Attacks on energy and water also threaten health services as Ukraine approaches its third winter in wartime.

As Russian missiles rain down on hospitals and critical energy infrastructure keeping their lights on, Ukraine’s health system faces what could be its most challenging season yet in its third winter of full-scale war, the World Health Organization’s top European official warned Thursday.

“This will likely be the toughest winter of the three that Ukraine has faced since the war started,” Dr Hans Kluge, WHO’s regional director for Europe, told Health Policy Watch in an interview following a press briefing from Kyiv. “Many partners are scaling up assistance to ensure uninterrupted heating, water, electricity – but who knows what tomorrow will bring.”

Since the war began, nearly 2,000 Russian attacks on Ukrainian health facilities, workers and vehicles have been confirmed, resulting in 171 medical staff and patient deaths and 529 injuries. In the last six weeks alone, WHO verified over 30 attacks on 22 facilities across Ukraine.

On Thursday, shelling killed three ICRC staff members at a planned aid distribution site near the frontline in eastern Donetsk.

Power grid attacks cripple healthcare

Large Russian attacks on frontline Ukrainian regions over the past two weeks have targeted energy grids as well as cities.

Russia’s failure to overrun Ukraine militarily has led to a new strategy: making the country unlivable by targeting schools, hospitals, railways and energy systems. The assault on Ukraine’s energy grid directly affects the health system’s ability to provide care. 

The largest missile barrage since the war began occurred just two weeks ago, damaging key energy infrastructure and leaving nearly 250,000 people without power in the Sumy region alone.

“All the attacks on civilian energy infrastructure have direct impacts on hospitals,” Kluge said, speaking at the conclusion of a weeklong WHO tour of the country’s health services. “If you don’t have fridges to safely store blood, for example, then you don’t have blood transfusions – that has an immediate and drastic impact.”

Vaccine storage is another potentially deadly knock-on effect of power outages. If vaccines cannot be refrigerated, routine vaccinations cannot be conducted, putting patients at risk of easily preventable diseases.

 “If this continues, we may well see an increase in vaccine-preventable diseases,” Kluge said. “This, of course, is very regretful because they can be prevented – that’s the whole point of vaccines.”

Kluge (centre) with Jarno Habicht, WHO Ukraine lead (right)

Despite the attacks, Ukraine’s health system has shown resilience, with 93% of facilities nationwide still operational. WHO and Ukraine’s Health Ministry have installed modular clinics near frontline villages where health facilities were destroyed, with 40 such clinics planned across six regions by year-end.

“We had outreach teams who were going to the other side of minefields, ensuring that civilians get their health care services and were equipped with medicines,” said Jarno Habicht, WHO’s representative in Ukraine, who accompanied Kluge on the tour.

 “Every war disrupts, and it disrupts also the health services that we have in Ukraine,” he added. “Ukraine’s system works, but we also see areas where the services are very difficult to access.” 

Blackouts by Design

Russia has destroyed about 50% of Ukraine’s energy infrastructure and 60% of its power generation capacity since the start of its invasion in 2022. Cornerstones of Ukraine’s power grid – including the Zaporizhzhya nuclear power plant, the Kakhovka hydroelectric dam, and the Dnipro hydroelectric power station – have been destroyed or forced offline.

Ukrainians across the country face at least six hours a day without electricity. Even in the capital, some days offer only 10 hours of power. DTEK, Ukraine’s largest private power provider, is operating at 10% of its pre-war generation capacity. The current national power deficit is approximately 35%. DTEK estimates that come winter, blackouts could reach 20 hours a day. 

The consequences of mounting blackouts for a health system already struggling with current outage levels could be severe. Some regions – like Kherson, Mykolaiv, Sumy and particularly Kharkiv – will likely be more impacted due to the extensive destruction of energy infrastructure.

A joint assessment by the WHO and Ukrainian Ministry of Health in July shared with Health Policy Watch found 13% of hospitals were already experiencing significant power outages. Of the facilities with generators available, 33% were not installed or operational. Overall, 16% of all available generators were offline.

Electrical blackouts have also created a new problem: secure and reliable access to clean water. The governors of Dnipro and Poltava sounded the alarm to the WHO delegation led by Kluge this week. 

“Water systems could be compromised – as water distribution sites depend on uninterrupted power supplies,” Kluge said. “This could lead to increased water and foodborne diseases.”

Accessing and affording primary healthcare

Modular primary healthcare clinic, opened 9 September in the Odessa region, offers one response to shortages.

The war has also dealt a significant blow to the finances of Ukrainians, particularly those forcibly displaced – with knock-on effects on families’ ability to access the health care services they need. 

“One in four households is living below the poverty line,” said Habicht, who also accompanied the delegation. “With less means available and rising prices for medicines and other goods, health needs are increasing while access is becoming more challenging.”

Recent WHO assessments reveal that over 80% of households report problems obtaining needed medicines, with 6% unable to access essential medications. One-third of respondents cited insufficient funds to purchase medicines. Some 8% of households lack access to primary healthcare facilities. 

In health clinics, staffing shortages are another critical issue. “Some people are leaving,” Kluge said, noting the snowball effect of COVID-19 and the war on health workers. “In one instance, a hospital went from 800 staff to only 120. Fatigue, burnout, and anxiety are very prominent among the health workforce.”

Mental health problems escalating

Ukrainian children take refuge in a shelter – frontline children have spent the equivalent of 4-7 months underground.

Mental health problems are escalating, with an estimated 10 million people at risk. Ukraine has responded with a national program, training nearly 100,000 non-specialists online to provide mental health support.

A recent UNICEF survey estimates that children in Ukraine’s front-line areas have spent 3,000 to 5,000 hours — about four to seven months — underground since the war began. Half of children ages 13-15 have trouble sleeping, and three-quarters of those ages 14-34 reported needing emotional or psychological support.

“What struck me very much were the children who lost a leg or an arm. How, if they got modern prosthetics, they bounce back,” Kluge said. “They want to be a champion in the Paralympics – their dreams don’t stop.”

Image Credits: @hans_kluge/Foreign Policy, @pavlentij, X/@hans_kluge, @WHOUkraine, UNICEF.

Mpox vaccines in deep freeze storage in Kinshasa, DRC, awaiting distribution in remote regions.

