Over one-half of Americans are not sure if pasteurised milk is safer than raw milk. In the time of avian flu epidemics in US cattle, this could even prove dangerous.

As the fourth human case of H5N1 avian flu in a US farmworker in Colorado was confirmed Wednesday by the US Centers for Disease Control and Prevention (CDC), so far, only farm workers, and not consumers, have reported avian flu infections.

This is likely due, at least in part, to the successful inactivation of the virus during the milk pasteurization process, experts say. And yet one-half or more Americans seem to have little idea about the dangers of drinking raw milk, according to a recent poll conducted by the University of Pennsylvania researchers.

The survey, which included a demographically representative sample of the US adult population, found that less than half (47% percent) of the U.S. adults surveyed understood that drinking raw milk not as safe as drinking pasteurized milk. Conversely, 53% of respondents don’t actually believe that pasteurized milk is safer. And 9% of respondents actually believed raw  milk is safer, while 15% said it was just as safe and 30% were unsure.  

Nearly a quarter (24%) of Americans either do not believe that pasteurization is effective at killing bacteria and viruses in milk products (4%) or are not sure whether this is true (20%), according to the survey of over 1000 US adults, conducted by the Annenberg Public Policy Center (APPC). The survey has a 3-3.5% statistical error rate.

Around half of US adults failed to recognize that raw milk  can be more dangerous than pasteurized milk products.

That, despite the fact that studies report that pasteurized milk limits hospitalizations for related illnesses by an order of 45, according to the APPC report. 

The French Scientist Louis Pasteur invented the pasteurization process 160 years ago, after recognizing that it killed off otherwise dangerous bacteria present in unheated wine. The process, which soon became a milk industry standard in the United States, successfully inactivates the modern-day avian flu virus, significantly limiting the risk of infection for the general public. 

Politics and milk 

In fact, only about 2% of Americans report drinking raw milk at least once a month, according to a Food and Drug Administration (FDA) study based on 2019 data.

Paradoxically, however, raw milk sales in the US have increased in recent months, according to some US media reports, despite the recent risks posed by a widening circle of avian influenza among dairy cattle.

Debate has been spurred  by the increased anti-science bent of some US political leaders. Presidential candidate Robert F. Kennedy Jr., for instance, who also has been a staunch opponent of COVID vaccination, has been quoted saying that he drinks raw milk exclusively.

The APPC survey also found that Republicans are more likely than Democrats to believe that drinking raw milk is as safe as pasteurized milk (57% vs. 37%). People living in an urban environment also are more likely to believe that pastuerized milk is safer than raw milk as compared to people in a rural environment (49% vs. 32%).

“The difference in views of raw milk that we see between Democrats and Republicans is difficult to disentangle from the difference between rural and urban dwellers,” said Kathleen Hall Jamieson, director of the Annenberg Public Policy Center. “Those in rural areas are both more likely to identify as Republicans and to consume raw milk.”

55 more dairy herds reported infected in last 30 days

Some 55 more cattle herds in seven states have been infected with the virus over the past 30 days, according to CDC tracking. Infections in the past 30 days represent 40% of the total of 138 cattle herds infected in 12 states since the outbreak in dairy cattle was first reported on 25 March, the CDC reported. 

States affected by avian flu spread in dairy cattle

The real number of infections of both humans and cattle is very likely underestimated, insofar as farmers have been reluctant to have their staff or herds tested, experts warn.

Even so, the CDC maintained that infection risks for the general public remain low. 

“Based on the information available at this time, this infection does not change CDC’s current H5N1 bird flu human health risk assessment for the U.S. general public, which the agency considers to be low,” the CDC said in a statement.

Image Credits: Cotonbro studio, APCC, CDC.

The air in relatively ‘clean’ Mumbai is still killing citizens.

NEW DELHI – On 2 November 2023, extreme air pollution caught Delhi off-guard. It shut down schools and led to flight cancellations, curbs on construction and other emergency responses. 

That every little increase in air pollution increases the risk of death has been well-established for some years. But till now the effect of short-term air pollution on mortality has remained largely undocumented in detail in India, where most of the world’s most polluted cities are located. 

In a new, peer-reviewed study published in the Lancet on Thursday (4 July), researchers found that 7.2% (or approximately 33,000) of all deaths each year across 10 cities could be linked to short-term PM 2.5 exposure higher than the World Health Organization (WHO) guideline of 15 micrograms/cubic metre (µg/m³). PM 2.5 is a highly toxic ultra-fine particulate matter with a diameter of 2.5 microns, which is far thinner than a strand of human hair. 

This is the first multi-city study in India to assess the link between short-term pollution exposure and death with cities spanning different agri-climatological zones.

The bottom line, the authors say, is that the current Indian government standard for PM 2.5 of 60 µg/m³ is “substantially higher” than it should be as a measure of ‘safe’ air quality. In comparison, WHO’s 24-hour standard is 15 µg/m³.  

NCDs are the leading cause for air pollution-related deaths

The Lancet paper doesn’t look at the cause of death as that level of primary data isn’t always available. However, many studies including recent ones in India have shown that air pollution triggers or aggravates non-communicable diseases – specifically NCDs like heart attacks, strokes, lung cancer, and chronic lung disease – which can turn fatal. Of the total air pollution deaths, NCDs account for nearly 90% of the disease burden. 

The researchers are from 14 organisations including Sustainable Futures Collaborative in Delhi, Institute of Environmental Medicine in Stockholm, Indian Institute of Management Ahmedabad, Public Health Foundation of India, Ashoka University in Sonipat, Mount Sinai in New York, and Boston University. 

To come to their conclusions, the researchers analysed primary data on mortality between 2008 and 2019 in 10 cities of India. They used an advanced system of machine learning-based analysis which, simply put, used factors that would have a bearing on air pollution-related deaths, namely wind speed, atmospheric pressure and mixing height. 

This causal modelling approach enabled the researchers to isolate the effect of locally generated pollution as these factors are linked to the dispersal and transport of air pollution. 

Combined with other data from monitors, satellites and other sources, the study looked at over 3.6 million deaths in the 11-year study period. What the more complex causal modelling shows is that the risk of death is greater than what the earlier basic approach showed. 

No safe level of air pollution

The causal modelling estimated an increase in the risk of death by 3.57% for every rise of just 10 µg/m³ metre over a two day period, as compared to 1.42% by a more basic study. 

Apart from the usual high-pollution suspects like Delhi and Varanasi, the study looked at places commonly perceived as having clean air, like the Himalayan city of Shimla and the coastal metropolises of Chennai and Mumbai. The authors say this is the first such multi-city study on the links between short-term air pollution exposure and deaths in India. 

Overall, 7.2% of all daily deaths were attributed to PM 2.5 concentrations higher than the WHO guidelines. Annually there are estimated to be approximately 33,000 deaths in these 10 cities. Over a third are in Delhi, where the average annual PM 2.5 level was 113 micrograms which is more than 22 times the WHO’s safe standard. The share of PM 2.5 linked deaths was also the highest in the Capital, at 11.5% compared to the lowest 3.5% in Shimla. 

The surprises are Mumbai and Kolkata, with deaths numbering around 5,000 each, annually. 

“We are seeing a high level of risk and a high number of deaths even in cities that have moderate levels of air pollution exposure. Mumbai, for instance, despite being a coastal city with around a third of the annual PM 2.5 levels of Delhi is still seeing over 5,000 deaths yearly from air pollution,” a lead author of the report, Dr Bhargav Krishna, Fellow at the Sustainable Futures Collaborative, explained to Health Policy Watch.

