INB co-chairs Anne-Claire Amprou and Precious Matsoso

The mpox outbreak – characterised by the all-too-familiar lack of vaccines for Africa – provided added impetus to the global negotiations for a pandemic agreement, which resumed at the World Health Organization (WHO) headquarters in Geneva on Monday. 

Ethiopia, speaking for Africa, said that mpox, recently declared a public health emergency of international concern, “calls for a more focused approach to address the outstanding elements in the draft pandemic agreement to ensure that it’s balanced and addresses the gaps that perpetuate past inequalities and inequities, particularly in the developing countries”. 

“We cannot maintain the status quo,” stressed Ethiopia.

Mpox “illustrates the importance of a pandemic agreement that will effectively cover and address the full [pandemic prevention, preparedness and response] cycle”, added the European Union (EU).

Warm-ups

While the Intergovernmental Negotiating Body (INB) last met in July, four warm-up “interactive dialogues” were held last week addressed by experts and aimed at clarifying the big topics ahead of the negotiations. These focused on the pathogen access and benefit-sharing (PABS) system, One Health and what legal architecture is most appropriate for adopting the agreement.

PABS – how to share information about dangerous pathogens speedily and in a way that parties benefit if they share the information – is the heart of the agreement for many countries.

Ethiopia, speaking for the Africa region, stressed that PABS is “an integral part of the pandemic agreement, and its success will determine the fate of the entire agreement and its coming into force”.

Ethiopia, speaking for Africa at INB 11.

The International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) appealed for flexibility in the agreement.

“We believe it is possible to reach an agreement that addresses the needs of countries while enabling the private sector to innovate and respond effectively to future pandemics,” said the IFPMA’s Greg Kumer.

“Each pathogen of pandemic potential is unique, and so too will be the response of each company. The agreement must recognize the diversity within the biopharmaceutical industry as each company has different strengths based on its size, location, technology, platform and manufacturing capabilities,” said Kumer.

“We call for a framework that allows companies to choose from a menu of options to maximize their impact.”

He also called for for “creativity and proactive engagement” to “tackle critical challenges such as improving demand forecasting, ensuring surge financing for procurement in low income countries and addressing regulatory barriers”. 

Legal architecture

Aside from negotiating the content of the agreement, member states are debating how it should be adopted to ensure maximum effect. They are deciding whether to adopt it in terms of Article 19 or Article 21 of the WHO Constitution.

Under Article 19, the agreement would be a treaty-like “operative instrument” that, once adopted by the World Health Assembly (WHA) by a two-thirds majority, states would need to sign and ratify – potentially delaying adoption by years.

Under Article 21, the WHA has the authority to adopt regulations on “procedures designed to prevent the international spread of disease”. Once adopted by the WHA, member states would be bound by the regulations unless they opt out.

However, Knowledge Ecology International warned: “An Article 19 treaty will carry more legal authority for many member states, which has advantages, but in some forms and for some countries, the ratification of a treaty will be challenging, and may take considerable time.”

WHO’s Chief Legal Officer Steven Solomon also explained that the agreement itself had the potential to set up other structures – such as on PABS and One Health. These could either be annexes or protocols, and these too could be incorporated under Articles 19 or 21.

Decisions would need to be made based on what the approval mechanisms are internationally and domestically, said Solomon.

“Will the governance for the instruments be the same? Will there be complementary governance processes? If so, how will that complementarity and coordination be developed? And then the third consideration is, of course, implementability,” stressed Solomon.

US Ambassador Pamela Hamamoto stated her country’s preference for PABS to be adopted under Article 21 to enable “the broadest participation and allow for rapid adoption”. 

“Some experts [at the interactive dialogue] cautioned that if the pandemic agreement were adopted under Article 19, pursuing a PABS instrument under Article 21 could present complexities for aligning parties to both instruments and coordinating entry into force,” she added.

The Pandemic Action Network’s (PAN) Aggrey Aluso urged member states not to opt for protocols of annexes but to keep PABS, technology transfer, intellectual property and One Health as “robust in the text of the final agreement”.

“We think relegating issues to separate protocols only would further fragment the global PPR ecosystem and undercut the global solidarity and universality needed for meaningful change,” stressed Aluso.

Next two weeks

Addressing the opening, South Africa urged member states “to guard against losing the caring spirit and solidarity that existed at the beginning of this process. It is that commitment to humanity and the principles of solidarity in addressing equity that will carry us to change the current status quo.”

The rest of this INB, until its conclusion on 20 September ,will be conducted in closed negotiation sessions. 

Fanny Malemia, who is deaf and has a speech impediment, had a miscarriage after communication problems with health workers.

Pregnant women with disabilities in Malawi face a myriad of challenges, despite several policies and an Act stipulating the need to respect disability rights, including in health service provision.

BLANTYRE, Malawi – When Lynes Manduwa miscarried, nurses in the gynaecology ward at Queen Elizabeth Central Hospital (QECH) ganged up and confronted her husband.

“They confronted him for impregnating me [a woman with disabilities] and blamed him for the miscarriage, which was actually due to the usual biological reasons, which even women without disabilities would also experience,” she recalls.

Twelve out of every 100 Malawians aged five and older have a disability, according to Malawi’s 2018 Population and Housing Census.

“I’m certain they do this and other awful things to women with disabilities seeking maternal health care. I lost a colleague who tried to deliver by herself at home because she was mistreated in her previous hospital visit,” claims 58-year-old Manduwa, who has a mobility impairment and uses clutches and a wheelchair interchangeably.

Her suspicion derives from what she has experienced at antenatal clinics during all her four pregnancies (including the miscarriage).

“I was worried about the reception at every clinic every day. I was always told to wait for the doctor. They [nurses] considered me a special case. Everyone would be attended to by the midwife on duty except me. The doctor would come later on after their ward rounds,” tells Manduwa, who had Caesarean Sections for her three surviving children.

“It feels embarrassing to sometimes have nurses call each other to discuss your issues openly among themselves just because they are dealing with a person with disabilities,” states Manduwa, herself a disability rights advocate, revealing that it’s hard for women with disabilities to deliver with dignity at public health facilities.

Lynes Manduwa says health workers berated her husband for impregnating a disabled woman after she lost a baby.

She says there is a big gap in Sexual Reproductive Health (SRH) justice for women like her, attributing it to myths that women with disabilities have a different biological makeup.

There is a lack of special needs designated washrooms and labour wards, making it hard for women with disabilities to freely use the facilities. The facilities rely on the women’s guardians to assist them around, in the process, compromising their privacy.

“The labour ward is almost inaccessible for us, there is a need for functional adjustable beds. Ambulances are also inaccessible. All these factors leave our privacy compromised,” Manduwa says.

Language barriers

For women with hearing and speech impairment, such as Fanny Malemia, communication challenges with health personnel have had drastic consequences.

“I lost a three month old pregnancy due to poor communication with health workers,” reveals the 29-year-old Blantyre resident that we interviewed through a sign language interpreter.

While pregnant in 2018, she experienced bleeding and abdominal pain. But due to poor communication, health workers at a Zingwangwa Health Centre failed to decipher what she was really trying to say, until a friend accompanied her to the referral Queen Elizabeth Central Hospital where a scan revealed she had an ectopic pregnancy. This is a life threatening pregnancy condition. 

“The fallopian tube had decomposed, and I had an emergency surgery,” she looks away, fighting a tear, distressed by the memory of her loss.

Fanny Malemia had an ectopic pregnancy, but it was not picked up until very late because of her struggle to communicate with health workers.

Malemia recollects: “I endured a double psychological battle. This loss also disturbed my relationship with my husband (…) until I became pregnant again a year later.”