The Democratic Republic of Congo (DRC) is planning to launch its mpox vaccination campaign in early October, marking a critical step in the fight against the ongoing outbreak across Africa, said Dr Jean Kaseya, Director-General of the African Centres for Disease Control and Protection (Africa CDC), on Thursday. 

Kaseya spoke at a press briefing following last week’s arrival of the first 99,100 doses of Bavarian Nordic’s (MVA-BN) vaccine in DRC, the country at the epicentre of the new mpox outbreak.

The DRC’s immunization efforts are complicated by the ongoing conflict with M-23 rebels in outbreak hotspots like South Kivu Province and its embattled capital city, Goma, in the country’s east.

Meanwhile, UNHCR, the UN Refugee Agency, appealed for $21.4 million to boost health services and critical mpox response for about 10 million refugees and host communities across 35 African countries, where overcrowded shelters and limited access to resources are exacerbating the risk of mpox transmission. 

With nearly 25,000 suspected cases reported in Africa so far this year, including in dozens of communities hosting displaced populations, sustained international cooperation and financial support is more urgent than ever to prevent further spread and strengthen public health systems across the continent, said the UN agency in a special report, released Wednesday.

Outbreak has spread to 20 nations

Spread of mpox cases in Africa, as per Africa CDC’s 12 September briefing.

Twenty of the African Union’s (AU) 55 member states across all five AU regions have reported at least one confirmed mpox case, according to the latest Africa CDC report on 8 September, for a total of 24,873 suspected cases, of which 5,549, were laboratory confirmed.

By Thursday, just four days later, the number had swelled to 26,543 reported cases, with nearly 6,000 laboratory confirmed, Kaseya said at the briefing, illustrating the snowballing nature of the epidemic. There have also been 724 reported deaths, for an estimated 2% fatality rate. Some 63% of those infected are men, while 47% are women, and 41% are children under the age of 15, according to the Africa CDC data.

Testing rates are woefully low

But testing rates, at 52.9% are woefully low, he added, saying, “We cannot rely solely on confirmed cases for decision-making and response.”

Vaccine supply and distribution efforts

Kaseya emphasized Africa CDC’s commitment to supporting the planned DRC October vaccine launch, saying that he would attend and get vaccinated himself to demonstrate the vaccine’s safety to the vaccine-hesistant Congolese and wider African public.

“We are ensuring all logistics are in place, including the training of vaccinators and the movement of vaccines to the provinces,” said Kaseya. He noted that Africa CDC teams will be on the ground at the provincial level to support the vaccination program, ensuring a smooth rollout amidst the complex logistics of such a large-scale campaign.

Mpox vaccines arrive on the tarmac in Kinshasa, DRC

The DRC has received about 265,000 doses of the mpox vaccine, primarily from the European Union through a partnership with Bavarian Nordic. But the vaccines are currently being held in cold storage in the capital city of Kinshasa, and transporting them thousands of kilometres away to conflict-ridden eastern DRC is a huge logistic challenge in a country that is the size of western Europe, DRC officials say. 

“Logistic problem, these are I think the biggest challenge because we have to bring the vaccines from Kinchasa to other parts of the country, where we not only have problems with roads, but with distances that are very, very big,”  Dr Roger Kamba, DRC Health Minister, told the BBC recently, adding that there are also more than seven million internally displaced people do to the ongoing conflict with M-23 militants in eastern DRC, 

“So I think we will start maybe at the beginning of October, in two or three weeks, we will start vaccination.” 

He added that the 265,000 doses received so far are “not enough” in a country of more than 100 million people. “But we think that we will receive more doses from Japan, for example, we think it can give us maybe nearly 3 million doses.”  

Kamba was referring to a reported Japanese pledge of several million doses of its new LC-16 vaccine, which has the advantage of being a one-dose vaccine, also approved for use in children. 

Shortages of syringes and protective gear

Additional MVA-BN vaccine donations also are due to come from the United States, which recently donated 50,000 doses to the DRC, and from other international partners, including France and Germany, Kaseya said at the Africa CDC briefing.

Despite these contributions, Kaseya again highlighted that the continent faces a significant vaccine shortfall, with a total need of 10 million doses to adequately protect populations at risk.

A major challenge in the vaccination effort has been the lack of syringes accompanying vaccine donations. Africa CDC said it is working with UNICEF and regional suppliers to address this gap, ensuring that essential supplies are available when the vaccination campaign begins.

Geographic distribution of reported mpox cases, the Democratic Republic of the Congo, 1 January to 26 May 2024 (7,851 cases). Since then infections rates have accelerated further.

The vaccination campaign will initially focus on high-risk areas identified as hotspots for the outbreak, including South Kivu, in Eastern DRC, and Equateur province, in the north west, Kaseya said. 

Equateur is seeing longer transmission chains of the most deadly Clade 1A variant of mpox, which typically spreads from forest animals to household members through skin-to-skin contact as well as through contact with shared items like towels and bedsheets, and can have a mortality rate as high as 10%. 

South Kivu is seeing a surge in a novel strain Clade 1B mpox variant. Somewhat less lethal, it is also being transmitted through heterosexual sexual contact as well as within households and communities – unlike the original Clade 2 variant that is generally much milder, and spread internationally in 2022 and 2023, mainly among men who have sex with men.

The outbreak in these regions has been particularly severe, with children under the age of five representing a substantial proportion of cases. Kaseya stressed the importance of prioritising these vulnerable groups and ensuring adequate protection through vaccination.

Father of six, seeking shelter at a displacement site near Goma in July, after his wife was killed by a rebel bombing in North Kivu, eastern DRC.

Scaling up genomic surveillance

Africa CDC revealed it is also scaling up genomic sequencing efforts to better understand the virus’s spread and its genetic variations across the continent – where a mix of suspected variants are being reported, but genomic mapping remains limited. He said that the goal is to sequence a minimum of 200 samples from each affected African Union member state.

Current data, however, indicates that Clade 1B is the predominant strain affecting children in the eastern part of the DRC, while the milder Clade 2 is more commonly found in West Africa.

Kaseya underscored the need for  financial support to sustain the vaccination campaigns and broader response efforts. Africa CDC’s mpox continental preparedness and response plan is currently calling for $600 million, to not only address immediate outbreak needs but also to build stronger public health infrastructure, including enhanced laboratory and surveillance capacities.

Combatting mpox among Africa’s displaced populations

UNHCR map reflects the convergence of displaced groups and mpox spread.