“Similarly Hyderabad, Kolkata, Bengaluru, Chennai, Ahmedabad and Pune, all of which have annual PM2.5 levels below the current Indian standard, are still seeing a high number of deaths each year. This should drive us to focus not just on those cities that have high seasonal exposures, but even those that may be considered relatively ‘clean’ but are in reality polluted at a level that causes significant health impacts.”

Mumbai air in March 2023.

Mumbai, where remarkably the air pollution has been higher than Delhi on some days, was shown to have almost 5,100 deaths, the second highest after the national capital. That is 5.9% of all deaths in what is India’s financial capital. Here, every increase of 10 micrograms of PM 2.5 was associated with a 2.41% increase in daily deaths. 

Over 7% of daily deaths attributable to increases in short-term PM 2.5
First such study in Indian cities, say authors
City Average Annual Pollution 

(PM2.5, mg/m³)

 Attributable Fraction of Deaths (%) Attributable Deaths Per Year
Delhi 113 11.5 11,964
Varanasi 82.1 10.2 831
Kolkata 55.2 7.3 4,678
Pune 45.3 5.9 1,367
Mumbai 41.7 5.6 5,091
Hyderabad 38.9 5.6 1,597
Ahmedabad 37.9 5.6 2,495
Chennai 33.7 4.9 2,870
Bangalore 33 4.8 2,102
Shimla 28.4 3.7 59
Total 53.6 7.2 33,627

Source: Lancet

Shimla proves that there is no safe level of air pollution, according to the report. It has the lowest air pollution level of  the 10 cities, yet that was still a risk as 3.7% of all deaths were attributable to short-term PM 2.5 exposure. 

Impact on policy action 

The findings are crucial for immediate policy action and further studies to cover hundreds more towns and rural areas. Immediate action would cover sources of pollution like diesel generators, waste burning, and transport, sources that are commonly seen in many urban neighbourhoods. 

While much of the headline-grabbing focus is on extreme pollution, these findings show the need to act against all sources of air pollution all year round. Acting only on extremely high days of pollution will only  yield marginal benefits regarding daily mortality.

 In particular, the paper calls out the Graded Response Action Plans, largely used in Delhi and its neighbouring cities. GRAPs are usually cited by local governments as their action to cut pollution but are implemented only in peak pollution season which is from October right through winter. 

Toxicity of local pollution

There are some interesting findings which aren’t widely known. The study confirms that the risk of mortality rose more quickly at lower levels of PM 2.5 but plateaued as levels increased. More studies are needed to understand why exactly this happens. The causal modelling showed that the effects of air pollution on deaths were especially strong in cities with lower levels of pollution such as Bengaluru, Chennai and Shimla. 

The study fills a data and communication gap in addressing the health crisis caused by toxic air. On one hand, it establishes a link between rising air pollution and deaths, on the other, it makes the risks a lot more relatable because it shows the impact over just two days of exposure than over many months or years. 

So what can residents in these cities do to protect themselves? Bhargav says individual responses could include wearing a mask, choosing when to step outdoors (pollution tends to be highest during the morning and evening when temperatures dip), and reducing pollution sources inside their home. 

However, the onus lies on governments and policymakers. 

“The levels of air pollution we see in India are extremely high and this study clearly shows how day-to-day variations in these levels lead to considerable mortality,” said Dr Petter Ljungman of the Karolinska Institute, and one of the researchers involved in the study.

“Interestingly we saw that local pollution sources are likely to be more toxic than more distant sources which has implications for policymakers addressing this highly relevant threat to human health.”

Image Credits: Chetan Bhattacharji.

Scientists at the West African Centre for Cell Biology and Infectious Pathogens (WACCBIP), University of Ghana, setting up a genome sequencing experiment in the laboratory.

Almost 15 years ago, when the University of Ghana established its Office of Research, Innovation, and Development, it did so with the goal of bolstering the West African nation’s research capacity. 

In the African region, where less than 0.5% of GDP is devoted to research, and a significant number of Africa’s educated is siphoned off to other countries, the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) has spearheaded the effort to make universities like the University of Ghana research-intensive and competitive. 

TDR support for research capacity-strengthening activities at the University of Ghana focuses on enabling researchers to tackle infectious diseases of poverty through quality implementation research, the study of bridging basic science research and practice. 

This could mean examining why many patients on antiretroviral therapy drop out of treatment, or identifying barriers to TB treatment adherence – both the subject of recent publications authored by researchers at the University of Ghana.

Capacity-building works

Professor Gordon A. Awandare at TDR’s Joint Coordinating Board meeting in Geneva, 12 June 2024

“Capacity-building actually works,” remarked Professor Gordon A Awandare,  Pro Vice-Cancellor of Academic Student Affairs at the University of Ghana, at a TDR 50th anniversary event in Geneva, where he gave a detailed review of the collaboration before TDR’s Joint Coordinating Board on June 12. 

He cited, as one example, his own career trajectory. Awandare began a career in research through a TDR grant that allowed him to complete his masters training, and then got an opportunity to study for a PhD at the University of Pittsburgh while attending a  conference on malaria with support from TDR.  He returned home to the University of Ghana in 2010, founding the West African Centre for Cell Biology of Infectious Pathogens (WACCBIP) in 2014. Since then, the Centre, supported by the Wellcome Trust and the World Bank, has endowed 400 fellowships and received $53 million in grants, thereby directly reducing the “brain drain” across the African region.

A decade-long partnership

The University of Ghana leads efforts to train students in implementation research. Newly enrolled master’s students during their lab induction at WACCBIP, University of Ghana.

In 2014 the University of Ghana’s School of Public Health  signed a partnership agreement with TDR to create a regional training center that leads activities in the African region for strengthening capacity in implementation research to tackle infectious diseases of poverty.

The initiative has so far trained more than 25,000 individuals across Africa, including health practitioners, decision-makers and researchers.                                    

“Looking at how far we’ve come as a training centre, it is our desire to become a centre of excellence where the annual programmes can be extended to say five years,” said Professor Phyllis Dako-Gyeke, who led the TDR-supported research training programmes at University of Ghana until her passing on 11 June. 

But the success of an almost decade-long relationship is not without its challenges. Sustainable donor support and aligned interests on research priorities remain key, she said.           

Real-time research 

Implementation researchers at UG have tackled issues from TB treatment adherence to antiretroviral therapy. Here, a community health worker conducts an interview in Obuasi, Ghana to identify barriers and facilitators for TB control.

Dr Emmanuel Asampong, coordinator of the regional training centre at the University of Ghana, notes that “the impact of implementation research on disease themes in Africa and beyond is impressive because the initiative uses  real-time research results in various contexts – such as the neglected tropical diseases programme, the national malaria programme, and the tuberculosis control programme – to provide solutions to challenges.” 

The global program, which has played a significant role in positioning University of Ghana as a research-intensive university, supports seven regional training centres across six WHO regions. With additional partners in Colombia, Indonesia, Kazakhstan, Malaysia, Senegal and Tunisia, the program develops and updates implementation research courses, provides faculty training and supports career development. 

Map of capacity building TDR regional training centers
The global program, which has played a significant role in positioning University of Ghana as a research institution, also supports NTD research in six WHO regions.

The University of Ghana also partners with TDR on a postgraduate training scheme, which provides a full academic scholarship  for master’s students. The training is specifically focused on implementation research to tackle infectious diseases of poverty. 

The list of TDR alumni across the world runs long, and the University of Ghana can claim many  public health leaders among them. 

“My postgraduate training at the University of Ghana, supported by TDR, was an invaluable catalyst in shaping my academic and professional journey,” said Dr Mbele Whiteson, Senior Resident Medical Officer at the Ministry of Health in Zambia. “I have learned to recognize the intricate interplay between health outcomes and social determinants.”‎

This is the third article in a series on TDR’s research capacity strengthening programme – building skills of public health researchers, implementers, health practitioners and policy-makers in the fast-developing field of implementation research for improving uptake of effective health interventions.