Unfortunately, none of her female friends could effectively communicate with health personnel, so a sign language interpreter from her local Living Waters Church (LWC) would accompany her and the husband, who is also deaf on antenatal visits.

“I regarded it as a calling to help Malemia through this journey. She was lucky, but I noted a lot of suffering for women with disabilities at our public health facilities,” says Bishop Emmanuel Zalira.

While the bishop admitted to being “highly uncomfortable being among women, mostly chatting about their sexuality issues and singing safe motherhood songs”, he could not leave Malemia without an interpreter, as “women with disabilities are likely to get the wrong treatment.” 

The Malawi National Association for the Deaf (MANAD) says miscommunication between health workers and their members are very common and worrying.

MANAD Executive Director Bryson Chimenya says lack of sign language interpreters in health facilities makes it difficult for women with hearing impairments to communicate with health personnel.

“Deaf women face numerous challenges. Healthcare professionals display unfavourable attitudes towards them. Just recently, one woman [having hearing impairments] was slapped during labour because the nurses and the patient couldn’t communicate,” he says.

No specialised training

The Midwives Association of Malawi (MAM) says it’s sad that women like Manduwa and Malemia have allegedly endured such treatment. It says the association’s professional vow and calling is to offer comprehensive midwifery care without discrimination, emphasising that women with disabilities deserve the best just like anyone else.

“At any given interaction opportunity and through continued professional development sessions, we repeatedly remind our members of the need for respectful maternity care,” MAM President Keith Lipato said.

Acknowledging that inadequate facilities compromise care for women with disabilities in public hospitals, Lipato says asides absence of disability friendly infrastructure, midwives do not have special training to care for those with speech and hearing disabilities among other disabilities.

“The curriculum needs to have content on caring for patients with disabilities to prepare the midwives,” he suggests, urging women with disabilities to report any ill-treatment to MAM.

Kamuzu University of Health Sciences (KUHes), Malawi’s major medical training institution, admits to the absence of specialised training on handling persons with disabilities, stating that some surface content is covered in their four-year nursing programmes.

No official complaints 

QECH, a central hospital that treats around 400,000 patients annually, says it has never received any complaint about discrimination or mistreatment based on one’s disability. 

“We are open to hearing diverse views on how we can improve the care we offer to our patients. We would be happy to hear from any section that is willing to help us make the hospital environment more responsive to their specific needs,” says QECH Director, Dr Kelvin Mponda.

If a patient and provider cannot communicate, he says, it is within the medical ethical confines to have a family member, whom the patient is comfortable with to help fill the gap to ensure appropriate medical care.

“Abusing patients in any form doesn’t reflect the position of QECH towards any section of the society, if proof can be provided, this is a punishable offence,” he says.

Simon Munde, executive director of the Federation of People with Disabilities in Malawi (FEDOMA), an umbrella of organisations of persons with different disabilities, says there that many survivors of poor treatment opt to suffer in silence.

“It’s not uncommon for  health personnel to express their disappointments or shock that a woman with disability fell pregnant. It’s sometimes considered as a sign of not being considerate to impregnate a woman with a disability,” added Munde.

No specialised health workers

Despite international commitments, we have established that Malawi has no specialised health care workers, instead, the responsibility is left with unqualified guardians, tasked with the interpreter and caring responsibilities of pregnant women with disabilities. 

Doreen Ali, Director of Reproductive Health in the Ministry of Health (MoH), admits the lack of trained health care workers to communicate with speech and hearing impairment women seeking maternal care.

She acknowledges challenges that women with disabilities face in accessing maternal health services, stating that MoH is working on a strategy to strengthen communication with such women. 

Director of Reproductive Health in the Ministry of Health (MoH), Doreen Ali

Ali reveals that MoH’s department of policy and planning is currently working on the establishment of special needs health workers. 

She says MoH intends to review health workforce curricula to enhance a human-rights based and intersectional approach to disability, including psychosocial, intellectual and cognitive disability, to address stigma, stereotyping, and discrimination in health service delivery.

“Health workers will be trained through the pre-service curriculum to get prepared and have the skills when providing maternal services,” she says.

The MoH, through the reproductive health department, has developed the obstetric protocols for the management of emergencies like ectopic pregnancies and bleeding. These  provide the information for health care workers to follow when managing all patients with bleeding or ectopic pregnancy.

“Currently health workers rely on guardians for communication since they are yet to be trained in sign language,” says Ali.

Policy exclusions

At the end of the National Disability Mainstreaming Strategy and Implementation Plan (NDMS & IP) 2018 – 2023, the policy failed to achieve its strategic goal of attaining the highest attainable standard of health by persons with disabilities.

This is despite the document acknowledging that persons with disabilities have comparatively limited access to health services due to critical shortage of human resource, especially occupational therapists, physiotherapists, dermatologists, ophthalmologists, speech therapists, medical social workers and medical rehabilitation technicians (audiologists, orthopaedic technologists).

Sexual and Reproductive Health Justice Expert Dr Godfrey Kangaude

The NDMS & IP also admits to the inaccessibility of health infrastructure to persons with mobility and visual challenges, communication challenges and negative attitudes towards persons with disabilities on the part of some medical staff, especially in addressing reproductive health needs for women with disabilities. 

Sexual and Reproductive Health Justice Expert Dr Godfrey Kangaude says every country should ensure ‘reasonable accommodation’ to ensure that persons with disabilities have the same quality of Sexual Reproductive Health and Rights (SRHR) services as persons without disabilities. 

Kangaude  says it’s unethical for health care workers to say demeaning words questioning who and why they impregnated a disabled person (like in Manduwa’s case), “This is  a violation of a persons’ dignity and autonomy, to be considered as not worthy to reproduce….women with disabilities also want to be pregnant and they shouldn’t be derided for it. ”

Kangaude flags that knowledge is powerful in shifting attitudes and helping people appreciate alternative and better ways of doing things, which aligns with respect for other people.

Holding MoH to account

Manduwa says FEDOMA has on several occasions tried to engage MoH on this, but nothing has changed.

“We normally advocate with authorities to ensure disability inclusive health service delivery in all health facilities. With support from Sight Savers and UK Aid Match, we have trained health workers in gender and disability mainstreaming,” Munde says.

But the Malawi Council for Disability Affairs (MACODA) expressed ignorance about any specific initiatives being undertaken by the MoH.

The organisation said that it is actively engaging MoH on its obligations under the newly enacted Malawi Persons with Disabilities Act of 2024. Section 25 of the Act mandates and obliges health institutions to provide accessible health services tailored to the specific needs of persons with disabilities seeking healthcare. It further prohibits any form of discrimination in the provision of health care and rehabilitation services to persons with disabilities.

Protecting rights

MACODA Public Relations Officer Harriet Kachimanga says the organisation is committed to promoting and protecting the rights of persons with disabilities, including their SRH rights. 

MACODA Public Relations Officer Harriet Kachimanga

“We believe that accessible maternal health services are vital for ensuring that women with disabilities receive the care and support they need during pregnancy and childbirth,” she says pledging her organisation’s continuous dialogue with MoH on the newly enacted Act.

Malawi’s policies have not been in accordance with the international agreements she is party to, such as the  Convention of the Rights of Persons with Disabilities (UN CRPD)-an international agreement protecting and protecting human rights of people with disabilities and the African Disability Protocol– the legal framework based on which African Union member states are expected to formulate disability laws and policies to promote disability rights in their countries.

The Southern Africa Federation of the Disabled (SAFOD), an umbrella body for 16 organisations across the region, observes that the health status of persons with disabilities is often poorer than that of the general population due to the inequalities accessing healthcare services.

