WHO Director-General Dr Tedros Adhanom Ghebreyesus unveiled a bold new WHO Healthy Recovery Manifesto – including an unprecedented call to governments to stop subsidizing the fossil fuel industry to the tune of US$ 400 bilion annually – driving both climate change, air pollution, and an epidemic of chronic diseases that also sharply increased mortality risks for people infected with COVID-19.

The move coincided with the European Union;s unveiling of a much anticipated Covid-19 recovery plan with a green investment edge. Named Next Generation EU the €750 billion package aims to address the economic and social fallout of the coronavirus pandemic with direct investments in renewable energy technologies and support to countries to shift to low-carbon economies. 

The six WHO-endorsed manifesto principles include oft-repeated calls for healthier cities, food systems, and clean water.  However, WHO’s blunt call to governments to “stop using taxpayers money to fund pollution” steps out of the Organization’s traditional comfort zone. The manifesto also calls for an end to biodiversity destruction and the “unsafe management and consumption of wildlife”, noting that it is these activities that lead to the transmission of deadly animal pathogens such as COVID-19 to humans, and “increase the risk of emerging infectious diseases.”  

These steps, WHO says, will lead towards healthier societies, more resilient to future outbreaks and epidemics. 

“The human cost of COVID-19 has been devastating, & the so-called lockdown measures have turned lives upside down,” said Dr Tedros in a press briefing. “But the pandemic has given us a glimpse of what our world could look like if we took the bold steps that are needed to curb climate change and air pollution. Our air and water can be clearer, our streets can be quieter and safer, and many of us have found new ways to work while spending more time with our families.”

Both the WHO and EU proposals were unveiled just a day after over 40 million healthcare workers issued a call to place climate-friendly initiatives at the heart of COVID-19 economic recovery. 

Turn “Immense Challenge into Opportunity”

“The recovery plan turns the immense challenge we face into an opportunity, not only by supporting the recovery but also by investing in our future: the European Green Deal and digitalization will boost jobs and growth, the resilience of our societies and the health of our environment,” European Commission President Ursula von der Leyen said in launching the plan. 

The plan would require all 27 EU member states to back it up with concrete investments. It comes as the bloc faces the prospects of a EU-wide recession. However, Member States have remained divided on whether the plan represents the best way forward.

France, Germany, Spain and Italy have welcomed the package, with French President Emmanuel Macron hailing it “a crucial step”.  But Austria, Denmark, the Netherlands, and Sweden — known as the “frugal four” — have protested the proposal, saying the aid should instead come in the form of low-interest loans. As such, the plan in its current form is unlikely to pass in its current form, given that it does not have unanimous support. 

Climate-Friendly Initiatives Core to in the European Union Plan
Urban pedestrian & green space (Photo: CCAC)

One key pillar of the EU plan is “supporting the green transition to a climate-neutral economy.”  A new “Recovery and Resilience Facility” of €560 billion would offer financial support for investments and reforms focusing on green and digital transitions.

The plan also earmarks €91 billion per year in EU grants and loan guarantees to businesses and households that install green technologies such as rooftop solar panels, building insulation and  heating systems based on renewable energy.

The facility also sets aside €5 billion in guarantees for “green mortgages”, tying low-carbon renovations into property sales, giving schools, hospitals, and social housing the priority.

Other climate-friendly instruments include a proposal to strengthen an EU Just Transition Fund, with up to €40 billion to assist economically weaker Member States in accelerating the transition towards climate neutrality, and a €15 billion injection of funds into the European Agricultural Fund for Rural Development, to support a trajectory for rural areas to reach climate neutrality.

The plan has been largely praised for centering on climate-friendly initiatives. However, some advocates have criticised the plan for leaving out ocean health initiatives, and other climate NGOs blasted leaked drafts of the plan for being too lenient towards polluting industries such as automakers and fossil fuel.

“The European Commission’s €1.85 trillion recovery plan is contradictory at best and damaging at worst,” said Greenpeace in a statement. “It does not solve the problem of existing support for gas, oil, coal, and industrial farming – some of the main drivers of a mounting climate and environmental emergency. The plan also fails to set strict social or green conditions on access to funding for polluters like airlines or carmakers,” the NGO added.

WHO Manifesto For Green COVID-19 Recovery

The bold new WHO manifesto begins with a comment by Dr Tedros on the intimate links that have been laid bare between viral threats and other emergencies, pollution and climate change and wildlife and biodiversity destruction:

“The pandemic is a reminder of the intimate and delicate relationship between people and planet. Any efforts to make our world safer are doomed to fail unless they address the critical interface between people and pathogens, and the existential threat of climate change, that is making our Earth less habitable,”

The  WHO Healthy Recovery Manifesto includes six key principles, described as “prescriptions” for a healthy and green recovery from COVID-19, which include the following key messages:

1) Protect and preserve the source of human health: Nature

“Human pressures, from deforestation, to intensive and polluting agricultural practices, to unsafe management and consumption of wildlife, undermine these services. They also increase the risk of emerging infectious diseases in humans  – over 60% of which originate from animals, mainly from wildlife. Overall plans for post-COVID-19 recovery, and specifically plans to reduce the risk of future epidemics, need to go further upstream than early detection and control of disease outbreaks. They also need to lessen our impact on the environment, so as to reduce the risk at source.”

Pangolin, Manis javanica – harbors coronavirus infections, and is hunted for its meat and scales

2) Invest in essential services, from water and sanitation to clean energy in healthcare facilities

“Around the world, billions of people lack access to the most basic services that are required to protect their health, whether from COVID-19, or any other risk. Handwashing facilities are essential for the prevention of infectious disease transmission, but are lacking in 40 % of households. Antimicrobial-resistant pathogens are widespread in water and waste and their sound management is needed to prevent the spread back to humans. In particular it is essential that health care facilities be equipped with water and sanitation services, including the soap and water that constitutes the most basic intervention to cut transmission of SARS-CoV-2 and other infections, access to reliable energy that is necessary to safely carry out most medical procedures, and occupational protection for health workers.”

3) Ensure a quick, healthy energy transition

“Currently, over seven million people a year die from exposure to air pollution – 1 in 8 of all deaths. Over 90% of people breathe outdoor air with pollution levels exceeding WHO air quality guideline values.  Two-thirds of this exposure to outdoor pollution results from the burning of the same fossil fuels that are driving climate change. Energy infrastructure decisions taken now will be locked in for decades to come. Factoring in the full economic and social consequences, and taking decisions in the public health interest, will tend to favour renewable energy sources, leading to cleaner environments and healthier people. Several of the countries that were earliest and hardest hit by COVID-19, such as Italy and Spain, and those that were most successful in controlling the disease, such as South Korea and New Zealand, have put green development alongside health at the heart of their COVID-19 recovery strategies.”

Solar panels supply energy for hot water at Bertha Gxowa Hospital in Johannesburg. Photo: Health Care Without Harm

4) Promote healthy, sustainable food systems

Diseases caused by either lack of access to food, or consumption of unhealthy, high calorie diets, are now the single largest cause of global ill health. They also increase vulnerability to other risks – conditions such as obesity and diabetes are among the largest risk factors for illness and death from COVID-19. Agriculture, particularly clearing of land to rear livestock, contributes about ¼ of global greenhouse gas emissions, and land use change is the single biggest environmental driver of new disease outbreaks. There is a need for a rapid transition to healthy, nutritious and sustainable diets. If the world were able to meet WHO’s dietary guidelines, this would save millions of lives, reduce disease risks, and bring major reductions in global greenhouse gas emissions.

5) Build healthy, liveable cities

Cycling in Fortaleza, Brazil – the city strengthened its active transport plans as part of the Healthy Cities Partnership

“As cities have relatively high population densities and are traffic-saturated, many trips can be taken more efficiently by public transport, walking and cycling, than by private cars. This also brings major health benefits through reducing air pollution, road traffic injuries – and the over three million annual deaths from physical inactivity. Many of the largest and most dynamic cities in the world, such as Milan, Paris, and London, have reacted to the COVID-19 crisis by pedestrianizing streets and massively expanding cycle lanes – enabling “physically distant” transport during the crisis, and enhancing economic activity and quality of life afterwards.”

6) Stop using taxpayers’ money to fund pollution – halt US$ 400 billion in fossil fuel industry subsidies

“Financial reform will be unavoidable in recovering from COVID-19, and a good place to start is with fossil fuel subsidies.

Globally, about US$400 billion every year of taxpayers money is spent directly subsidizing the fossil fuels that are driving climate change and causing air pollution. Furthermore, private and social costs generated by health and other impacts from such pollution are generally not built into the price of fuels and energy. Including the damage to health and the environment that they cause, brings the real value of the subsidy to over US$5 trillion per year-  more than all governments around the world spend on healthcare – and about 2,000 times the budget of WHO.

Placing a price on polluting fuels in line with the damage they cause would approximately halve outdoor air pollution deaths, cut greenhouse gas emissions by over a quarter, and raise about 4% of global GDP in revenue. We should stop paying the pollution bill, both through our pockets and our lungs.”

New ‘WHO Foundation’ Aims To Raise More Flexible Funding For The World Health Organization
Dr Tedros (left) and Thomas Zeltner (right) sign an MOU between the WHO and the newly established WHO Foundation

Meanwhile, WHO also unveiled a new initiative Wednesday to address some of its own pressing financial problems – triggered by the temporary suspension of funding from the United States as well as by a longer term decline in “assessed contributions” by WHO member states to the Organization. 