Sophia Samantaroy contributed to the writing and research of this story.

Image Credits: WACCBIP, TDR, African Regional Training Centre (ARTC), University of Ghana/TDR.

modernaAs H5N1 avian flu spreads in US dairy cows, the US Department of Health and Human Services (HHS) has granted approximately $176 million to Moderna to develop an mRNA-based vaccine for influenza with pandemic-potential.

“We have successfully taken lessons learnt during the COVID-19 pandemic and used them to better prepare for future public health crises. As part of that, we continue to develop new vaccines and other tools to help address influenza and bolster our pandemic response capabilities,” said HHS Secretary Xavier Becerra this week.

This award will help Moderna to set up additional pandemic influenza vaccine response capability, using existing domestic large-scale commercial mRNA-based technology and manufacturing platforms developed during the COVID-19 pandemic and ongoing seasonal influenza vaccine development, according to HHS.

The US government has also secured a fair pricing agreement “which will continue ensuring enduring equitable access to vaccines,” it added. Moderna’s COVID-19 vaccine was one of the most expensive on the market during the pandemic.

“The award made today is part of our longstanding commitment to strengthen our preparedness for pandemic influenza,” noted Assistant Secretary for Preparedness and Response Dawn O’Connell.

“Adding this technology to our pandemic flu toolkit enhances our ability to be nimble and quick against the circulating strains and their potential variants.”

The rapid spread of H5N1 bird flu in US dairy cows has rattled the US, affecting 12 states, according to the American Veterinary Medical Association.

The award will enable the rapid development of an mRNA vaccine targeted to various influenza strains with pandemic potential, and enable development and manufacturing to pivot quickly, if needed, to address other threats.

Image Credits: Jernej Furman/Flickr.

 Some 750 million people globally want to quit smoking but most lack access to help to do so.

Digital cessation programmes, behavioural support, and medication for tobacco cessation in adults are some of the measures contained in first-ever guidelines to help people quit smoking published recently by the World Health Organization (WHO). 

One in five adults – 1.25 billion users worldwide – consume various tobacco products such as  cigarettes, heated tobacco products, water pipes, smokeless tobacco products, or cigars. 

Even though more than half of them – around 750 million – want to quit, only 30% have access to effective cessation services.

Among the treatments recommended to help them are counselling, teaching patients to change their smoking-related habits, dedicated apps or calls, nicotine replacement therapy and medication.

 What works best is a combined approach: behavioural support and pharmacotherapy, WHO states. Member states are encouraged to provide quitting help for no or low fee to make it as accessible as possible.

The guideline marks a “crucial milestone” in combatting tobacco addiction, WHO Director-General, Dr Tedros Adhanom Ghebreyesus said in a press release. “It empowers countries with the essential tools to effectively support individuals in quitting tobacco and alleviate the global burden of tobacco-related diseases.”

Tobacco smoking affects nearly every organ of the body, causing over 20 types of cancer, increasing the risk of heart disease, stroke, and many other conditions. According to the WHO, tobacco kills half of its users and affects non-smokers through second-hand exposure.

Health system change, medication and behavioural support

The guidelines feature advised changes in the health systems: tobacco use status and implemented cessation interventions should be included in the patient’s medical records; it is also recommended that health care workers are trained on the appropriate therapies and provide a short behavioural support talk to smokers who want to quit. 

Treatments included in the guidelines: counselling, digital support, pharmacotherapy, and embedding smoking cessation in the healthcare system are key recommendations.

Pharmacotherapy using nicotine replacement therapy and drugs such as varenicline, bupropion, and cytisine, especially when combined with behavioural support. This may include skills and strategies for changing behaviour as well as more general counselling. 

Traditional, complementary and alternative therapies are not recommended due to insufficient evidence for their effectiveness.

Varenicline, but not vapes

While the guidelines strongly recommend the use of varenicline, they do not mention a possible role for vapes in quitting traditional cigarettes, more harmful than their e-cigarette alternative. 

A recent study published by the JAMA Network suggests vaping can be as efficient as varenicline in helping smokers quit – although, as WHO argues, it has little effect at the population level. 

WHO states that “e-cigarettes are beyond the scope of this guideline because the potential benefits and harms of using these products are complex, and are addressed in a separate body of literature. These products may be addressed in the future as evidence accumulates.”

The tobacco industry is highly invested in marketing vapes, framing them as a safer alternative to traditional smoking even though they are also addictive and harmful. The WHO might be more cautious to promote e-cigarettes knowing its statements can be used by tobacco firms to promote their products.

“We need to deeply appreciate the strength it takes and the suffering endured by individuals and their loved ones to overcome this addiction,” said Dr Rüdiger Krech, Director of Health Promotion at WHO, in a press release. “These guidelines are designed to help communities and governments provide the best possible support and assistance for those on this challenging journey.”

Image Credits: Sarah Johnson, WHO.

Women at a gynaecology clinic in Nepal.

While a vaccine exists to prevent human papillomavirus (HPV), the main cause of cervical cancer, over 20 therapeutic HPV vaccine candidates are currently in development.

These therapeutic vaccines aim to “boost the body’s immune response so that it can either fight and clear high-risk strains of the virus or abnormal ‘precancerous’ cells,” according to the World Health Organization (WHO).

The global body issued a report on Wednesday to guide vaccine developers about the preferred product characteristics (PPCs) for any new therapeutic vaccines in priority disease areas – primarily low and middle-income countries (LMICs).

Eliminating cervical cancer, which kills one woman every 90 seconds,  is a major public health initiative for WHO. The key goals of its current strategy are to vaccinate 90% of girls with preventive vaccines, screen 70% of women with a high-performance tests like DNA screening, and treat 90% of women with cervical cancer or precancerous cells in the cervix by 2030.

Cervical cancer mortality 2022

Millions of adults have missed out

A therapeutic vaccine “is likely to be especially beneficial for adult women who did not receive the HPV vaccination before contracting the virus and in poorer countries, where millions of women still lack access to effective cervical screening and cancer treatments,” according to WHO.

Currently, the HPV preventive vaccine is targeted at school children before they become sexually active. Most countries offer it to boys too as they can carry HPV and infect girls and women.

Only 28 of the 47 countries in the WHO African Region, the region with the highest rates of cervical cancer, had introduced prophylactic HPV vaccine into their national immunisation programmes by January.

Africa’s most populous country, Nigeria, introduced the vaccine in parts of the country last October. Others do not yet have it as part of their immunisation programme. 

This means that millions of adult women are not vaccinated. In addition, many women do not get screened for HPV, while others might be diagnosed with pre-cancerous cells or cervical cancer yet not get access to treatment.

Complementary vaccines

“Therapeutic HPV vaccines could be a catalytic innovation that complement these existing interventions, increasing options for the millions of women who have already acquired HPV and reducing their risks of developing life-threatening cancer in the future,” said Dr Sami Gottlieb, a medical doctor and epidemiologist at WHO’s Department of Sexual and Reproductive Health and Research. 

Cervical cancer screening 2019
Cervical cancer screening 2019

An expert group convened by the WHO identified that therapeutic vaccines would be useful in places where it has been difficult to scale up cervical cancer screening and treatment, and as “an alternative, simpler treatment to reduce loss to follow-up” of women who are effectively treated following a positive test. 

“A wide variety of approaches have been used to develop therapeutic HPV vaccine candidates, including peptide, protein, DNA, RNA, and bacterial- and viral-vectored vaccine platforms,” according to WHO.

Vaccine candidates have mainly targeted the regression of CIN2/3 lesions and invasive cervical cancer, while a few candidates focusing on clearance of high-risk HPV infection are now in phase 1 and 2 studies.