As for the UNHCR’s $21.4 million appeal, this aims to bolster health services for some 9.9 million forcibly displaced people and host communities in 35 countries across Africa in countries grappling with the spread of mpox. 

Those, most vulnerable populations, are at the highest risk of contracting the disease due to overcrowding and lack of access to basic hygiene and sanitation, warned Allen Maina, UNHCR’s public health chief. 

“For refugees and displaced communities already facing enormous challenges in accessing healthcare, these conditions place them at higher risk of falling sick and make it harder to protect themselves,” Maina stated in a news release.

Africa hosts over a third of the world’s forcibly displaced people, many of whom reside in countries experiencing mpox transmission. These communities are already contending with protracted conflict, chronic funding shortfalls, and other humanitarian crises, making them particularly susceptible to outbreaks.

UNHCR cautioned that the mpox outbreak could further stretch already overburdened humanitarian resources, disrupting critical services such as food distribution, education, and protection activities.

Maina emphasized the need for sustainable financing to strengthen health systems, water and sanitation facilities, and other services, ensuring resilience against current and future health emergencies.

“We need to support governments and partners in the mpox response to ensure that no one is left behind,” Maina said. “Sustainable financing is crucial to maintaining essential services for the most vulnerable.”

Image Credits: BBC/YouTube, Africa CDC, WHO , © UNHCR/Blaise Sanyila, UNHCR.

Polio campaign gets unmderway in northern Gaza on 10 September, the third phase of the staged outreach.

Over half a million Gazan children have been vaccinated against the deadly polio virus over the past 12 days, WHO said on Thursday, on the final day of a campaign that began 1 September, and which officials said appears to have attained the goal of reaching over 90% of the population of children under 10 years of age – at least in its first phase. 

But the longer-term health challenges faced in the war-torn enclave were underlined by a new WHO report, stating that some 22,500 Gazans who have sustained ”life-changing” injuries in the grinding 11-month Israel-Hamas war, will need long-term rehabilitation services that are unavailable from a shattered health system. 

Brief humanitarian ‘pauses’ against grim background of conflict

Dr Rik Peeperkorn, WHO representative to the Occupied Palestinian Territories (OPT), speaking from Gaza.

The polio vaccine campaign has unrolled in the shadow of new Israeli military evacuation orders and aerial bombings in parts of Gaza where displaced Palestinians were sheltering, along with the Israeli military’s discovery of six dead Israeli hostages in a tunnel under the southern city of Rafah, reportedly shot dead by Hamas shortly before the army’s arrival. 

Even so, brief lulls in fighting due to a series of ‘humanitarian pauses’ agreed to by all sides enabled local medical teams, coordinated by WHO, to conduct the three stage polio immunization drive across the central, southern and northern regions of the 365 square kilometre Palestinian enclave. The campaign, involving hundreds of local medical staff, was planned and launched after the initial discovery of poliovirus in Gaza sewage in July, followed by the confirmation of an active polio case in a 10-month old baby in August. 

The case was traced to a vaccine-derived strain of poliovirus, which is commonly emitted in feces, but can mutate and infect other under-immunized children, particularly in degraded sanitation conditions like those faced in wartime Gaza today.      

“So far in the north we have reached 105,909 children under ten years of age. In the middle area: 195,722 and in the south 250,820,” said Dr Rik Peeperkorn, WHO coordinator for the Occupied Palestinian Territories (OPT), in a WHO press briefing on Thursday. 

“This brings the total number of children vaccinated as of yesterday to 552,451. Numbers for today are still awaited,” he said. 

While the original 90% target involved reaching 640,000 children, that estimate of the under-10 population is being revised downward, in light of actual findings during the campaign, Peeperkorn stated. The same outreach must be repeated in a month’s time to deliver a second polio vaccine dose. 

‘Heartening to see response’

“It has been heartening to see the response to the campaign,” Peeperkorn told reporters at a briefing, broadcast from Gaza. “Everywhere the team has gone, parents are doing all they can to ensure their child does not miss vaccination. Many vaccination sites received more than expected crowds. Special coordinated missions were also conducted to reach children in insecure and hard to reach areas.

“I think that it’s amazing what has happened and what is possible where you have specific humanitarian policies, especially for the children, for the families, for everyone. 

“I don’t want to use that word, but it has even a bit of a ‘festive’ environment. Children came out [to be vaccinated] very well dressed. Many children on the streets …were.so joyful, joyful on the which haven’t been the case for the last 11 months. 

“So if this is possible in polio, why can’t we not translate this for other areas?”

Need to extend the polio ‘bubble’ to other humanitarian response efforts

“We are, and we were, and we are a little bit in a polio bubble,” Peeperkorn continued. 

“But we need to extend that, of course, to all the other humanitarian priorities,” he stressed, adding that food, fuel and medical supply distribution remain extremely difficult, while the area also faces looming winter cold and rain, after the scorching heat of the past summer. 

“We still face all of the same challenges we have for the last 11 months, if you talk about security, about getting the right goods and supplies humanitarian goods into Gaza,distributing those humanitarian goods across Gaza, and a deconfliction mechanism.  A lot of our humanitarian missions are still canceled.

“Over the last three weeks, we probably have nine missions to the North, many of those critically essential fuel missions for hospitals. Only four happened. 

“So if it is possible with polio, why can’t we do that in in a much broader area, and make sure that you establish these proper humanitarian corridors, even in a time of conflict?” 

Rehabilitation needs are huge and entirely unmet

Gaza doctor checks amputated limb of a young man.

Along with the constant interruptions in daily humanitariana relief efforts, the rehabilitation needs for injured Gazans constitute a huge, unmet need, for which almost no health services currently exist.

Without quick access to rehabilitation, many injuries will rapidly become even worse, noted Peeperkorn and other WHO experts at the briefing, citing the examples of spinal injuries that can cause knock-on bladder dysfunction, if not treated in time.

The new WHO report estimates trauma injury rehab needs using data from 8,878 injured patients, who were treated by Emergency Medical Teams (EMTs) between January and May, 2024. Based on that data, it extrapolates that at least one quarter of the esetimated 95,000 Palestinians injured in Gaza since the start of hostilities on 7 October, 2023, are estimated to have “life changing injuries that require rehabilitation services now and for years to come.”