The WHO Foundation was launched today to raise funding from the general public and other  “non-traditional sources” for the Organization. The new foundation will give the agency a source of unearmarked income, providing more flexibility in financing WHO’s General Programme of Work. 

“The creation of the foundation represents a truly innovative approach to diversify WHO’s resource mobilization strategy. This new approach is clearly an urgent need,” said WHO Foundation founder and former Swiss Secretary of State for Health Thomas Zeltner.

“One of the greatest threats to WHO success is the fact that less than 20% of our budget comes in the form of flexible assets contributions from Member States,” said Dr Tedros at the press briefing. “For WHO to fulfill its mission and mandate, there is a clear need to broaden our donor base, and to improve both the quantity and quality of funding we receive – meaning more flexibility.”

WHO is one of the few international organizations that, up until now, has no legal channel for receiving donations from the general public, he noted. 

The success of the COVID-19 Solidarity Fund, which has raised more than US $241 million in a few short months, served as a good proof-of-concept for the WHO Foundation, which aims to raise money for a broader, more flexible and more long-term portfolio encompassing all of WHO health programmes.

Currently, almost 80% of the funding that WHO receives comes in the form of voluntary contributions earmarked for specific programmes, according to Dr Tedros. 

“This means that WHO has little discretion over the way it spends almost 80% of its funds,” he explained.

More flexible funding, channeled through the new WHO Foundation, will allow the organization to address some underfunded programmes that have not caught the eye of other large donors. attention. 

“All funding of the WHO Foundation will help implement WHO’s General Programme of Work. On average, between 70-80% of the funds we raise will go directly to the WHO Secretariat. The remaining 20-30% will be used to strengthen public health globally by working with implementing partners of WHO,” said Zeltner.

Still, money raised by the new Foundation is meant to “complement, not supplement” existing resources available to the agency, clarified Zeltner.

The WHO Foundation will be set up as an independent, non-profit organization under Swiss law. A Memorandum of Understanding between the WHO and the WHO Foundation was signed Wednesday by Zeltner and Dr Tedros to set the framework for how the Foundation will collaborate with the agency.

Image Credits: Twitter: @WHO, Wikimedia Commons, Piekfrosch/wikipedia, Health Care Without Harm, FAO/Shutterstock, City of Fortaleza.

WHO Regional Director for the Americas Carissa Etienne at a regular press conference

As global COVID-19 cases topped 5 million this past week, Latin America has surpassed Europe and the United States in terms of new cases being reported everyday, said WHO Regional Director for the Americas, Carissa Etienne, at a Pan American Health Organization press conference on Tuesday.

There have been almost 32,000 new cases of COVID-19 in Latin America and the Caribbean over the past 24 hours, as compared to 24,000 in the United States and 18,000 in WHO’s European Region – which includes the recently hard-hit Russian Federation and Turkey as well as western European states, such as Italy, Spain and the United Kingdom, which saw a major wave of infections in March and April.

However, the United States and Brazil are now the two countries with the highest cumulative number of reported cases worldwide, added Etienne.  And the Americas region as a whole has seen 2.4 million of the world’s 5.5 million reported cases, as well as 143,000 of the 350,000 deaths. As of Tuesday evening, the United States reached the 100,000 mark for deaths from the novel virus.

The latest data is ‘truly alarming’, Etienne said in light of the fact that non-communicable diseases (NCDs) like diabetes, cancers or other respiratory diseases are “pervasive” throughout the “Americas” region – and those diseases make people more vulnerable to serious illness from Covid-19. 

“We have Never Seen Such a Deadly Relationship”

Prior to COVID-19, about 80% of all deaths in the Americas were already due to such non-communicable diseases and almost 40% of these deaths were premature, as they occurred before 70 years of age, said Etienne. The Americas Region, according to World Health Organization’s definitions, includes Latin America and the Caribbean as well as the United States and Canada.

That means one in four people in the Americas is at an increased risk of poor outcomes if they become infected with COVID-19, said Etienne.

“We have never seen such a deadly relationship between an infectious disease and NCDs”, said Etienne. “One of the most concerning aspects of the COVID-19 pandemic in PAHO is the disproportionate impact of the virus on people suffering from non-communicable diseases.”

Latin America has 62 million people living with diabetes and 1.2 million people living with cancer, and these populations are much more vulnerable to COVID-19.

Diabetics are twice as likely to have severe COVID-19 disease, according to a recent review of 16,000 patients with COVID-19. And in one Chinese study, almost 30% of cancer patients died from the virus, as compared to only 2% on average, said Etienne. 

Smoking increases vulnerability to COVID-19

Smoking prevalence is another risk factor in the Americas that is exacerbating the current crisis. About 15% of adults in the region still smoke, increasing the likelihood of developing severe illness from COVID-19, as smoking reduces respiratory capacity and promotes cancers, heart and lung disease.

For all of these reasons, she said, health systems need to prioritize prevention and control of non-communicable diseases along with supporting the pandemic response –  as treating NCDs can prevent COVID-19 from becoming life-threatening. 

“As cases continue to rise in our region, our efforts to protect those with underlying conditions must intensify,” she said. “We must ensure timely access to care for chronic diseases to prevent them from becoming life-threatening.”

“Fighting non-communicable diseases now is integral to our response to COVID-19. We need aggressive preventive measures to protect people with diabetes, respiratory and cardiovascular diseases from the new coronavirus.”

If measures are not taken now to help people with NCDs, health systems will be faced with a “parallel epidemic” of preventable deaths in persons with those conditions.

The New Epicentre Of Infection – Latin America

There can be ‘no doubt’ that Latin America has become the epicenter of the COVID-19 pandemic, said Etienne at Tuesday’s press conference.

And over the past day, the ‘highest increase’ in cases was seen in Latin American countries like Chile, Brazil and Peru.

While Chile has reported almost 5000 new cases in the past day, a 7% increase, Brazil has seen almost 16000 new cases over the past 24 hours, a 5% increase. Meanwhile, Peru and Mexico have each witnessed a 4% increase in cases over the past day, said Etienne.

Some countries in the region have successfully ramped up testing; Chile, for instance, has reached the milestone of 25,000 tests per million people, comparable with the highest range of testing rates in Europe at the height of the pandemic wave there. But testing is still ‘not sufficient’ in most other countries, said Director of PAHO’s Department of Communicable Diseases Marcos Espinal – The majority of South American nations are still only managing to test less than 5000-6000 people per 1 million, a figure that is much lower than most European countries.

The Americas has 40% of the world’s cases and 40% of total deaths

Image Credits: WHO, WHO.

Solar panels provide electricity to Mulalika health clinic in Zambia. Reliable power supply ensures reliable function of core health programmes. Green energy also creates local jobs and can fuel economic recovery in the aftermath of the COVID-19 pandemic, proponents say.

More than 40 million health professionals from 90 countries worldwide have issued an open letter to G20 leaders and their chief medical advisors, urging them to support climate smart  development in their plans for economic recovery from COVID-19. 

The appeal to the Group of 20  of the world’s most industrialized countries, supported by some 350 professional organizations, including the World Medication Association, says green growth is medically mandated – to save lives both from climate and air-pollution related threats which would also make societies more resilient to pandemics such as COVID-19. 

The call comes just ahead of a critical moment for climate-related investments – the upcoming G7 Summit now planned for the end of June, which is to convene leaders of the world’s seven most advanced economies to discuss pandemic recovery.  In a recent Tweet, US President Donald Trump, who is hosting the Summit, said that he’d like to convene leaders in person at Camp David, outside of Washington DC, sometime around the originally planned date, which was to have been 10-12 June.

“The amount of money governments and central banks are preparing to spend on Covid-19 economic recovery is so massive that it will inevitably shape humanity’s chances of climate survival,” noted a the Covering Climate Now initiative of Columbia Journalism Review and The Nation, in a recent blog. “If those trillions of dollars are invested in shoring up the industries and infrastructure of the incumbent fossil fuel economy, it will lock in rising temperatures for decades to come, ensuring climate catastrophe. If those trillions are instead invested in transforming the world to a zero-carbon economy, they could rescue millions of people from unemployment and poverty and open vast investment opportunities for businesses, while perhaps also preserving a livable planet in the bargain.”

Conflicting Signals in Global Economies

The health professionals’ call came as French President Emmanuel Macron announced an US$ 8.8 billion bailout of the French car industry, prioritizing development of electric vehicles, for which car buyers will receive a 12,000 Euro subsidy each. The United Kingdom has also said it would stress green growth in its recovery plans. And many European cities have created “pop-up” bicycle lanes to ease crowding on public transport systems in the COVID-19 era – a move that has been celebrated by cycle activists.

Cycling has become a more popular way to get around during the COVID-19 pandemic.

However, in many more countries, returning to business as usual seems to be a bigger priority, and fossil fuel power development is still occuring apace across most of the developing world.

China is expanding its coal power capacity at home and in investments in South-East Asia and Africa. Australia is developing the world’s largest open pit coal mine to supply fuel to India. Japanese environmentalists are mounting a campaign against their country’s planned investment in a coal-fired power plant in Viet Nam.

Existing and planned coal power production (carbonbrief.org)

In the Eastern Mediterranean Region, Israel has largely spurned the power of solar in favor of a heavy dependence on its new offshore natural gas reserves.  The equally sun-drenched countries of Turkey, Cyprus, Greece and Libya are bitterly vying for control of other Mediterranean gas reserves. And African countries such as the Democratic Republic of Congo aim to develop untapped shale oil sources, some in sensitive rainforest areas.