Vaccines in development include candiates from Barinthus Biotherapeutics, TheraVectys and Genticel.

‘Therapeutic HPV vaccines would ideally have high efficacy in both clearing high-risk HPV infection to prevent development of cervical precancers, and treating high-grade precancers that have already developed,” according to WHO. 

At a minimum, first-generation vaccines would be expected to clear infection and/or prevent high-grade cervical precancer due to HPV types 16 and 18, according to WHO.

These vaccines could be given to adult women through population-based vaccine delivery – without a diagnostic test if that was not available. 

Therapeutic HPV vaccines that could reverse the progression of high-grade cervical precancers (at a minimum HPV 16 and 18) could be used as an alternative or adjunct to existing cervical treatments in women with cervical precancer according to positive screening tests. 

“Both types of vaccine could potentially play a role in addressing each of the identified gaps in cervical cancer prevention programmes. 

“The choice of target population, including the optimal age range and the delivery strategy in a given setting, will not only depend on intrinsic vaccine characteristics – such as efficacy in clearing infection rather than causing regression of high-grade precancers – but also on factors related to the environment into which these vaccines are introduced.”

 

Image Credits: Tom Pietrasik/ WHO.

Ashley Bloomfield, co-chair of the Working Group on Amendments to the International Health Regulations and Precious Matsoso, co-chair of the Intergovernmental Negotiating Body (INB) on the eve of the World Health Assembly

Following the 77th World Health Assembly (WHA)’s endorsement of a delay of up to one year for finalizing a pandemic agreement, the Intergovernmental Negotiating Body (INB) is set to resume talks on 16-17 July 2024. 

INB member states will face contentious procedural issues and thorny debates over the resolution of substantive matters including a system for Pathogen Access and Benefit Sharing (PABS), One Health; and a formula assuring more equitable access to pandemic health products, where wide gaps remain.

Debate around these outstanding issues is a focus of this latest issue of the Governing Pandemics Snapshot. The issue, produced by the Global Health Centre at the Geneva Graduate Institute, also unpacks the WHA-approved amendments to the International Health Regulations and their meaning.  

Contentious procedural issues

The INB is set to resume its work with a two-day session on 16-17 July 2024. At the 10th INB session, members face two potentially contentious procedural issues and resume discussions on how to tackle key unresolved substantive matters. 

The May WHA decision to continue the pandemic talks for up to one more year, also allows for the INB to decide on rotation of the INB’s leadership. Known as ‘the Bureau’, this consists of six regional country representatives including two co-chairs from The Netherlands and South Africa. 

Over the past few months, there was widespread grumbling amongst INB members regarding the Bureau’s management of the process involving both technical issues as well as perceptions of missed opportunities for bridging gaps in diverse country positions. At the same time, delegates also have acknowledged the difficult challenges the Bureau faces in forging consensus on hotly debated issues such as PABS.

INB co-chairs Roland Driece and Precious Matsoso.

While there are unconfirmed reports that the Dutch co-chair, Roland Driece, may be stepping down, the Africa Group is supporting its co-chair, Precious Matsoso, to continue in her position. Meanwhile, the status of the other Bureau members remains unclear. Maintaining the same members would ensure continuity, institutional knowledge, and established working relationships. 

Conversely, a change in the leadership structure could introduce fresh ideas and new approaches, and a more gender-balanced leadership team, given that the current structure is predominantly male (5 out of 6 members).

The composition of the Bureau is closely linked to the second matter of interest for member states: methods of work. How the Bureau has run the INB has frequently been mentioned as another source of frustration for member states. The wording of the WHA decision suggests that member states wish to retain the possibility of revising both the leadership structure as well as the organization of the INB’s work going forward. 

Closely linked to this is the question of how the group will handle the work completed during the first phase of negotiations? Will the ‘convergence’ already achieved on 143 paragraphs out of 177 be preserved? Or will they reopen the entire text for further negotiations?

PABS remains the key unresolved issue

One of the most challenging, unresolved issues is certainly the establishment of a PABS system, currently included in Article 12 of the draft agreement. Given its technical complexity and the deep disagreement signified by the almost complete lack of convergence text in the INB outcome report, it is likely to continue being the make-or-break article of the talks.  

Negotiators have so far reached agreement only on the fact that such a system should exist, and should enable the rapid and timely sharing of pathogen materials and sequence information with pandemic potential alongside the “fair and equitable” sharing of benefits that derive from them. 

But the precise architecture for pathogen sharing remains unresolved and will be central to the next phase of negotiations. Disagreements persist over the modalities, terms and conditions for sharing relevant materials – with pharma and high-income countries pressing for modalities that ensure the preservation of free access, while low- and middle-income countries aim for a closer linkage between sharing of pathogens and access to benefits. 

Related to this, the use of standardized, legally binding contracts, user registration requirements, intellectual property rights, remain open. And finally, there is the question of whether any sharing mechanism set out in the Pandemic Agreement would effectively supersede similar provisions of other international instruments, notably the Nagoya Protocol of the Convention on Biological Diversity – a key demand of pharma and high-income countries.

In relation to the sharing of benefits, another key disagreement regards the actual percentage, or proportion, of vaccine and medicines set-asides to be offered for free or at concessionary prices in the event of public health emergencies of international concern and pandemics.

Some factions, notably LMICs are pushing for higher, fixed percentages, while higher income countries say that the proportions need to remain flexible and responsive to the context and geo-location of any pandemic emergency.

PABS as a separate technical instrument? 

Given the obvious complexities, it also remains unclear whether the final details of the PABS system will be delineated in the framework of the Pandemic Agreement, or if they might possibly be moved into a separate protocol or other legal instrument. 

Pre-WHA, proposals on the INB table included the possibility of having the WHA launch an open-ended intergovernmental process to negotiate the details of the PABS system in a separate instrument. Notably, this option is not included in the most recent version of the draft INB text, as it was “frozen” before the Assembly. But the idea was being informally circulated by the INB co-chairs as part of a draft WHA resolution in the last INB negotiations (INB 9) just prior to the Assembly.

Given the substantial amount of technical and operational complexity required to create an effective PABS system, it is very possible that INB negotiators may ultimately reconsider this approach.

It is noteworthy that several countries have emphasized the necessity of broadening the discussion to include experts from beyond governmental spheres in the PABS debate, full of technical nuance. Engaging expert participation will be crucial for developing a robust and effective PABS system that will significantly impact scientists, universities, researchers, and industries.

One Health 

A researcher explores evidence around the wildlife-trade- pandemic nexus

Negotiators have also extensively debated the inclusion of the One Health approach in the agreement, which acknowledges the interconnection between the health of people, animals, and ecosystems. Developed countries mainly support a strong One Health article in the pandemic text. But a number of developing countries, backed by CSOs, have raised concerns about the regulatory burden, costs, and potential barriers to agricultural trade that such provisions could imply.

While the draft agreement suggests an initial convergence on a One Health approach, the current text is very general and there remains divergence on developing an additional instrument after the adoption of the agreement to further define its modalities, terms, conditions, and operational dimensions. 

Developing country negotiators are aware of the importance attached to this approach by developed nations and may leverage it tactically in future negotiations.  

At the same time, a number of other prominent CSOs have protested this becoming a geopolitical football. Those One Health advocates point to the fact that high income countries, as well as LMICs, need to adopt stronger measures to prevent the spread of pathogens such as H5N1. And at the same time, LMICs that are on the front lines of pathogen spillover from the wild can reap huge benefits from greater integration of One Health approaches into pandemic prevention. 