Some 13 455 -17 550 people are estimated to have undergone severe limb injuries, which constitute “the main driver of the need for rehabilitation,” Peeperkorn stated, quoting the report. Many of those injured have more than one injury, the analysis found. The most common injury is to a major extremity,  followed by amputation, burn, spinal cord injury and traumatic brain injury. Between 3105 and 4050 limb amputations have been conducted.

The analysis does not distinguish between injured combatants and non-combatants – a distinction the Hamas-controlled Gaza Ministry of Health also has avoided in its 11 months of reporting on injuries and deaths – the latter now estimated at more than 40,000 lives lost.

The WHO analysis also made no estimate of the distribution of such injuries between men, women and children – despite the detailed breakdown in injury types and needs. Asked why age and gender were not at least considered, a WHO spokesperson cited the “limited availability of data” as noted in the report.

Gaza rehab services decimated

At the same time needs are mounting, Gaza’s pre-war rehab services have been decimated, the report underlines.  The enclave’s only limb reconstruction and rehabilitation center, located in Nasser Medical Complex and supported by WHO, ceased operations in December 2023, due to a lack of supplies and the flight of specialized health workers.  The hospital was further damanged during bitter fighting in February. Additionally:

  • The three pre-existing inpatient rehabilitation units (Al Amal, Sheikh Hammad, Al Wafaa) are not operational.
  • The only 2 prosthetic centres were located in Gaza city. One was damaged, one has been inaccessible throughout the war. Some basic repair services have newly restarted at one and a new service is being established in the South.
  • At least 39 rehabilitation professionals are reported killed. Many others are displaced.

Currently, only 17 of 36 hospitals remain partially functional in Gaza, while primary health care and community-level services are frequently suspended or rendered inaccessible due to insecurity, attacks, and repeated evacuation orders, WHO noted.

“The huge surge in rehabilitation needs occurs in parallel with the ongoing decimation of the health system,” said Peeperkorn. “Patients can’t get the care they need. Acute rehabilitation services are severely disrupted and specialized care for complex injuries is not available, placing patients’ lives at risk. Immediate and long-term support is urgently needed to address the enormous rehabilitation needs.” 

Image Credits: WHO, HPW, WHO.

George Vradenburg, founding chairman of the board of the Davos Alzheimer's Collaborative
George Vradenburg, founding chairman of the board of the Davos Alzheimer’s Collaborative

NAIROBI, Kenya – Dementia is rapidly becoming a significant public health concern across the globe, with projections estimating 150 million people will be affected by 2050.

“Dementia is a health, financial and social problem of almost unimaginable proportions,” said George Vradenburg, founding chairman of the board of the Davos Alzheimer’s Collaborative (DAC). “It may prove to be the sinkhole of the 21st Century.”

Sub-Saharan Africa is facing its own alarming rise, where 2.13 million people were living with dementia in 2015, a number expected to more than triple to 7.62 million by mid-century.

By 2050, Africa is expected to have the largest population of people over the age of 60. At the same time, some African countries, such as Kenya, will also have the highest number of individuals under 20.

According to Zul Merali, director of the Brain and Mind Institute at Aga Khan University, this presents not just a challenge but a significant opportunity. By studying the aging brain, dementia, and Alzheimer’s in Africa’s diverse population, researchers may gain valuable insights into risk factors and develop earlier interventions for these diseases that could help individuals worldwide.

“With 80% of the people with dementia likely to be in the Global South by 2050, it’s imperative that we bring the high-resource communities and the Global South together to solve the problem,” said Vradenburg.

More than 200 people gathered in Nairobi on Wednesday for Nature’s first-ever two-day conference on brain health and dementia in Africa, driven by the need to unite the Global North and Global South in tackling the dementia epidemic, as Vradenburg described.

The event, titled “The Future of Dementia in Africa: Advancing Global Partnerships,” brought together researchers, industry leaders, local government, policymakers, and individuals with lived experience.

The conference is focusing on key challenges, the latest research on dementia’s epidemiology, risk factors, genetic breakthroughs, clinical trials, early detection and diagnosis.

DAC and the Aga Khan University Brain and Mind Institute are co-sponsors of the event. In a joint statement with Nature, they described the event as a pivotal moment for Africa, providing an opportunity to unite efforts, exchange knowledge, and create strategies specifically designed to address the continent’s unique challenges in tackling dementia.

Merali said that Africa is largely unprepared for the spike in people with dementia.

“If you look at the world literature, you will see that most of the information comes from the Global North as it pertains to dementia and Alzheimer’s disease,” Merali explained. “The data from Africa is less than 1%, so there is a huge gap. We don’t know what’s going on or how to get ready for it.”

From left: George Vradenburg, Zul Merali and Vaibhav Narayan
From left: George Vradenburg, Zul Merali and Vaibhav Narayan

Which risk factors are relevant to Africa?

Many dementia risk factors have been identified in the Global North, but understanding which are most relevant in Africa is crucial, Vaibhav Narayan, executive vice president for strategy and innovation at DAC, told Health Policy Watch.

He noted two possible scenarios: the same risk factors exist in the Global North and Global South but are more prevalent in Africa, leading to a more significant impact, or some risk factors are unique to the continent.

“I would call this an emerging field,” Narayan told Health Policy Watch. “Larger and larger studies are being done.”

Narayan suggested that some risk factors, particularly climate change-related ones, could be more significant in Africa.

“What most people don’t realize is that the stressors caused by climate change are both physiological—your brain may be exposed to higher temperatures for longer, you may be breathing in pollutants—but also psychological.

The stress of impending crop failure, for example, can accelerate cognitive decline and push toward dementia,” Narayan said.

He also highlighted migration patterns, especially forced migration for work or safety, as another potential stressor unique to Africa.

Merali added that another unique risk factor in Kenya may be the many people who ride motorcycles, often without helmets. Young individuals involved in motorcycle crashes could face a higher risk of developing brain disorders, including dementia and Alzheimer’s, later in life.

“We want to ensure we understand these risk factors, their impact on brain health and cognitive decline, and, perhaps most importantly, how to reduce them,” Narayan added. “What are the interventions at the policy, individual, community, societal, and national levels? That will take time.”

Dr Chi Udeh-Momoh, a translational neuroscientist affiliated with Imperial College London, the Karolinska Institute, and Bristol University, is already focused on understanding these risk factors.