SAFOD Director-General Mussa Chiwaula

The organisation says, among others, women with disabilities experience stigma and discrimination owing to stereotypes, misconceptions regarding their sexuality such as asexuality, hyper sexuality, and possibilities of having unsafe deliveries, inability to carry the baby to term and inability to care for the new born.

“This is a serious problem in Africa. The seriousness of this problem is that it can lead to risks of complications, maternal morbidity and mortality for pregnant women with disabilities. These women like everyone else deserve to be treated with dignity and respect,” says SAFOD Director General Mussa Chiwaula.

He says African governments and health ministries have a responsibility to ensure an inclusive health care system for persons with disabilities, suggesting that other partners such as SAFOD, Non-Governmental Organisations, development partners, academia, and the media need to hold the government accountable by lobbying and advocating for an inclusive health care system.

SAFOD strongly believes every person has the right to accessible, affordable, and acceptable quality health care service information including SRH rights. 

The World Health Organisation says, an estimated 6.2 percent of the one billion people with disabilities globally are women. 

Manduwa, Malemia and many other women with disabilities look forward to discrimination free maternity experience at public health facilities.

This story was supported by the Pulitzer Center through Underreported stories in Africa project

Image Credits: Josephine Chinele, Jospehine Chinele.

Laurent Muschel, Head of Health Emergency Preparedness and Response Authority (HERA) at the European Commission hands the mpox vaccines to DRC Health Minister Samuel Roger Kamba (centre) and Africa CDC Director General Dr Jean Kaseya

Now that the first mpox vaccines have arrived in the Democratic Republic of Congo (DRC) courtesy of a European Union donation, the challenge is to ensure that they get to where they are needed most.

This includes war-torn eastern DRC, camps of displaced people in North and South Kivu, and the immediate family members of those with mpox, particularly parents and siblings of infected children – an estimated 60%-plus cases in the DRC.

The Africa Centres for Disease Control and Prevention (Africa CDC) and United Nations Children’s Fund (UNICEF) announced the arrival of 99,100 doses of Bavarian Nordic’s Jynneous (MVA-BN) vaccine on Thursday.

The DRC, the epicentre of the outbreak, declared mpox an epidemic over 18 months ago but its drug regulator only authorised the emergency use of the two mpox vaccines – Jynneous and Japan-based KM Biologics’ LC16 vaccine – in late June. 

The World Health Organization (WHO) is currently reviewing Jynneous and LC16 for emergency use listing (EUL). Had it moved to do so sooner, the DRC and other affected areas would have been able to use this to get the vaccine.

Africa CDC Director General Dr Jean Kaseya told a Friday media briefing that the drug regulators in Rwanda, Cameroon and Nigeria had now issued EULs for Jynneous, which enabled them to also receive vaccine donations.

“We are expecting the [EUL] form from Burundi very soon,” added Kaseya of the country with the second highest toll, which is also one of the poorest countries in the world with very weak infrastructure.

Jynneous is not listed for use in children. However, WHO’s Dr Ana-Maria Restrepo told a briefing on Wednesday that countries would be able to use it off-label for children.

Mpox cases continue to rise

Mpox cases continue to rise in the continent with 5,466 suspected new cases (252 confirmed) and 26 deaths in the past week, according to Kaseya.

“Displaced families living in crowded schools, churches and tents in farmers’ fields have no space to isolate when they develop symptoms of the disease,” warned the UN High Commission for Refugees(UNHCR).

“UNHCR staff have found some affected individuals trying diligently to follow preventive measures and protect their communities by sleeping outside.  A balanced diet is also important for recovery, a reality out of reach for many of the displaced who subsist on meagre food rations.”

The UNHCR also noted that, while rapid testing of suspected cases is critical, “in unstable zones of the eastern DRC, the security risks and circuitous routes necessary to get samples to a laboratory mean delays, hence test results cannot be used effectively to break transmission chains”.

One African response plan

In response to the outbreaks, Africa CDC and WHO Africa have devised a joint continental response plan to ensure a coordinated approach to the outbreaks.

According to the plan’s foreword, the COVID-19 pandemic exposed “vulnerabilities in our health systems, showed Africa’s inequity and unfair treatment in terms of access to medical countermeasures, highlighted the urgent need for enhanced preparedness, and underscored the importance of swift, coordinated action in the face of emerging health threats”.

A key lesson learnt was that public health emergencies require “solidarity, resilience, and collaboration”.

In this regard, the continent has resolved to follow a single coordination mechanism, continental response plan, budget, and monitoring and evaluation mechanism.

The plan divides African member states into four categories based on their mpox status and risk level. The highest risk is countries with sustained human-to-human transmission, followed by countries with sporadic human cases since January 2022 or endemic zoonotic reservoirs.

Countries needing enhanced readiness due to their proximity to countries with ongoing transmission are the third category, while the fourth is those who are not currently facing an outbreak or near one.

“The plan includes measures to strengthen surveillance, laboratory detection, case management, infection prevention and control, vaccination, risk communication and community engagement and research and innovation,” according to a joint media release.

Image Credits: WHO.

Prof R Subramanian, who heads the air quality sector at the Center for Study of Science, Technology and Policy, addressing the India Clean Air Summit.

Fundamental policy changes aimed at fixing India’s seemingly intractable air pollution health crisis were suggested at the India Clean Air Summit (ICAS) held in Bengaluru recently. 

Among the dozens of presentations by air quality scientists and officials, five key elements emerged for policy action that can speed up the reduction of air pollutants. These involve: adopting an airshed approach rather than the prevalent city-centric approach; changing the core focus of the National Clean Air Programme (NCAP); tackling indoor household pollution; sharply reducing combustion and black carbon emissions; and plugging data gaps with low-cost sensors and modelling. 

Hosted by the Center for Study of Science, Technology and Policy (CSTEP), the sixth meeting of what has become a staple of the global air quality ecosystem, was attended by over 300 Indian and international scientists, government officials, policymakers, health officials, political leaders and civil society. 

India’s ambient air pollution, both outdoors and indoors, has been linked to over two million premature deaths annually. This includes about 170,000 children. Pollution levels have stayed in the same ballpark for the last five years, which is more than 10 times the WHO’s guidelines (see IQAir table below); in places like Delhi it is about 20 times higher. 

Change focus from cities to airsheds

India’s main air pollution control programme, NCAP, is currently city-focused. It incentivises 131 cities to reduce pollution, and in return, these are allocated federal funds. The problem with this approach is that much of cities’ pollution comes from outside their jurisdiction, so urban local bodies (ULBs) are helpless. 

In a new study, CSTEP documented the emission inventory, or local sources of pollution, in 76 Indian cities, perhaps one of the largest such studies anywhere. 

Take, for example, Ghaziabad which borders Delhi in the east and has been identified as one of the most polluted cities in the world. The PM 2.5 pollution measures over 28,000 tonnes per year. But 95% is from the greater city area. PM 2.5 is a microscopic particulate matter pollutant which can settle deep inside the human body and is linked to multiple health disorders such as chronic lung disease, strokes, heart attacks, cancers as well as depression and hypertension. 

It is similar to Davangere, a small town in Karnataka. 

Meanwhile, for an industrial town like Kalinga Nagar in Odisha, which has large factories inside and outside city jurisdictions, the share of PM 2.5 is almost equally divided. 

The report points out that most of the cities will not be able to achieve NCAP’s target of reducing pollution by 40%. 

“Our preliminary air quality modelling results also suggest that emissions from outside the city – what we call the airshed – can also be significant contributors to urban air pollution,” said Dr R Subramanian, who heads the Air Quality Sector at CSTEP.