Air Pollution – SARS COV-2 Virus Synergies
Pedestrians in Bangladesh cover their faces to keep from breathing in dust and smog. Air pollution takes 22 months off the average life expectancy in Bangladesh. (Photo: Rashed Shumon)

Long before COVID-19 came onto the stage, WHO data reported that air pollution causes some 7 million people to die prematurely every year, as a result of air pollution-related heart attack, stroke, respiratory illnesses and cancers.  

In the COVID-19 pandemic, people with the same heart and lung conditions, as well as cancers, have been dying from the new SARS-COV-2 virus in far greater proportions – thus the link to air pollution, including from fossil fuel sources, and ultimately climate change.  Several studies of mortality from the pandemic also have drawn an even more direct connection, including sharply higher COVID-19 mortality rates among people living in more polluted areas of Italy and the United States. 

“Before COVID-19, air pollution – primarily from traffic, inefficient residential energy use for cooking and heating, coal-fired power plants, the burning of solid waste, and agriculture practices – was already weakening our bodies,” the letter from the health professionals  states.

“It  increases the risk of developing, and the severity of: pneumonia, chronic obstructive pulmonary disease, lung cancer, heart disease and strokes, leading to seven million premature deaths each year. Air pollution also causes adverse pregnancy outcomes like low birth weight and asthma, putting further strain on our health care systems.

“A truly healthy recovery will not allow pollution to continue to cloud the air we breathe and the water we drink. It will not permit unabated climate change and deforestation, potentially unleashing new health threats upon vulnerable populations,” states the letter, referring to these as drivers that have increased the transmission of certain animal pathogens among human populations.

“We have witnessed first hand how fragile communities can be when their health, food security and freedom to work are interrupted by a common threat,” the letter also states. “”These effects could have been partially mitigated, or possibly even prevented by adequate investments in pandemic preparedness, public health and environmental stewardship. We must learn from these mistakes and come back stronger, healthier and more resilient.”

World Medical Associaiton & International Council of Nurses Among Signatories
WHO Tweet supporting the green recovery call to action by health professionals.

The signatories include the World Medical Association, the International Council of Nurses, the Commonwealth Nurses and Midwives Federation, the World Organization of Family Doctors and the World Federation of Public Health Associations, as well as individual health and medical personnel.

“Health professionals are at the frontlines of this emergency, and we are seeing the immense loss of lives because of acting too late,” Miguel Jorge, the president of the World Medical Association, was quoted as saying.

“We know now more than ever that healthy lives depend on a healthy planet. As we walk on the road to recovery, we need to build a system that will protect us from further damage. We need a healthy and green recovery.”

The appeal also was supported by the World Health Organization, which issued a Tweet stating that it, “aligns with this resounding call to action from the world’s health community.”

As Virus Threat Fades – Same Old Polluting Practices Return
The Dhauladhar mountain range of Himachal, visible from 200 km away in Punjab, India, after air pollution drops to its lowest level in 30 years

While COVID-19 related lockdowns in places such as China, India and northern Italy vividly illustrated how ‘blue skies’ can return once pollution is curbed, healthcare professionals fear that as the immediate impacts of the virus fade, the world is resuming the same old polluting practices without having learnt lessons that are critical to a “climate recovery”.

A climate-smart recovery would also reduce the likelihood of future pandemics as well as climate breakdown, they say.

The letter calls for recovery packages to prioritise investments in public health such as in clean air, clean water and low-carbon development, arguing that such investments would reduce air pollution and greenhouse gas emissions while building greater resilience to future pandemics and creating more sustainable jobs. The signatories also warn governments to learn from the failures exposed by the pandemic to tackle vulnerabilities in the economy and safeguard frontline healthcare workers,  pointing out that when human health is compromised, the economy suffers.

Green Recovery Would Be More Profitable

A recent study from Oxford University, for instance, found that green recovery measures – such as conditional bailouts for fossil fuel-dependent industries to encourage them to shift to greener processes, and increased infrastructure to support electric vehicles and bicycles – would yield more jobs and a better return on investments than returning to business as usual.

“A healthy recovery recognises that human health, economic health and the planet’s health are closely connected; the pandemic has demonstrated that economic recovery must be achieved in ways that strengthen our global health resilience,” said  Jeni Miller, executive director of the Global Climate and Health Alliance. “This is not the time to go back to business as usual, it is a time to take bold steps forward to create a future that protects both people and the planet,” she added.

The signatories argue that investing in greener economies would be more profitable – as well as reducing air pollution, promoting healthier diets, more walking and cycling, and protecting biodiversity. But clear economic incentives are needed to stimulate the transition:

“To achieve that healthy economy, we must use smarter incentives and disincentives in the service of a healthier, more resilient society,” the letter’s signatories state. “If governments were to make major reforms to current fossil fuel subsidies, shifting the majority towards the production of clean renewable energy, our air would be cleaner and climate emissions massively reduced, powering an economic recovery that would spur global GDP gains of almost 100 trillion US dollars between now and 2050. 

The letter has been sent to all G20 leaders, including the United Kingdom’s Boris Johnson, German’s Angela Merkel and China’s Xi Jinping, who have seen public pressure to adopt greener economic recovery measures, as well as to those leaders who have been criticised for a lax approach to the Covid-19 crisis or for using it as an excuse to weaken environmental protections, including US President Donald Trump, Russian Federation’s Vladimir Putin and Brazil’s Jair Bolsonaro.

–Updated 27 May 2020

Image Credits: Shutterstock/TonyV3112, UNDP/Karin Schermbrucker for Slingshot , Rashed Shumon, Twitter: @Deewalia.

COVID-19 responders learn how to properly don and doff protective gowns in Kenya

In contrast to Europe and the Americas, Africa has just 1.5 percent of the world’s reported cases of COVID-19, and less than 0.1 percent of the world’s deaths, World Health Organization Director-General Dr Tedros Adhanom Ghebreyesus noted on Africa Day 2020.

“Africa appears to have so far been spared the scale of outbreaks we have seen in other regions,” said Dr Tedros. “Of course, these numbers don’t paint the full picture. Testing capacity in Africa is still being ramped up, and there is a likelihood that some cases may be missed.”

Still, African countries’ histories of facing outbreaks of infectious disease have played in their favor, said the WHO Director-General.

“Africa’s knowledge and experience of suppressing infectious diseases has been critical to rapidly scaling up an agile response to COVID-19,” he said.

For example, a coalition of African leaders, organized through the African Union chaired by South African President Cyril Ramaphosa, was set up early in the global pandemic to coordinate cross-country preparedness efforts. Infrastructure and knowledge from battling previous outbreaks was used to rapidly scale COVID-19 interventions, as seen in South Africa’s rapid deployment of mobile diagnostic teams, and the Democratic Republic of the Congo’s use of Ebola screening infrastructure for COVID-19 temperature screening.

Additionally, citizens across the continent have largely understood the need for strong lockdown measures, taken early by many African nations. WHO Regional Director for Africa Dr Matshidiso Moeti on Monday thanked citizens for abiding by stay-at-home orders where possible, acknowledging the hardships that many were facing.

“I’d like to very much commend and thank [the citizens]… because we think that it’s thanks to these measures that we have not started to see the kind of evolution of the pandemic in Africa that we were projecting,” said Moeti. “They accepted the need for some of these measures, although many of them recognize that it would be very tough on them in the households, particularly if you take into account the proportion of African people that are in a sector where you need to be out, earning your money in order to be able to put food food on the table.”

Japan Lifts State Of Emergency As Other Asian Countries Seesaw On COVID-19 Control

On Monday, Japan officially lifted its state of emergency in all its provinces ahead of the May 31st deadline, regarding the emergency situation as “no longer necessary” according to the Ministry of Health. The country has been largely praised for its efficient coronavirus response, relying almost solely on quick contact tracing, testing, and isolation of cases.

India also lifted its restriction on domestic air travel effective Monday, although there were mixed opinions on the move. Meanwhile, Philippines President Rodrigo Roa Duterte commanded its government agencies to expedite the repatriation of more than 24,000 overseas Filipino workers (OFW) within the week.

In China, clusters of cases in Jilin province in the northeast have led to officials to lockdown cities only a couple weeks after the original pandemic epicentre Wuhan began relaxing lockdown measures.

Tensions between China and the US remain high. China’s Foreign Minister Wang Yi remarked that a “political virus is spreading in the US, with some politicians ignoring facts and promoting conspiracy” at a video press conference on Sunday. Still, Wang expressed hope that there could be future collaboration between China and the U.S. for addressing global challenges. 

Park rules in Paterson, New Jersey, USA.
New Death Projections in US Cast Somber Outlook If States Are Too Eager To Reopen

In stark contrast to the Chinese approach, states across the US have begun relaxing social distancing guidance even as new cases continue to appear.

And health experts warn that relaxing COVID-19 measures early could lead to a fresh wave of coronavirus deaths. Some 23,000 more people could die if states failed to reimplement social distancing measures, according to a new analysis by epidemiologists at the Columbia Mailman School of Public Health. 

And enacting federal social distancing measures just two weeks earlier could have prevented 83% of the US’ nearly 100,000 coronavirus deaths, according to the same study. 

But experts fear that social fatigue from complying with the stringent measures mean that citizens will be loathe to comply with any renewed measures. As such, the importance of scaling up public health measures to rapidly detect and contain the virus, as well as improve health education, is even more important in the next phase of the fight.