She told Health Policy Watch that her team is working on developing “normative data” to better understand the causes of dementia in the Global South, particularly in Africa, which has a vast diversity.

Udeh-Momoh is researching the molecular and biobehavioral factors contributing to resilience in African populations — how individuals cope with and adapt to extreme stress while still thriving.

Udeh-Momoh and her team’s mission goes beyond identifying the causes of dementia; they aim to detect it early using cutting-edge tools and innovative approaches. These include advanced neuroimaging, retinal imaging, digital cognitive assessments, and traditional tests like paper-and-pencil exams and brain games designed to establish a baseline for memory and cognition in the local population.

How can dementia be prevented?

A peer-reviewed article in The Lancet has revealed that up to 45% of dementia cases could be prevented by addressing a small number of key risk factors.

While the Global North has primarily focused on treating Alzheimer’s at its later stages, Africa, with its younger population, has the potential to focus on modifiable risk factors and lead the way in developing pragmatic and scalable prevention programs.

“Lifestyle changes are critically important and just as important as pharmacological or drug treatments,” Merali said.

New treatments are becoming available. The first FDA-approved drugs for Alzheimer’s, such as Leqembi for mild dementia and Kisunla for adults with early symptomatic Alzheimer’s, are now on the market. However, these medications were primarily tested in clinical trials in the Global North and are prohibitively expensive, making them inaccessible to many communities.

Narayan suggested that, instead of focusing on Alzheimer’s drugs, doctors in Africa could treat identified risk factors, such as  hypertension or obesity.

Vradenburg, meanwhile, has concentrated his efforts on developing vaccines for dementia.

“We know that the Global South is experienced in administering vaccines, which are generally low-cost,” he said, adding that if researchers can identify and diagnose those at risk of dementia in the next decade, vaccines could be available by 2030. These vaccines could even achieve widespread adoption to prevent the disease and its symptoms, he said.

Man with dementia (illustrative)
Man with dementia (illustrative)

 

Why is there a stigma around dementia in Africa?

Finally, another essential factor to consider in Africa is the stigma surrounding dementia.

Merali explained that many people in Africa do not know what dementia is. Often, they believe it is a normal part of aging, and when symptoms become more severe or unusual, some attribute them to witchcraft or evil spirits.

“As a result, individuals with dementia can become targets, frequently ostracized, and in some cases, even beaten or lynched,” Merali said. “We need to educate the population.”

He emphasized that understanding dementia as a medical condition would lead to people being treated with more compassion and respect.

Narayan echoed these concerns: “Today, many people think dementia is just a part of aging. The key to removing the stigma around not only dementia but also mental health disorders like depression is to show the world that these are actual biological diseases.”

He added that the work being done by DAC and the Aga Khan University to develop objective medical tests, such as blood or imaging tests, will help people recognize that dementia is a disease and not the individual’s fault.

Vradenburg shared a historical perspective: “I’m old enough to remember when cancer was a word no one dared to say—it was referred to as the ‘big C,’ and it took decades to move past that.”

He pointed out that over time, the medical community learned that early detection, catching cancer at stage one instead of stage four, was crucial to survival.

Vradenburg said he believes dementia is undergoing a similar transition today.

Image Credits: Pexels, Maayan Hoffman.

Kenya
Antibiotic use in agri-food production is driving AMR.

Targets that aimed to reduce the use of antimicrobials in the livestock industry have been dropped from the latest version of the draft UN Political Declaration on Antimicrobial Resistance (AMR), reportedly as a result of pressure from major meat-producing nations and the veterinary drug industry. 

The draft declaration, which aims to curb growing pathogen resistance to leading antibiotics, antiviral and antiparasitic drugs, was distributed amongst UN member states on 9 September ahead of the United Nations High-Level Meeting (HLM) on 26 September.

 The May version of the declaration had a target of “at least 30%” reduction in “the quantity of antimicrobials used in the agri-food system globally” by 2030, as reported earlier by Health Policy Watch.  The latest, near final, draft, includes only a vague commitment to “strive meaningfully” to reduce use.

By far the biggest use of antibiotics worldwide is agriculture, and particularly the livestock industry, with an estimated 80% of antibiotics in the US alone administered to animals, not people.  Drug resistant bugs, meanwhile, are estimated to kill nearly 5 million people a year. 

With regards to reducing the use of antibiotics in livestock production, Dr Holy Teneg Akwar from the World Organisation on Animal Health (WOAH) told a media briefing on Wednesday that “countries will develop their own targets taking their respective contexts into consideration”.

“There were a lot of sensitivities around the commitments on antimicrobials in farm animals,” added Javier Yugueros-Marcos, head of AMR at the World Organization for Animal Health (WOAH).

The media briefing was convened by the “Quadripartite” group managing AMR globally – the World Health Organization (WHO), Food and Agricultural Organization (FAO) UN Environment Programme and  WOAH.

The targets were dropped as a result of pressure from the US as well as other meat-producing nations in the developed world, including Australia, New Zealand and Canada, according to a report by the US-based non-profit, Right to Know..

“The massive overuse of antibiotics on factory farms in the United States is a serious threat to public health,” US Senator Cory Booker said in a statement on the outcome of the final UN draft.

“Federal agencies have a troubling history of deferring to corporate interests on this issue, and I am very concerned about any role that the United States played in weakening international commitments to reduce antibiotic use in farm animals,” said the Democratic Party Senator, who is campaigning for improved control of antibiotics in food-producing animals in the US.

 Animal vaccination plan

The declaration does direct countries to use antimicrobials in animals and agriculture “in a prudent and responsible manner in line with the Codex Alimentarius AMR Standards” and WOAH’s “standards, guidance and recommendations”.

It also commits to a global animal vaccination plan by 2030, based on WOAH’s list of priority diseases to reduce antibiotic use.

The declaration directs the UN FAO to develop further global guidance to also prevent and reduce antimicrobials in plant agriculture – another source of AMR risk.

“The misuse of essential drugs in food production, whether in livestock farming, aquaculture or crop production, accelerates the emergence and spread of resistance,” Junxia Song, FAO senior animal health officer, told the media briefing.

Some “common [animal] bacterial infections have become harder, and sometimes impossible, to treat”, she added.

“These resistance strains can transfer from animals to humans through direct contact or through the agri-environment or the food chain, creating a cycle that worsens the AMR crisis.”