“We need a broader, comprehensive approach that reduces emissions from the city and the airshed at large – actions that likely require national or state-level interventions and investments in systemic change to reduce fossil fuel and biofuel use in favour of clean, renewable energy. This will move us firmly towards clean air for all – for people in cities, periurban areas, and in villages across the country.”

Ashish Tiwari, the top environment officer of Uttar Pradesh, India’s most populous state and one of the most polluted, called for NCAP to drop its city-centric approach and target airsheds. 

“We have strongly recommended that NCAP must adopt this airshed approach. And I am happy to tell you that MoEFCC (Ministry of Environment, Forests and Climate Change) has started mulling over it, and very soon, I think the airshed coordination committee of eight IGP states will see the light of day,” said Tiwari.

Focus on PM 2.5

Delegates at the India Clean Air Summit

Announced in 2019, NCAP’s target is to reduce up to 40% the concentration of PM 10 by 2025-26. While PM 10 is a health risk, the finer PM 2.5 pollution can be more toxic and easily defeat the human body’s defence mechanisms. At times, the larger PM 10 can be controlled using equipment like vacuuming and mist-spraying trucks used to contain road dust. 

There’s no silver bullet to cut air pollution, but ensuring clean cooking fuel was one step backed by many scientists and officials in India and other parts of the Global South. Currently, the use of heavily polluting fuels, like wood, coal and biomass, is widely used, which emits a “cocktail” of toxic elements, as health expert Professor Kalpana Balakrishnan, a senior WHO and ICMR official, described it. 

These include PM 2.5, carbon dioxide, carbon monoxide, benzene, sulphur oxides and nitrogen oxides, among others. All this is inhaled near the polluting stove. 

Balakrishnan pointed out that different studies have put the share of household air pollution anywhere between 20 to 50%, which is a significant part of India’s ambient air pollution crisis. 

In 2016, the government launched a widely hailed programme, the Pradhan Mantri Ujjwala Yojana (PMUY), to provide free subscriptions to a gas cylinder; some refills are free but most are paid. Studies have documented a decline in PM 2.5 exposure thanks to the Ujjwala scheme. 

Several experts at ICAS called for more funding to reduce costs for the beneficiaries. Women, invariably those cooking at home, prefer using a cooking gas cylinder. But the cost of refilling – about Rs 800 or $10 per cylinder – is a challenge for most low-income beneficiaries.

However, there is a divergence between the government and health experts. In the current financial year, the government’s budget support for cooking gas subsidies has declined by 2.5%. Various studies have report

Uttar Pradesh, which has 18 million Ujjwala beneficiaries, the highest, is banking on other ‘clean’ cooking solutions such as bio-digesters and induction cooktops, Tiwari said at ICAS. He flagged the low-income status of the beneficiaries, saying, “PMUY is actually linked with the income level of the households. So that will take time. We have to think about the intermediate solutions for clean cooking. So increased bio-gas uses can actually break down PM 2.5 by 97%, black carbon by 92%, and carbon dioxide-equivalent by 70%.”

However, Balakrishnan, pointed out that there are several studies where primarily LPG (liquified petroleum gas) was used, comparing it to the use of biomass. In a “majority, or virtually all of the outcomes, the central estimate is favouring LPG. So there is very convincing evidence that the use of LPG, A, reduces exposures, B, is associated with improved health outcomes…”

Reduce combustion, track super-pollutants

Scientists like Dr Sarath Guttikunda, Founder and Director of Urban Emission, pointed out that another significant way to start reducing air pollution was to address the increasing combustion of fossil fuels. He presented data to show a rising trend in the production and consumption of coal, oil and gas. 

Monthly data shows rising production and consumption of fossil fuels. 

Monthly data shows rising production and consumption of fossil fuels.

Anumita Roychowdhury, executive director at the Centre for Science and Environment and one of the panellists at ICAS 2024, warned that some pollutants, particularly black carbon, were not being monitored enough.

“Science is telling us that there are some subsets of particulate matter such as black carbon that have much more warming potential than CO2. Moreover, when they settle on snow and glaciers, they melt and result in a water security threat. They also affect cloud formation and interfere with rainfall patterns,” she said. 

Black carbon (BC) is strongly correlated with increased blood pressure levels, a high-risk factor for cardiovascular disease and strokes. It affects pregnant women and has been linked to low birth weight. Because it has a short lifespan of about a week or two in the atmosphere and yet so many devastating effects, it is known as a super-pollutant. Common sources of BC include brick kilns, burning waste, incomplete combustion of fuels, forest fires, and burning of crop stubble. There are policies and programmes in place to reduce these, but they need to be accelerated. 

Plugging data gaps 

Finally, air quality monitoring has drastically improved with the government installing regulatory-grade monitors, from a handful a decade ago to about 550 now. But these are mainly in cities. A solution that has emerged over the last few years is low-cost sensors. At a fraction of the cost of the regulatory ones, these are reliable enough to provide actionable data. Hundreds of these are already in use nationwide as part of various programmes. 

If there has to be one backbone of the entire air quality management system, several participating scientists and officials cited the importance of modelling.

Guttikunda explains: “While monitoring data continues to be the cornerstone of regulations and management, air quality modelling needs to be the foundation of most of the discussions because this exercise provides us with information on how much, where is, when is, and what is contributing to the observed pollution levels. Going forward, in India, we need more emphasis on building this capacity.”

However, he cautions that since ambient monitoring is limited to specific locations and mostly to the cities, this data may not always reveal the full picture. “We need to keep a closer look at fossil fuel consumption trends in India, which determine the emission loads and pollution levels that we experience.”

Science vs pseudo-science

The clean air conference gave space to some frank talk about a crisis that frequently makes headlines in India. Dr Sachin Ghude, a government scientist at the Indian Institute of Tropical Meteorology, has helped to design the modelling system for Delhi based on which authorities may shut down schools and industrial units and restrict traffic among the more stringent measures to cut pollution in the short-term. 

Ghude took on the more controversial measures such as smog guns, water sprinkling, and cloud seeding often adopted or considered in Delhi and some other cities. He was clear that these are not effective in reducing pollution. Ironically, Delhi’s local state government was almost simultaneously pursuing cloud seeding.

ICAS was supported by Bloomberg Philanthropies, Open Philanthropy and Clean Air Fund, and partnered with Clean Air Monitoring and Solutions Network (CAMS-Net). 

Disclosure: Chetan was a communications consultant at ICAS.

World Meteorological Organization’s latest bulletin finds that wildfire emissions cross borders and entire continents.

Climate change, wildfires and air pollution are locked in a deadly cycle threatening human health, ecosystems and agriculture worldwide, the World Meteorological Organization (WMO) warned on Thursday.

The WMO sounded the alarm in its latest bulletin on air quality and climate, the fourth such publication this year. With a special focus on wildfires, the report analyzes global and regional concentrations of particulate matter pollution and its harmful effects on health and crops in 2023.

Ambient air pollution causes more than four million premature deaths annually in addition to high economic and environmental costs, according to World Health Organization (WHO) figures.

“Climate change and air quality cannot be treated separately. They go hand-in-hand and must be tackled together,” said WMO Deputy Secretary-General Ko Barrett. “It would be a win-win situation for the health of our planet, its people and our economies, to recognize the inter-relationship and act accordingly.”

Fine particulate matter, or PM2.5, is the major health hazard in air pollution. These microscopic particles, about 30 times smaller than human hair, can penetrate deep into the lungs and enter the bloodstream. Sources include fossil fuel combustion, wildfires, vehicles, construction sites and wind-blow desert dust.