Access to health products 

Intense discussions are also to be expected on substantive issues related to access to health products, as highlighted by our colleague Suerie Moon, in a separate article in this edition of the Governing Pandemics Snapshot. 

Considering these deep divides as outlined above, and a fading political momentum, experts have warned that one additional year of work still might not be enough to bring these discussions to a close.  

Strong leadership, political commitment, and good-faith international cooperation, such as that which facilitated the successful amendment of the International Health Regulations, will be essential to bring the Pandemic Agreement to a final agreement in time for the May 2025 WHA. 

Dragging deadlines

Concerns about meeting the latest deadline for WHA 2025 are all the more pertinent in light of the fact that the past six months of negotiations have seen member states repeatedly add to, and prolong, working sessions well beyond their original time frames. 

As of January 2023, negotiations had already been underway for almost two years, when the INB faced a crunch to complete the agreement by May 2024. That, as per its original WHA mandate received in December 2021, at the height of the COVID pandemic. 

Since the beginning of the year, four sessions of the Intergovernmental Negotiating Body (INB) have taken place. 

The eighth meeting of the INB, held from February 19 to March 1, 2024, advanced discussions through the work of the drafting group and thematic subgroups, focusing on a proposal tabled by the Bureau in October 2023. However, this marathon, two-week negotiation session did not achieve a significant breakthrough.

In early March, following member states’ request, the Bureau circulated a Revised Draft of the negotiating text of the WHO Pandemic Agreement. The INB9, which convened from 18-28 March 2024, considered that draft. 

Member states proposed numerous amendments and textual edits, resulting, at the end of the session, in a 110-page document with no clear strategy for bridging differing views. The gaps were all the more glaring in light of the Bureau’s stated intention of convening INB9 as the final meeting before WHA77. But delegates were so far divided on key topics at the close, that a new INB session was scheduled to continue negotiations.

‘Consensus-ready’ text did not bridge gaps 

A new Proposal for the WHO Pandemic Agreement was released on April 22 ahead of the ‘resumed’ INB9 (29 April to 10 May). This draft text, according to the Bureau, featured a streamlined, ‘consensus-ready’ text. 

It included ample use of qualifiers such as ‘voluntary’ and ‘as appropriate’. It also deferred the resolution of more contentious issues like PABS and One Health to two additional, separate instruments to be negotiated at a later stage.

The “consensus-ready text,” unfortunately, did not bridge divided opinions, as member states remained deadlocked in opposing blocs – including the “Equity Bloc” of primarily LMICs; a bloc of European Union, North American and other high income nations, as well as the African Group and other geopolitical alliances.  

Unwilling to concede turf, member states agreed to continue working in yet another resumed INB9 session from May 20-24, concluding only on the Friday just before the Monday start of WHA77. 

The net result was nearly a month of non-stop negotiations for member states under the auspices of the INB, as well as the separately constituted Working Group on International Health Regulations. 

By 24 May at 6pm it became clear that no agreement on the pandemic agreement would be reached, with convergence achieved for only 13 out of 34 articles – and the ball was punted to the WHA. 

More successful IHR Working Group 

IHR co-chairs Dr Ashley Bloomfield and Dr Abdullah Asiri shortly before the WHA approved the amended rules.

By that same Friday, the IHR Working Group managed to arrive at a more successful conclusion, and the few outstanding issues remaining were resolved during WHA, leading to final approval of the amended IHR, on June 1, 2024. Unlike the Pandemic Agreement, the amendments don’t require member state ratification – although nations may opt-out from the amendments if they wish. 

Buoyed by the successful completion of the negotiations on the IHR, the hope is that the coming months will also put the INB over the goal post in time for the 78th WHA in 2025, at the latest, or if ready earlier, at a special session of the WHA in 2024.

Daniela Morich is Manager and Adviser of the Governing Pandemics Initiative at the Global Health Centre, and a lawyer with previous professional experience in multilateral negotiations.

Ava Greenup is Project Associate of the Governing Pandemics Initiative at the Global Health Centre.

This is an article from the fourth issue of the Governing Pandemics Snapshot, which also carries an analysis of the recently adopted International Health Regulations by Geneva Graduate Institute Professor Gian Luca Burci, as well as a discussion on access to health products within the IHR and the Pandemic Agreement, by Global Health Centre Director and Geneva Graduate Institute Professor of Practice Suerie Moon.

Image Credits: Wildlife Conservation Society .

Pollution in Delhi peaks in late autumn when drifting emissions from crop burning exacerbate the usual urban household, traffic and industrial sources

A growing body of evidence from India is firmly establishing the country’s toxic levels of air pollution as a leading cause of ill health, particularly non-communicable diseases (NCDs).

The results are significant because the country’s politicians have repeatedly questioned the validity of research that links air pollution with reduced life expectancy and worsening health. 

As many as 80 out of the 100 most polluted cities in the world are in India, as Health Policy Watch reported earlier ithis year, making air pollution a huge health stressor. 

The latest research from India demonstrates how air pollution is worsening anaemia, hypertension, diabetes, cholesterol levels and mental health, as well as other diseases.

Around 74% of all deaths worldwide are attributed to NCDs, according to the World Health Organization (WHO), and while air pollution is already a major risk factor, worsening air quality will worsen the disease burden due to NCDs further. 

Dr Soumya Swaminathan, fomer WHO Chief Scientist.

“The evidence base on the health impacts of air pollution in India is growing. There is a fair amount of data now on the adverse effects of poor air quality on not only respiratory diseases like asthma and COPD [chronic obstructive pulmonary disease], but also cardiovascular and neurological diseases, as well as an increase in metabolic disorders like diabetes mellitus,” former WHO chief scientist Dr Soumya Swaminathan told Health Policy Watch.

“The impact is particularly serious among pregnant women and young children, because it affects the growing organs of the fetus and young child and is likely to have permanent effects on physical and cognitive development,” added Swaminathan, who recently became co-chairperson of Our Common Air (OCA), a new global commission that has been launched by Clean Air Fund (CAF) in London, and the Council on Energy, Environment and Water (CEEW) in New Delhi. 

“[MS Swaminathan Research Foundation] has recently completed a study on the impacts of climate change on women and children in India, where air pollution is one of the major considerations and the evidence has all been collated,” she said of the foundation started by her father that she now chairs.

There are now around 500 studies on the impact of air pollution on health in India, according to Palak Balyan who leads the research team at Climate Trends, a Delhi-based research consultancy. 

She added that some gaps persist as the availability of health data is limited and most of the research comes from clusters around key cities like Delhi and Chennai, but not as much from the country’s rural areas.

Globally there were 8.1 million deaths due to air pollution in 2021.

Shocking and counter-intuitive statistics 

A few statistics that have emerged from recent research have been shocking and some even counter-intuitive, Swaminathan said. 

“The fact that women who stay mostly indoors [in cities] are often exposed to a higher dose of air pollutants than men who work outdoors. This has been documented in a study from Delhi… The fact that life expectancy in parts of north India is reduced by as much as five to seven years because of poor air quality,” she said. 

Indoor air pollution in the developing world is linked to the lack of access to clean cooking fuels, and the health impacts that research has highlighted would have takeaways for other developing countries in similar situation around Asia, Africa and Latin America.   

Swaminathan added that it is also becoming clear that air pollution affects not just the respiratory system but also distant organs like the heart, blood vessels and the brain, which is alarming. 

The State of the Global Air report 2024 listed air pollution as the second largest risk factor of deaths in 2021 after hypertension. However air pollution is also known to worsen hypertension.

Air pollution was the second largest risk factor of deaths in 2021.

 

“Globally, it is established that exposure to air pollution is a major risk factor for hypertension,” said Professor Sagnik Dey from the Centre for Atmospheric Sciences at the Indian Institute of Technology in Delhi. Most of this research is in developed countries but research from India is also emerging on this connection.