“Our results also indicate that without sufficient broader testing and contact tracing capacity, the long lag between infection acquisition and case confirmation will mask the rebound and exponential growth of COVID-19 until it is well underway,” says lead researcher Jeffrey Shaman, professor of environmental health sciences at the Columbia Mailman School of Public Health in a press release. “Efforts raising public awareness of the ongoing high transmissibility and explosive growth potential of COVID-19 are still needed at this critical time.”

A COVID-19 triage tent in Italy
High COVID-19 Death Rates in Italy & Sweden  

Sweden had a seven-day rolling average of  6.08 deaths per million between 13 May and 20 May, overtaking the UK, Italy and Belgium to have the highest coronavirus per capita death rate in the world regardless of its low population densities and limits in international travel.

In contrast to countries like France and Germany, social distancing implemented in Sweden depending largely on the discretion of individual Swedes, without harsh controls, fines, or policemen.

However,  the high mortality rate has thrown the government’s decision to avoid strict lockdown into further doubt- especially as its neighboring countries such as Norway, Denmark and Finland, where much tighter restrictions are put in place, have seen dramatically lower numbers of deaths over the past month.

Sweden’s decision to keep open schools, bars and restaurants and to continue to allow gatherings of up to 50 people has been praised by many who believe that the country will be better equipped for a “second wave” with certain degree of herd immunity through the relatively relaxed measures. However, WHO experts have repeatedly warned that early antibody surveys are showing that a far higher proportion of the population will remain susceptible to a second wave, casting strong doubt on the ‘herd immunity’ approach.

Meanwhile, a recent analysis of death registry data by two Italian economists shows that Italy had a 40% higher death rate from February to March 2020, as compared to the same time the previous year.

The economists estimated that the virus may have killed 0.1% of the local population in less than 40 days and that its mortality is vastly underreported in official statistics.

But on the bright side, the analysis shows that stringent containment measures were significantly lower in the Veneto region, which has “embraced mass testing, contact tracing and at-home care provision.” Neighboring Emilia-Romagna and Lombardia did not fare as well.

The economists also found that closure of service activities is effective in reducing COVID-19 mortality – a 10% increase in proportion of the service industry closed correlated with a 15% lower death rate in municipalities. In this second paper, the economists draw from daily death registry data on 4,000 Italian municipalities to investigate two policies, namely the shutdown of non-essential businesses and the management of the emergency care system. However, shutting down factories is much less effective. In addition, results also show that morality strongly increases with distance from the intensive care unit (ICU).

Svet Lustig Vijay contributed to this story

Image Credits: Twitter: WHOAFRO, Paterson Great Falls, Servizio Nazionale della Protezione Civile.

Child receives vaccine

Due to COVID-19, polio and measles campaigns have been suspended in 27 countries, and polio vaccination campaigns have been put on hold in 38 countries,  UNICEF’s Executive Director Henrietta Fore has warned. 

Some 80 million infants in at least 68 countries are likely to be affected by the suspension of routine immunization services, said Fore in a joint press conference with warned UNICEF along with the World Health Organization, GAVI – The Vaccine Alliance, and the Sabin Vaccine Institute, on Friday. 

Vaccination campaigns (which seek to vaccinate large parts of the population in a short period of time) have also been badly hit, especially for measles and polio: Measles campaigns have been suspended in 27 countries and polio vaccination campaigns put on hold in 38 countries.

“We fear that COVID-19 is a health crisis that is quickly turning into a child-rights crisis” Fore said in a press statement. We cannot let our fight against one disease come at the expense of long-term progress in our fight against other diseases,” she added. “We have effective vaccines against measles, polio and cholera. While circumstances may require us to temporarily pause some immunization efforts, these immunizations must restart as soon as possible, or we risk exchanging one deadly outbreak for another.”

The reasons for disrupted immunization services range from stay-at-home orders, redeployment of health workers for COVID-19, lack of personal protective equipment – but also delays in air travel to ship vaccines.

Pandemic threatens to Unravel Vaccine Progress

“Immunization is one of the most powerful and fundamental disease prevention tools in the history of public health. Disruption to immunization programmes from the COVID-19 pandemic threatens to unwind decades of progress against vaccine-preventable diseases like measles,” said WHO Director-General Dr. Tedros Adhanom Ghebreyesus, speaking at the press event. 

“This pandemic is threatening to unravel this progress, risking the resurgence of other diseases”, said Seth Berkley, chief executive officer of GAVI. These include illnesses more likely to affect children such as measles and polio – but also diseases that can attack people of all ages including cholera, meningitis, tetanus, typhoid and yellow fever, he said.  

More children all over the globe are now protected against more vaccine-preventable diseases than at any point in history. Basic vaccine coverage in the world’s poorest countries has risen from 59% in 2002 to 81% today, helping reduce vaccine preventable diseases by 70% during that time period, said Berkley.

Even so, before the COVID-19 pandemic, measles, polio and other vaccines were out of reach for 20 million children below the age of one every year.

A 6-month-old baby receives a delayed vaccine shot at a community health centre in Beijing, China.
‘People Reluctant to Come for Immunization Services’

Many countries have temporarily and justifiably suspended preventive mass vaccination campaigns against diseases like cholera, measles, meningitis, polio, tetanus, typhoid and yellow fever, due to risk of transmission and the need to maintain physical distancing during the early stages of the COVID-19 pandemic.  Added one WHO official, “People are reluctant to come for immunization services, out of concern for themselves, and out of concern of course for the healthcare workers.”  

However, in the long-run, vaccinations will save more lives.

“Not only will maintaining immunization programmes prevent more outbreaks, it will also ensure we have the infrastructure we need to roll out an eventual COVID-19 vaccine on a global scale,” added Berkley.

“We need joint concerted efforts to put vaccinations back on track,” Fore added, “and there are many ways we can do that.

“First  countries need to intensify their efforts to track unvaccinated children, so that the most vulnerable populations are vaccinated, as soon as it becomes possible to do so. Second, we eed to address the gaps in vaccine delivery. Third, we need to look for innovative solutions to keep vaccines going. Fourth, vaccines, need to be affordable and accessible to those who need them the most.” 

Despite Lockdowns and Flight Restrictions – Some Countries Offer Creative Examples For Continuing Vaccines

A UNICEF statement from early May cited a 70-80 percent reduction in planned vaccine shipments, leading to a “massive backlog”, as a result of the cancellation of commercial flights and the “exhorbitant cost” of securing cargo space.

However, despite lockdowns and stay-at-home measures, some countries, such as Uganda and Lao PDR, have found creative ways to maintain routine immunization, Fore said.  This includes carrying out vaccines in pharmacies, cars or supermarkets, while incorporating physical distancing in delivery.

She noted that in March, “Lao scheduled a rollout for HPV vaccine [which has] reached more than 70% of the population…. Uganda is ensuring that immunization services continue along with other essential health services, even funding transportation to ensure outreach activities.”  

WHO is due to issue new advice to countries on maintaining essential services during the pandemic, including recommendations on how to provide immunizations safely.

In early June, the United Kingdom government will host the Global Vaccine Summit, which aims to raise “at least” US$ 7.4 billion for Gavi to protect 300 million children in 68 lower-income countries against deadly diseases from 2021-25.  

Substantial pledges have already been received from the UK, the US, Norway, Germany, Canada, Italy, Japan, Saudi Arabia Spain  – But more is needed to reach the target, added Berkley.

“It is vital that GAVI receives the resources we need to continue our work over the next five years,” he said. 

He added that GAVI would also likely be a major conduit for any future COVID-19 vaccine as well – which will be the only real way to build herd immunity and get rid of reservoirs of infection. 

Image Credits: EPA/Francis R. Malasig, UNICEF/Zhang Yuwei.

This story was updated 4 June to reflect the Lancet study’s retraction.

WHO Chief Scientist Soumya Swaminathan provides reasoning behind pausing hydroxychloroquine arm of the Solidarity Trial.

Enrollment of new patients in the hydroxychloroquine (HCQ) arm of the World Health Organization’s Global COVID-19 Solidarity Trial will be put on pause, as the trial’s oversight committee reviews all available data on COVID-19 and hydroxychloroquine, WHO Director-General Dr. Tedros Adhanom Ghebreyesus said on Monday.

The WHO decision on Saturday came just a day after a major observational study published in The Lancet found a higher mortality rate in COVID-19 patients who have received hydroxochloroquine, chloroquine, or a combination of either drug and azithromycin, as compared to COVID-19 patients who did not receive any treatments.

The Lancet paper was later retracted on 4 June by three of the authors due to concerns about the “veracity of the primary data sources.”

“The executive group [composed of experts from 10 countries involved in the trial] has implemented a temporary pause of the hydroxychloroquine arm within the Solidarity trial,” said Dr Tedros speaking at a WHO press conference. “The group has agreed to review a comprehensive analysis and critical reappraisal of all evidence available globally. The review will consider data collected so far in the Solidarity trial, and important, robust randomized available data to evaluate the potential benefits and harms from this drug.”

WHO Experts Clarify Reasoning Behind Hydroxycholoroquine Arm Suspension

Still, WHO experts said that mortality conclusions could not be definitively drawn from an observational study, such as the one reported by The Lancet. WHO’s Chief scientist Soumya Swaminathan acknowledged that unlike randomized controlled trials such as the one WHO is conducting observational studies can yield misleading results.

“We know that the evidence from observational studies, however large they may be, is still subject to inherent bias. What’s really important is to have well-conducted randomised control studies, done in large numbers,” said WHO Chief Scientist Soumya Swaminathan, also speaking at the press briefing.

