NCDs
A nurse vaccinates a baby at a clinic in Accra, Ghana. Investments in nursing can have a ten-fold economic benefit in LMICs.

More than 4.5 billion people lack access to essential health services, while globally 60 million lives are lost due to failures of health care systems, translating into a 15% loss of global GDP.

Yet the consequences in terms of poor health and economies are preventable through increased investments in nurses who deliver upwards of 80% of hands-on care, according to a new report from the International Council of Nurses (ICN). 

Investments in the health workforce in low and middle-income countries (LMICs), and particularly nurses, would result in a massive return on investment at a ratio of 10:1, the report finds.

The economic burden of inadequate health systems is at the forefront of the report, whose release coincides with Sunday’s observance of International Nurses Day. This year’s theme on “the economic power of care” echoes the outsized contributions nurses make to global economic growth, and identifies critical areas for strategic investments in the face of increasing healthcare demands and burnout.

“What governments must recognise is that such investment in nursing is not a cost: investing in health care saves money, and our experts say having a healthy population could boost global GDP by $12 trillion or 8%,” remarked ICN President Pamela Cirpriano. 

The report finds that countries need to increase the size of their nursing workforces so that they have 70 nurse for every 10,000 population, in order to reach key Universal Health Coverage (UHC) benchmarks by 2030. And that means at least 30.6 million more nurses need to be educated and employed around the world. 

In countries where there are more nurses per capita, UHC coverage is also higher.

The report cites WHO data from 2023 to the effect that effective Universal Health Coverage (UHC) could save 60 million lives by 2030, and increase global life expectancy by 3.7 years.

“But achieving it requires a massive increase of investment in the nursing workforce,” Cirpriano stressed, noting that, “nurses are the drivers of Primary Health Care (PHC) which has been recognized by the United Nations as the catalyst for reaching the UHC 2030 goals.”

Costs of underinvestment of nursing
The ICN report identified the numerous costs of underinvestment in nursing

Cost-cutting measures will backfire

Although nurses make up 50% of the healthcare workforce, national investments in nurses education, salary and conditions have been eroded, rather than bolstered, in the post-COVID era.  

“Faced with the global shortage of nurses instead of investing in the current nursing workforce we are seeing too many governments choosing short-term and cost reduction driven policies, such as international recruitment, creating new non-registered nurse roles and looking to reduce the length of nurse education,” said ICN Chief Executive Officer Howard Catton.

“These are the wrong choices, taking us in the wrong direction, and seriously risk putting people off joining the profession and seeing more of our experienced nurses quit or leave earlier than they would have done. 

Even in high income countries such as the United States see “nurses frequently grapple with insufficient staffing levels, heavy workloads, and resource constraints, all of which can detrimentally affect their job satisfaction and retention,” said Lisa Kitko, RN & PhD, dean of the University of Rochester School of Nursing, speaking to Health Policy Watch. 

“It’s essential to recognize the economic value that nurses bring to health care organizations through their expertise, skills, and contributions to patient outcomes,” she said. “As the largest health care profession, and most trusted, nurses are uniquely positioned to improve lives and strengthen communities. They consider the future of health care more systemically, integrating the physical, social, and mental well-being of patients.”

A 1:10 return on investment ratio for nursing

The report notes that every $1 invested in health systems generally brings a return of $2-$4. “Stronger health systems equal better health, and healthier populations bring significant returns on investment.” 

But the economic returns are even greater for lower-and-middle-income countries (LMICs). Investment in the LMIC health workforce, particularly nurses, would result in a massive return on investment at a ratio of 1:10.

“We know investments in nursing will create improvements in health care delivery, be a catalyst for economic development, and will advance peace and social well-being,” said Cipriano. 

“What we do has an impact far beyond the visible care we deliver in hospitals, homes, communities, and crisis settings.”

The report notes the cascading benefits of investments in the nursing workforce include not only better direct job creation but better health overall, leading to productive gains in other sectors.

An opportunity for increased gender equality

Benefits of investments in nursing
The benefits of investments in the nursing sector range from empowering women to fostering peace

Investing in nursing and the broader care economy also “is crucial for closing gender gaps,” the report streses. Improving pay, working conditions, and career advancement opportunities in nursing empowers women and stimulates the rest of the economy, especially in the context where approximately 90% of nurses worldwide are women.

For the same reasons, investing in the nursing workforce also can help alleviate poverty, especially for women and girls.

Such investments also require more economic focus and renumeration for roles that are now unpaid care work. Some 76% of unpaid care work is performed by women, and  when care work is paid, it is characterized by low wages. The report sees the economic opportunity in improving pathways to better paid care work. “Better care systems and recognizing and redistributing unpaid care work can significantly contribute to closing gender gaps in labor markets,” notes the report.

Furthermore, the report highlights how investments in nursing have cascading economic benefits, including globally. One prominent example is the more than $50 billion that nurses educated in the global south and working in the global north send home in remittances each year.  At the same time, LMICs have also suffered a significant nursing “brain drain” as affluent countries rely increasingly on importing nurses from abroad, rather than investing in a stronger domestic healthcare work force.  