Breathing Fire: Wildfire Smoke Linked to Sharp Rise in Dementia Risk

The WMO’s focus on wildfires aligns with emerging research highlighting the unique dangers of wildfire smoke. Recent studies suggest it may be more harmful than other forms of air pollution, potentially increasing risks of dementia, cognitive decline, cancer, heart attacks, pregnancy complications, strokes and attention deficits.

In 2023, Canadian wildfires burned a record area, seven times more than the 1990-2013 average. Smoke from these fires spread across the United States and reached Europe, while Algerian wildfire smoke crossed the Atlantic to Latin America, underscoring the international scope of the threat.

With climate change intensifying fire seasons globally, health risks from wildfire smoke are escalating worldwide, the WMO reported.

“Smoke from wildfires contains a noxious mix of chemicals that affects not only air quality and health, but also damages plants, ecosystems and crops – and leads to more carbon emissions and so more greenhouse gases in the atmosphere,” said Dr Lorenzo Labrador, a scientific officer in WMO’s Global Atmosphere Watch network.

While the bulletin focuses on 2023 data, Barrett noted that the trends have continued into the current year.

“The first eight months of 2024 have seen a continuation of those trends, with intense heat and persistent droughts fuelling the risk of wildfires and air pollution,” he said. “Climate change means that we face this scenario with increasing frequency.”

Record wildfires suffocate ecosystems, agriculture

Air pollution’s dangers extend far beyond human health. Pollutants such as nitrogen and sulphur that settle on Earth’s surface threaten ecosystems and agriculture. These contaminants reduce vital ecosystem services, including clean water, biodiversity and carbon storage

The threat to agriculture is also significant. High concentrations of particulate matter can block sunlight and hinder plants’ carbon dioxide absorption. In heavily polluted areas of India and China, experimental evidence shows particulate matter deposition reduced crop yields by up to 15%, according to the WMO bulletin.

Farming practices in Central Africa, China, India, Pakistan and Southeast Asia — regions most affected by pollution’s impact on agriculture — contribute significantly to particulate matter pollution. These practices include stubble burning, fertilizer and pesticide use, soil tilling, harvesting, and manure management.

Emissions rise in North America, India but fall in Europe, China

The WMO bulletin used two different products to estimate global particulate matter concentrations: the Copernicus Atmospheric Monitoring Service and NASA’s Global Modeling and Assimilation Office.

Both Copernicus and NASA found that North American wildfires caused exceptionally high PM2.5 emissions compared to the 2003-2023 reference period.

Large, persistent fires burned from early May in western Canada until late September 2023, the bulletin said. This worsened air quality in eastern Canada and the northeastern U.S., particularly New York City. Smoke travelled across the North Atlantic to southern Greenland and Western Europe.

Above-average PM2.5 levels were also measured over India, due to increased pollution from human and industrial activities.

China and Europe measured below-average levels, thanks to decreased human-source emissions. This trend has been observed since the first WMO Bulletin in 2021.

In recent years, China, once heavily reliant on coal, has become a world leader in renewable energy, resulting in reduced emissions.

Monthly mean anomaly in total aerosol optical depth at 550 nm for June 2023 relative to June 2003–2022.

Wildfires spike ozone levels

Wildfires have also spiked ozone levels in several regions.

Devastating wildfires struck central and southern Chile in January and February 2023, killing at least 23 people. More than 400 fires, many intentional, burned vast plantations and woods. High temperatures and winds fuelled the fires in an area affected by a decade-long drought.

Daily short-term ozone exposure increased drastically at several monitoring stations across the country as a result. Chilean authorities declared an environmental emergency in various central Chile regions.

“Concurrent observations of ozone, carbon monoxide, nitrogen oxides and PM2.5 in central Chile show the extreme detriment to air quality caused by intense, persistent wildfire events made more common in a warming climate,” the WMO bulletin reported.

The WMO released the bulletin ahead of Clean Air for Blue Skies Day on Sept. 7 – a U.N.-designated day to highlight air quality and improve cooperation.

This year’s theme: “Invest in Clean Air Now.”

Image Credits: WMO, WMO.

Dr Ana-Maria Restrepo

UN agencies have vaccinated more than 187,000 children against polio in central Gaza over the past three days, which was more than expected, The World Health Organization (WHO) Director-General Dr Tedros Adhanom Ghebreyesus told a media briefing on Wednesday.

The vaccination drive, aimed at children up to 10 years of age, continues in southern Gaza on Thursday.

“Together, we are helping to prevent the spread of polio in Gaza, but other health needs remain immense,” said Tedros.

“We acknowledge that the humanitarian pause has been respected to allow the vaccination campaign to be conducted safely and successfully. We ask not only for that to remain the case, but also for a ceasefire,” added Tedros.

However, the WHO’s Dr Rik Peeperkorn


Dr Rik Peeperkorn, joining the briefing from the WHO’s office in Gaza, said that UN agencies still needed a further three days at least to complete the polio vaccination campaign in southern Gaza before heading to the north of the territory.

“I’m deeply concerned about the overall health situation,” added Peeperkorn, explaining that only 16 out of 36 hospitals were partially operational, while less than a third of  the 152 primary health care centres were partially functional.

“We’ve seen an enormous spread in infectious diseases – more than 600,000 cases of diarrhoea, more than 510,000 cases of hepatitis, a huge number of acute respiratory infection; dismal, horrible water and sanitary conditions etcetera.”

Dr Rik Peeperkorn

DRC to start weekend mpox vaccinations

Mpox vaccines donated by the European Commission’s Health Emergency Preparedness and Response Authority (Hera) will arrive in the Democratic Republic of Congo (DRC) on Thursday and the country’s health ministry plans to start vaccinations over the week, said Tedros.

“WHO is working with our partners to coordinate vaccine demand, share information on doses available and ensure those doses are directed to areas where they can contribute to controlling the outbreak,” he added.

While up to 60% of the DRC’s mpox cases are children, the donated vaccine – Bavarian Nordic’s Jynneos (also called MVA-BN) is not yet registered for use in children.

However, the WHO’s head of R&D, Dr Ana-Maria Restrepo, said that the DRC could use the vaccine off label for children, and that there were a number of studies – including clinical studies – that had established its effectiveness in children.
“Vaccines alone will not stop these outbreaks,” Tedros stressed. “We’re also working to strengthen surveillance, risk communication, community engagement, clinical and home care and coordination between partners at every level.”

The WHO’s Dr Maria van Kerkhove added that the WHO was “deeply concerned” about the spread of mpox Clade 1b in Burundi, the site of the second largest outbreak after the DRC.

“What’s concerning about Burundi is that the cases are dispersed through the country, so we aren’t seeing these small pockets of outbreaks. This indicates that there’s more transmission, there’s more circulation that’s happening,” said Van Kerkhove.

Surge in cholera deaths

The WHO also published global cholera statistics for 2023 on Wednesday, showing a 71% increase deaths and a 13% increase in cases in 2023 in comparison to 2022.

“Over 4000 people died last year from a disease that is preventable and easily treatable,” said Tedros.

“Conflict, climate change, unsafe water and sanitation, poverty and displacement all contributed to the rise in cholera outbreaks last year,” he added, flagging that the geographical distribution of the disease had changed significantly, with cases from the Middle East and Asia declining by a third while cases in Africa more than doubled. 

Cholera is an acute intestinal infection spread through contaminated food and water. Communities with limited access to sanitation are most affected.

“Afghanistan, the DRC, Malawi and Somalia continue to report large outbreaks of over 10,000 suspected or confirmed cases, with Ethiopia, Haiti, Mozambique and Zimbabwe adding to the tally in 2023,” according to the WHO report.