AMR threatens the livelihoods of 1.3 billion people who depend on livestock, said Song. 

“The World Bank  projects that in a high AMR impact scenario, livestock production in low income countries could decline by 11% by 2050, raising costs for farmers and driving up food prices,” she added.

Reducing mortality by 10% and raising $100 million

Two key targets for reducing AMR-related mortality, as well as raising funding to combat AMR, did survive member state negotiations into the present draft. There is a commitment to reducing global AMR deaths by 10% by 2030 against the 2019 baseline of an estimated 4.95 million deaths associated with AMR every year.

A target of raising $100 million “from international cooperation” has also been set to ensure that 60% of countries develop and implement national AMR action plans by 2030.

Aitziber Echeverria, UNEP’s AMR co-ordinator, warned that drug resistance was being developed and transmitted in the environment.

“Global attention to AMR has been dominated by a focus on human health,” said  Echeverria. “But there is a widespread agreement that tackling it requires a multi-sectoral One Health approach that considers the health of humans, animals, plants and the wider environment, including ecosystems, as interconnected and interdependent.

“The most important sources of microorganisms with antimicrobial-resistant genes in the environment is the human waste that ends up in sewage, wastewater or landfills,” she warned.

WHO priorities

Dr Yvan Hutin, director of the WHO AMR division

Dr Yvan Hutin, director of  the WHO AMR division, told the media briefing that resistance to antibiotics was often rapid, often happening within 10 years.

“Every time we are smart at inventing an antibiotic, nature is quite fast in evolving and finding a counter-measure. 

The speed of AMR resistance

“The problem is that our pipeline is dry. Our capacity to actually even add some more antibiotic on this graph is not what it used to be. Resistance is emerging and the pipeline is running out.”

The WHO has proposed four steps to address AMR: preventing infection (through ensuring access to clean water and sanitation, immunization and infection prevention control); universal access to affordable, quality diagnostics and appropriate treatment of infection; strategic information science and innovation (guided by science); and effective governance and finance. 

The WHO has also developed “stop light” characterisation of antibiotics, with “green antibiotics” for common infections that have the lowest resistant potential; orange antibiotics  that have higher resistant potential and are for less common infections, then “red” reserve antibiotics only to be used when they’re absolutely necessary. 

The Quadripartite leaders expressed their “cautious optimism” about the political declaration and the expected outcome of the HLM. The last HML was held in 2016.

Progress since the last UN HLM on AMR in 2016

Image Credits: International Federation of Red Cross and Red Crescent Societies / The Kenya Red Cross Society, Yvan Hutin/WHO.

Violence against women and girls is set to triple by 2060 due to climate change, according to a latest report by UNFPA.

Tens of millions of women and girls in sub-Saharan Africa will experience “catastrophic levels” of intimate partner violence because the world is failing to make progress on the climate crisis, according to new projections by UNFPA, the United Nations sexual and reproductive health agency.

The report, jointly produced by UNFPA, the International Institute for Applied Systems Analysis (IIASA), and the University of Vienna, found that rising global temperature is increasing rates of intimate partner violence.

“Extreme heat threatens the safety and well-being of the most vulnerable women and girls all across Africa,” said UNFPA Executive Director Dr Natalia Kanem. “Heat stress can put the health of pregnant women and their babies at risk, increasing the chance of preterm birth and stillbirth,” she added.

This report is part of the growing body of evidence linking climate change and intimate partner violence. In June 2022 a review that looked at existing literature on the subject was published in The Lancet, but for many regions the evidence base is severely limited.

Climate change is known to exacerbate existing stressors like economic ones. In regions where women are already vulnerable, worsening household economic situation and rising frustration led to a rise in violence against women, the research has so far established.

For those working in disaster management, this is already a well-known phenomenon where violence against women and young girls tends to rise in the aftermath of a disaster. With climate change leading to a rise in disasters, a rise in violence against women is also being noted globally.

“The climate crisis has also led to shocking levels of violence in the home – an impact often overlooked by policymakers,” Kanem said.

Climate action can limit damage.

Violence set to triple in sub-Saharan Africa

The number of people experiencing intimate partner violence in sub-Saharan Africa will nearly triple from 48 million in 2015 to 140 million in 2060, in the worst-case scenario where emissions rise and temperatures warm by more than 4°C by the end of the century. This number also takes into account the stalling of socioeconomic development in the region.

Studies show that extreme temperatures and heat waves can drive up aggression and intimate partner violence. The collapse of agriculture, water scarcity and housing insecurity is a further trigger — leading to increased conflict and risk of women and girls suffering physical and emotional abuse. Natural disasters linked to warming temperatures trigger forced displacement, which is associated with higher levels of intimate partner violence.

In parts of sub-Saharan Africa, which is on the frontlines of the climate crisis, more than half of women and girls reported experiencing intimate partner violence in the previous 12 months.

Climate action can limit harm

This spike in violence can be averted if countries work to limit global temperature rise to 1.5 degrees Celsius, as outlined in the Paris Agreement, and pursue the 2030 Agenda for Sustainable Development, the report said.

At present, the world is off track on both these goals. Global temperatures have breached the 1.5 degrees Celsius for an entire year now, and without drastic changes, the temperatures will continue to rise.

In addition, policymakers currently look at SDG and climate action as either/or choices rather than complementary ones.

The best-case scenario will see the share of women affected by violence in sub-Saharan Africa decline from 24% in 2015 to 14% in 2060. Overall, the difference between climate action success and failure is 1.9 billion preventable cases of intimate partner violence between 2015 and 2060, according to the report.

Scenario

Temperature increase

IPV cases 2015

IPV cases 2060

Percentage change

Best case

1.5°C

48 million

48.95 million

2 per cent

Worst case

4°C

48 million

140 million

192 per cent

“UNFPA’s new research points the way forward: decisive climate action needs to build resilience in affected communities, which starts with putting the needs of women and girls first,” Kanem said.

Women and girls who experience intimate partner violence will need access to climate-resilient health care, including medical and psychological support.

UNFPA has asked countries to invest climate finance in health and protection systems that work for women and girls in the future, in the face of increasing climate shocks and displacements.

Countries have also been asked to include the sexual and reproductive health and rights of women and girls –  including the risk of gender-based violence –  in their national climate plans.

Image Credits: Climate Change Impacts and Intimate Partner Violence in Sub-Saharan Africa .

