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

World Health Assembly members set aside the contentious issue of restoring Taiwan’s observer status at the member state forum – to focus on the challenges posed by the COVID-19 pandemic, and linked to that WHO reform. 

That was despite a growing push by the United States, backed by Europe and their western Pacific allies for a stronger role for Taipei in WHO fora – an elected government representing some 23 million people which has managed to keep its COVID-19 cases to less than 600.  

The Taiwan issue was dealt with at a two-hour closed door WHA meeting, then followed by public, declaratory remarks by two countries, Honduras and Marshall Islands, in support of Taiwan’s re-admission, and two opponents, China and Pakistan, and concluding with no action for the moment. Left to unravel, a full-fledged public debate would have consumed a day of speeches, leaving bitter deadlock among member states pro and con, observers said.

WHO Reform Agenda

But meanwhile, political consensus appeared to be shaping up around initiatives being advanced by both European countries, the United States and other G-7 allies, to strengthen the hand of the WHO signficantly – in terms of its emergencies powers to get data and take action – as well as its technical capacity and created channels for more sustainable financing. 

“A key lesson of the COVID-19 pandemic is that there is a gap between WHO’s 194 member state expectations, … and its de- facto capacities to fulfill them,” said Jens Spahn, German Federal Minister of Health, speaking on behalf of the European Union, on Monday, the first day of the week-long WHA session, which picks up from a two-day WHA emergency event in May. 

Referring to a recent report on WHO’s health emergencies operations by an Independent Oversight Advisory Committee, Spahn said that the EU had already launched informal discussions among its member states in October to define a WHO reform agenda. That process will resume soon after the WHA sessions, he said.

Virtual World Health Assembly nerve center at WHO’s Geneva headquarters, with only a skeletal staff around the table, due to the pandemic.

He said the the EU Council was already supporting a number of concrete measures “to strengthen WHO’s role – without prejudice to the ongoing reviews and evaluations.”

Spahn referred to a laundry list of actions needed to strengthen WHO’s mandate in the framework of existing, binding International Health Regulations, “including with regards to travel and trade restrictions, independent epidemiological onsite assessments, reporting by state parties, monitoring and evaluation, and through revision of the PHEIC [Public Health Emergency of International Concern] declaration alert system,” he said. 

Other tasks, he noted, include “include strengthening WHO’s role in preparedness response, its standard-setting functions, it’s work on zoonotic diseases.”

COVID Needs to Be Game Changer- Member States Need to Put Their Money On The Table 

But equally important to a stronger mandate to act in emergencies, is the degree of funding needed to execute, Spahn said. And for that, member state contributions need to match the size of WHO’s mandate. 

“Currently there is a major discrepancy in between how we all praise the importance of a well functioning and effective WHO, and our common will to finance WHO, through our membership fees. Let us open our eyes:  are US$ 490 million US dollars in [combined global] membership fees per year, adequate to fulfill WHO’s mandated role? Hardly.  Germany is ready to explore all possible options to make who stronger. But in the end, this will only be possible. If the 194 members of this organization, take on more financial responsibility. 

“From Germany’s point of view, the COVID-19 pandemic must be understood as a game changer. None of us was adequately prepared. We will have to change the way we are doing business… Preparing costs billions, responding costs trillions.”

Two draft reform plans are already circulating, one as a European Union ‘non-paper‘, and a “WHO Roadmap” published by the United States Department of Health and Human Services, which focuses more narrowly on ways to improve WHO’s emergency response mandate and systems, obliging member states to greater transparency.  But diplomatic sources say that there are many points of synergy and convergence between the two.

Said one source close to the discussions, both initiatives in fact evolved out of the same conversations among the (G-7) Group of 7 most industrialized countries, and there had been “fairly good consensus on direction and elements”. Even if two concept notes have emerged now, “much of it is the same and includes elements that had been talked about in the broader group.”

In a parallel discussion on the WHO budget, Belgium’s WHA representative said that WHO needs to provide more precise and ‘updated reporting’ on its financial status and any shortfalls caused by the pandemic- calling for a longer discussion at the next Executive Board meeting in the context of proposed reform moves.

“It would be helpful if the Secretariat could provide us with a short update on how WHO is managing financially during COVID-19, and how gaps caused by retracting donors can be dealt with or not,” the representative said. “Predictable, flexible and sustainable financing is one of the core issues to strengthen WHO and to allow it to act independently,”  added Belgium. “We believe that the Secretariat should develop, together with the independent review panel, proposals on the amount and type of funding, especially core funding, that WHO needs in order to be able to fulfill its mission.”

Taiwan Set Aside – For Now

As for Taiwan, a procedural move by 13 WHA member states to restore its observer status, led by Belize and backed by the United States, Canada and other European and Western Pacific allies was discussed largely behind closed doors, in an early afternoon WHA session. The move was hotly opposed by Beijing as a threat to its sovereignty – even though Taiwan had served as an observer to the WHA until 2017. Following a terse agreement two countries from each side of the divide presented their arguments publicly.

Speaking on behalf of Taiwan’s inclusion, Honduras and The Marshall Islands, referred to the Island’s exemplary record in controlling the virus and the technical expertise that it has to share in pandemic control, saying that the Assembly “has continued to exclude Taiwan for political reasons.  They are prioritizing poilitical considerations over health considerations here.

China, meanwhile, said that including Taiwan as an observer to the Assembly would violate the agreed-upon UN “One China principle … that both sides of the straits belong to China.”

 

Meanwhile US Ambassador Andrew Bremberg issued a video coinciding with the debate, describing Taiwan as “a democratic role model, generous donor and a force for good. Taiwan is an exemplary partner in addressing the world’s most serious challenges- especially during this global pandemic.

“We believe Taiwan’s inclusion would benefit the world and the WHO.  Taiwan’s model COVID19 response has proteted the health and safety of the 23 miliion people living on the island. Taiwan’s generous efforts to share scientific and technical expertise, and its donations of tens of millions of masks and hundreds of thousands of medical supplies, have saved countless lives.

“In preventing Taiwan’s participation, the WHO is allowing some to politicize public health, and allowing its core mission to suffer. The solution is simple, the Director General should invite Taiwan to participate as an observer. This was the status quo from 2009 until 2016.  Nothing has changed since them, except the democratically elected leadership of Taiwan, which is not an acceptable reason to block Taiwan’s participation”.

Bremberg also said that going forward, the WHO should include “substantively, without limitations, Taiwan health experts with expertise in the COVID-19 pandemic response, including in technical meetings and full accesss to all relevant facilities and virtual spaces. This is a desire shared by a growing number of countries within this body, who respect Taiwan as a responsible and generous actor, with world-class health expertise.”

Although WHO has officially stated, throughout the pandemic, that Taiwanese experts do have access to WHO technical consultations, other insiders familiar with the Organization say that any meetings with experts had to first go through WHO’s legal department, technical barriers were placed on virtual consultations, and experts with any government title or ranking had to be screened by Beijing – placing the bar impossibly high.

Until 2017, Taiwan had access to the WHA as an observer, upon the personal invitation of the Director General. But following the Taiwanese election of a new government dominated by the more nationalistic, the Democratic Progressive Party, relations with Beijing soured – and the invitations ceased. WHO’s current Director General, Dr Tedros Adhanom Ghebreyesus has been reluctant to buck the pressures from Beijing.

We Are Family – Hit Featured In Lighter Moments Of WHA

 

While the bitter Taiwan dispute remained as vivid reminder of the limits of WHO calls for global “solidarity”, the Assembly was marked by lighter moments. Those included the release of a new cover for the classic “We Are Family” hit by Singer Kim Sledge – featuring health workers from around the world singing the classic pop song – and a performance by the Tonga Nurse Choir, in honor of WHO’s Year of The Nurse and Midwife.

Director General Proposes ‘Peer Review’ of Countries’ Emergency Preparedness

Meanwhile, in his opening remarks Dr Tedros also called upon WHO member states to “address the shocking and expanding imbalance between assessed contributions and voluntary, largely earmarked funds,” observing that WHO’s annual budget is equivalent to what the world spends on tobacco products in a single day.

And he proposed a new system of “peer review” for emergency preparedness. The Universal Health & Preparednesss Review – would bring countries together for transparent review of each other’s response capacities.  He invited Cameroon, the Central African Republic, France and Germany to test the concept in a pilot phase.

WHO Director General Dr Tedros speaking at the 73rd World Health Assembly

The WHO Director General also warned that “a vaccine cannot address the global under-investment in essential public health functions and resilient health systems, nor the urgent need for a “One Health” approach that encompasses the health of humans, animals and the planet we share.”

No Vaccine for Climate Change

“It’s time for the world to heal – from the ravages of this pandemic, and the geopolitical divisions that only drive us further into the chasm of an unhealthier, un-safer and unfairer future” he said.

Drawing linkages between the current pandemic and the inter-related crises of unsustainable development, he added:  “We cannot afford to see health merely as a byproduct of development or a commodity that only the rich can afford.

“There is no vaccine for climate change. The world has reached a fork in the road. We cannot afford to pump carbon dioxide into the atmosphere at the same rate, and still breathe clean air, we must chose.”

Number of COVID-19 cases against number of deaths reported to WHO as of 8 November 2020.

Meanwhile, Michael Ryan, Executive Director, WHO Health Emergencies Programme (WHE), gave an update on the COVID-19 pandemic, noting that the world had reached “the grim milestone” of 50 million cases globally. Sharp increases in cases are being seen right now in Europe, the Americas and the Eastern Mediterranean Region – while cases in Africa, Southeast Asia and the Western Pacific are more stable or even declining.