The WHO’s Dr Philippe Barbosa said some technical surveillance issues that influenced the increase in mortality, many people died before they had reached health facilities.

“The very large cholera outbreaks are deadlier,” said Barbosa. “But treatment is simple and cheap. It is immoral that people do not have access to treatment, safe water and hygiene.”

Understanding pathogen origin

On Wednesday, the WHO also published a global framework to help member states to investigate the origins of new and re-emerging pathogens, with the guidance of its Scientific Advisory Group for the Origins of Novel Pathogens (SAGO).

“We still don’t know how the COVID-19 pandemic began, and unfortunately, the work to understand its origins remains unfinished,” said Tedros.

“As I have said many times, including to senior Chinese leaders, China’s cooperation is absolutely critical to that process. That includes sharing information on the Huanan Seafood Market, the earliest known and suspected cases of COVID-19, and the work done at laboratories in Wuhan, China.

“Without this information, none of us are able to rule any hypothesis out. Until or unless China shares this data, the origins of COVID-19 will largely remain unknown.”

The WHO framework outlines six areas in which scientific investigations are needed to identify the origins of outbreaks: early investigations; human studies; animal-human interface studies; environmental and ecological studies; genomic and phylogenetic studies; and laboratory biosafety and biosecurity assessments.

A pharmacist advises a patient on how to take her medicine.

When policymakers, advocates, diplomats, and practitioners come together this month at the UN General Assembly, drug-resistant superbugs will be on everyone’s mind. Antimicrobial resistance (AMR), the phenomenon where bacteria and other infectious agents no longer respond to treatments, will be the topic of a UN High-Level Meeting on 26 September to discuss this serious and growing problem. 

AMR directly resulted in the deaths of more than 1.3 million people in 2019, according to The Lancet, and is making it more challenging to combat diseases like HIV, tuberculosis, and malaria as more drug-resistant strains emerge. 

AMR can also make routine surgeries and medical procedures riskier as the effectiveness of antibiotics declines. Low- and middle-income countries (LMICs) face the highest burden – dramatically accelerated by the overuse and misuse of antibiotics and other antimicrobials in people and animals. 

While drug-resistant pathogens can affect anyone, anywhere, at any time, LMICs face a relatively greater burden due to inadequate sanitation and hygiene, limited access to quality medicines and vaccines, the high cost of medicines, high disease burden, insufficient regulations and clinical training on appropriate practices, and low laboratory capacity to diagnose infections and detect drug-resistant microorganisms, among many other factors.

As governments convene to address AMR, one possible outcome will be adopting a new political declaration that analyzes the progress made so far, identifies gaps, and commits to a set of solutions. While a declaration is a welcome step that demonstrates strong political will and the high-level meeting itself is recognition of the severity and urgency of fighting AMR, the more critical part comes next: action. 

AMR is a complex issue that requires a multisectoral approach. Drawing on my decades of experience in pharmaceutical management – including time working for a ministry of health – there are three key ways that we can strengthen pharmaceutical systems to help squash these superbugs.   

Invest in supply chains and pharmaceutical systems 

It is hard to properly complete a prescribed course of antibiotics if the pharmacy has run out. Medicine shortages are often supply chain failures, so investing in supply chain improvements will keep medicines on the shelves.

This can be done in several ways. One is to integrate digital tools and strengthen health worker skills so they can accurately predict the demand for a drug, keep a sufficient quantity of that drug in stock, and make sure it reaches patients before it expires. Equally important is to boost distribution so that the right medicines are where they are needed, when they are needed, and in the right amounts.

A fully stocked shelf of medicines will not help a patient who can’t afford them. That’s where creative financing options like pooled procurement – when governments or state agencies band together to bulk order and negotiate for better drug prices—can help lower costs.

Lastly, developing and revising standard treatment guidelines and essential medicines lists prioritizes the right medicines and provides guidance on their use. These efforts to fortify pharmaceutical systems are critical to fighting AMR not only because of the availability of antibiotics but also because they help ensure a timely flow of safe and affordable vaccines and drugs to prevent diseases and quickly stop their spread, reducing the number of people who need antibiotics in the first place.

Strengthen laboratory systems 

It is difficult for a health professional to effectively treat an infection if they don’t know what it is. The answer to that question is most often found in a laboratory with the right technology and trained professionals.

LMICs, particularly those with remote or hard-to-reach areas, often have scarce or nonexistent testing facilities, and health workers treat illnesses based on symptoms rather than lab tests. Unfortunately, treating sick individuals with antimicrobial agents without knowing what is causing their illness or the sensitivity of the bug to the prescribed medicine can be ineffective and contribute to AMR. 

Ensuring that health care providers have access to laboratories equipped to test for a wide range of pathogens can go a long way toward ensuring that the right medication is used, thereby reducing the incidence of AMR. Strengthening laboratory systems can also improve a country’s ability to detect emerging or re-emerging AMR threats.

A strong surveillance system means that you have the necessary equipment and human resources to detect any threat quickly and the tools and platforms to communicate across borders and globally. Well-trained surveillance teams and well-equipped laboratories similarly are crucial for detecting diseases with epidemic or outbreak potential, such as mpox or COVID-19. 

Facility improvements, surveillance systems, and transparent data sharing demand attention on a legal and policy level. Stakeholders could make significant strides against AMR with a commitment to strengthening laboratory systems around the world.

 Address behavior to ensure appropriate use of antimicrobials  

Patient education is important to ensure appropriate use of medicine.

While resources and technology play a crucial role in containing the threat of AMR, a comprehensive strategy should also incorporate the need for behavior change to correct inappropriate medicine use. 

For health workers, training and oversight on infection prevention and control will help stop hospital-acquired infections from happening in the first place. Prescribers need systems, tools, and training to foster awareness of AMR and how to combat it. 

For example, the World Health Organization’s AWaRe classification helps prescribers know which antibiotics to Access, which to Watch the use of, and which to Reserve for specific circumstances. 

Dispensers can benefit from training on proper counseling around antibiotic use, and regulations and oversight could curb falsified and substandard medicines and end the practice of selling antibiotics without a prescription. 

Communications campaigns that involve journalists and civil society organizations can help patients understand the problem and the importance of taking their full course of medications, not sharing medications with others, and seeing a medical professional to be prescribed the right medicine.

Many call AMR a “silent pandemic,” but AMR and the devastation it is causing has been speaking up plenty. The world just hasn’t always been listening. This month’s meeting in New York rightfully puts AMR in the spotlight as the major global health concern that it is. The bigger question is whether that attention will be sustained and translated into action. To make meaningful progress, governments should commit to a comprehensive systems approach and put enough resources toward adopting and implementing national action plans to effectively stop this not-so-silent pandemic once and for all.

Francis “Kofi” Aboagye-Nyame is a pharmaceutical management expert with the global health nonprofit Management Sciences for Health. A trained pharmacist, he has more than 30 years of experience including overseeing pharmaceutical strengthening projects on behalf of international donors in more than 40 countries.

 

Image Credits: National Cancer Institute/ Unsplash, Laurynas Me/ Unsplash.

Patients undergoing chemotherapy for cancer.

How many children worldwide have been orphaned by the death of their father due to cancer?

This is one of the pressing questions researchers will aim to answer and that is a topic amongst the abstracts at this month’s World Cancer Congress. The study, conducted by the France-based International Agency for Research on Cancer (IARC), builds on a previous 2022 report revealing that one million children lose their mother to cancer each year. According to the research team, these children often feel trapped in a “vicious cycle of disadvantage.”