All the countries in the top five most polluted in the world are low-and middle-income countries with low resources and high hypertension burden. 

Dey added that initiatives like the India Hypertension Control Initiative focus on screening programmes which have a place but improving air quality will have to go with it. 

“We have strong evidence that additionally if India really works towards clean air, there will be a much accelerated progress and much larger health benefit,” Dey said.

Remaining research gaps

Establishing the health impacts of air pollution requires robust health data, and Balyan said most of the India-based research uses credible health data sourced from the country’s National Family and Health Survey (NFHS) which offers a representative sample. 

But this data is secondary data, and while there are studies that use primary data from communities, getting this data can be challenging. 

Even when the patients come into the health system, often this data is not captured as healthcare professionals are spread thin.
“Doctors are not trained or equipped with this kind of knowledge and also they don’t have this much of time to devote to each patient. When they ask patients’ history they rarely go to the any kind of questions which relates the problem of that patient to environmental stress or occupational stress,” Balyan said. 

Dey also added that a key gap is that often that the health and environment departments work in silos.

Enough evidence to act

Despite the difficulties of gathering primary data, there is enough compelling evidence both globally and on the India level for policy makers to act. 

Currently China, India and Pakistan top the list of the countries with the most number of air pollution deaths, according to the State of the Global Air report 2024. 

India recently re-elected Prime Minister Narendra Modi’s government for the third time. Issues related to health, climate and environment were rarely brought up by his government or the opposition during the election campaign. But India’s air quality has not shown any significant improvement in the past half a decade despite allocation of budgets, and in fact has worsened in some pockets, as Health Policy Watch reported earlier. 

Experts said improvements in air quality will be followed by health gains for the local communities. 

“Many cities around the world have improved air quality in relatively short time-periods and have seen positive impacts on health very quickly. Investing in air quality will have huge pay-offs for health and also for the economy,  and should be a high priority for all governments,” Swaminathan said. 

Image Credits: Flickr, State of Global Air Report 2024.

Satellite technology for telehealth consultations in a rural Guyana community; one of a number of health innovations the small Caribbean nation has spearheaded recently.

While this week’s CARICOM summit in Grenada has been postponed due to Hurricane Beryl, when it does convenes, a key item on the agenda will be the new ‘HeDPAC’ initiative to deepen South-South partnerships to meet shared global health challenges – from pandemic threats to climate change.

In remote communities of Guyana, the introduction of new satellite technology is enabling freshly trained community health workers to get patients an accurate diagnosis and rapid, appropriate treatment in ways unimaginable only a few years ago.  

In Rwanda, meanwhile, the government’s achievement in getting the COVID-19 vaccine innovator, BioNTech, to set up its first mRNA manufacturing facility in Kigali is a success story that small island states in the Caribbean would love to emulate. 

At a high-powered dinner on the sidelines of the recent World Health Assembly, health ministers and high level officials from Africa and the Americas, set out a shared vision for a way forward on closer collaboration between the two regions under the umbrella of a new South-South partnership initiative, known as HeDPAC (Health Development Partnership for Africa and the Caribbean). 

The initiative grew out of an initial set of pandemic-era collaborations between Africa and the Caribbean and was incubated at WHO  until its launch as an independent non-profit in December 2023. 

“HeDPAC offers a model for self-service cooperation. And for sharing knowledge, expertise and resources,” said WHO Director General Dr Tedros Adhanom Ghebreyesus, at the event, noting that the aim is to enhance health infrastructure, improve access to essential medicines, and strengthen health systems.” 

WHO Director General Dr Tedros Adhanom Ghebreyesus

Partnership building self-sufficiency  

The overarching aim, says HeDPAC CEO Haileysus Getahun, is to foster a partnership  between countries in the global south around key objectives critical to handling future pandemics, as well as creating more robust health systems today. 

The peak of the COVID-19 pandemic exposed the flaws in models of North-South cooperation that have come to dominate the global health landscape – when countries in the Global North hoarded the vaccines, medicines and medical products, he observed. The lack of equity and global solidarity were glaringly absent. 

South-south collaboration is one important antidote; a way to foster more self-sufficiency among countries and stakeholders on a more even playing field with a vision of universal health coverage. 

Three concrete priorities   

Jarbas Barbosa, WHO Regional Director of the Americas/PAHO.

The issues HeDPAC is targeting are not new, but they are perhaps the most critical building blocks to change. They include: 

  • More local R&D, manufacturing of drugs, vaccines and other medical products; 
  • Health workforce strengthening, particularly at primacy health care levels; 
  • Building health system resilience to shocks ranging from climate to supply chain breaks. 

“These are completely aligned with our regional priorities,” declared Jarbas Barbosa, WHO Regional Director of the Americas/PAHO, at the WHA conversation.  

Along with the dependency on outside sources for vital medical supplies laid bare during COVID,  Latin American and Caribbean countries currently are facing a shortage of some 600,000 health care workers, Barbosa observed. 

In Africa, the shortages are even more glaring, according to WHO. A 2023 report showed 37 African nations ranked below the global recommended minimum of 4-5 health workers per 1,000 population.

When the South swings together ….

Alison Drayton, Assistant Secretary-General for Human and Social Development at CARICOM

Registered in Rwanda and Barbados, the initiative aims to work with heads of state and political leaders but without the bureaucratic handcuffs of a formal intergovernmental organization, Getahun said. 

Early champions included the President of Rwanda, Paul Kagame,  Prime Minister of Barbados Mia Mottley and President Irfaan Ali of Guyana. Mottley gained international recognition for her Bridgetown initiative for international debt reform aimed at reducing the crippling burden of low- and middle-income countries to free up more funds for investments in solutions for climate, health and other vital development priorities. 

“My experience has been when the South swings together, we achieve far beyond our wildest dreams,” said Alison Drayton, Assistant Secretary-General for Human and Social Development at CARICOM, the intergovernmental organization of 20 Caribbean states, at the WHA event.

She noted that CARICOM and HeDPAC are currently engaged in the development an MOU to address the three priority areas of: health workforce, health system resilience and local manufacturing of medical products. 

The discussions on collaboration will continue at the 47th CARICOM Conference of Heads of Government. The meeting, planned this week in Grenada, has been postponed because of the effects of Hurricane Beryl.

Moving beyond pandemic poverty 

Barbados received its first shipment of 33,600 doses of COVID-19 vaccines, through the WHO co-sponsored COVAX facility, in April 2021. But after an initial spurt, COVAX deliveries faltered, leaving many low- and middle-income countries scrambling.

On the other side of the ocean, the African Union is a key partner with bonds forged in the early days of the COVID pandemic, when both African and Caribbean countries found themselves struggling desperately to obtain the most basic medical products like protective masks and gloves, and later vaccines.  

“When the world wouldn’t give us vaccines and the world wouldn’t sell us vaccines, and we pulled together an important procurement initiative, to my amazement, it was not just Africa but our brothers and our sisters from the Caribbean who supported this,” declared Dr. Ayoade Alakija, who had, at the time, been asked to lead the Africa Union’s Vaccine Delivery Alliance (AVDA). 

Thanks to those relationships, Caribbean countries like Jamaica, ultimately secured significant  vaccine supplies from African partners at a time when rich nation hoarding and the rise of India’s SARS-CoV2 Delta variant made vaccines almost impossible to secure.  

“And so we have done this before, this South-South collaboration… because we are the same people,” she said.

It was in that period that the initial framework for HeDPAC was laid, recounted Getahun, in an interview with Health Policy Watch. 