On a brighter note, a senior WHO advisor, Bruce Aylward, briefed Member States on the progress made in organizing global procurement systems for COVID-19 drug treatments, tests and forthcoming vaccines  the Access to COVID-19 Tools (ACT) Accelerator. The Accelerator’s multi-pronged strategy aims to create systems for more equitable distribution of life-saving COVID-19 rapid tests, treatments, and future vaccines through a new “COVAX Facility” which over 180 WHO member states have now joined.

The Accelerator has raised over US$15 billion in finance already, although billions of dollars still need to be raised, Aylward said.  Seehere our Health Policy Watch story on the new drive to build and procure a global toolkit of COVID-19 drugs worth $US 6 billion.

As the WHA proceedings were unfolding, more good news came that Pfizer’s COVID19 vaccine candidate had achieved 90% efficacy in its interim clinical trial results.

 

Image Credits: WHO.

COVID-19 mRNA vaccine candidate developed by Pfizer and BioNTech.

A COVID-19 vaccine candidate developed by Pfizer and BioNTech has far exceeded expectations, showing a 90% efficacy rate so far among the tens of thousands of volunteers who were immunized in a clinical trial, the company said on Monday.

“Today is a great day for science and humanity. The first set of results from our Phase 3 COVID-19 vaccine trial provides the initial evidence of our vaccine’s ability to prevent COVID-19,” said Albert Bourla, CEO of Pfizer, in a press release. 

Albert Bourla, CEO of Pfizer.

In another statement Bourla added: “We are one step closer to potentially providing people around the world with a much-needed breakthrough to help bring an end to this global pandemic.”

In the trial of over 43,000 participants across six countries, there have been 94 cases of COVID-19 in people not previously infected; but fewer than 9 of those cases were in participants who received both shots of the vaccine – leading to the estimate of 90% efficacy for interim trial results, just disclosed.

The trial will continue until 164 cases of COVID-19 are recorded among trial and control arm participants, so as to confirm the efficacy rate. 

Plans are on track for Pfizer and BioNTech to apply to the US Food and Drug Administration (FDA) for an emergency use authorization in the third week of November, Bourla said. 

That will be the milestone moment when a required two months of safety data has been collected for all of those who participated in the trial. No serious safety concerns have been raised so far, the press statements said -although no breakdown by age group has been provided either. Some 42% of participants were from diverse ethnic and racial backgrounds.

The FDA previously said that a COVID-19 vaccine trial should be at least 50 percent effective, which the Pfizer and BioNTech vaccine candidate has far exceeded. 

“The big news is that we have a #SARSCoV2 vaccine with a strong signal of efficacy,” said Eric Topol, founder and director of the Scripps Research Translational Institute, on Twitter. “We’ll have at least one vaccine into Phase 1a rollout before year end, which is a stunning achievement – from virus sequence to vaccination in < 12 months.” 

“This is a victory for innovation, science and a global collaborative effort,” said Ugur Sahin, BioNTech CEO. “Especially today, while we are all in the midst of a second wave and many of us in lockdown, we appreciate even more how important this milestone is on our path towards ending this pandemic and for all of us to regain a sense of normality.” 

Avoiding the Election

Pfizer’s announcement narrowly missed the US presidential elections last week  – fulfilling the previous commitment  that the company would not be ready earlier to apply for the authorization. 

Despite the victory of Democratic contender Joe Biden, who has now been recognized as the new President-elect,  US President Donald Trump immediately took to Twitter to trumpet the vaccine breakthrough, saying: 

“STOCK MARKET UP BIG, VACCINE COMING SOON. REPORT 90% EFFECTIVE. SUCH GREAT NEWS!”

President-elect Joe Biden took a much more cautious approach, welcoming the progress as “excellent news” giving Ameicans “cause for hope” – but warning that a vaccine would only become widely available later next year. 

“Americans will have to rely on masking, distancing, contact tracing, hand washing, and other measures to keep themselves safe well into next year. Today’s news is great news, but it doesn’t change that fact,” Biden said. 

There had been concern that timing an announcement to coincide with the election might negatively influence public confidence in a vaccine, with Pfizer CEO Albert Bourla criticising President Donald Trump for politicising the vaccine timeline.

Will the Vaccine be Administered Equitably?

Although the results, should they be confirmed, are encouraging news for fighting the pandemic, the Pfizer vaccine, in particular, will pose huge challenges for distribution in low- and middle-income countries because it requires a cold storage temperature in extremes of -70°C. 

Vaccine storage containers being loaded into air cargo. Establishing temperature controlled conditions is essential to respect cold chain requirements.

In addition, there is the question of vaccine supply and distribution. Pfizer and BioNTech estimate that some 50 million vaccine doses could be manufactured by the end of 2020, enough to immunize 25 million people, and 1.3 doses in 2021. They have also said that they are positioned to manufacture more than 1 billion doses during 2021. 

Global health leaders have warned for months that initial vaccine supplies will likely be limited and need to be reserved for healthcare workers and high risk individuals around the world.  

However, Operation Warp Speed, a US government programme aiming to rush a COVID-19 vaccine to market, already signed a $1.95 billion deal with Pfizer for 100 million doses of the vaccine in July. Pfizer also has reached supply agreements with the EU for 200 million doses, covering 100 million people, as well as with the United Kingdom, Canada and Japan. 

If Pfizer’s vaccine is indeed the first to make it to market, the big question that the world will be watching is this: will the company would be obliged to begin distributing all of its initial batches in the USA and other high-income countries where it has already signed procurement deals – with remaining middle- and low-income countries served much later, and after appropriate cold-chain infrastructure is established?   

On the more positive side, the Pfizer vaccine candidate is only one among 10 other vaccine candidates in late-stage clinical trials worldwide. Moderna, a pharma company developing a COVID-19 vaccine with similar technology as Pfizer, has also announced their plans to release their interim clinical results and apply for an FDA Emergency Use Authorization by the end of November. It requires a more moderate – 20°C temperature for shipping and long-term storage.

Science of mRNA Vaccines
Description of Pfizer’s use of mRNA technology to develop COVID-19 vaccines.

Pfizer and BioNTech’s drug is an RNA vaccine. This treatment is based on a part of the virus’ genetic code – messenger RNA (mRNA) – that contains the genetic information needed to produce the coronavirus’ receptors.

If a synthetic mRNA is successfully administered to a person, their cells are then able to build proteins that mimic the receptors, triggering the immune system without causing illness.

The 90% efficacy rate was achieved 7 days after the second dose of the vaccine, which is taken three weeks after the first, totalling 28 days. It has also been shown to block nearly 20 mutated versions of the virus strain, the company said. However the duration of protection obtained remains undetermined. 

Image Credits: Pfizer, World Economic Forum, Flickr – CDC Global, Pfizer.

COVID-19 drug development
Employees at Roche, one of the companies developing monoclonal antibodies for the scheme.

A WHO co-sponsored partnership is laying the groundwork for a worldwide distribution plan of $US 6 billion worth of the most effective COVID-19 drugs, including cutting-edge monoclonal antibodies treatments if proven effective – so as to ensure that high-income countries do not snap up all available new therapies as they arrive on the market.

The proposed basket of medicines would be procured under the auspices of the World Health Organisation’s (WHO) co-sponsored ACT Accelerator: a collaboration with seven other UN and global health agencies and philanthropies, including Unitaid and The Wellcome Trust, to provide equitable access to COVID-19 drugs.

The scheme requires more than US$6 billion – $750 million of which is required by February 2021, according to the plan. Due to be released in the coming week, it is currently under review by the ACT Accelerator’s Facilitation Council, co-chaired by Norway and South Africa, represeneting both donor countries and as well as low- and middle-income countries (LMICs) that would benefit from reduced prices and drug reserves.

The new procurement scheme is being supported by Bill and Melinda Gates Foundation and Mastercard Impact Fund – which banded together with Wellcome in a COVID-19 Therapeutics Accelerator to provide funding and support for the drug procurement effort.

Partners of the WHO co-sponsored Act Accelerator.
Procurement Plan Includes Monoclonal Antibodies, but Excludes Remdesivir – Due To Lack of Proven Benefit

More than half of this investment would go to procuring and distributing monoclonal antibodies, as part of what is referred to as the Therapeutics Pillar – 1 of 4 pillars of the Accelerator scheme, alongside vaccines, diagnostics and health systems.

Monoclonal antibodies appear to be a promising treatment: these artificial antibodies are manufactured copies of those created by the body to fight invading viruses. The emerging  treatment would join key approved treatments – like the steroid dexamethasone – in the medicine basket.

A Unitaid spokesperson, speaking on behalf of the ACT-A Therapeutics pillar, told Health Policy Watch that the procurement plan is being developed as part of the “investment case” for the ACT-Accelerator therapeutics pillar – which will then be shared with donors to recruit the needed $US billion in funding.

“What this investment case is doing is preparing the ground so that when a certain drug is proven to be effective and when it gets the go-ahead from the WHO, we are ready to go.”

The spokesperson added: “The ACT-Accelerator Therapeutics Pillar (co-convened by Unitaid and Wellcome) analysed the treatment pipeline to identify promising treatments with strong clinical safety and efficacy data that could be scaled up. Following this analysis, monoclonal antibodies (mAbs) and proven repurposed therapeutics like corticosteroids (dexamethasone and hydrocortisone) are the most promising options so far. The pillar is preparing different pathways to support access to mAbs as well as monitoring the pipeline and maintaining flexibility to invest in and support other promising therapeutics.”

She stressed that the plan would only be executed with drugs that are actually approved by regulators and the WHO. “Everything is evidence-based and the fundamental principle is to ensure that LMICs don’t lose out.”

Roche Also Confirms Contact With Act Acccelerator

Drugmakers Novartis and Roche are both developing monoclonal antibody treatments; Roche has collaborated with Regeneron to develop and manufacture an antibody treatment known as REGN-COV2.

