loud and clear – your days are numbered,” said Princess Dina Mired of Jordan, a longtime advocate for cervical cancer elimination, and member of the director-general’s expert group on cervical cancer elimination. 

“We have let you run wild, causing much destruction and grief to hundreds of thousands of our women and their families for far too long. And the worst part is, you managed to do all of that, not because you were super smart, but simply because we let you infect women.”

“We made it easy for you, but not after today, because today we have a plan,” she added. “A solid plan to put you back where you belong – to the annals of history.”

The WHO’s three-pronged strategy, which was adopted by the World Health Assembly in a remote vote during August, offers a clear roadmap to expand Human Papilloma Virus (HPV) vaccination coverage, as well as cervical cancer screening and treatment by 2030: 

  • 90% HPV vaccination coverage of girls by age 15.
  • 70% screening coverage for women by age 35 and again by 45.
  • 90% access to treatment for cervical pre-cancer and cancer, including access to palliative care.

If successful, the WHO’s strategy could prevent over 40% of new cases of the disease, and 5 million related deaths by 2050, 90% of which are in low- and middle-income countries.

HIV & Cervical Cancer – The Double Whammy

Cervical cancer, like many other diseases, exploits those with weakened immune systems, especially in sub-Saharan Africa where HIV is still rampant, added panelists on Tuesday.

In fact, 85% of women that live with both HIV and cervical cancer are in sub-Saharan Africa, according to a meta-analysis of 24 studies from Monday, which was published in The Lancet.

Shockingly, women with HIV are six times as likely to contract cervical cancer, warned Shannon Hadder from UNAIDS, referring to the Lancet report. This explains why women in eastern and southern Africa are ten times more likely to die of cervical cancer, in comparison to women in Western Europe or Australia. 

She also warned that innovative technologies, such as artificial intelligence based screening tools, will not fulfill their potential unless we confront deep social inequities that impede access to preventative care and treatment. 

“This situation is not acceptable, and that’s why we don’t accept it,” added Marisol Touraine, chair of Unitaid and a former  French Minister of Social Affairs. “We cannot accept inequity because we have effective tools and solid policies [to prevent and treat cervical cancer].”

Even in countries that have the tools to offer high-quality care, gender inequities, as well as misinformation, are substantial roadblocks to improved cervical cancer management. In Swaziland, for example, 63% of men and 58% of women agreed that they had to seek permission from their male partner to visit a health care center, said Hadder, referring to a recent nationwide survey. 

Misinformation is another challenge that needs to be addressed quickly, she said, noting that in the same survey, 48% of respondents felt that only women with multiple partners were infected by cervical cancer. 

“There’s nothing shameful about our biology, and no woman needs permission from a man to access health care.”

High HIV rates in Sub-Saharan Africa exacerbate cervical cancer

Cervical Cancer – Treatable with Cost -Effective Strategies 

Eliminating cancer would have once seemed an impossible dream, but we now have cost-effective tools to make that dream a reality, said Dr. Tedros on Monday. 

Investing in cervical cancer can generate substantial societal and economic returns. For every dollar invested, the WHO estimates a US$ 3.20 return to the economy – and the figure rises to US$ 26.00 when the indirect benefits on families, communities and societies are considered.

Even though 93% of all cervical cancers are preventable, it is the fourth most common cancer in women worldwide. In 2018, an estimated 570 000 women were diagnosed with cervical cancer, and about 311 000 women died from the disease.

Almost all cervical cancer cases (99%) are linked to infection with high-risk human papillomaviruses (HPV), an extremely common virus transmitted through sexual contact.

Image Credits: The Lancet .

TB screening activities in a rural village, Cambodia.

Médecins Sans Frontières. As the COVID-19 pandemic threatens to derail the global response to tuberculosis (TB), Médecins Sans Frontières/Doctors Without Borders (MSF) called on governments to accelerate testing, treatment, and prevention for TB, and called on donors to provide the financial support needed to ensure increased access to new medical tools for diagnosing and treating millions of people with this killer disease. A report released today by MSF and the Stop TB Partnership—Step Up for TB—surveys 37 high TB-burden countries and shows that critical medical innovations are reaching far fewer people who urgently need them, because many countries continue to lag behind in getting their national policies in line with new World Health Organization (WHO) guidelines.

“Instead of stepping up for TB, we are at risk of slipping back due to COVID-19,” said Sharonann Lynch, Senior TB Policy Advisor for MSF’s Access Campaign. “We cannot stress enough how urgent it is now for governments and donors to intensify their efforts so thatcritical medical innovations and tools reach people with TB. We finally have better drugs and tests to tackle and prevent this extremely infectious yet curable disease, so it’s both mind-boggling and unacceptable that they’re still not being used to save as many lives as possible.”