Antibiotic manufacturing water pollution
Waste from antibiotic manufactoruring causes some of the highest levels of environmental antibiotic pollution.

Manufacturers of antibiotics are dumping waste into waterways that is driving antimicrobial resistance (AMR), warns the first-ever guidance from the World Health Organization (WHO) on waste water management and AMR.

Antibiotic pollution is “largely unregulated” and a “neglected” issue,  according to the WHO guidance, which explains how to mitigate liquid and solid waste during the formulation of active pharmaceutical ingredients (APIs). 

High levels of antibiotics in waterways downstream from factories have been “widely documented,” according to the guide, which notes that the highest concentrations of antibiotics in the environment come from manufacturing plants.

Resistant pathogens can be traced back to discharge from pharmaceutical manufacturing plants, hospitals, farms, or sewage systems. Even properly functioning wastewater treatment systems may not fully remove resistant pathogens and their genes, a Centers for Disease Control and Prevention (CDC) fact sheet notes. 

“Pharmaceutical waste from antibiotic manufacturing can facilitate the emergence of new drug-resistant bacteria, which can spread globally and threaten our health. Controlling pollution from antibiotic production contributes to keeping these life-saving medicines effective for everyone,” said Dr Yukiko Nakatani, WHO Assistant Director-General for AMR said in a recent press release. 

Manufacturing steps

The guidance, which covers each manufacturing step from the formation of APIs to the finished product, provides a framework for policymakers, antibiotic procurers, investors, wastewater management, industry, and other stakeholders to set targets for pollution mitigation.

It sets targets based on predicted no-effect concentrations (PNECs) for antibiotic resistance and for ecological effects (PNECeco). Two further levels “enable progressive improvement to methods that provide a greater degree of certainty that discharges are not leading to harmful effects.” It also includes best practices for risk management, public transparency, and how to progressively implement these policies. 

Given the urgency and danger AMR poses, several organizations – including the WHO Executive Board, G7 health ministers and the UN Evironmental Program (UNEP) – have called for the creation of guidelines to regulate antibiotic manufacturing..

AMR claimed 1.27 million lives in 2019, surpassing deaths from HIV and malaria. Deaths are projected to reach 10 million annually by 2050. Despite AMR’s burden on public health, the issue remains underfunded, with little innovation and talent to produce new lines of antibiotics. 

Once antibiotic residues enter the environment, especially aquatic ecosystems, they exert pressure on bacteria -both pathogenic and non-pathogenic – to adapt and become resistant. Yet quality assurance criteria “typically do not address” antibiotic pollution, says the guidance. 

The WHO’s awareness campaign earlier this year highlighted patient stories and experiences with AMR. 

Reducing unnecessary risk

Globally, there is a lack of accessible information on the environmental damage caused by manufacturing of medicines, and the potential risks of AMR. Although research is still ongoing on the extent of manufacturing pollution and the rise of resistant pathogens, the experts behind the guidance operate under the assumption that progress can be made to limit the risk.

“The guidance provides an independent and impartial scientific basis for regulators, procurers, inspectors, and industry themselves to include robust antibiotic pollution control in their standards,” said Dr Maria Neira, WHO Director of the Department of Environment, Climate Change and Health, in a press release.

“Critically, the strong focus on transparency will equip buyers, investors and the general public to make decisions that account for manufacturers’ efforts to control antibiotic pollution.” 

Hopes for political commitment

Causes of AMR
The UN General Assembly will host a high-level meeting on AMR September 26.

The guidance comes just a few weeks before diplomats descend on New York City for the United Nations General Assembly High Level Meeting on AMR on 26 September. The last HLM on this issue was eight years ago.

Experts, like Wellcome Trust’s Jeremy Knox, head of infectious disease policy, expressed hopes that the HLM will spur “some commitments which are steps in the right direction,” in earlier Health Policy Watch coverage. 

Advocating more stringent regulation may close loopholes that allow antibiotic pollution to end up in the environment in the first place.

“The role of the environment in the development, transmission and spread of antimicrobial resistance needs careful consideration since evidence is mounting,” said UNEP’s Jacqueline Alvarez. 

“There is a widespread agreement that action on the environment must become more prominent as a solution.”

Image Credits: Janusz Walczak, FAO.

Cholera oral vaccine Sudan
A child received an oral cholera vaccine, one of the vaccines prioritised by AVMA.

While COVID exposed the urgency of ensuring that Africa can manufacture vaccines, the current mpox and cholera outbreaks have painfully underscored the continent’s vulnerability.

African countries affected by mpox are dependent on vaccine donations from wealthy countries, while a dire global shortage of cholera vaccines has forced the World Health Organization (WHO) to advise countries to give people one dose instead of the optimal two.

Back in June, the vaccine platform, Gavi, launched the African Vaccine Manufacturing Accelerator (AVMA), together with the African Union and Africa Centres for Disease Control and Prevention (Africa CDC).

“AVMA is a financing mechanism established to make up to $1.2 billion available over 10 years, commencing with AVMA’s launch in June 2024, to accelerate the expansion of commercially viable vaccine manufacturing in Africa,” a Gavi spokesperson told Health Policy Watch.

High hopes are invested in AVMA, but the initiative has also been criticised for offering incentives that favour established international manufacturers rather nurturing than smaller, truly African manufacturers.

Initiative ‘favours major producers’

“Without proper attention to who owns and controls the production and underlying technologies, there is a risk that well-meaning donor investments reinforce market dynamics that favour a handful of major international producers over truly local efforts. This is particularly relevant for AVMA,” argue researchers Els Torreele and Heather Sherwin in the journal, PLOS.

Gavi defines local production as “geographically located on the African continent”, which means that international non-African companies are eligible for financing. 

“We have clearly stated throughout extensive consultations, as well as in public board documents, that eligibility for AVMA is based on geographic location of manufacturing rather than location of ownership,” Gavi’s spokesperson told Health Policy Watch.

Gavi wants to build “a thriving and sustainable vaccine manufacturing sector on the African continent” and is “dedicated to fostering a sustainable and resilient manufacturing base in Africa”.

“With that objective in mind, any manufacturing operations physically located in Africa which serves that end, irrespective of ownership, will be eligible,” added the spokesperson.

The development of Johnson & Johnson’s COVID-19 vaccine candidate.