A spokesperson for Roche told Health Policy Watch: “As part of our commitment to addressing the pandemic, we’ve had preliminary discussions with partners of the ACT-Accelerator about the access plan for REGN-COV2 antibodies.

“These discussions were in the context of development and production of COVID-19 therapeutics, which could eventually inform planning of the ACT-A Therapeutics Partnership,” the spokesperson added. “It is too early to speculate on future decisions, but we will continue working with them and other groups regarding REGN-COV2.”

On the other hand, Remdesivir, a drug approved by the United States Food and Drug Association (FDA), will not be included following a WHO study that found almost no evidence for reduced mortality. WHO announced it was issuing guidance on using remedesivir, but this information is yet to be published.

Cheaper Drugs for LMICs; Equitable Distribution Could Prevent 60% of Deaths

The aim is to ensure that LMICs receive access to these drugs, preventing pre-orders for supplies being locked-up by rich countries.

A recent model, created by researchers at the Northeastern University MOBS Lab, Massachusetts, found that distributing vaccines equitably based on population size could prevent up to 60% of deaths, highlighting the benefits of a scheme like the ACT Accelerator.

The scheme is intended to keep a consistent flow from research and development, to distribution and the administration of the vaccine. Drugmakers Novartis and Roche, both developing monoclonal antibodies, are confirmed to have had contact with WHO regarding the scheme.

Roche has collaborated with Regeneron to develop and manufacture REGN-COV2. A spokesperson from Roche told Health Policy Watch that approximately 2 million doses were projected to be supplied within the first half of 2021.

 

Image Credits: Roche.

WHO Director-General Tedros Adhanom Ghebreyesus speaking at WHA 71 in May, 2018 – before the pandemic. Photo: WHO

This year’s 73rd edition of the World Health Assembly resumes virtually on Monday, after a two-day emergency huddle in May – against sharply rising COVID-19 infection rates in Europe and the United States, deep geopolitical divides – and calls for reform of the WHO that could strengthen its mandate but also may be resisted by countries concerned about encroachments on their sovereignty. 

At the same time, rays of hope include the prospect of new vaccines coming on the market in early 2021, promising new drug therapies under develoment, and the fact that some of the poorest countries, primarily in Africa, are weathering the virus much better than wealthier counterparts to the north. 

Add to that “hope-list”, the pending replacement of the most contentious and combative United States President seen in recent history, Donald Trump, with Democratic president-elect Joe Biden – a seasoned negotiator keen on bringing the US back into the multilateral fold. Biden has already said he’d rejoin the WHO on his first day in office, January 20, 2021.

In his victory speech Saturday night in Wilmington, Biden pledged to make the coronavirus pandemic his top priority upon taking office and even well before; he was to convene a senior task force of scientists on the issue as early as Monday, to implement a new strategy on combatting COVID-19.

President-elect Joe Biden says the coronavirus will be at the top of his agenda, in his victory address in Wilmington, Delaware, Saturday evening.

In the wake of the election, the tone of US career diplomats is already sounding a bit more conciliatory. Colin McIff, deputy director of the US Health and Human Services’ Office of Global Affairs tweeted on Saturday: “Looking forward to working with you and all partners for a stronger @WHO next week at a resumed #WHA73.”   

WHO’s Director General Dr Tedros Adhanom Ghebreyesus put out his own olive branch, following on from leaders as diverse as the UK’s Boris Johnson to the head of the African Union, saying in a tweet on Sunday morning, “Congratulations to President-elect Joe Biden and Vice President-Elect Kamala Harris! My WHO colleagues and I look forward to working with you and your teams. Crises like the COVID19 pandemic show the importance of global solidarity in protecting lives and livelihoods.”

That said, the thorny issue of admitting Taiwan as an “observer” to the WHA still could create significant electricity between the United States and its Canadian, European, Australian, South Korean and Japanese allies on the one hand – and China on the other – with big blocs of countries in the African region and elsewhere potentially forced to choose sides right at the start of the WHA tomorrow in a procedural vote.  

That is, unless WHO Director General Dr Tedros Adhanom Ghebreyesus decides to take the heat himself and issue a personal invitation to Taiwan – which he is entitled to do. That could be perceived as a major goodwill gesture to the United States, including president-elect Biden – not to mention the Taiwanese government, which has performed exceptionally in the pandemic.  And judging from a recent series of tweets by the US Mission in Geneva as well as statements by senior US Congressional leaders, Washington is putting on the pressure. 

As one western diplomatic observer told Health Policy Watch, “my understanding is that both paths are technically possible. That doesn’t mean the DG will invite, but in our view he has that power.”

 

International Health Emergency Resolution & Independent Reviews

Beyond the politics of Taiwan, the most key issues on the weeklong WHA agenda (9-14 November) will revolve around COVID-19, focusing on both the Organization’s and countries’ responses to date, as well as needs going forward. That will include a draft resolution by countries calling for stronger emergency response in the context of the legally binding International Health Regulations. Reports by two independent review committees will also be presented to member states. One looks at the performance of WHO’s own Health Emergencies team. A second  initial report is from an independent panel charged with reviewing pandemic preparedness and response of both the global health organization and countries themselves.  

Along with that, a draft resolution on “Strengthening preparedness for health emergencies: implementation of the international health regulations (IHR),” remains one of the few substantive resolutions to actually be debated and adopted at this WHA session. Other key actions, on COVID, WHO reform and other global health and disease resolutions and strategies, were either adopted in the two-day May virtual meeting. Or they were approved remotely in August, via written exchange, including a “silence procedure” in which a country’s ‘no-comment’ signaled its agreement.    

The resolution on the legally binding International Health Regulations, approved after the first SARS pandemic, asks WHO to examine the need for and potential benefits of, “possible complementary mechanisms to be used by the Director General to alert the global community about the severity and/or magnitude of a public health emergency in order to mobilize necessary support and facilitate international coordination.” 

In plainer language, this would be an “amber” alert, like the orange signal at a traffic light, which would tip off countries to developing emergencies earlier than the current system does – and before they get out of control. Such as signal has been proposed by a diverse range of countries, including the United States and European Union states.

While that technical measure may enjoy wider support, the many other clauses of this resolution also open the door for bigger debates over potentially controversial measures to strengthen WHO’s authority to demand data from countries and enforce surveillance in the framework of the IHR. It remains to be seen how China and its allies will respond to such overtures – in light of the criticism leveled about Beijing’s lack of transparency in sharing data about the virus in the early stages of the pandemic – through to the present where the virus origins remain murky and unexplored.  

While the resolution is couched in typical UN diplomatese, aimed to build consensus, it has other potential hotspots beyond the virus itself.  These include standard  WHO and UN references to sexual and reproductive health rights – which have often been opposed by conservative Middle Eastern nations as well as the United States – in the Trump era. 

Independent Reviews of WHO & Pandemic Response  

Active cases of COVID-19 around the world and COVID-19 deaths globally 8 November 2020 – hitting new records in the USA and Europe.

The other politically-charged debate is likely to revolve around the reports by two independent review committees charged with assessing WHO’s own Emergencies Programme as well as the broader pandemic response by WHO and countries themselves.  

The first, by the the Independent Oversight and Advisory Committee for the WHO’s Health Emergencies Programme, published only last week – provides the most detailed look, to date, at WHO’s internal functioning during the pandemic, following reforms undertaken after the 2014-2016 Ebola epidemic.  It cites as progress a strengthened WHO presence at country level, building greater confidence and cooperation. At the same time, it notes that staffing at country level is “spread thin” shortcomings – with only about 70% of the 1583 budgeted positions at headquarters and in countries having been filled.  In terms of  the timely delivery of urgent health products, critical to emergency response, it says that over the past several years:

“Both WHO staff and partners consistently point to a critical gap in the procurement system and supply chain management of the Organization. Findings suggest that persistent delays in procurement and delivery erode partners’ confidence in WHO’s capacity and accountability on the ground.” However, those shortcomings are being addressed more effectively in the COVID-19 context with a new Inter-Agency coordination cell better linking WHO and other UN and partner organizations on the ground:

Although scarce on details, an initial report by the Independent Panel for Pandemic Preparedness and Response, articulates a vision of a “root and branch” review of pandemic response at country as well as global health level. “Most catastrophes for most people are far-off events, but this pandemic has touched us all,” states the report by the committee, led by two former prime ministers,  Ellen Sirleaf Johnson of Liberia and New Zealand’s Helen Clark, “…It has deepened our resolve to carry out a root and branch review to uncover what could and should have been done better to avert this pandemic, and to propose a plan for all necessary steps to ensure that the world is better prepared in future.” 

Reform, Reform and Reform

While not explicitly on the agenda – as yet – diverse member state proposals for WHO reform are already being developed, and will be hovering in the background of these debates. Key proposals, submitted by Germany and France on the one hand, and the United States, on the other, which are designed to address systemic weaknesses in the Organization laid bare by the pandemic. 

A Franco-German reform proposal, ostensibly circulated as a “non-paper”  focuses on a more reliable funding base for WHO, now highly dependent on “voluntary” contributions by nations; stronger emergency response and legal mandates in emergencies. 

“It is clear that Member States’ (MS) expectations vis-à-vis WHO have by far outgrown their willingness to provide funding to the organization,” states the paper. Over 80 percent of the WHO’s program budget comes from voluntary contributions, the majority of which is from 15 donors. This leads to donor dependency and a gap between what member states wanted implemented and the finances available for it. 

“While the response to COVID-19 offers the great opportunity to reinforce WHO’s leadership role also vis-à-vis other global health actors, it could – if not adequately steered by MS [member states] – lead to further fragmentation in particular in global health security structures,” said the paper, which sets out 10 actions key actions as remedies.