The World Cancer Congress will occur from September 17-19 in Geneva. Some 2,000 people from around 100 countries are expected to take part. Attendees will hear from Malaysian Health Minister HE Datuk Seri Dr Dzulkefly bin Ahmad; Olivier Michielin, chairperson of the Department of Oncology, Geneva University Hospitals; Pierre Maudet, Geneva State Counsellor in charge of Health; and many more related leaders. The event is a project of the Union for International Cancer Control (UICC), the largest and oldest – founded in 1933 – international cancer organisation. Today, UICC has over 1,100 member organisations in 170 countries and territories.

The event will focus on six themes: Prevention, screening and early detection; cancer research and progress; healthcare systems and policies; cancer treatment and palliative care; tobacco control; and people living with cancer

“I think the highlights of any congress are the plenaries because that’s when everyone attending the congress gathers in the same room to discuss and listen to a subject matter that is critically important to the community,” Cary Adams, CEO of UICC, told Health Policy Watch. “This year’s plenaries cover global advocacy, which will lead to the high-level meeting on non-communicable diseases next year; the challenges of women and cancer, and the differences between cancer affecting women and men, and what can be done to ensure that gender differences are appreciated country by country; and the third plenary on the real-world applications of new technologies like AI, which are important to the global cancer community. I always look forward to the plenaries because I know the subject matters are pertinent and relevant to all.”

In Dwazark Community, Freetown, Sierra Leone, students at St. Augustine School are receiving the HPV vaccine to protect against cervical cancer.

HOW CANCER DEATHS COULD BE AVOIDED

Equity in cancer care will play a big role in this year’s event, said Eric Grant, communications and media manager for UICC. He told Health Policy Watch that participants will look at ways to ensure that there is access to care regardless of gender or geography, amongst other factors.

A related, first-of-its-kind study will debut at the congress that quantifies the socioeconomic burden of ovarian cancer across 11 countries and highlights the significant disparities between countries and income groups.

Relatedly, there will be a session on cancer care during humanitarian crises, drawing on experiences from Sudan, Gaza, and Haiti.

UN Headquarters in Geneva: Participant in 43rd Session of the UN Human Rights Council dons mask to protect herself from COVID-19. All parallel sessions and side events have been cancelled.

WHY GENEVA?

According to CEO Adams, the World Cancer Congress is being held in Geneva for the second time since 2022, a decision originally influenced by the COVID-19 pandemic.

“We normally take the congress around the world, but given the pandemic, we felt it was inappropriate to go to a location where it was unclear what the COVID situation would be,” Adams explained. “We spoke to the Geneva Government and various organisations that support international events here and received a very positive response. So, in 2022, we decided to hold the Congress in Geneva.

“The board then decided, as a result of how successful that meeting was and given the ongoing challenges of the pandemic, that although tradition says that we take the congress around the world, there would be real value and benefits in running it a second time in Geneva,” he continued. “I must say that given that the first congress in 2022 ran so well and everyone enjoyed being in the hub of global Health, meeting organisations like the World Health Organisation, the Medicines Patent Pool, FIND, and individuals from other UN agencies in Geneva, it was an experience that could be repeated and would be appreciated just as much the second time around. So that’s why we’re in Geneva for a second year.”

This year’s congress will once again have a focus on COVID-19, including the release of an IARC assessment on the pandemic’s impact on cancer diagnosis and stage distribution based on data from population-based cancer registries in seven countries.

Ad for tobacco

TOBACCO ADVERTISING REMAINS ‘SIGNIFICANT’ OBSTACLE

When it comes to the causes of cancer, multiple sessions will deal with the impact of commercial determinants on Health, such as the influence of tobacco and alcohol on cancer.

Grant highlighted that tobacco advertising remains a significant obstacle to reducing tobacco use. One session will equip attendees with skills to monitor, document, and expose the tactics used by the tobacco industry.

A new study on tobacco advertising on social media in Germany will be presented. Another study will examine how the “no safe level” message regarding alcohol consumption relates to cancer risk.

The use of artificial intelligence and other new technologies in healthcare to transform patient care and enhance diagnostics and treatments will also be explored—both from the standpoint of the advancements they can provide and challenges like data privacy.

PATIENTS WILL BE PRESENT

Grant told Health Policy Watch that about 40% of UICC’s members are members of patient groups, meaning they had cancer themselves. They will have a strong presence at the congress. Mobilising their voices can help encourage policymakers to move legislation forward to support cancer diagnosis, treatments and patients, Grant said.

“We’re fortunate at the World Cancer Congress in that we appeal to not just oncologists, added Adams. “There is a tendency for people to think that a cancer congress will be attended only by oncologists, but this is not true for the World Cancer Congress. We have organisations attending, such as patient groups, cancer societies, cancer leagues, research institutes, and cancer hospitals. They come from a range of disciplines—from tobacco control specialists to palliative care specialists, advocates, and fundraisers—and we get a wide variety of ages and a really diverse population of people, but with a common ambition to improve cancer control in their country, whether that’s improving prevention, early detection, treatment, care, or supportive care.

“That is a unique aspect of this congress.”

This article is part of a Health Policy Watch-UICC media partnership, with no financial compensation involved.

To register for the congress, visit https://www.worldcancercongress.org.

Image Credits: National Cancer Institute, Roche, Gavi, UN Photo / Jean Marc Ferré, Standford School of Medicine .

While more countries are concerned about antimicrobial resistance (AMR) than a decade ago, many are reluctant to commit to a specific target to reduce the overuse of animal antibiotics as they negotiate a political declaration ahead of the United Nations high-level meeting on AMR.

The zero draft of the declaration issued on 20 May proposed a target of “at least 30%” reduction in “the quantity of antimicrobials used in the agri-food system globally” by 2030.

But “a lot of countries still seem keen to water down very concrete commitments on things like reducing animal use of antibiotics”, Jeremy Knox, head of infectious disease policy at Wellcome Trust, told a media briefing on Monday.

However, Knox said he was “cautiously optimistic” about the outcomes of the UN high-level meeting set for 26 September – eight years after the only other HLM on the issue in 2016.

Wellcome has proposed three key strategies to address AMR  – a political “rallying cry” (such as the climate sector’s target of no more than a 2ºC temperature increase), a global scientific evidence panel on AMR, and sustained political follow-up, said Knox.

“I don’t think we’ll end up with the kind of very clear and ambitious rallying cry that we might have hoped for, but I do think we will see some commitments which are steps in the right direction,” said Knox.

“We will most likely have something like an ambition for a 10% reduction in mortality [on the 2019 baseline figure of 1.27 million annual deaths] but that’s narrower and less ambitious than some of us might have hoped for.”

Wellcome head of infectious disease policy Jeremy Knox

Investors call for action

The Investor Action on AMR (IAAMR) initiative, supported by 80 investors who represent $13 trillion in assets, issued a call on Tuesday for global policymakers to take “critical action against the escalating AMR crisis”.

AMR claimed 1.27 million lives in 2019, surpassing deaths from HIV and malaria, with this figure set to rise to 10 million annually by 2050.

“With the global economic costs associated with AMR likely to reach $100 trillion and lead to a 3.8% decrease in global GDP by 2050, the investor community is increasingly concerned with the negative impact AMR will have on global financial markets, economic stability and long-term value generation,” said IAAMR in a statement. 

IAAMR was founded by the Access to Medicine Foundation, the $75 trillion FAIRR investor network and the UK Department of Health and Social Care,

“Companies – from pharma to pork producers – take advantage of lax regulations allowing the routine use of antibiotics in animals enabling them to cut corners in animal welfare, while diminishing antibiotic effectiveness in humans,” said Jeremy Coller, Founder and Chair, of FAIRR, which works on building a more sustainable and equitable food system.