‘Not building equitable access’

But Torreele, in an earlier article, argues that this will not build equitable access.

“To ensure equitable vaccine access in low and middle-income countries when and where needed, countries and local producers in the Global South must have ownership and decision-making over vaccine manufacturing technology and facilities, what they produce, and for whom,” she says.

“Moderna or BioNTech producing their proprietary vaccines in Africa does not build sustained regional capacity or resilience to respond to local health needs. Instead, it risks deepening dependencies on commercial interests that will always be prioritised over people’s health needs in shareholder-driven companies.”

But Gavi believes that its recipe of international and local players offers the best remedy for the dearth of African manufacturers.

“Developing a substantial and durable vaccine manufacturing industry in Africa, starting from a small base, needs local and regional entrepreneurs, and international resources and capacity,” says the spokesperson.

“The AVMA’s structure, with caps on the total amount of support individual manufacturers can receive and inclusion of African and international owners, is designed to attract support and investment from the broadest possible constituency,” it argues.

“This will allow the continent to benefit from a broad ecosystem of actors if long-term capacity is to be established from a relatively low baseline. This will also incentivize investment and ensure critical skills and capacity are transferred to the African continent.”

High bar for AVMA support

 AVMA offers subsidies at two critical points: when a company is awarded World Health Organization (WHO)  pre-qualification for “priority vaccines”; and per-dose on delivery if they are successful in securing Gavi-UNICEF vaccine tenders. 

Critics say this bar is too high, as WHO pre-qualification favours large international companies with access to capital to finance product development and a regulatory dossier, rather than local players.

“While we would wish that African manufacturing gains momentum and builds scale as soon as possible safety, standards and quality assurance are vital elements,” Gavi responds.

“Adherence to correct regulatory processes is absolutely essential, hence the WHO pre-qualification requirement.”

The spokesperson also called for national, regional and global actors to build “the right regulatory environment” for “sustainable vaccine manufacturing on the continent”.

A critical component of this is the African Medicines Agency (AMA), which is limping along without ratification from many of the continent’s powerhouse countries. It would enable continental approval of medicines instead of all 55 different countries having their own approval processes, which are painfully slow.

One of the hitches with mpox vaccine donations has been the slow pace of countries to grant regulatory approval for them. The Democratic Republic of Congo, which has been battling large mpox outbreaks for two years, only approved the vaccine in late June.

African Union leaders sign an agreement with Rwanda’s Ministry of Health to establish the African Medicines Agency’s first headquarters in the capital, Kigali, in June 2023.

Vaccine accelerator’s focus

AVMA’s payments to manufacturers are incentive-based, with the highest – called “milestone payments” – being offered to “modes of manufacturing most likely to support pandemic preparedness.” 

“Accelerator payments” are also being offered, which are a per-dose top-up in addition to the market rate that manufacturers are paid on winning Gavi-UNICEF tenders. These payments acknowledge the cost and risk of vaccine development and production.

AVMA will support mRNA and viral vector platforms covering eight key vaccines for cholera, malaria,  measles-rubella (MR), hexavalent (wP), Yellow Fever, pneumococcal, Ebola,  Rotavirus as well as the six -in-one hexavalent vaccine (protecting against diphtheria, tetanus, whooping cough, poliomyelitis, Haemophilus influenza type B and hepatitis B).

“The idea is to focus manufacturers on production in the most viable markets, or priority antigens, helping to secure accelerated, competitive entry of new manufacturers where there is an unmet market need,” said the spokesperson.

Support will be “predominantly directed towards vaccines whose drug substance is manufactured in Africa, with initial consideration also given for ‘fill & finish only’ projects using imported drug substance.”

Business-as-usual ‘will not deliver equity’

But Torreele is sceptical: “Many of the investments in local vaccine manufacturing, even with public funds, seem to assume that new producers will be able to successfully compete and be profitable in the global vaccine market. 

She describes the vaccine market as ”cut-throat and oligopolistic”, with “significant entry barriers, and favouring the biggest players adopting economies-of-scale business models”. 

“In 2021, excluding COVID-19 vaccines, just four pharmaceutical corporations (MSD, GSK, Sanofi and Pfizer) captured 73% of the global vaccine market worth $42 billion, while the single biggest producer by volume, the Serum Institute of India, barely captured 2% of the value while supplying 20% of all doses at near-cost prices,” she notes.

Torreele and Sherwin urge AVMA and the European Union’s Global Gateway African investment initiative to “target the needs of emerging local producers”, including “access to affordable capital to finance at-risk the technical work needed to adapt, optimize, and establish a regulatory dossier for submission to regulatory authorities and other push incentives.” 

“Business-as-usual market dynamics will not deliver equity,” they argue.

What about the Pandemic Agreement?

Meanwhile, during the resumed pandemic agreement negotiations in Geneva on Monday, the South Centre said: “Current efforts for equitable and timely access to vaccines, treatments and diagnostics (VTD) are ad hoc, voluntary, uncoordinated, underfunded and focused on last-mile delivery.”

The South Centre, which represents 55 organisations in the Global South and is a stakeholder in the negotiations, called for the core provisions of the pandemic agreement to  “provide for concrete means to enhance equity and development allocation and procurement of these VDTs”.

A robust pandemic agreement, together with AVMA and other initiatives may finally change Africa’s vaccine desert – but these efforts need political will, innovative thinking and financial resources.

Image Credits: WHO, Johnson & Johnson, Rwanda Ministry of Health.

INB co-chairs Anne-Claire Amprou and Precious Matsoso

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

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

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

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

Warm-ups

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

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

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

Ethiopia, speaking for Africa at INB 11.

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

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

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

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

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

Legal architecture

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

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

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

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

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

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

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

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

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

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

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

Next two weeks

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Language barriers

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

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

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

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

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

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

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

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

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

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

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

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

No specialised training

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

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

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

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

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

No official complaints 

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

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

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

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

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

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

No specialised health workers

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

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

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

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

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

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

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

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

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

Policy exclusions

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

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

Sexual and Reproductive Health Justice Expert Dr Godfrey Kangaude

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

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

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

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

Holding MoH to account

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

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

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

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

Protecting rights

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

MACODA Public Relations Officer Harriet Kachimanga

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

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

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

SAFOD Director-General Mussa Chiwaula

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

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

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

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

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

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

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

Image Credits: Josephine Chinele, Jospehine Chinele.