Foremost among there are: increasing assessed and core contributions to WHO; greater member state oversight of WHO health emergencies actions; greater access of WHO mandated experts to investigate potential outbreaks; a stronger, WHO-facilitated coordinated global system for health emergency preparedness and response; and robust reviews of country levels of public health preparedness and compliance with rules for early reporting and sharing of information about threats. 

A more technocratic US proposal, published in September, focuses on a roadmap for strengthening WHO’s speed of gathering data, assessment, reporting and responding to potential epidemic risks, as well as a new “amber” alert for emerging public health emergencies.  

The proposal asks member states to grant more rapid access to outbreak areas by WHO-led response teams and to ensure member state compliance with International Health Regulations obligations – clear references to charges that China failed to act swiftly or transparencly enough in December when evidence of the SARS-CoV-2 virus began circulating.  

“This roadmap sets out areas where we believe there is an opportunity to strengthen the WHO by increasing accountability and its ability to be impartial and objective, improve transparency and its overall effectiveness, by providing it with a more comprehensive set of tools that are fit-for-purpose to address new and emerging threats,” said the US reform proposal. 

“It is essential to strengthen oversight mechanisms and clarify mandates to ensure full transparency and participation by Member States, other global health partners and the public”, the proposal adds, also noting that mechanisms need to be considered to “facilitate more rapid access to outbreak aras for WHO-led response teams… Such access is crucial to the early containment of outbreaks.”

The US proposes that a new  “Intermediate Public Health Alert IPHA or (amber light)” – be incorporated into the legally binding IHR which could signal a developing emergency before it becomes a full-scale global threat. Additionally, greater transparency in the decision making of emergency committees is requested.

The proposal also calls for delinking travel restrictions from trade  in pandemic response –  to minimize the economic impacts of health emergencies and ensure the functioning of global supply chains. 

And, the US proposal also asks for greater powers and budgets to be vested in the new WHO Chief Scientist’s Office “to raise the quality of, and confidence in, guidance documents and normative materials.” 

WHO Executive Board discussion on coronavirus outbreak in early February 2020 , led by Deputy Director General Zsuzsanna Jakab and Emergencies Head Mike Ryan. It was the last face-to-face meeting in Geneva of the governing body before WHO declared an international health emergency.

“We are fully committed to the reform in WHO, which has to be a continuous process,” said Zsuzsanna Jakab, Deputy Director-General of the WHO at a pre-WHA session, co-sponsored by the Geneva Graduate Institute’s Global Health Center and the UN Foundation. “We are also very happy to note that several member states or groups of countries, like the EU, for example, have initiated the reform process…There are also other initiatives from the United States, and we are encouraging member states to bring these initiatives together in a consolidated, coherent way.”

Jakab encouraged member states to continue to “come up with bright ideas on how we can make WHO even better and respond to the ever changing environment” and to bring the initiatives to the Executive Board in January 2021. 

Countries Need To Be Involved & Consulted More 

Clemens Auer, Austria’s Special Envoy for Health to the WHO, at the Global Health Center session on Thursday.

Whatever criticism has been leveled at WHO’s pandemic response, particularly in the early days, the failure has been mutual, most stakeholders will quietly agree. 

At Thursday’s pre-WHA session,  a representative of one member state, Austria, stressed that shortcomings in pandemic response, lie both with the WHO administration but also with core member states that direct its operation.  

“We didn’t do a good job on the multilateral level, on the international level when it comes to [COVID-19] crisis management,” said Clemens Auer, Austria’s Special Envoy for Health to the WHO. 

But countries were also to blame for WHO’s shortcomings, he added.  The 33 Executive Board member states that are the core governing body overseeing WHO’s operations also were notoriously slow to even call for a meeting during the “largest public health crisis of our generation. 

“It took until early October for the Executive Board of the WHO, the governing body next to the World Health Assembly, [to be] convened on issues of COVID.”

Auer spoke at a Global Health Center session entitled, “Backsliding or Building Beyond COVID-19? An Introduction to the Resumed 73rd WHA”. 

Member states need to be more proactive in the interactions at the Executive Board and the World Health Assembly – and that goes for member states from the global South, said Ilona Kickbusch, founding director and chair of the Global Health Centre, at the same session. 

She lamented the fact that the Executive Board’s mandates has been eroded over the years by a series of subtle, but important changes in rules and procedures. “I personally feel one of the worst governance decisions ever taken in the WHO was to change the way the Executive Board functions. It is no longer a board, it is no longer a body that really advises the Director-General and the other member states, and that is reflected in how it functions and it’s reflected in why it’s not called on.” 

US Withdrawal from WHO Is A ‘Positive Disruption’   

Ilona Kickbusch, founding director and chair of the Global Health Center, speaking at the Global Health Center session Thursday.

Even so, Kickbusch described the temporary retreat of the US from the WHO arena – even if reversed by an incoming Biden administration, can also be seen as  a “positive disruption” that creates opportunities for change. 

The vacuum provides an opportunity for regions like the European Union, as well as low and middle income countries to take a stronger lead. 

“With the ‘hegemon’ actually not around for now, can we build a more equitable global health decision making situation, within the WHO, but [also] in global health generally?” asked Kickbusch. Following the recent US moves, for instance, Europe’s role in the WHO was discussed explicitly at an EU Ministerial Council meeting of ministers of health at the end of October, for the first time in recent memory. 

Amidst widespread speculation that the US may rush back to center stage, Kickbusch has taken a more muted attitude saying in one Tweet: “Why not US participation? CooperAtion?  Don’t we need new leadership models in global health?

The crisis also has raised deeper and more systemic issues about how money from a few large country donors, as well as philanthropies, can disproportionately skewer the Organization’s policies and spending priorities. 

The current system is overly reliant upon voluntary donations by countries, rather than assessed contributions and that allows the member states that pay the most to also “call the tune” of the WHO, observed Kickbusch. 

That was echoed by Auer who described how member states “got a wake up call when Donald Trump announced that the US is leaving WHO because all of a sudden we were called…to jump in to fill the financial gap.” 

Meanwhile, a parallel global health architecture also has emerged, led by philanthropies such as the Bill and Melinda Gates Foundation, said Felipe Carvalho, Médecins sans Frontières Access Campaign Coordinator in Brazil. These private actors exercise their own vision about issues related to the licensing and procurement for billions of dollars annually in health products, which in turn curbs some of the decision-making power of member states and civil society. 

Member states also are vulnerable to vested interests, which in turn may lead them to influence WHO’s outreach and agendas on a range of issues, from sugar taxes and tobacco control, Kickbusch added, recalling how Cuba had opposed the 2005  WHO Framework Convention on Tobacco Control because of its production of cigars. 

Ultimately, policymakers need to stand up to such interests, however, if they want to fend off the next big public health crisis, said Kickbusch. And countries in the global south along with the north, need to speak up, she added, saying:  

“The representation of countries, particularly countries of the global south is strong in these bodies…My question is: are the countries of the global south going to use the fact that they have a heck of a lot of votes to actually introduce and push for a stronger WHO?…We need to rely on the countries of the global south, and I hope we can also rely on the European Union…to change the power relationships and the governing processes within that Organization.”

“If a strong alliance of countries wants an independent, strong WHO and a WHO that is less dependent on others who come in and provide support, then they should build that alliance. I do think this is an issue that needs to be taken up, otherwise, I do not think we will get the kinds of changes that we are aiming for.”

Dispute Over Taiwan Issue May Generate Electricity 

Despite the quest for unity, the big question facing the WHA on the morning it resumes, will be the US-backed proposal to reinstate Taiwan as a WHA observer  deferred at the May WHA 73 session, may re-emerge again – with unpredictable results in terms of the big geopolitical divide between China and the USA, western Europe and allies. . 

In May, some 13 member states, led by Belize, submitted a proposal to invite Taiwan as an observer, backed by a strong statement from US Secretary of State Mike Pompeo – and publicly backed by others, including  Canada. 

That proposal was deferred until the November session. Now, tomorrow, it could be resolved by a sudden, dramatic gesture by Dr Tedros to invite Taiwan. Or it could be subject to a big and potentially bloody debate at the outset of the WHA about whether to take a vote at the start of the Assembly – laying bare again the polarization between China and the US and its allies. 

On Friday, the pro-Taiwan bloc picked up significant diplomatic steam, following a joint call by some 644 European parliamentarians from 25 countries upon Dr Tedros to admit Taiwan as an observer. 

The US Mission in Geneva issued its own statement bluntly asking DG Tedros to take action, saying: “the United States urges Director General Tedros to participate in the upcoming World Health Assembly on November 9-14. That was followed by a tweeted video stating “when the World Health Assembly re-convenes, November 9-14, the people of Taiwan deserve a seat at the table. We urge WHO Director General Tedros to invite Taiwan to participate in the upcoming World Health Assembly.”

Congressional Republican leaders like Senator Marco Rubio make it clear that the US will be watching closely to see if WHO makes such a gesture – perceived in Washington as a important course correction of WHO’s perceived “pro-China” bias in the early pandemic days. 

“Senator Rubio calls on the WHO to allow Taiwan to meaningfully participate in #WHA73,” tweeted Rubio’s media team.  “As many nations face a 2nd wave of #COVID19, Taiwan sets a record for 200 days without infections.  Beijing’s agenda to block Taiwan deprives us all of expertise and threatens global health,” he said under the hashtag #TaiwanCanHelp. 

In fact, Taiwan served as a WHA observer, under a personal invitation from the WHO director genera until  2017 – when the practice was abruptly ended by outgoing WHO DG Margaret Chan, herself a former official in Hong Kong, precisely as Tedros stood for election, and as China was stretching its geopolitical muscle more strenuously in the Asian Pacific region.