HeDPAC CEO Haileysus Getahun

“At the time, Prime Minister Mia Mottley of Barbados was the head of the CARICOM. She reached out to African Union president Uhuru Kenyatta (president of Kenya until 2022). She asked for collaboration between Africa and the Caribbean,” said Getahun.

“After that discussion, the first meeting of the heads of government of CARICOM and the AU was held in September 2021, which laid out clear steps for the two regions to collaborate.”

In November 2022, Mottley, Kagame [then AU champion for Institutional Reform],  and Guyana’s President Irgaan Ali met in Sharm el-Sheikh in November 2022 on the margins of COP27. 

Together with European Commissioner Ursula von der Leyen, Africa CDC and WHO’s DG, the African and Caribbean Heads of State etched the outlines for a new ‘transatlantic alliance for health and vaccine equity.’ 

The initiative quickly won  support in other quarters, including the International Finance Corporation, the World Bank’s investment arm, and several major philanthropies.    

“After observing the inequities and inequalities of COVID, we have to take the valuable lessons  and if a pandemic happens again, the valuable lessons will not be forgotten,” Getahun remarked.

Paul Kagame, Mia Mottley and Ursula von der Leyen at a meeting on the margins of COP27 in Sharm el Sheikh,  November 2022.

“What makes us unique is that we work with heads of government, ministers and political leaders at the highest level to advance a common vision of health development. We utilize political clout but without the handcuffs of a formal intergovernmental organization,” Getahun said. 

HeDPAC’s priorities emerged from a series of consultations of Ministers of Health from the two regions, he said, pointing out that all three pillars – manufacturing, health workforce and resilience – are all critical to greater pandemic preparedness as well as vibrant health systems more broadly. 

“These are the most pressing challenges, on which we will focus. The rationale is not to try to be everywhere.”

And while the first priority is fostering cooperation between like-minded African nations and the Caribbean, that mandate could eventually extend to promoting South-South collaborations more broadly, Getahun suggests.  

“We believe Africa-Caribbean partnership is the starting point, but we are also drawing interest from countries in other regions.’’

Learning from Rwanda’s experience with BioNTech  

International political leaders at the launch of BioNTech’s new facility in Kigali in December 2023.

As just one example of learning from others’ experience, Caribbean nations like Guyana are keen to see how they could duplicate Rwanda’s success in bringing a major pharma experience to their region.

In December 2023, BioNTech launched its first ‘BioNTainer’ in Kigali. The 35,000 m2 modular manufacturing facility is set to produce new mRNA vaccine candidates for malaria, tuberculosis and HIV for use firstly in clinical trials – followed by mass rollout if they are demonstrated to be efficacious.   

“There are many things that are happening in Africa. There are many things that are happening in South America, but very often the good things that happen on one side [of the ocean] are not shared with the other side,” said Guyana’s Minister of Health Frank Anthony at the WHA side event.

 “This will be a platform by which we can share what is happening between the two regions – and HeDPAC can be the bridge that allows us to do that.”

“From the pandemic we could see the needs and the inequities that exist because of lack of medicines or vaccines, and we don’t want that to be repeated. In some cases we had monies available, but we could not get the things that we needed.  

“And therefore, we thought that if we can fix this by locating manufacturing in our regions, so that when these things occur we can easily be able to access it, that this is going to be an important way to prepare for future pandemics.

“What Rwanda has done is major….  Using the mRNA vaccine platform can be a good way to produce other types of vaccines. And I think this is going to be the future. So if we can borrow what they have done, if they can assist us with accelerating [the process], that would be extremely positive. 

Using technology – hybrid courses and satellite health consultations 

At the same time, Caribbean nations also have valuable lessons to share.  

The Guyana Health Minister described how his country, with a widely dispersed population of just 800,000 people, has initiated a new hybrid programme of nurses training to rapidly expand the workforce. 

Guyana’s innovative nurses training initiative grabbed headlines in local media.

The online programme, developed through a collaboration with the University of Sao Paulo’s College of Nursing, enrolled nearly 1200 nurse trainees in 2023 its first year and plans to scale up further over the next several years.  

Simulation centres are being established in core health care facilities along the coast and in more remote regions, to allow students to participate in practicals that are essential for the Registered Nurses (RN) degree.     

“We can easily share that with other countries that are interested in using the courses that we have,” said Anthony. “You don’t have to move from Africa. You don’t have to move from the Caribbean. You will be able to go online and get these courses. That’s how we can share trying to find solutions to the problems that are facing us.”

Courses for community health workers also are being revamped, with health workers taught to use telecom and satellite technology to diagnose serious diseases in remote locations with the support of experts elsewhere. 

Satellite technology in rural Guyana enables high-quality telehealth consultations

“We call it ‘’tele-pathology’,” said Anthony, describing how high-resolution slides of suspect tissue can be quickly relayed to a partner hospital, Mount Sinai in New York City, to diagnose dangerous malignancies. 

Some two dozen clinics in remote regions of the country have been equipped with satellite technologies that allow doctors to “examine” patients remotely together with a local health worker to obtain a fast diagnosis in an emergency. .  

He shared the recent story of one patient whose life was saved through the quick action of a community health worker whose remote consultation led to the rapid diagnosis of life-threatening sepsis. 

“They called a medivac and he was airlifted to a hospital and operated on right away. Otherwise, he probably would have died by the time they figured out what’s wrong and got him to the hospital.”  

Elevating the status of community health workers  

Translating such stories of success into more systematic approaches is one of the big challenges that HeDPAC wants to facilitate, said Getahun. 

He notes that while community health workers are the foundations of primary health care, many  countries still treat them as quasi-volunteers, working for stipends and funded by donor grants – rather than as civil servants in the public health system. 

Catalyzing government moves to advance their status as regular civil servants is one important  HeDPAC target, he says. “This creates employment opportunities for women with far-reaching societal impacts’’.     

Mapping of Community Health Worker accreditation and salary status in Africa, Latin America and the Caribbean.

Throughout much of central and southern Africa, CHWs lack either regular salaries or accreditation.

In Rwanda, a PHC success story, CHWs are accredited but not salaried. But a major 4×4 reform of the health workforce launched in 2023 by the national government could lead to changes for that workforce as well. The 4×4 initiative is part of a broader Rwandan aspiration to quadruple the healthcare workforce and meet the WHO recommended goal of at least 4 health care professionals per 1000 people. 

And as an outgrowth of the new Africa-Caribbean links, doctors and nurses from Cuba are supporting Rwanda with training for its health workforce, said Rwanda’s Minister of Health, Dr. Sabin Nsanzimana.

“As we speak, a group of Cuban doctors has landed in Rwanda to support our 4×4 initiative,” he said. 

It takes guts…   

Ethiopian Minister of Health, Dr Mekdes Daba.

Regional collaborations in manufacturing and procurement will become all the more critical as countries seek to realize the promise and potential of the new African Vaccine Manufacturing Alliance (AVMA), experts also note. 

Only last week, AVMA secured commitments of more than $1 billion in finance at the kickoff at  the Gavi, the vaccine alliance replenishment drive co-hosted by France and the African Centres for Disease Control. The new initiative aims to facilitate the production of 60% of the continents’ vaccine needs with local supplies by 2040.  

Collective manufacturing and procurement arrangements are just as vital to small Caribbean nations that can’t possibly compete alone in global markets.  

“It’s so important to take a regional and cross regional approach, with south south solutions because it offers the possibility of creating economies of scale, and more sustainable production, and building thus a diversified production capacity,” said Johanna Hill, World Trade Organization Deputy Director. 

“Initiatives like this take guts and that’s where HeDPAC has been born – from that guts of taking into consideration South- South collaboration,” added Ethiopia’s Minister of Health, Dr Mekdes Daba.  