“What is important now is to make sure that we reinforce to the world that nurses no longer want to be hidden,” said Cipriano at a recent webinar. ICN CEO Howard Hatton added that “for too long, people have dismissed the economic value of caring as being irrelevant or of having no value, that is plainly wrong.” 

“Social cohesion, peace, and prosperity”

While much of the report identifies the economic implications of nursing, it also makes an argument for the connections between the work nurses do and peace. The report notes that “through their work, nurses address the root causes of ill health and the risk factors that lead to conflict.

As frontline workers and primary care providers, nurses “see the connections to other issues, such as political conflicts, family breakdowns, loss of jobs, poverty and mental health crises,” the report states.

“With their trusted position within communities, nurses can play a critical role in bringing people together, building bridges and the wider partnerships and relationships that are the foundations of peace and community cohesion.”  

Kitko, who is also a vice president of the University of Rochester Medical Center, said that she’s “observed a growing acknowledgement from health care leadership of the need to invest in nursing education, training, and professional development. Today, nurses have unprecedented opportunities to shape policy, conduct research, deliver high-quality care, and spearhead transformative changes aimed at strengthening the well-being and resilience of our nursing workforce.”

At the same time, many societies and governments continue to undervalue nursing, she notes, warning that “people often overlook the advanced education, specialized skills, and leadership roles that many nurses hold.

“We must continue to promote the image of nursing, highlighting nurses’ expertise, compassion, and impact on patient care.”

Image Credits: Kate Holt/USAID, International Council of Nurses , International Council of Nurses.

INB co-chair Precious Matsoso briefs the media on Friday night.

Despite the huge human and economic cost of  COVID-19, over two years of negotiations and substantial diplomatic pressure, the World Health Organization’s (WHO) Intergovernmental Negotiating Body (INB) failed to reach consensus on a pandemic agreement by Friday (10 May), the last scheduled day of negotiations before the upcoming  77th World Health Assembly (WHA).

But the exhausted INB delegates have resolved to solider on with talks right up to the eve of the WHA, which begins on 27 May.

Briefing a handful of media left at the Geneva headquarters on Friday night, co-chairs Roland Driece and Precious Matsoso said the negotiations had finally started to make progress in the past two weeks.

“The closer you get to the endpoint, the more willingness there is to move. We worked very hard and deep into the night, but there’s just so much so many issues that we need to agree upon and which are sometimes very technical or political,” said Driece.

“I think this is the last mile,” said Matsoso, adding that One Health, pathogen access and benefit-sharing (PABS), intellectual property and human resources had preoccupied delegates – although the human resources article was almost entirely “yellowed”, which meant it had been agreed by the working group.

The INB has developed a schedule of work based on significant areas that still lacked convergence, she added.

“Of course PABS is one… But once you get that, the rest is history,” said Matsoso. “You may ask  why we have given PABS so much attention. It’s because they all say it’s the heart, so if it doesn’t go with the instrument, it means there will be no heartbeat.”

She added that there would be one or two days’ work interspersed with breaks in the next two weeks, but that the actual dates still had to be agreed on.

Earlier, some delegates told Health Policy Watch there was simply was not enough time to attend to the outstanding issues. Others, notably Eswatini, remained more hopeful saying that if INB reconvened in the week before the WHA, scheduled to start on 27 May, many of the outstanding gaps could potentially be closed. 

“If we can work intelligently and with dedication, I think we can deliver a stronger outcome at the World Health Assembly,” the delegate said.

INB’s mandate

“Our mandate is to report to the WHA on the outcome of the process, and that is what we will do,” said Driece. “And the outcome will be where we will be a day before the WHA. We do hope if we put all the efforts in that it’s going to be with the final agreements. But if not, we just report on where we are at that moment.”

If no agreement is reached in the next two weeks, other options include an extended WHA running into June, a WHA Special Session in November or December or – the least popular option – postponing the deadline until the next WHA in May 2025.

Whatever happens in the next two weeks, the INB is obliged to report an outcome at the WHA, including sharing the latest draft of the agreement so far, including all of the bracketed, green and yellow text, WHO’s legal department has reportedly told delegates on Friday.  The INB will also recommend a way forward on final negotiations, with the WHA making the final decision.  

WHO chief legal officer Steven Solomon told the media briefing that “the INB wants to provide the assembly with a basis to consider their two and a half years of work. They want to meet their mandate to give the assembly a basis to consider their work.”

Solomon added that there is confusion about what adoption by the WHA means.

“Adoption doesn’t mean the treaty applies to any country. It’s the start of a process by which countries go back and consider whether this instrument makes sense for them. They would consider, at the domestic level, whether they should ratify the agreement.

“What I’ve seen in the press, and in, particularly social media, is the view that if it’s adopted, then it applies. You all know that’s not the case, but it’s not necessarily clear.

“And I guess the other thing I’d say is that every negotiation of every international agreement, begins as a marathon and finishes with a sprint. Member states have been running this marathon for two and a half years, and they’re in the sprint phase now. That shows their commitment to to achieving a result that delivers both global health equity and global health security, and is effective at preventing future pandemics and responding to them.”