Last week, WHO’s leadership last week attempted to shift the decision back to the WHA court: 

“Observership is a question for member states,” said Steven Solomon, principal legal officer for governing bodies of the WHO, at a WHO press conference on Friday, adding only that:  

“Technical work of the Secretariat, of the Director-General with everyone everywhere continues to ensure that we advance the principle of health for all, as embodied in our constitution.”

But in the wake of Joe Biden’s election, a WHO gesture by Tedros to invite Taiwan into the room would be just the show of WHO bipartisanship on the thorny China-Taiwan issue – that could be a test of whether the new Biden administration can not only give, but get something from the global health organization. If not, it could wind up in a vote, which will force non-aligned States in Africa and elsewhere to make a difficult choice about sides. 

Steven Solomon, principal legal officer for governing bodies of the WHO, at a WHO press conference on Friday.

Other World Health Assembly Business

Along with the debates on the IHR Health emergencies framework, the COVID-19 emergency, WHO’s pandemic response and reform initiatives, the weeklong agenda, will cover key themes related to a wide range of other WHO objectives, including efforts to expand primary health care and vaccine coverage, as well as strategies that promote healthier populations.  

New initiatives tackling cervical cancer, tuberculosis, and influenza preparedness feature prominently in the agenda. But as these were in fact already approved remotely by member states in August due to the constraints of the virtual WHA format – the debate over the related resolutions or decisions will in fact be largely rhetorical. Confounding things further, certain sub-issues, such as TB and neglected tropical diseases (NTDs), will be grouped together in member states’ statements – making it more difficult to follow trends in countries’ approaches, attitudes and actions, by theme. 

These features of the virtual format, as well as the fact that civil society responses are also sharply limited, constrain possibilities for genuine dialogue and consensus-building, which is such an important feature at the WHA. Civil society groups have complained about this as well as the limited time allocated to comments by the dozens of organizations that are recognized as WHA observers. Key agenda items are presented here, theme by theme:   

Primary Health Care and Universal Health Coverage: 

Other Health Emergencies topics 

Healthier Populations 

A WHO press release on the upcoming WHA session also cites the big advances that have been achieved – despite the challenges posed by the pandemic. Those include: the establishment of the Access to COVID-19 Tools (ACT) Accelerator; an Immunization Agenda 2030, where WHO updates to member states of progress will be provided.  A civil society primer, by the Geneva Global Health Hub, is presented here. The WHA sessions, all virtual, can be followed online here. 

Image Credits: WHO, Johns Hopkins, HPW/Catherine Saez, Global Health Center.

Up to 17 million mink are to be culled in Denmark following the discovery of a COVID-19 mutation
Up to 17 million mink are to be culled in Denmark following the discovery of a COVID-19 mutation

There is so far no evidence that the outbreak of mutant SARS-CoV-2 virus strains exploding in Danish mink farms threaten the development of a successful COVID-19 vaccine, said top World Health Organization (WHO) officials on Friday.

More than 200 mink farms in Denmark have reported cases of SARS-CoV-2 infections, prompting Denmark’s prime minister, Mette Frederiksen, to order a cull of virtually the country’s entire farmed population of 17 million mink.

In a press conference Thursday, Frederiksen described the virus mutations as posing a “serious risk” to the development of a vaccine and to global public health. Denmark is the largest producer of mink fur in the world, exporting primarily to China and Hong Kong.

WHO Chief Scientist Soumya Swaminathan says it is too early to reach conclusions on SARS-Cov-2 mutation found in mink.

WHO Chief Scientist Soumya Swaminathan sought to allay fears that the mutant variants posed a threat to the COVID-19 vaccines that are likely to come on the market early next year: “We don’t have any evidence at the moment that it would [impact vaccine efficacy].”

“It is too early to jump to conclusions as to the implications of these specific mutations,” Swaminathan added. “WHO is leading a group of evolutionary biologists and bio thematic experts that are tracking these mutations, and we have seen plenty of them.”

Variations of the SARS-CoV-2 virus isolated from mink have mutated spike proteins, according to Denmark’s State Serum Institute. The institute confirmed that multiple mutations in the spike proteins – a distinctive feature of the SARS-CoV-2 virus, allowing the virus to easily penetrate animal and human cells – had been isolated from infected mink samples.

These spike proteins have also been key targets for various vaccines now under development, including those by Pfizer, Moderna, Johnson&Johnson and AstraZeneca, all of which aim to stimulate immune system recognition of signature spike protein features and mount a response.

At a WHO press conference on Friday, Dr Michael Ryan, Executive Director of the WHO Health Emergencies Programme, said: “This type of thing happens all the time. This is a global pandemic and millions of people are affected and many animals have been exposed.”

“There is a potential that the virus could come back to humans,” he added, referring to the need to increase security and surveillance on farms and to monitor viral evolutions. “Right now, the evidence that we have does not suggest that this variant is in any way different in the way it behaves.”

He clarified that while it may have a “slightly different signature”, it is still the same virus. The variant must be evaluated over time to determine if that variant also will impact the dynamics of viral transmission and immune response.

Fears of an Ineffective Vaccine are ‘Idiotic’

This is not the first instance of coronavirus being detected in farmed mink. News of the virus infecting mink was first reported in the first wave of the virus in the Netherlands over the spring and in June, 90,000 mink were culled in Aragon, Spain.

However, while the circulation of the virus among new animal populations heightens the risks that transmission can resume, even if it is interrupted, experts said that it was irresponsible to suggest that the virus mutations seen so far could be resistant to the vaccines under development.

Professor Francois Balloux, director of the University College, London Genetics Institute, tweeted that reporting vaccine development is at risk is “completely irresponsible” and problematic, writing that the, “scare story is just idiotic.”

He clarified that while “vaccine-escape mutations” may or may not arise in humans, they definitely would not be fuelled by variations emerging in minks.

Pandemic-Based Urge for Illicit Animal Trade Restrictions

Meanwhile, a new World Trade Organisation (WTO) report highlights how the global trade in animals and wildlife is a factor driving the risk of zoonotic disease spread, increasing the likelihood of other pandemics, such as COVID-19.

In its report, entitled Future Resilience To Diseases of Animal Origin: The Role Of Trade, WTO underlined that illicit trade, in particular, needs to be better managed and that WTO members have a right enshrined in existing WTO rules to protect their countries health systems by regulating such trade.

Nearly 3 million human deaths each year are caused by more than 50 zoonoses – even before the pandemic occurred – the report estimates. Additionally, 20% of livestock production is lost due to animal diseases annually, an estimated loss of US$ 300 billion.

The report stressed that more effective action requires greater collaboration between WHO, the World Organisation for Animal Health (OIE) and the Food and Agriculture Organization of the United Nations (FAO), in collaboration with the WTO to control the trade in wild animals, in particular – although it stops short of recommending an action plan.

The report makes only one oblique reference to the recent COVID-19 outbreaks in mink farms, otherwise stating that:

“In the case of domestic or farmed animals, disease outbreaks are monitored and controlled, depending on the capabilities of veterinary authorities and other related actors at the national level. Large volumes of trade in animals and animal products take place safely, following international standards and national requirements. This limits chances to detect and report diseases in wildlife, and to collect data and knowledge, which are key for the management and control of such diseases.”

Of greater concern is unregulated and illicit trade of animals, where there is no similarly close surveillance of wildlife:

“Unregulated or illicit trade in animals – whether farmed, domestic or wild – implies a higher risk of spreading disease. Since the outbreak of the pandemic, some experts and international institutions have called for closer controls, in particular of trade in illicit wildlife, given that such trade does not necessarily respect existing sanitary requirements, and thus undermines government’s efforts to prevent disease transmission.”

WTO referred to calls made earlier in the pandemic by The Lancet and the UN Environment Programme for tighter controls of illegal wildlife trade. The report stops short however of providing clear cut recommendations about how trade rules could be tightened.

COVID-19 is the worst outbreak in recent history of a zoonotic disease – a disease originating in animals and transmitted to humans – but the pandemic has underscored how interrelated human health, global food security, worldwide nutrition and animal health are.

While some arguments for domestication and wild animal consumption may at least have a nutrition aspect, mink today are raised and sold almost exclusively as a prestige item for the fashion industry, raising questions among animal rights activists and environmentalists about why such trade should even exist.

Image Credits: Nettverk for dyrs frihet / Net. for Animal Freedom.

Research into mRNA vaccines
The study found that if a vaccine was equitably distributed by population, 65% of global COVID-19 deaths could be averted.

Rather than hoarding vaccine supplies, rich countries that ensure global access to a new COVID-19 vaccine will pave the way to a larger reduction in pandemic related deaths worldwide, according to a new model developed by the Boston-based Northeastern University.

Their findings reinforce the argument the World Health Organization and other global health leaders that vaccine nationalism will boomerang, slowing down the progress combatting the pandemic.

Researchers at the Northeastern University MOBS Lab created two model scenarios: one in which 2 billion doses of a vaccine is monopolised by 50 high-income countries, and one in which the drug is distributed based on a country’s poupulation.

Both scenarios were run with two vaccines: one that had 80% and one 65% efficacy in terms of protective potential. A vaccine with a minimum efficacy of 50% could provide herd immunity, according to a separate study published in The Lancet.

The Northeastern University model found that if the 50 wealthiest countries stockpiled a vaccine with 80% efficacy, only 33% of the deaths that would otherwise occur that year could be averted, compared to 61% if the vaccine were to be distributed equitably. The same findings occurred in the case of the less efficient vaccine, where by hoarding would prevent 30% of deaths as compared to worldwide distribution, which would prevent 57% of deaths.