“I lost my grandma from COVID, a very dear, very dear person to me,” she added.  “We’ve [all] lost parents, family members, and it was very late for us to get the vaccine. So when things like a pandemic happen, we see how interconnected we are. 

“Now, it’s time to use this connectedness to realize our potential for South-South Collaboration.” 

This story was updated to note the postponement of the CARICOM meeting.

Image Credits: @DPA, HeDPAC, Caricom.org, PMO Barbados, Guyana Standard , Community Health Impact Coalition @Mapbox @OpenStreetMap.

Women carrying grain in Sudan

Fourteen months into its devastating civil war, one-half of Sudan’s 25.6 million population faces levels of food security ranked as “crisis,” emergency, or “catastrophic,” according to the latest Integrated Food Security Phase Classification (IPC) analysis. 

The IPC analysis of Gaza also found that a “high and sustained risk” of famine persists across the entire occupied territory as conflict between Israel and Hamas rages on – although increased food aid deliveries since have so far averted earlier predictions of widespread famine, made in March. Even so, some 96% of the population of 2.15 million people face emergency levels of food insecurity, the latest IPC report stated. Nearly 343,000 Gazans, or 15% of the population are currently experiencing “catastrophic” levels of food insecurity (IPC 5), according to the IPC assessment. 

Sudan’s food insecurity, meanwhile, has reached the worst recorded levels the country has ever seen. The humanitarian emergency has left 755,000 people at catastrophic levels of food insecurity (IPC Phase 5) in 10 states, with the widening spectre of famine. At current levels over 1,000 people per day are at risk of death, the report stated.

Map of Sudan food insecurity
The IPC’s latest projections show intense levels of food insecurity concentrated in the western portion of the country.

Some 8.5 million Sudanese – 18% of the population – are likely to experience catastrophic emergency-level levels of food insecurity (IPC Phase 4) within the coming months, warned  the IPC, which ranks food insecurity and hunger on a 1-5 scale.

The latest survey, conducted between late April and early June, marks a dire and rapid deterioration in the food security situation since IPC’s December 2023 report. Nearly 8 million more Sudanese have faced  high levels of acute food insecurity, ranked as IPC 3 or greater – an increase from 17.7 million to 25.6 million in just six months. 

Violence disrupts aid, fuels famine

Grain shipment in Sudan
The prolonged conflict in Sudan is hindering key humanitarian aid, inlcuding the World Food Programme’s work.

Intense fighting between the Sudanese Armed Forces (SAF) and the paramilitary rebel group, Rapid Support Forces (RSF), has led to the most brutal civil war seen in decades, with snowballing effects on health, hunger and displacement. 

Since violence erupted on 15 April 2023 between the Sudanese Armed Forces (SAF) and the RSF, the country has experienced the highest levels of food insecurity in its history. 

Armed fighting between the two factions that began in Khartoum quickly spread from the capital region to engulf Greater Darfur, Greater Kordofan, Khartoum and Al Jazirah states in the western regions of the country near the border with Chad. These regions are also now the epicentre of the hunger crisis. 

“There is a risk of Famine in 14 areas – affecting residents, internally displaced persons (IDPs) and refugees – in Greater Darfur, Greater Kordofan, Al Jazirah states and some hotspots in Khartoum if the conflict escalates further, including through increased mobilization of local militias,” warned the June IPC report. 

Systematic obstruction of aid

Despite the tremendous needs, the warring parties have  systematically obstructed aid workers and deliberately denied access, said the Inter-Agency Standing Committee (IASC) on Sudan in a statement last month. 

“Movements across conflict lines to parts of Khartoum, Darfur, Aj Jazirah and Kordofan have been all but cut off since mid-December. The closure of the Adre border crossing in February – our main route into western Sudan from Chad – means that limited assistance is trickling into Darfur. Aid workers are being killed, injured and harassed, and humanitarian supplies are being looted,” the IASC said.

Earlier this year, nearly 860,000 people were denied humanitarian aid in Kordofan, Darfur and Khartoum states. The Committee warns that these represent “deliberate hindrances to humanitarian assistance that leave the civilian population without the essentials to survive [and] violate international humanitarian law.”

“This is the worst hunger crisis that has ever been recorded in Sudan. The biggest challenge aid agencies are facing is humanitarian access. We need unhindered access to reach the people most in need with life-saving assistance. Any further delays can be catastrophic and will result in deaths. It is evident the most vulnerable children and their families are bearing the brunt of the conflict,” said John Makoni, Interim National Director for World Vision Sudan.

OCHA: Gaza aid deliveries still being hindered  

Food insecurity Gaza
The entire Gaza Strip faces ICP Phase 4 Emergency food insecurity. A child receives nutritional supplements from the WFP.

While increased food deliveries to Gaza have led to “a marked improvement in the food consumption outcome indicators” in all areas of Gaza, according to the IPC, the UN Office for the Coordination of Humanitarian Affairs (OCHA) warned that access constraints continue to hamper aid operations, including efforts to scale up nutrition support. 

Some 8,000 children under five years old have been diagnosed and treated for acute malnutrition in Gaza since the war began, according to the World Health Organization.

But limited access in the north is preventing the establishment of new nutrition services there, OCHA noted. Escalations in fighting in southern and central Gaza, following Israel’s invasion of the Rafah border area, have severely limited the World Food Programme’s (WFP) ability to deliver food supplies. 

“Due to insecurity and lack of access, only two stabilization centers for severely malnourished patients can operate,” said WHO’s Director General Dr Tedros Adhanom Ghebreyesus in a June X post.

IPC mapping of Gaza hunger risks present and future.

Despite these challenges, WFP reached more than 766,000 people in Gaza with food in June, “though these rations have been reduced due to limited aid and dwindling food stocks,” said the WFP in a statement, noting that it had provided some 9.4 million hot meals through a network of more than 90 community kitchens. 

Sanitation and hygiene challenges

Gazans struggle to obtain basic supplies of food and water amidst mounting piles of garbage and debris

WHO and other agencies also warned of the severe hygiene and sanitation situation brought about by the conflict, the closure of borders and the demise of services for waste and sanitation. 

“Further concentration of displaced populations into areas with significantly reduced water, sanitation, hygiene (WASH), health and other essential infrastructure increases the risk of disease outbreaks, which would have catastrophic effects on the nutritional and health status of the population,” warned WHO in a statement June 25, as fighting across the enclave continued to displace civilian populations over and again.

People in Gaza are living surrounded by piles of waste and sewage, said the UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) in a post on X. 

Efforts to collect and transfer solid waste to temporary sites continued this month, but at a lower rate due to the lack of fuel. Fuel shortages could also hinder ongoing maintenance work on the electricity feeder line for the Southern Gaza Seawater Desalination Plant.  And due to a lack of cooking fuel, Gazans are burning toxic plastic waste and other trash, UNRWA stated. 

Pleas for more aid

More than two months have passed since the International Humanitarian Conference for Sudan met in Paris, the IASC has received just 16% of the $2.7 billion needed to avert the looming famine. The limited support from donors follows a worrying lack of international attention towards the conflict.

The IASC writes that “donors must urgently disburse pledges made in Paris and fast-track additional funding for the humanitarian appeal. With a famine on the horizon, we must deliver much more life-saving aid now, including seeds for farmers before the planting season ends.”

In Gaza, the OCHA has issued a flash appeal, calling for $2.82 billion for UN agencies and NGO partners to address the needs of the more than three million people in the Gaza Strip and the West Bank. The WHO adds that given the unpredictability of the ongoing conflict “and humanitarian access challenges, any significant change may lead to a very rapid deterioration into Famine.”

Image Credits: WFP/Abubakar Garelnabei, IPC , WFP/Ali Jadallah​​​​, IPC , UNRWA .