WHO Emergencies head Mike Ryan also underlined that WHO’s decision to suspend the hydroxychloroquine arm of the WHO Solidarity Trial was not due to any negative preliminary results that had already been flagged in the ongoing WHO study.

Rather, the decision was a “proactive” one made to “err on the side of caution,” said Swaminathan.

“There were also a lot of questions coming from our own principal investigators in countries, and we knew that the regulatory agencies in many countries were also discussing these data…So the steering committee decided that in the light of this uncertainty that we should be proactive, err on the side of caution and suspend enrollment temporarily into the hydroxychloroquine arm,” she told reporters.

As one part of the review, the trial’s independent data safety monitoring board will be analyzing data collected so far to see if there are any “signals” that the drug is failing, and send them to the trial’s advisory committee for further review, said WHO Health Emergencies Executive Director Mike Ryan.

“We will expect that if there is no signal of failing, and we don’t have any problems, we will try to use the drug,” said Ryan.

Dr Tedros highlighted that hydroxychloroquine, which has been widely approved for use for malaria and the autoimmune disease Lupus, is still safe to use in patients with those diseases.

Researchers Criticise The Lancet Study Design
Analysis of HCQ studies finds that randomised control studies (green) are more likely to find the drug has a positive effect on COVID-19, compared to observational studies (red)
(Credit: Didier Raoult et al.)

Other researchers have also criticised The Lancet study’s design. While the study had analyzed a large body of data from 671 hospitals in 6 continents, there could still be bias in the analysis that is obscuring the true effects of the drug.

In smaller RCTs for example, positive results for hydroxychloroquine had been found. Treatment failure had so far mainly been identified only in observational studies, according to an analysis by Didier Raoult, director of the Marseille University Hospital Institute for Infectious Diseases ( IHU Méditerranée Infection).

One major critique is that The Lancet study does not adequately adjust for the fact that many of the patients in the study are more likely to be severely ill, and are already at increased risk of death.

Critics contend that The Lancet study primarily observes patients experiencing more severe disease who began receiving HCQ later in disease progression, while the drug has shown promise when given earlier or used as a preventative treatment. For example, India now recommends the prophylactic use of hydroxycholoroquine to protect against COVID-19 infection in all healthcare and frontline workers, following results from a small observation trial that found the likelihood of infection was lower in those who took the drug.

“Another poorly designed interpretation of a hydroxychloroquine data set for COVID-19. A larger poorly designed “trial” only leads to larger erroneous conclusions,” tweeted Steven Phillips, a Yale-educated internal medicine doctor who specializes in zoonotic infectious diseases.

About two-thirds of the patients in The Lancet study were from North America, where delays in testing mean that patients aren’t identified until 5 to 7 days after they begin showing symptoms, says Phillips.

“HCQ early COVID-19 treatment isn’t embraced in the US. It’s given only to the sickest patients, without contrary evidence in this study. To state that the baseline disease severity between treatment & control is equal was incorrect,” he added.

For example, one measure used in The Lancet study to determine baseline disease severity is the “quick sequential organ failure assessment”(qSOFA) score. There is little difference between qSOFA scores across different disease severities, so the score is “proving a bad stratifier for COVID,” tweeted antimalarial pharmacology researcher James Watson, a lead scientist at the Mahidol Oxford Tropical Medicine Research Unit (MORU).

“So a quick conclusion is that they have just inadequately adjusted for disease severity, which is driving the treatment allocation [of HCQ or no HCQ],” added Watson.

“I agree with one thing the authors said: ‘Randomized clinical trials will be required before any conclusion can be reached regarding benefit or harm of these agents in COVID-19 patients,'” Phillips tweeted in conclusion.

Image Credits: Matthieu Million, Yanis Roussel, Didier Raoult.

Bagh Bazaar, Kolkata, post cyclone Amphan

Even as Eastern Africa and the Horn of Africa are facing unprecedented flooding and locust swarms, a cyclone that has hit Southeast Asia, is presenting new challenges there in the battle against the COVID-19 pandemic.

Torrential rain, fierce winds of up to 180 km per hour, and a 16-foot tall storm surge cut off road links, snapped power lines, destroyed crops and displaced hundreds of thousands in Bangladesh and India’s West Bengal region after the storm made landfall  last Wednesday. 

In India, Kolkata was particularly hard hit by the cyclone.  And while vulnerable Rohingya refugee camps in Bangladesh escaped its worst effects, several United Nations agencies and NGOs warned that Amphan could thwart existing efforts to contain the current COVID-19 pandemic. In Kolkata, many residents had to be forcibly displaced from their homes to shelters, due to their fears of becoming infected, authorities said.  At least 5 cases of COVID-19 have already been confirmed in Cox’s Bazaar, the largest refugee camp in Bangladesh.

Amphan Could Exacerbate Efforts to Contain COVID-19 pandemic in Region

Early evacuation of 2.5 million people in Bangladesh and half a million people in India helped mitigate the worst effects of the cyclone, but some civilians refused to evacuate from their homes for  fear of becoming infected by COVID-19 in crowded shelters, authorities said.

In the West Bengal city of Kolkata, “we have literally had to force people out of their homes, make them wear masks and put them in government buildings,” a senior police official told Reuters. 

There are now “hundreds of thousands” of Indians sheltered in relief camps across West Bengal, Indian government officials said – fueling fears that the shelters may spawn a breeding ground for COVID-19.

In Bangladesh, some two million people in total had been evacuated to over 12,000 cyclone shelters, and supplied with masks and sanitizers to combat the spread of the coronavirus, according to the UN. In the temporary shelters as well as the crowded refugee camp of Cox’s Bazaar, home to around a million Rohingya refugees from Myanmar, conditions are ripe for virus transmission, officials warned.

“With 40,000 people crammed per square kilometre [in Cox’s Bazar] maintaining social distance is impossible. People share water and toilet facilities making it extremely challenging to maintain the strict hygiene needed,” said Oxfam’s Bangladesh Country Director Dipankar Datta. “If a serious outbreak is to be avoided more prevention and containment measures – adapted to the needs of women and men – must be rapidly put in place.”

“Communities are already vulnerable to the devastating health crisis and we know that if people are forced to seek communal shelter, they will be unable to maintain physical distancing and run the risk of contracting or transmitting the disease,” warned the International Organization for Migration’s (IOM) Deputy Chief of Mission Manuel Pereira.

Relief Efforts Swing Into Action 

Indian Prime Minister Narendra Modi announced a US $132 million emergency relief package for West Bengal after he was flown through the cyclone affected areas on Friday. A day later, he deployed 5 columns of the Indian army to help restore infrastructure.

German NGO Welthungerlife released 100,000 Euro on Monday to fund Cyclone Amphan relief efforts. In Bangladesh local NGOs, such as the Bangladesh Women’s Development BRAC released BDT 30 million for the response, following a pre-release of US$138,000 in funds from the International Federation of the Red Cross .

Children displaced by cyclone Amphan get a meal from relief workers in Kolkata, India

Despite its precarious coastal location, Cox’s Bazaar fortunately escaped the worst wrath of the storm.  UN agencies and NGOs had issued early warnings about the potentially devastating effects should the storm hit the refugee camp frontally. 

As it turned out, just over 7,000 Rohingyas refugees in the settlement were directly affected, and 555 had been moved to temporary shelters or were staying with relatives while their homes were repaired, UNHCR’s Charlie Yaxley told UN News. Some 118 shelters were destroyed and 1,423 had been damaged, while relief organizations were positioning to respond.

Across Bangladesh, however, over 370,000 houses have been damaged as of Friday, according to the UN Office of Humanitarian Affairs.

In neighboring India, the cyclone left a “trail of destruction”, said one relief officer. Reports were that the cyclone so far had claimed  80 lives in eastern India’s West Bengal and some 20 lives in neighboring Bangladesh, mostly from people trapped in collapsed homes or electrocuted by falling wires. Some 176,000 hectares of crops, 200 bridges, 150 km of dams and 1,100 km of road in coastal districts had been damaged.

Relief workers battling cyclone aftermath under Covid-19 shadow in Kolkata, India

UNESCO World Heritage Mangrove Forest Suffers Major Blow In Trail of Destruction

The Sundarban mangrove forest straddling India and Bangladesh has also suffered a devastating blow – The UNESCO World Heritage Site is the largest contiguous mangrove forest in the world, and is  home to some 4 million Indians. The total damage of the cyclone could amount to 1 trillion rupees ($13 billion), said Indian state officials to Reuters.

The Sundarban’s embankments may have been breached, with many houses already damaged, Anamitra Anurag Danda, a senior fellow at the Observer Research Foundation think-tank, told Reuters.

Road connectivity is a priority right now, said Kolkata’s deputy mayor Atin Ghosh to Reuters. And although municipal teams, civil defence and police personnel are working “overtime”, “there is an acute shortage of manpower due to coronavirus related restrictions,” he said.

And water contamination from heavy rains and flooding could lead to a spike in illnesses, warned the UN Office for the Coordination of Humanitarian Affairs (UNOCHCHA).

Massive damage is also expected to standing crops and plantations.  The cyclone destroyed farmland in Bangladesh’s low-lying coastal areas, damage that will likely endanger livelihoods, the non-profit ActionAid said.

“Communities need urgent support as they are without basic necessities such as food, clean water and materials to rebuild their homes,” Farah Kabir, the country director of ActionAid Bangladesh said.

Eastern India and Bangladesh are frequently battered by cyclones between April and December, although climate change is making them more frequent and severe, experts say.  On the other side of the hemisphere, Caribbean regions like the Bahamas are less than a week away from the beginning of their hurricane season, said Caribbean Community and Common Market Chair Mia Mottley last week at the World Health Assembly.