The study indicates that the planned COVAX vaccine facility, co-sponsored by Gavi, The Vaccine Alliance and the World Health Organization, could be an effective means of minimising the total number of coronavirus deaths across all countries.  See more details here.

 

Image Credits: Moderna, INC.

Vulnerable populations in Africa face falling through the cracks as resources continue to be focused on COVID-19, Matshidiso Moeti WHO Regional Director for Africa fears.

BRAZZAVILLE – The COVID-19 pandemic has dealt a heavy blow to key health services in Africa, raising worries that some of the continent’s major health challenges could worsen.

A preliminary analysis by the World Health Organization (WHO) of five key essential health service indicators finds a sharp decline in these services between January and September 2020 compared with the two previous years. The indicators included numbers of: outpatient consultations, inpatient admissions, births by skilled birth attendants, treatment of confirmed malaria cases, and provision of the combination pentavalent vaccine (a vaccine protecting against five diseases including tetanus and hepatitis B) in 14 countries.

The gaps in services provided this year and in previous years were the widest in May, June and July, corresponding to the period when many countries had imposed lockdowns to check the spread of COVID-19. During these three months, services in the five monitored areas dropped on average by more than 50% in the 14 countries surveyed, in comparison with the same period in 2019.

COVID-19 responders learn how to properly don and doff protective gowns in Kenya, May 2020.

“The COVID-19 pandemic has brought hidden, dangerous knock-on effects for health in Africa. With health resources focused heavily on COVID-19, as well as fear and restrictions on people’s daily lives, vulnerable populations face a rising risk of falling through the cracks,” said Matshidiso Moeti, WHO Regional Director for Africa at a press conference on Thusdsay.

“We must reinforce our health systems to better withstand future shocks. A strong health system is the bedrock for emergency preparedness and response. As countries ease COVID-19 restrictions, we must not leave the door open for the pandemic to resurge,” said Dr Moeti. “A new wave of COVID-19 infections could further disrupt life-saving health services which are only now recovering from the initial impact.”

Even prior to the COVID-19 pandemic, maternal mortality in sub-Saharan Africa was higher than almost any other region of the world, accounting for about two-thirds of global maternal deaths in 2017. During the pandemic, skilled birth attendance in all 14 countries surveyed dropped, an indicator of increased risks to mothers giving birth. In Nigeria, for instance, over 97 000 women gave birth somewhere other than health facilities and over 193 000 missed postnatal care within two days of giving birth. There were also 310 maternal deaths in Nigerian health facilities in August 2020, nearly double the figure in August 2019. 

An additional 1.37 million children across the African region missed the Bacille Calmette-Guerin (BCG) vaccine which protects against Tuberculosis (TB) and an extra 1.32 million children aged under one year missed their first dose of measles vaccine between January and August 2020, when compared with the same period in 2019.

Immunization campaigns covering measles, yellow fever, polio and other diseases have been postponed in at least 15 African countries this year, but the introduction of new vaccines has been halted and several countries have reported running out of stocks.

“Now that countries are easing their restrictions, it’s critical that they implement catch-up vaccination campaigns quickly,” said Moeti. “The longer, large numbers of children remain unprotected against measles and other childhood diseases, the more likely we could see deadly outbreaks flaring up and claiming more lives than COVID-19.”

WHO has issued guidance on how to provide safe immunization services, including ways to conduct vaccine campaigns while avoiding transmission of COVID-19.  The Central African Republic, the Democratic Republic of the Congo and Ethiopia have already carried out catch up measles vaccination campaigns. Thirteen other African countries aim to restart immunization campaigns for measles, polio and human papillomavirus in the coming months and WHO is providing guidance on COVID-19 prevention measures to keep health workers and communities safe, WHO said in a press release.

WHO has also provided guidance to countries on how to ensure the continuity of other essential health services by optimizing service delivery settings, redistributing health work force capacity and proposing ways to ensure uninterrupted supply of medicine and other health commodities.

As part of the COVID-19 response, health workers have received extra training in SARS-CoV-2 infection, prevention and control, and laboratories have been strengthened and data collection and analysis improved. These efforts support the fight against the virus while also building up health systems.

Image Credits: Twitter: WHOAFRO.

Schoolgirls line up to receive the HPV vaccine in Central Primary School in Kitui, Eastern Kenya.

Health experts will meet at the upcoming Geneva Health Forum to discuss the World Health Organisation’s (WHO) new roadmap for the elimination of cervical cancer. Hopes are high for funding to expand services in countries where they are needed the most.

At Newlands Clinic in Harare, Zimbabwe, the waiting room is always busy with women waiting to do a simple cervical cancer screen as part of the routine package of available reproductive and sexual health services. HIV positive women can receive free screening, and follow-up treatment if they are found to be at risk of cervical cancer, which is the most common form of cancer among women living with HIV.

Newlands is one of a growing number of clinics across Zimbabwe and other countries in sub-Saharan Africa that have started to incorporate cervical cancer prevention, screening and treatment services, into their women’s health programmes. The countries with the highest incidences of cervical cancer – Malawi, Mozambique, Comoros, Zambia and Zimbabwe – also have a high prevalence of women living with HIV/Aids, which makes rolling out these services all the more urgent.

Even so, the lack of public awareness and an equally large dearth of funding and international support have created challenges against making such services more mainstream.

“HIV, TB, Malaria – those are major killers so they tend to get the lion’s share of the attention,” says Dr Cleophas Chimbetete, deputy director of Newlands Clinic, who is one of a number of experts speaking at a keynote session on Cervical Cancer Elimination at the upcoming Geneva Health Forum running from 16-18 November.

“Cervical cancer can only be addressed if we have more international organisations coming in to assist, to make noise, and to make cervical cancer programmes. Because [at the moment] most cervical cancer screening is linked to HIV programmes.”

He and other experts gathering at the forum hope that a new global strategy from the WHO to eliminate cervical cancer as a public health problem will give more impetus to donor action. The WHO strategy sets out a roadmap for expanding vaccination, screening and treatment worldwide by 2030.

A Preventable and Treatable Disease

Cervical cancer is still the fourth most common form of cancer among women in the world, despite being one of the few malignancies that is preventable and highly treatable providing it is diagnosed and managed early.

The cancer also reflects global inequity, as its burden is greatest on low- and middle-income countries (LMICs) where access to public health services are limited. In 2018, nearly 90% of all cervical cancer-related deaths worldwide occurred in LMICs, where the proportion of women who die from the disease is greater than 60%. This is more than twice the number than in many high income countries.

The tools to prevent, detect and treat the disease already exist, yet developing countries face a number of challenges in expanding vaccination and screening programmes. The WHO’s strategy, therefore, marks a long overdue call to the global community to put the elimination of cervical cancer higher on their agenda, ensuring that all countries have the necessary policies, health services and funding in place.

Rolling out the Vaccine

As of 2020, less than a quarter of low-income countries have introduced the HPV (human papillomavirus) vaccine, a safe and effective way to protect women from a key cause of cervical cancer, into their national immunisation schedules.  In contrast, more than 85% of high-income countries have done so.

In recent years, however, more and more LMICs have taken steps to roll out the vaccine.

In Zimbabwe, where cervical cancer is the leading cause of cancer-related deaths among women, the country introduced the HPV vaccine into its national immunisation programme in 2018 with funding from Gavi, the Vaccine Alliance, which allocated funds sufficient to reach over 800,000 girls aged 10-14.

Gavi has been supporting the vaccine’s gradual roll-out to LMICs since 2013. That has enabled Dr Chimbetete’s clinic in Harare to offer the vaccine to adolescents, as well as screening and treating older women.

“Once people are aware, the uptake is good, but there still needs to be a lot of work to highlight the importance of HPV vaccination among the general population,” he says.

Beating the Stigma in Cameroon

Like Zimbabwe, Cameroon introduced the HPV vaccination onto its national immunisation programme last month following a six-year long pilot phase.

Completion of the pilot, first launched in 2011, faced many challenges. Dr Simon Manga, a reproductive health specialist for the Cameroon Baptist Convention Health Services (CBCHS), explains that parents initially were reluctant to have their children vaccinated, thinking it would make them sterile.

Now the national immunisation programme is getting started, some communities that initially accepted the vaccine earlier this year have later refused it, due to an unfounded belief that it is in fact an experimental COVID-19 vaccination. Misinformation has been rife on local and social media during the pandemic, with Gavi CEO Seth Berkley describing the situation in one article as “the worst I have ever seen.”

Dr Manga said: “People are afraid that they want to sterilise their girls, and worst of all it coincided with the period of COVID-19, so there’s an idea that the white man wanted to come and test the COVID-19 vaccine in Africa. There’s currently a lot of resistance.”

Dr Manga is a member of the National Planning Committee for the vaccine programme. He still hopes that with the help of the government and cooperation from community leaders, vaccine uptake will expand. A nationwide campaign is currently being organised to raise awareness about the importance of the vaccine and to quash the rumours that have been circulating.

Inexpensive Cancer Screening with Novel Methods

Dr Manga also supervises the CBCHS’ Women’s Health Programme (WHP) which offers cervical cancer screening as well as breast examinations as part of its other reproductive health and family planning services.

Like most facilities rolling out these services in Africa, the screening method used is not the traditional “pap smear” that requires expensive laboratory analysis, but rather an on-the-stop visual inspection of potential abnormalities on a cervix dabbed with acetic acid, and then exampled with the help of new digital cervicography. Here, too, HIV positive women are prioritised due to their increased vulnerability to cervical cancer.

Unlike the vaccine, there is no national programme for free screening services, and Dr Manga explains this is a major barrier for women. When the CBCHS have trialled free services before, the uptake has been unsurprisingly high.