“An estimated 80% of antibiotics are administered to livestock rather than people in the United States alone. Investors recognise that AMR is not only a threat to the health of our people and planet, but to the financial well-being of those who rely on investment returns to fund their retirements.” 

IAAMR has seven proposals, three of which dovetail with Wellcome’s three strategies. Like Wellcome, they want a “rallying” aim, political will and an independent global scientific panel on AMR along the lines of the Intergovernmental Panel on Climate Change (IPCC).

This proposal has the support of the governments of the UK and Saudi Arabia, according to IAAMR.

‘Crisis of innovation, talent and market’

There is a “crisis of innovation” in the development of new antibiotics, says Damiano de Felice, chief of external affairs at CARB-X, a public-private partnership that supports the development of new antibiotics.

Even the AMR Action Fund, which was given $1 billion from big pharmaceutical companies, the European Investment Bank and Wellcome, “struggled to find investment opportunities in clinical development exactly because the pipeline is insufficient”, he added.

In the early stages of development, there is a lot of innovation – but most of the product developers are vulnerable because they “tend to be very small”, often coming from academia.

“The few companies that have been scientifically successful in bringing a new product to the market, have done very poorly financially,” he told the Wellcome media briefing.

“At least seven of the small biotech companies that brought a new antibiotic on the market in the past five to 10 years all had significant financial problems, and most of them actually went bankrupt.”

De Felice describes the market conditions for new antibiotics as “broken”. Large pharma companies are not that interested in antibiotics as they are short courses, face competition from generics – and clinicians tend not to prescribe them “to prevent the development of resistance”.

This lack of investment and interest also means that researchers don’t stay in antibiotic R&D – resulting in a “crisis of talent”.

But, says de Felice, there are “push” and “pull” incentives to address these problems. Push incentives provide financial, technical and business support to developers for R&D. Meanwhile, 

A pull incentive meanwhile rewards a new antibiotic which has already been brought to the market, and at least $300 million a year for 10 years should be available for this, he estimates.

‘Best time for bugs’

Anand Anandjumar, co-founder and CEO of Bugworks

Anand Anandjumar, co-founder and CEO of Bugworks, a small biotech company based in Bangalore, wants the UN political declaration on AMR to include a commitment to support innovation.

“We are looking at a long, dark, dangerous battle, so at least setting some very basic goals like five new antimicrobials by 2030 – that gives us about six years to work with – would be good,” said Anandjumar, whose company gets support from CARB-X.

“The bugs that we are seeing today, which are resistant to most antibiotics, are not going to wait for humanity to figure out solutions in our own timelines,” Anandjumar told the Wellcome briefing.

“If you’re a bacteria, there’s no better time than today,” he added. “You have heavy abuse of antibiotics on the one side. Therefore the bacteria are becoming much smarter and are developing mutations and other skills to avoid it. 

“On the other side, you have no R& D because the big pharmaceutical companies don’t find this exciting.”

India has one of the “toughest problems with AMR because of the easy availability of antibiotics and population density, he added,

“It’s a great honour to work on creating a new class of antibiotics from India, because the worst bugs are here.”

He added that AMR was being exacerbated by climate change and war: “Rising temperatures are making bugs much more pathogenic and virulent”, while the wars in Ukraine and Gaza are creating conditions for “superbugs”.

A health facility in DRC’s Maniema receives donated health supplies to address an mpox outbreak in June 2022, but the country has yet to get a single mpox vaccine.

While the Democratic Republic of the Congo (DRC), the epicentre of mpox, has yet to get a single vaccine dose despite battling large outbreaks since 2022, a flurry of activity last week aims to finally change this.

Last Friday, UNICEF announced it had issued an emergency tender for the procurement of mpox vaccines.

Usually, the World Health Organization (WHO) has to issue an emergency use listing (EUL) or full approval before UNICEF or the vaccine alliance, Gavi, can procure vaccines.

But WHO Director-General Dr Tedros Adhanom Ghebreyesus clarified at a media briefing last Friday that the global body has given UNICEF and Gavi authorisation to waive the usual procedure to speed up the procurement of the vaccines.

The emergency tender allows UNICEF to set up conditional supply agreements with vaccine manufacturers that will enable it “to purchase and ship vaccines without delay once countries and partners have secured financing, confirmed demand and readiness, and the regulatory requirements for accepting the vaccines are in place”, said UNICEF.  

UNICEF is also coordinating vaccine donations with the vaccine platform, Gavi, the Africa Centre for Disease Control and Prevention (Africa CDC), WHO and Pan American Health Organization (PAHO).

Derrick Sim, Gavi’s interim chief vaccine programmes officer, said that the tender enables “UNICEF to purchase and deliver vaccines after Gavi and other partners make funding available and sign purchase or donation agreements with manufacturers for the most immediate dose needs”.

“Securing access to supply and financing, delivering doses, and in parallel ensuring countries are ready to administer them, are all vital actions that need to be conducted rapidly but thoroughly, and in a coordinated manner. We welcome this tender as another positive step our alliance and Africa CDC are taking in this response,” added Sims.

Meanwhile, Africa CDC Director General Dr Jean Kaseya said he expects the DRC to start receiving donated vaccines from the US and EU this week.

No approval for mpox vaccines

The WHO decision on EULs for the two vaccines – Bavarian Nordic’s Jynneous (also called MVA-BN) and the Japanese company KM Biologics’ LC16 – is expected in mid-September. As they are already authorised in the European Union and USA, this is expected to be straight forward. 

The DRC issued emergency use approval for the vaccines in late June, but some other African countries with mpox outbreaks – including Burundi, Rwanda, Uganda and Kenya –  have yet to do so.

This will make their access more difficult and once again underscores how useful and important the African Medicines Agency (AMA), currently in the process of being set up, will be in health emergencies. 

Over 18,000 suspected mpox cases, including 629 deaths, have been reported in the DRC so far this year. Four out of five deaths have been in children.

A health worker examines skin lesions that are characteristic of mpox on a child at an mpox treatment
centre near Goma in DRC, on 14 August 2024.

‘Scramble for funds’

The WHO estimates that $135 million is needed to address mpox. Currently, each mpox vaccine costs $100.

Helen Clark, former co-chair of the Independent Panel for Pandemic Preparedness and Response, called on Gavi and other donors to see whether they can use some $1.8 billion left in the COVID-19 vaccine platform, COVAX, for vaccine access for the mpox response. 

“This current scramble for funds is a major reason why The Independent Panel recommended the establishment of an emergency surge finance mechanism – a recommendation which is highly relevant right now,” said Clark in a statement issued on behalf of all active members of the Independent Panel.

“The most urgent focus and investment on the ground must be on rolling out and intensifying basic public health measures,” added Clark.

Focus on public health measures

“It is clear that existing diagnostics cannot be immediately scaled, the vaccines available are insufficient in number and will take time to deploy, and there currently is no proven treatment. 

The spread and harm of mpox can and must be reduced by public health measures that are tailored to the affected communities and to the transmission patterns of the local outbreak. This includes support to health facilities and health workers, and investment in community risk communication and engagement to ensure people understand the risks of both zoonotic infection and human-to-human transmission.”

Over the weekend, over 75 organisations under the Pandemic Action Network sent a letter to the G20 Health Working Group meeting currently underway, urging them to prioritise “the immediate need for resources, including vaccines, to address the mpox outbreak”. 

“The G20 must honour its commitment to prioritising prevention, preparedness, and response to pandemics, including boosting local and regional production of medicines, vaccines, and strategic health supplies,” the letter added.

Image Credits: Eugene Kabambi/ WHO, Guerchom Ndebo/ WHO.