 

Image Credits: Ramakrishna Math & Ramakrishna Mission, Ramakrishna Math & Ramakrishna Mission, Ramakrishna Math & Ramakrishna Mission.

Workers manufacture PPE in a Kenyan factory (Photo: MOH, Kenya)

Low and middle-income countries urgently need affordable personal protective equipment, diagnostics, treatments and vaccines to ward off even bigger waves of COVID-19 infection and mortality – and global production capacity is failing to ensure timely supply even of those products now on the market.

Now, more than ever, producers in poor countries need to be integrated into the health products ecosystem – at national, regional and global level – something that is good for public health, local economic development – and global public health security.

In the wake of the far-reaching commitments already made by the global community at the World Health Assembly, to stimulate R&D and voluntarily pool new intellectual property (IP), James Zhan, senior director of Investment and Enterprise, and Christoph Spennemann, head of the IP Unit at the United Nations Conference on Trade and Development (UNCTAD), are calling upon the UN system, governments, industry and international investors to create a bold new partnership.

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Remarkable efforts are underway to ensure effective research and development (R&D) of COVID-19-related diagnostics, treatments and vaccines, inter alia at last week’s World Health Assembly, and in the context of a recently announced WHO voluntary technology pool. But the international COVID-19 response is largely lacking a comprehensive strategy on how to ensure the missing link between R&D and distribution, i.e. large-scale manufacturing.

Already this has been plainly evident in the shortages of face masks, gloves and gowns for health workers in Africa – items that are generally simple to manufacture and yet often had to be shipped from thousands of miles away. 40% of the global market in personal protective equipment (PPE) is supplied by manufacturers in only three countries outside of Africa, and 35% of globally available medical products are sold in only three countries outside of Africa, according to UNCTAD. At least 47 countries have implemented one or more measures affecting exports of products or sub-products used in the public health response to COVID-19.

Once a treatment or vaccine for COVID-19 is available, massive demand is likely to outstrip supply even more rapidly and visibly – with huge consequences for health equity. Earlier hopes that, due to climatic conditions, countries in the global South might be less affected, are vanishing quickly. The pandemic is now hitting LMICs, with Latin America being considered a new epicenter of the pandemic, according to a WHO statement of 22 May.

Boosting local productive capacity therefore becomes a necessity to ensure public health security in LMICs (SDG 3). As the virus knows no borders, productive capacity in LMICs in return contributes to global health security.

In a longer-term perspective, local productive capacity nurtures expertise and creates quality jobs in LMICs, thus contributing to structural transformation and economic growth (SDGs 8 and 9), as well as pandemic preparedness.

Need to Act Urgently – So No Country Is Left Behind
Pharma R&Ds; an increasingly high tech affair. (Photo: Adobe Stock)

We need to act urgently. For vaccines, for instance, The Economist notes  that worldwide vaccine production – which is currently at over 5 billion doses a year – will not be sufficient to meet the massive new demand. Repurposing existing facilities is not a solution: this is not always feasible and would also reduce the capacity to make regular vaccines to address life-threatening diseases like measles and polio.

Diversifying the sources of pharmaceutical production could be of particular value for the supply of active pharmaceutical ingredients (APIs). Producers in LMICs, but also the global pharmaceutical industry are too dependent on suppliers in a very limited number of countries, and more diversified API production could increase overall health security.

We need to avoid a scenario where poor countries are left behind. This necessitates new industrial alliances, parallel manufacturing by multiple companies in multiple locations, and creative approaches to IP to ensure rapid availability of new technologies for high volume production. To boost productive capacity in LMICs, it is critical to engage in global partnerships among governments, local producers, development partners, and international investors and technology holders.

Not every LMIC is ready for this. But some have succeeded in establishing a local pharmaceutical or vaccines industry that can comply with international quality standards. Other countries are actively supporting the development of their domestic pharmaceutical industry to ensure public health security.

Many more countries should be able to engage in the production of personal protective gear that is equally vital in the COVID-19 battle.

Drug manufacturing facility in Ethiopia (photo: UNCTAD)
Five Challenges

However, local investors and producers alone cannot fulfill the daunting task of changing production patterns on their own. They are typically faced with five key bottlenecks.

  • Lack of capital, technology and skills. The key objective of any pharmaceutical production is to meet requirements related to drug safety, quality and efficacy, as well as WHO-based Good Manufacturing Practice (GMP). This requires technological capacity and know-how that is missing in most low income and some middle-income countries. Upgrading these capacities requires upfront capital. Commercial banks are often hesitant to provide loans to pharmaceutical projects considered highly risky.
  • Low quality and standards. In many LMICs, drug regulatory authorities lack the capacity to check and enforce companies’ adherence to quality standards and GMP. This is a major barrier to potential investment by GMP-compliant firms, which are concerned about unfair competitive advantage from non-GMP-compliant firms that can produce at lower cost.
  • Weak enabling policy frameworks. Cooperation with foreign investors and technology holders is essential to ensure the transfer of relevant technology and know-how. Unfavourable rules on investment, IP and drug regulation may discourage foreign investment or upset the balance between protection and technology dissemination. Tariffs and taxes imposed on ingredients needed for local production make local manufacturing less attractive.
  • Small markets and unstable demand. Many LMICs have relatively small population and weak purchasing power. Economies of scale are an important factor in attracting investment. But countries often fail to agree on harmonizing medicines procurement, thus missing an important opportunity to combine purchasing power and stabilize demand.
  • Poor infrastructure. The “last mile” to the patient is often difficult to stride, especially in low income countries with poor infrastructure. Many low-income countries are struggling with infrastructure challenges, including electricity cuts and cold chain interruptions.
Mass production of PPE in Kenya (Photo; MOH, Kenya)
Ten Actions

To address these bottlenecks, we suggest ten major actions to create a national enterprise ecosystem:

Investment in skills development to ensure GMP-compliant production

GMP-related skills can be promoted by attracting know-how transfer from foreign investors, by hiring foreign consultants and by exploiting existing technologies. Uganda has used multi-year government purchase commitments to ensure training of local pharmacists by an Indian investor for a Kampala-based plant. Firms in Bangladesh have relied on hiring foreign experts to transfer know-how. In the COVID-19 context, LMIC investment promotion agencies could put together a “grey corps” of retired engineers from advanced countries willing to offer their assistance. And national patent offices should promote scientific understanding of COVID-19-relevant technologies in patents that are no longer valid, or which have been abandoned by their holders, such as AbbVie’s patent on the antiretroviral combination drug Kaletra (currently in clinical trials for a potential COVID-19 treatment).

Sterile manufacturing laboratory for pharmaceutics and biotechnology. (Photo: Adobe Stock)
Sharing COVID-19-related technologies to enable affordable mass production

New COVID-19 technologies should be shared with LMIC-based producers, accompanied by know-how transfer programs to ensure the rapid uptake of quality high volume production. Various initiatives can contribute, e.g. the recently announced WHO voluntary technology pool and the UN-supported Medicines Patent Pool, the Coalition of Epidemic Preparedness Innovations (CEPI), and philanthropy programs of the R&D-based pharmaceutical industry. The results of any publicly funded COVID-19-related R&D should be available and affordable to all, as a global public good, and existing IP rights should be waived for the territory of LMICs or be licensed at reasonable fees. LMIC governments need to establish stronger linkages between domestic producers, foreign investors and domestic research institutions, inter alia through voluntary IP licensing, and they need to be aware of the tools available to promote public health under the WTO TRIPS Agreement.

Target impact investors to access necessary capital

Impact investment by the end of 2018 had reached a global value of USD 502 billion. Time is here to ensure that this enormous financial resource is made available to help the world’s poor access essential COVID-19 treatments and vaccines as soon as they are available, inter alia through local production. For instance,  Swedish asset investors recently contributed USD 319 million to a social bond issued by the International Finance Corporation to help LMIC-based producers involved in the production of medical equipment and pharmaceuticals. Intergovernmental organizations, such as UNCTAD and its World Investment Forum, can play a key role in reaching out to impact investors to facilitate investments in social bonds.

Build partnerships to initiate “lighthouse” projects on low-hanging fruit

Successful short-term projects on simple technologies, especially in the production of test kits, personal protective equipment and ventilators, can set good examples to attract subsequent investment in more ambitious projects such as the production of treatments, diagnostics and, to the extent possible, vaccines. Investment promotion agencies should reach out to development banks, impact investors and social entrepreneurs to forge partnerships to fund initial “lighthouse” COVID-19 projects.

Improve investment incentives to increase local firms’ sustainability

Various measures can be considered, such as financial or fiscal incentives to produce COVID-19-related products. A very important investment incentive is medicines procurement, which in an infant industry context can be designed to include a price preference for local producers. Ethiopia, for example, allows a preferential margin of up to 25% on bids from local producers. To provide some predictability, preferential procurement should aim at a time span of five to ten years and include foreign investors that assist in local production. Advance purchase commitments as in the referred Ugandan case could be useful to kick-start manufacturing new products, such as COVID-19-oriented vaccines, where the market is unpredictable and companies need guaranteed purchases.

Use streamlined regulation to facilitate investment

To stimulate investment in COVID-19 medical products and ensure fast delivery to the needy, swift marketing approval is essential. Drug regulators should explore ways of fast tracking COVID-19-related applications, with support from WHO. In addition, current scenarios in many LMICs, where a producer needs to pursue multiple registration procedures with a multitude of different national agencies, paying multiple different registration fees, should be avoided in the future. Electronic procedures should be enabled for easy and swift registration of business activities, with support from UNCTAD’s e-regulations program.