While reporting on the severe impact of the COVID-19 pandemic on TB services, WHO revealed a sharp drop in the number of people diagnosed. Besides needing to catch up to maintain continuity of existing TB services, it advised countries to adopt and roll out better testing policies and practices. 

Presently, countries continue to fall short on rolling out up-to-date testing policies that can assist in reaching nearly 3 million people still being missed.As highlighted in the report, a whopping 85% of countries surveyed still do not use the lifesaving point-of-care urinary TB LAM test for routine diagnosis of TB in people living with HIV, as recommended by WHO. 

“As clinicians working on the frontlines of the raging TB epidemic, it is distressing to see the sluggish uptake of TB LAM in national treatment programmes, despite its proven role in saving the lives of people living with HIV,” said Dr Patrick Mangochi, Deputy Medical Coordinator for MSF in Malawi. “Countries must step up the use of TB LAM as a core component of testing services, otherwise delays in diagnosing people with TB and getting them started on treatment will continue to fail people with HIV who get TB.”

TB remains the world’s top infectious disease killer, with more than 10 million people falling ill and 1.4 million people dying due to this disease in 2019. Implementing WHO guidelines is urgently needed to minimise the unnecessary risk of COVID-19 by reducing visits to health facilities, without disrupting treatment. Countries must take immediate action to implement people-centred TB policies, including treatment initiation and follow-up at primary healthcare facilities. Also, national treatment programmes must prioritise the use of all-oral treatment regimens for people with drug-resistant TB (DR-TB) that no longer include older, toxic drugs that have to be injected and cause serious side effects. The report finds that only 22% of countries surveyed allow TB treatment to be started and followed up at a primary healthcare facility, instead of travelling to a hospital, for instance, and for medicines to be taken at home. Additionally, 39% do not use a modified all-oral shorter treatment regimen and 28% of countries surveyed still are using injectable medicines when treating children with DR-TB.

“I have been through an agonising journey of being treated with medicines with excruciating side effects, and lost one of my lungs,” said Meera Yadav, a survivor of extensively drug-resistant TB (XDR-TB) in Mumbai, India.“Finally, in 2016, I was able to access newer TB drugs as part of the regimen that saved my life. I don’t want anyone else to have to go through this ordeal. With newer medicines, it is now possible to give people all-oral treatment that works to cure them. People with TB can’t be excluded from accessing these innovations anymore, especially when they are afraid to visit treatment centers due to COVID-19.”

Image Credits: Yoshi Shimizu/WHO.

Women health workers in LMICs are often the targets for research but are rarely part of the decision-making process, Dhatt says.

Women must be exposed to digital technology as both users and innovators – in order to fashion and expand AI designs that meet the needs of hard-to-reach populations, said experts at a Geneva Health Forum.

Speaking at the session ‘How Can The World Advance Towards AI Maturity In Health?’ on Monday, Roopa Dhatt, executive director of the Women in Global Health network, noted that only 12% of people in AI research are women.

And while women health workers in low- and middle-income countries (LMICs) are the majority of front-line care givers and thus the target of many AI research solutions, they are “rarely part of the design or decisions”.

Roopa Dhatt, executive director of the Women in Global Health.

“We hear about human-centred design, but how often are we making sure the creators are people of diverse backgrounds?” Dhatt asked, whose network aims to advance gender equity in the health sector. She added: “We need to hardwire diversity and equity in all of our aspects of innovation.

“So the first thing is making sure that we have people from diverse backgrounds.”

The concern, she said, is that if “100% of the talent pool in health isn’t engaging, you are not going to get the best results”.

There is a similar disconnect between AI research goals and the prevailing levels of digital literacy among women. Globally, some 1 billion women do not currently have access to digital mobile technology, with a large majority of these women living in LMICs.

“That’s a pretty large number,” she added. “To say that you’re going to work on achieving universal coverage and health equity when a billion of the world’s population does not even have access to digital technology.”

Half of women’s contributions to global health remains unpaid.

The gender gap in health sector leadership is another link in the broken chain of digital transformation, she added, noting that around 70% of the global health workforce are women, but less than 25% of leadership roles are occupied by women. In addition, half of women’s contribution to global health remains unpaid.

Country Context Also Critical To Appropriate Research

“When it comes to digital specifically, it’s really important to understand what the context is,” said Kanishka Katara, Head of Digital Health (India) at PATH: a French-based non-profit that helps countries develop and scale digital technologies in health systems.

Kanishka Katara, Head of Digital Health (India) at PATH

Katara flagged, as an example, that countries have diverse responses based on the context of their national local health systems and health burden – which varies enormously, country to country.

“Issues from one place to another, even though they might appear to be the same, are very different,” he said. “We need more contextual, localised solutions for that.”

The Geneva Health Forum runs from 16-18 November. Follow Health Policy Watch’s coverage here and on Twitter.

 

 

 

Image Credits: WHO/UNITAID, Flickr – UN Women Asia and the Pacific, Geneva Health Forum.