In addition, encouraging those women who show signs of pre-cancer or cancer to return for follow-up treatment is also a challenge. Dr Manga explains many women do not understand the seriousness of the need for follow up, are put off due to the additional cost, or are advised not to return by faith healers in their communities.

Despite this, Dr Manga says the programme hopes to expand their services, increasing their use of mobile clinics and developing a “centre of excellence” by which local healthcare workers can gain training from different organisations and experts that they can use in their facilities. As with screening services, however, more funding is needed.

“One of the things that is slowing down our rapid expansion is funding – if we start getting funding then we can expand rapidly,” says Dr Manga. “[The WHO’s strategy] gives me hope that very soon there will be a lot of funding.”

Like in Cameroon, Costs are a Barrier to Treatment – More Funding is Needed

Because Dr Chimbetete’s clinic is funded by the Swiss-based Ruedi Lüthy Foundation, he has the mandate to provide the screening and treatment services free for HIV positive women. However this is not the case at public primary care clinics across the country.

At those clinics, while screening is widely available, follow-up treatment services generally come at a cost. Dr Chimbetete explains that the cost – which usually includes travel to a central facility that offers treatment as well as the treatment itself – prevents many women returning for follow-up, even when they know they have or are at risk of developing cervical cancer.

“Anything other than screening is not free, even in patients who are diagnosed with cervical cancer,” he explains. “Cost becomes an issue … especially now when we are going through economic challenges, it may not be a priority. So even though as a nation we are offering cervical cancer screening we still see very high incidences of cervical cancer because of all these issues.”

“Cervical cancer can only be addressed if we have more international organisations coming in to assist,” concludes Dr Chimbetete. “People need to make more noise. Noise has helped with HIV, noise has helped with TB, but I don’t think in my view we have made enough noise around cervical cancer. And now, because COVID has become such a huge global issue, there is a fear that everything else becomes insignificant. So some people really need to make noise around cervical cancer.”

Geneva Health Forum 2020 logo

This story was published in collaboration with Geneva Solutions – a new platform for peace & humanitarian, climate, global health, sustainable business & finance, and technology.

Image Credits: Keystone / EPA / Karel Prinsloo / GAVI, Geneva Health Forum.

US eleciton 2020 campaign signs
Signs supporting Biden and Trump split various small towns in Delaware County, upstate New York. The liberal state’s rural leanings have divided opinion.

While President Donald Trump’s mismanagement of Covid-19 may help Democratic contender Joe Biden turn the final corner in a tight US election, identity politics and the economy have loomed as bigger factors than health in voter choices. Voters in key battleground states, like Michigan and Nevada, explain why.

The United States election came just as the country was racking up some of the highest-ever daily rate of new coronavirus infections in the world. But in comparison to the economy, COVID-19 and health care issues still ranked lower on Americans’ priorities when people finally turned out to the polls.

US election 2020 signs
Signs supporting Biden and Trump split various small towns in Delaware County, upstate New York. The liberal state’s rural leanings have divided opinion.

All in all, the pandemic threat has failed to generate the kind of landslide support for the Democratic contender Joseph Biden that some had hoped for, or even anticipated – even if the vote count overnight early Thursday saw him inching his way toward victory.

Even so, “identity politics” – including a gaping rural-urban divide – remain more dominant factors in the campaign than the COVID pandemic that has transfixed the world.

Nor did health care seem to rate as high a concern either – even though some 20 million Americans stand to lose their health care coverage if the Affordable Care Act is finally overturned by a second-term Trump administration either through action in the US Supreme Court or Congress.

Massive ‘COVID Rebuke’ Didn’t Happen

While the mounting toll from the coronavirus has certainly played a role in a greater show of support among retirees and suburbanites for Biden in some places, a huge COVID-driven “rebuke” of Trump just did not occur at the magnitude that Democrats had expected.

This was already apparent in the early hours of Tuesday evening, before returns began to flow. A CNN exit poll found that about one-third of Americans considered the economy the most critical election issue. Only 1 in 6 voters considered the pandemic and 1 in 10 cited health care policy or violence, as their top issues. One in 5 people cited racial inequality.

Those attitudes were all the more apparent in the tsunami-like changes in early election results seen in key US “battleground states”, reflecting the log-jammed political divide between urban and rural voters, with suburban areas as wild cards.

Overnight Wednesday, mail-in ballots were still being counted in key states where battles raged,while a complicated calculus of 270 state “electoral college” votes, not the popular vote, determines the final outcome.

“There was a lot of energy and expectation – on the Democratic side and I would say even in America – that there was going to be a surge, a rebuke of Trump, particularly over the virus,” said political analyst, David Gregory, speaking to CNN.

“And what we’re seeing so far is that has not been the case. It’s a really tight race. We’re even seeing some evidence out of exit polling that a lot of voters out there are saying ‘hey, it’s really important we get this economy open, even if the virus spreads a little bit more.’”

Reported COVID-19 cases the day after the US election
A state-by-state map of US COVID-19 Cases Reported to the Centers for Disease Control over the Last 7 Days, as of 7pm CET, 4 November 2020.

 

Biden Benefits from “COVID” Vote but Only Marginally

That’s not to say that there was no ‘COVID factor’ at all.  More people from key demographic groups, like seniors and suburbanites, shifted significant votes to the Democrat’s Biden – as compared to Hillary Clinton four years ago. That surge of support was being felt in Michigan and Wisconsin, as well as in expanding suburban regions of sunbelt cities in Arizona and Nevada – making these states the major players in the final election outcome.

Polling stations were fitted with sanitizing stations.

“A lot of seniors don’t feel like he’s handled this very well – because literally they’re dying… people are legitimately dying I mean,” said one Nevada resident, a construction worker whose 64 year-old wife’s pre-conditions puts her seriously at risk from COVID-19.

Adding to the uncertainty in all of these states was the fact that unprecedented numbers of voters cast their ballots by mail, and those ballots were being counted last, rather than first, creating a dizzying set of ups and downs in the results.

Amidts pandemic concerns, however, another systemically hot issue in US politics – abortion – was a countervailing factor keeping many people loyal to Trump – virus or not.

“Abortion is a HUGE factor, I have heard many people say it alll comes down to who ‘will save the babies’,” said one businesswoman in Ann Arbor Michigan, who voted for Biden, where Biden was hanging onto a slight lead Wednesday evening.

“I honestly don’t get it,” she added. “No thoughts or consideration to helping the babies after they are born, but the pro-lifers are faithful in their voting. I’m seriously thinking of moving to Canada.”

“As far as I can tell, people care about healthcare but apparently believed the false dichotomy Trump presented of pandemic lockdown or the economy, and many preferred the latter,” a New York City public health expert said. “When Trump says that he did everything he could about the pandemic, and it was all China’s fault anyway, his supporters and apparently many other people believe him… After almost four years, you’d think people would have learned.  But he’s very good at what he does.”

Identity Politics Overwhelms COVID – No Matter Who Wins

In Trump strongholds like eastern Tennessee’s Putnam County, nestled in the foothills of the Appalachian mountains, a local store that sells Trump memorabilia just opened, and pickup trucks have been parading around downtown shouting the president’s praises, relates a prominent lawyer with deep roots in the community:

Nominee Joe Biden and Senator Kamala Harris as the latter accepts the Nomination for Vice President of the Democratic Party, 19 August 2020.

“One of the trucks carries a big flag with Trump’s sagging jowly face placed on top of Rambo’s body, firing an M-60 machine gun. And he drives around the Square yelling ‘Trump Trump Trump’. A disturbing number of people honk in support of him. From my window, Trump support has nothing to do with rationality,” said the attorney, who asked not to be named.

“Trump is a cult figure in red states like Tennessee,” he added. “He received 71% of the vote in Putnam County. We were reliably 55% Democratic until the 2010 election.” This was when local politics flipped during Barack Obama’s presidency – as racist rumors about the president’s origins and religious persuasion became rampant.

“Trump’s supporters share his fears and hatreds. More ‘bad others’ – illegal immigrants, rioters, black people and the much-feared and utterly non-existent ‘ANTIFA’ – dominate their fears. Trump rails against them and tells these people that they are right, they are smarter than people with education, than people with money, than these bad others. He makes their irrational prejudices into virtues. And they love him for it,” he added.

“A huge number of Americans simply do not understand the connection between government and their lives. Government is a ‘bad other’: the enemy, something to be mistrusted and opposed at all costs.

“So the Trump voter doesn’t give a flip about health care when they walk into the voting booth.  They do not believe that the government could ever provide them decent health care.

US President Donald Trump at recent rally. Supports are not wearing masks.

“They ‘know’” Obamacare has failed and is bad – even though it only ‘failed’ because the GOP congress wouldn’t fund it or implement it. The Trump voters vote on issues like their professed opposition to abortion and transgender rights, and their support for gun rights. Their vote for Trump has nothing to do with their own economic interests, except to the extent that their information system has told them that socialism is bad. And a vote for Trump is a vote against the undefined bad other, socialism.

“As for COVID, the Trump voters mostly do not believe it is real. They won’t wear masks. They assemble in groups, at churches and proms. Our hospital numbers are through the roof, but they don’t believe it, because their information sources tell them, doctors overreport COVID to get money – ‘those educated greedy doctors again.’

“And they chuckle to themselves, congratulating themselves on how they’ve seen through the liberal conspiracy, because at least THEY aren’t falling for this COVID nonsense. This is from people who have family members who have died with COVID. The denial is astounding, and inexplicable to me. But it is as real as the coffee in my cup.”

Conservatives See the Robust Trump Support Very Differently

Scott Jennings, a Republican campaign adviser from Kentucky, argued that Trump’s base of support had, in fact, expanded in this election to include new African American and Latino voters in areas like Miami-Dade county, where Trump had campaigned heavily and did even better than he had in 2016 against Hillary Clinton.