Young scientist in modern biological lab (Photo; Adobe Stock)
Invest in infrastructure

Investment incentives financed by national governments and development partners should prioritize the building of essential infrastructure for local production projects, such as ensured electricity supply. Innovative approaches such as the use of drones in Rwanda to fly needed medicines to patients in remote areas illustrate the importance of investing in digital connectivity.

Emphasize the regional approach to reduce costs

Regional cooperation will make the measures suggested above more sustainable. Regional economic areas such as the EAC, SADC and COMESA, and in particular the newly created African Continental Free Trade Area (AfCFTA) have the potential advantages of establishing regional value chains to enable small economies in the region to collectively build the productive capability. Different countries have different comparative advantages, and together they can participate in a value chain that generates the medical supplies and medicines that they need to fight major pandemics. The regional groupings should aim at abolishing tariffs and non-tariff barriers, while promoting transparency of non-tariff measures. In a similar vein, regional coordination of IP rights and their enforcement will promote legal certainty and predictability for traders, including those dealing with pharmaceutical products. Regional approaches to procurement enable the pooling of purchasing powers, and regional drug regulation substantially eases producers’ expenses and efforts for filing and processing multiple applications for the same pharmaceutical product.

Seek funding from official development assistance

Important amounts of official development assistance will be made available for the new Access to COVID-19 Tools (ACT) Accelerator Global Response Framework. Donors when operationalizing this initiative should consider the contribution that LMIC-based producers can make to global public health security. The statements made by global leaders at the 4 May pledging conference indicated will for a new approach: UN Secretary-General Guterres and French President Macron referred to the need to have COVID-19-related R&D results as global public goods,  and German Chancellor Merkel emphasized the need to discover new paths toward the production of vaccines. Boosting productive capacity in LMICs is indeed a case in point.

Pharmaceutical production line. 3D rendered illustration. (Photo: Adobe Stock)
Ensure sustainability of efforts despite an unpredictable market

This is a key concern in areas such as COVID-19, where investors cannot know for how long the pandemic will pose an actual threat to societies. It has been observed that many countries have failed to ensure pandemic preparedness, as past pandemics (Ebola, SARS) ceased rather quickly and made any further investment undesirable. An international coalition of governments, development banks, impact investors and like-minded stakeholders is needed to address this market failure and to define future roles in protecting humankind from the next pandemic.

Building and expanding local productive capacity cuts across multiple policy sectors and requires concerted actions by all stakeholders in order to effectively address the five key bottlenecks. Together, we can create a global enabling framework and national ecosystems to enable local manufacturing to contribute to both the local and global public health endeavor, and ultimately to achieving SDGs 3, 8 and 9.

The Way Forward

We envisage a two-pronged strategy to pursue our ten actions.

  1. Our proposal addresses a gap in the international COVID-19 response by boosting productive capacity in LMICs. UNCTAD will closely coordinate and cooperate with existing initiatives, especially the WHO voluntary technology pool and the ACT Accelerator Global Response Framework, with a view to adding value and creating synergies.
  2. UNCTAD will intensify collaboration with our five partner agencies, i.e. WHO, The Global Fund, UNICEF, UNIDO, and UNAIDS to implement the May 2019 Interagency Statement on Promoting Local Production of Medicines and Other Health Technologies. Other partners will also be welcome to join us at our World Investment Forum later this year to mobilize key global players to commit to longer term productive capacity building. Drawing the lessons from the COVID-19 crisis, we intend to increase LMICs’ resilience in pandemic preparedness beyond the pandemic.

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James Zhan is senior director of Investment and Enterprise at UNCTAD. He is also editor-in-chief of the UN World Investment Report, and the Transnational Corporations Journal. He chairs the Governing Board of the UN Sustainable Stock Exchanges Initiative (with all major stock exchanges worldwide as members). He initiated the establishment of the World Investment Forum. He is chief strategist for the World Association of Investment Promotion Agencies. He has held advisory positions with academic institutions, including Cambridge University, Columbia University, Cornell University, Oxford University and the University of Geneva. He has published extensively, and appears frequently in international media outlets and parliament hearings on key and emerging trade and investment issues.

Christoph Spennemann is in charge of the Intellectual Property (IP) Unit at the United Nations Conference on Trade and Development (UNCTAD). He oversees a program on IP and investment with emphasis on issues related to health, technology transfer, and the digital economy. Christoph holds a master degree in international economic law and European law of the Universities of Lausanne and Geneva and practised law in Berlin. Christoph has published and co-authored various articles in the areas of patent law, geographical indications and trademark law, particularly in the context of bilateral and regional free trade agreements and development cooperation policy.

The views expressed in this article are the authors’ personal opinions and do not necessarily reflect the position of the UNCTAD secretariat.

Image Credits: APO/MOH Kenya , (Photo: Adobe Stock), UNCTAD , Adobe Stock , UNCTAD.

Scientist conducting coronavirus vaccine research at NIAID’s Vaccine Research Centre, Moderna’s original collaborator on the SARS-CoV-2 vaccine.

A COVID-19 vaccine candidate made by Chinese researchers successfully induced the development of neutralizing and binding antibodies against SARS-CoV-2, the virus that causes COVID-19, according to early results from a non-randomized phase I clinical trial published Friday in The Lancet. 

The trial results follow on to results announced by Moderna earlier this week, which found that their vaccine candidate was able to induce neutralizing antibodies in 8 healthy volunteers. In vaccine trials, the development of neutralizing antibodies is the most sought-after immune response because these antibodies bind to viral particles in a way that immediately blocks infection.

The non-randomized Chinese study, which was published in The Lancet, reported preliminary safety and efficacy results for a vaccine in 108 healthy middle-aged adults at low, medium, and high doses; with 36 participants enrolled in each dosage level. At low dose and middle-doses, about a half of the individuals produced neutralizing antibodies after 28 days. At high doses, some three-quarters (27/36) of volunteers produced neutralizing antibodies. Regardless of vaccine dosage, over 90% of participants showed a four-fold increase in binding antibodies. 

“These results represent an important milestone,” said Wei Chen from the Beijing Institute of Biotechnology, who was responsible for the study. “The trial demonstrates that a single dose of the new adenovirus type 5 vectored vaccine produces virus-specific antibodies and T cells in 14 days, making it a potential candidate for further investigation.”

The Ad5-nCoV vaccine also stimulated a rapid T cell response in 83.3% of individuals that received a low dose – and in the medium and high- dose groups,  97% (35/36) of individuals exhibited rapid T cell responses. Certain types of T cells develop responses when exposed to specific antigens, or parts of disease-causing pathogens, and “remember” to attack the same pathogen once exposed to it again. Vaccines, which contain un-infective pieces of viruses or weakened viruses, help activate this immune memory by inducting a T-cell mediated response.

The most common adverse reactions to the vaccine persisted for less than 48 hours, which is usually considered acceptable for a vaccine. Side effects ranged from mild pain at the injection site reported in over half (54%, 58/108) of vaccine recipients, as well as fever (46%, 50/108), fatigue (44%, 47/108), headache (39%, 42/108), and muscle pain (17%, 18/108). 

Many Limitations to Chinese Vaccine Study & Concerns with the Adenovirus 5 Vector

Still, “the challenges in the development of a COVD-19 vaccine are unprecedented, and the ability to trigger these immune responses does not necessarily indicate that the vaccine will protect humans from COVID-19,” warned Chen.

Further, randomized trials are needed to tell whether the immune response the vaccine candidate elicits effectively protects against SARS-CoV-2 infection, he added.

And health experts have brought up concerns around the vector used to carry the vaccine, a weakened common cold-causing virus, adenovirus type 5 or Ad5.

“There has been a shadow with the Ad5 as a vaccine vector over the last decade, not seen with other Ad vectors for vaccines. Have these concerns been allayed?” tweeted Jeremy Farrar, director of the research foundation Wellcome Trust, in response to the study.

Farrar referred to a previous case where an HIV-vaccine candidate using the Ad5 vector was found to put study participants who received the vaccine at a higher risk of HIV infection – and further exploration of that vaccine candidate was promptly discontinued. It’s been posited that the T-cells activated by the Ad5-vector HIV vaccine candidate made the cells more vulnerable to infection by HIV-1, which attacks immune cells.

Of the concerns, the study authors write, “although the association between HIV-1 acquisition risk and Ad5 vectored vaccine is controversial and its mechanism is unclear, the potential risks should be taken into account in studies with this viral vector delivery platform.

“We plan to monitor the participants in our upcoming phase 2 and phase 3 studies to assess the indication for any such acquisition.” At least two other vaccine candidates using the Ad5 vector are listed in the World Health Organization’s draft registry of SARS-CoV-2 vaccine candidates, the study authors say.

However, another concern is that half of the participants in the COVID-19 vaccine trial also already had immunity to the Ad5 virus, and these participants showed weaker immune responses to the COVID-19 vaccine. 

“Our study found that pre-existing Ad5 immunity could slow down the rapid immune responses to SARS-CoV-2 and also lower the peaking level of the responses,” said Feng-Cai Zhu from Jiangsu Provincial Center for Disease Control and Prevention in China, part of the group that led the study. “Moreover, high pre-existing Ad5 immunity may also have a negative impact on the persistence of the vaccine-elicited immune responses.”

The authors note that the other limitations of the trial are its small sample size, relatively short duration, and most importantly, lack of a randomised control group – which may have biased their results.

To address these limitations, a randomised, double-blinded, placebo-controlled phase 2 trial in 500 healthy adults has been initiated in Wuhan to determine whether the results can be replicated, and if there are any adverse events up to 6 months after vaccination. For the first time, this will include participants over 60 years old, an important target population for the vaccine.

Moderna Vaccine Induces Immune Response In Limited Number Of Healthy Volunteers

In a parallel development, eight people injected with Moderna’s experimental COVID-19 vaccine, mRNA-1273, developed neutralizing antibodies against the virus, announced the US-based pharmaceutical firm on Monday.

Neutralizing antibodies were detected in 4 participants that were given a low vaccine dose of 25 micrograms, and in 4 others that received a higher dose of 100 micrograms, 43 days after receiving the vaccine. At these doses, the vaccine was generally safe and well tolerated, said Moderna in a statement.

Neutralizing antibody titers for the remaining study participants were not yet available. The data were from a Phase I clinical trial conducted in collaboration with the US National Institute for Allergies and Infectious Diseases (NIAID). 

“These interim Phase 1 data, while early, demonstrate that vaccination with mRNA-1273 elicits an immune response of the magnitude caused by natural infection starting with a dose as low as 25 micrograms,” said Tal Zaks, M.D., Ph.D., Chief Medical Officer at Moderna.

“When combined with the success in preventing viral replication in the lungs of a pre-clinical challenge model at a dose that elicited similar levels of neutralizing antibodies, these data substantiate our belief that mRNA-1273 has the potential to prevent COVID-19 disease and advance our ability to select a dose for pivotal trials,” added Zaks.

Based on these early results, Phase 2 trials for the Moderna vaccine were amended to include a 50 ug dosage and a 100ug dosage in order to finalize a dosage for Phase 3 studies. A 50ug dosage arm was added to the Phase 1  – NIAID study.

Phase 3 clinical trials could be initiated as soon as July 2020, an unprecedented speedy timeline for vaccine development.

However, similar to the Chinese vaccine study, the initial results don’t necessarily show that the vaccine induces an immune response strong enough to protect against COVID-19, nor do they show how long protection might last.

The concentration of neutralizing antibodies in the 8 participants was similar to the concentration found to be protective against COVID-19 in mouse models, although the results from animal models do not necessarily always correlate directly with humans. The 8 participants with neutralizing antibodies were sampled only two weeks after receiving the second dose of vaccine, and must be followed further in order to determine whether and for how long the neutralizing antibodies could protect against SARS-CoV-2 infection. 

Some 45 participants also developed ‘binding antibodies’, which can bind to a virus but do not make it less infectious.

Though Moderna’s vaccine study was led by the US National Institute of Allergy and Infectious Diseases (NIAID), the NIAID did not publish a press release, and declined to comment on Moderna’s announcement. If successful, this would be the first vaccine candidate that Moderna, a company that is experimenting with new, mRNA vectors for carrying vaccines, will bring to market. 

In recent months, health experts and government leaders are more and more pinning their hopes to quash the pandemic for good on a successful COVID-19 vaccine, as serological studies are beginning to show that a large proportion of countries’ populations will remain susceptible to the virus after the first wave.

Not everyone that gets infected with COVID-19 develops antibodies, suggest recent European serological surveys. In Switzerland, one of the hardest-hit countries in Europe, only 1 in every 10 people had antibodies against COVID-19 – and older people had about half as many antibodies as young and middle-aged individuals. 

Surveys in Spain and France also paint a solemn picture of immunity, as only about 4-5% of the population has detectable antibody levels. Though the number of people with antibodies is growing rapidly as infections increase, herd immunity is far away.

The creation of an effective vaccine is seen as the long-term solution to controlling the COVID-19 pandemic. Currently, there are more than 100 candidate COVID-19 vaccines in development worldwide.

Image Credits: NIAID.

This story was updated 4 June to reflect the paper’s retraction.

Colorized scanning electron micrograph of a dying cell (blue) heavily infected with SARS-COV-2 (yellow), the virus that causes COVID-19

New research published in The Lancet on Friday found that hydroxychloroquine and chloroquine has ‘no benefit’ for coronavirus patients, and could even increase the risk of heart arrhythmias and mortality. 

The study was retracted by three of its authors on June 4, due to the authors own concerns about the “veracity of primary data sources.”

“This is the first large scale study to find statistically robust evidence that treatment with chloroquine or hydroxychloroquine does not benefit patients with COVID-19,” said lead author of the study and Executive Director of the Brigham and Women’s Hospital Center in Boston Mandeep R. Mehra. “Instead, our findings suggest it may be associated with an increased risk of serious heart problems and increased risk of death.”

In the worst-case scenario, some 8% of patients in The Lancet study who were given hydroxychloroquine combined with azithromycin developed a heart arrhythmia (502/6,221), compared with 0.3% patients in the control group (226/81144).

Hydroxychloroquine and chloroquine use predicts in-hospital mortality

Treatment with hydroxychloroquine, chloroquine, or either drug in combination with azithromycin was also associated with higher odds of death, even after accounting for age, race, body mass index, and preexisting conditions.

While not a randomized control study, The Lancet article is the largest study to date on the hyped drugs, analyzing data from nearly 15,000 COVID-19 patients who received hydroxychloroquine, chloroquine, or a combination of either drug with a macrolide antibiotic such as azithromycin, and 81,000 COVID-19 patients who did not receive any of those treatments. The data came from 671 hospitals across 6 continents.

In light of mounting evidence that hydroxychloroquine provides little benefit to coronavirus patients, health experts are again repeating calls to take caution in rolling out emergency approval for unproven treatments, even as countries all over the map cautiously begin to authorize the use of hydroxychloroquine for COVID-19. India even issued a revised advisory on Friday expanding the use of hydroxychloroquine as a prophylactic treatment in healthcare workers and contacts of lab-confirmed coronavirus patients.

Experts from the World Health Organization have also been cautioning against widespread, unmonitored use of the drug. 

“We do point to the fact that… the current clinical evidence does not support the widespread use of hydroxychloroquine for the treatment of COVID-19, not until the trials are completed and we have clear results,” said WHO’s Executive Director of Emergencies Programme Mike Ryan, at WHO’s press conference on Friday, referring to evidence from clinical and systematic reviews carried out by the WHO Pan American Health Organization (PAHO).

Hydroxychloroquine, and hydroxychloroquine plus azithromycin are two of the drug regimens being tested for COVID-19 patients in WHO’s giant, multicountry Solidarity Trial.

The Lancet results support previous findings from a widely disseminated Brazilian study that found an increased risk of heart arrhythmias in COVID-19 patients receiving high doses of the drug. The study was discontinued shortly after, as subjecting patients to increased risk of death in the trial was deemed unethical by study coordinators.

The Lancet study however, does not explore another use for hydroxychloroquine – taking the drug to prevent onset of COVID-19.

India Revises Hydroxychloroquine Recommendations To Promote Prophylactic Use
Indian Ministry of Health recommends prophylactic use of hydroxychloroquine in revised advisory

On Friday, India’s National Task force (NTF) for COVID-19 issued a revised advisory on prophylactic use of hydroxychloroquine – expanding the recommendation to include all asymptomatic healthcare workers in COVID-19 positive and non-COVID-19 settings, all asymptomatic frontline workers in the COVID-19 response including contact tracers, and all asymptomatic household contacts of laboratory confirmed cases. 

The previous advisory, issued on 23 March, restricted the recommendation to healthcare workers who worked directly with confirmed and suspected COVID-19 patients, and asymptomatic household contacts of laboratory confirmed cases. 

The revised recommendation was based on a small prospective observational study of 334 healthcare workers. According to the advisory, the incidence of COVID-19 infection in the 248 healthcare workers who took HCQ prophylaxis in New Delhi was lower than the incidence of infection in those who did not take it after following up with the study subjects for a median of 6 weeks, however the exact reduction was not listed.

Still, the revised advisory recommends that the drug has to be given under ‘strict medical supervision with informed consent’ and ‘only on the prescription of a registered medical practitioner’ – noting a number of preexisting conditions that make taking the drug risky. 

The advisory also notes that only under ‘rare’ circumstances does hydroxychloroquine lead to the dangerous cardiovascular side effects. Among 1323 healthcare workers who took HCQ prophylaxis, serious side effects were reported in 7. Among those 7, three healthcare workers had a serious cardiac side effect – prolongation of QT interval on ECG.

“Rarely the drug causes cardiovascular side effects such as cardiomyopathy and rhythm (heart rate) disorders. In that situation the drug needs to be discontinued,” said the advisory. 

China, Spain, Brazil, and the United States have also issued recommendations for use of hydroxychloroquine in limited populations, largely restricting them to use in clinical trial settings in light of the new reports of serious cardiac side effects.

But the authors of The Lancet study still warn that the overall likelihood that these drugs improve clinical outcomes in COVID-19 patients is quite low, and underline that the medicines should not be recommended by countries for widespread treatment of COVID-19.

 “Several countries have advocated use of chloroquine and hydroxychloroquine, either alone or in combination, as potential treatments for COVID-19. Justification for repurposing these medicines in this way is based on a small number of anecdotal experiences that suggest they may have beneficial effects for people infected with the SARS-CoV-2 virus,”  said Director of the Heart Center at University Hospital Zurich Frank Ruschitzka, who also co-authored The Lancet study.

Image Credits: NIAID, The Lancet, India Ministry of Health.