The COVID-driven “rebuke” anticipated by the Democrats did not happen quite as expected.

Jennings said in an interview with CNN: “Republicans are pretty well stunned at how well Donald Trump did.

“There has been a clear realignment here for the Republican party to attract new working class voters of all races. When you look at the resilience of the Republican party in all these states with these large rural areas, among working class voters, the attraction of some new hispanic voters, even some African American voters.

“I also think there has been a rejection of the Democratic party, and in some cases the media, of the liberal elites in rural America. They feel like they are held to different rules: double standards. They’ve been browbeaten for their support of Donald Trump, and they turned out in droves yesterday to let folks know it. It’s not all bad for the party right now.”

Atmosphere of fear

Yet, despite the positive spin of some conservative pundits, Americans of all persuasions were bracing for Trump’s legal challenges, possible violence and more uncertainty, while a decisive vote still remained elusive.

With Michigan and Wisconsin finally swinging toward the Democratic contender Wednesday evening, the projected electoral college count for Biden stood at 253 out of the golden 270 votes needed. But large final counts of the mail-in vote remained outstanding in key states like Pennsylvania, Arizona and Nevada; wins in just two of the three would clear his path to victory.

From New York City to Washington DC and Dearborn, Michigan, more and more storefronts were being boarded up in the anticipation of potential violence from both left and the alt-right – depending on the way the election falls.

Supporters of President Donald Trump at a “Make America Great Again” campaign rally last week without masks in Phoenix Arizona. The state flipped in Biden’s favour in 2020.

The electric tensions were being fuelled by Trump’s comments already on election night. Appearing at about 2:30 a.m. Wednesday morning at a White House party of some 250 campaign supporters, Trump claimed victory and said that he would contest the continued tabulation of mail-in ballots still underway in many states.

“We want all voting to stop.  We don’t want them to find any ballots at 4 o’clock in the morning and add them to the list, OK,” Trump said in his televised remarks protesting the counting of mail-in ballots, as districts in key states around the country tried to process huge ballot backlogs.

“This is a fraud on the American public… an embarrassment to our country.  We were getting ready to win this election. Frankly we did win this election,” he said. “So our goal now is to ensure the integrity for the good of this nation. This is a very big moment… We want the law to be used in a proper manner. So we will be going to the US Supreme Court.”

People in rural and working class neighborhoods who bucked trends to support Biden have been keeping their heads particularly low – as Trump supporters roam their neighborhoods demonstrably, sometimes visibly armed.

The Reno construction worker who voted Biden said he had been afraid to post a campaign sign on his lawn for fear of violent reprisals. He is fearful that roaming brigades of Trump supporters parading through his neighborhood might also somehow finger him as a target – and has alerted a police officer just in case.

“They’re not hard to identify,” he said. “They drive around in jacked up pickup trucks with tattered American flags hanging out. It’s really sick what they have done with our flag.

“Our flag is considered a symbol of freedom and democracy and they’ve turned it into a symbol of racism and hatred and bigotry.”

Kerry Cullninan and Raisa Santos in New York City contributed to this story.

This story was published in collaboration with Geneva Solutions – a new platform for peace & humanitarian, climate, global health, sustainable business & finance, and technology.

Image Credits: Kerry Cullinan, Adam Schultz/Biden for President/Flickr, GPA Photo Archive/Flickr, Gage Skidmore/Flickr.

The White House, Washington DC. There is currently no clear winner for President
The morning after election day, the winner is still unclear.

With the winner of the presidency and party control of the Senate still unclear the morning after Election Day, the future of the nation’s health system remains uncertain. At stake is whether the federal government will play a stronger role in financing and setting the ground rules for health care coverage or cede more authority to states and the private sector.

As of 4pm CET, Biden has a small lead of 227 electoral votes – compared to Trump’s 213 – having overtaken the incumbent president in key states Michigan, Wisconson and Arizona. Pennsylvania, North Carolina and Georgia are undeclared.

US Presidential Nominee Joe Biden.

Should President Donald Trump win and Republicans retain control of the Senate, Trump still may not be able to make sweeping changes through legislation as long as the House is still controlled by Democrats. But — thanks to rules set up by the Senate GOP — the ability to continue to stack the federal courts with conservative jurists who are likely to uphold Trump’s expansive use of executive power could effectively remake the government’s relationship with the health care system even without signed legislation.

The president has also pledged to continue his efforts to get rid of the Affordable Care Act, and if the Supreme Court overturns the sweeping law as part of a challenge it will hear next week, the Republicans’ promise to protect people with preexisting medical conditions will be put to the test. In a second term, the administration would also likely push to continue to revamp Medicaid with its efforts to institute work requirements for adult enrollees and provide more flexibility for states to change the contours of the program.

If former Vice President Joe Biden wins and Democrats gain a Senate majority, it would represent the first time the party has controlled the White House and both houses of Congress since 2010 — the year the ACA was passed. A top priority will be dealing with the COVID-19 pandemic and the economic fallout. Biden made that a keystone of his campaign, promising to implement policies based on advice from medical and scientific advisers and provide more directives and aid to the states.

Current US President Donald Trump.

But also high on his agenda will be addressing parts of the ACA that haven’t worked as well as its authors hoped. He pledged to add a government-run “public option,” which would be an alternative to private insurance plans on the marketplaces, and to lower the eligibility age for Medicare to 60.

While Democrats will continue to control the House, the final makeup of the Senate is still to be determined. And even if the Democrats win the Senate, they are not expected to come away with a majority that would allow them to pass legislation without support from at least some GOP senators, unless they change the Senate’s rules. That could lower expectations of what the Democrats can accomplish — and may lead to some tensions among members.

But who controls Washington, D.C., is only part of the election’s impact on health policy. Several key health issues are on the ballot both directly and indirectly in many states. Here are a few:

Abortion

In Colorado, a measure that would have banned abortions after 22 weeks of pregnancy — except to save the life of the pregnant person — failed, according to The Associated Press. Colorado is one of seven states that don’t prohibit abortions at some point in pregnancy. It is also home to one of the few clinics in the nation that perform abortions in the third trimester, often for severe medical complications. The clinic draws patients from around the nation, so residents of other states would have been affected if the Colorado amendment passed.

In Louisiana, however, voters easily approved an amendment to the state constitution to say that nothing in the document protects the right to, or requires the funding of, abortion. That would make it easier for the state to outlaw abortion if the Supreme Court overturns Roe v. Wade, which makes state abortion bans unconstitutional.

Medicaid

The fate of the Medicaid program for people with low incomes is not on the ballot directly anywhere this election. (Voters approved expansions of the program in Missouri and Oklahoma earlier this year.) But the program will be affected not only by who controls the presidency and Congress, but also by who controls the legislatures in states that have not expanded the program under the Affordable Care Act. North Carolina is a key swing state where a change in majority in the legislature could turn the expansion tide.

Drug Policy

In six states, voters are deciding the legality of marijuana in one form or another. Montana, Arizona and New Jersey were deciding whether to join the 11 states that allow recreational use of the drug. Mississippi and Nebraska voters were choosing whether to legalize medical marijuana, and South Dakota became the first state to vote on legalizing both recreational and medical pot in the same election.

Magic mushrooms are on two ballots. A measure in Oregon to allow the use of psilocybin-producing mushrooms for medicinal purposes passed, and a District of Columbia proposal to decriminalize the hallucinogenic fungi was leading.

Also approved was a separate ballot question in Oregon to decriminalize possession of small amounts of hard drugs, including heroin, cocaine and methamphetamine, and mandate establishing addiction recovery centers, using some tax proceeds from marijuana sales to establish those centers.

California

As usual, voters in California faced a lengthy list of health-related ballot measures.

For the second time in two years, the state’s profitable kidney dialysis industry was challenged at the ballot box. A union-sponsored initiative would have required dialysis companies to employ a doctor at every clinic and submit infection reports to the state. But the industry spent $105 million against the measure. The measure failed, according to AP.

Voters were also asked to decide, again, whether to fund stem cell research through the California Institute for Regenerative Medicine via Proposition 14. Voters first approved funding for the agency in 2004, and since then, billions have been spent with few cures to show for it. The measure was winning in early returns.

California has been at the forefront of the fight over the so-called gig economy, and this year’s ballot included a proposal pushed by ride-hailing companies like Uber and Lyft that would let them continue to treat drivers as independent contractors instead of employees. Under Proposition 22, the companies would not have to provide direct health benefits to drivers but would have to give those who qualify a stipend they could use toward a premium for health insurance purchased through the state’s individual marketplace, Covered California. The measure was approved.

Finally, voters in the Golden State were asked whether to impose higher property taxes on commercial property owners with land and property holdings valued at $3 million or more, which could help provide new revenue earmarked for economically struggling cities and counties hit hard by COVID-19, as well as K-12 schools and community colleges. Community clinics, California nurses and Planned Parenthood jumped into the thorny political battle over Proposition 15 — taking on powerful business groups — eyeing revenue to help rebuild California’s underfunded public health system. The measure was too close to call in early returns.

Democrats in California, who control all statewide elected offices and hold a supermajority in the legislature, have been positioning for a Biden win, and some were already penning ambitious health care legislation for next year. Should Biden win, they said they plan to crack down on hospital consolidation and end surprise emergency room bills, and some were quietly discussing liberal initiatives such as pursuing a single-payer health care system and expanding Medicaid to cover more unauthorized immigrants.

 

KHN (Kaiser Health News) is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.

Image Credits: Library of Congress/Carol Highsmith, Mike Beaty/Flickr, Gage Skidmore.