Important progress

However, WHO officials, INB members and stakeholders stressed that the agreements, even in principle, on key points regarding equity, benefit sharing and technology transfer that have been reached so far are important for advancing equitable access to medicines and vaccines.

Provided there is no backsliding in subsequent rounds of negotiations, these would represent important, albeit imperfect, advances in preparing for and responding to the next pandemic. 

Draft text from late Thursday reflected the still large areas of disagreement with a number of critical articles still to be discussed. 

The text is still a mess of green (agreed on in plenary), yellow (agreed on by working group) and brackets

Friday morning’s session did not return to disputed articles but discussed various definitions. This is important for amendments to the International Health Regulations (IHR), due to be finalised in the coming week, which are supposed to use common definitions.

Knowledge Ecology International’s James Love told Health Policy Watch that, while the current text did not go far enough in many aspects to ensure equitable access to pandemic medicines and vaccines, there were important advances.

In Article 12, which deals with pathogen access and benefit sharing (PABS), “every version has some amount of vaccines that will be available to the WHO for free and affordable prices”, said Love. 

“Some people would like, more some people would like less, but no one is arguing it would be zero. So if that succeeds, it will definitely expand access.”

The current draft has two versions – either “up to” or “at least” 20% of health-related pandemic health products being allocated to the WHO for distribution. 

Love also said that a number of the articles also established new norms – such as on public money invested in research and development (R&D), technology transfer and global supply chains.

Putting an obligation on countries that fund R&D of pandemic products to “look after the access conditions” of whatever medicines and vaccines are produced as a result of their investment, not only in their own countries but worldwide, particularly in developing countries, is “something brand new”, said Love. 

While much of the language on technology transfer (Article 7) is not binding, the text does mandate countries and the WHO to move ahead on this, ditto with the establishment of global supply chains.

The progress achieved by those who believe in a multilateral approach to pandemic prevention could, however, be viewed as a setback by ultra-nationalists that would rather go it alone even in a pandemic, sources here warned.

For instance, parts of the media in the United Kingdom have been claiming, somewhat hysterically, that an agreement on benefit sharing would mean the UK would have to give up 25% of its vaccines in future pandemics.  But this is a distortion of the agreement, WHO officials have pointed out. 

Like any international instrument, the proposed agreement would be subject to ratification and countries’ sovereign laws – even though pathogens know no boundaries.

Negotiations for a pandemic agreement are unlikely to meet their deadline.

Despite much lost sleep for members of the World Health Organization’s (WHO) intergovernmental negotiating body (INB) this week, it is impossible for consensus on a pandemic agreement to be reached by the end of Friday (10 May), the last day of this final round of negotiations.

Various negotiators Health Policy Watch that they did not see how the deadline could be met, especially as on Thursday co-chair Precious Matsoso ruled out extending talks to the weekend, saying that member states needed to travel back to their countries.

The agreement was supposed to be presented to the World Health Assembly (WHA)  which starts on 27 May, for ratification. But now that this will not happen, sources close to the process say that two possible scenarios are being discussed.

Special WHA?

The one is that the INB is extended by six months, and that a WHA special session (WHASS) is called for the end of  the year to consider the pandemic agreement – as was the case in November 2021, when a WHASS agreed to embark on the pandemic agreement negotiations.

The second option is for the deadline to be pushed for a full year, with the agreement being presented to the 2025 WHA.

By Thursday evening, there were more articles in the draft agreement lacking agreement than those that had been green-lighted. 

Some of the thorniest issues – One Health (Articles 4 and 5), pathogen access and benefit-sharing, PABS (Article 12) and financing (Article 20) – still lack consensus.

However, agreement has largely been reached on Articles 6 (preparedness), 7 (workforce), 8 (communication), 9 (research and development), 10 (diversified production) 11 (tech transfer); 13 (supply chain); 13bis (procurement); 17 (whole of government) and 19 (cooperation).

Meanwhile, reliable sources told Health Policy Watch that Botswana, Kenya and Ethiopia now align with the Global North on PABS, One Health, and “mutually agreed terms” in Article 11, which may tip the balance of power in talks. Until now, the Africa group has operated in unison but the EU. However, Health Policy Watch was unable to confirm this with the delegations.

Botswana’s negotiators at the INB in March 2024. Botswana is reportedly aligning itself with the EU and US on three key issues.

There is no time to schedule additional negotiating time in the next two weeks as a number of other urgent meetings are scheduled, including the Working Group on Amendments to the International Health Regulations (WGIHR) and the Programme, Budget and Administration Committee of the Executive Board (PBAC).

Speaking after the 2021 WHASS, WHO Director General Dr Tedros Adhanom Ghebreyusus said that the agreement “will not solve every problem, but it will provide the overarching framework to foster greater international cooperation and provide a platform for strengthening global health security”.

However, after two years of negotiations, this framework has proved elusive. 

“With how much stuff they have to go through, it’s practically impossible to see how they will meet the deadline and there is still fundamental disagreement on the big ticket items,” said Nina Schwalbe, CEO of Spark Street Advisors and a key commentator on the process.

Many member states have criticised the Bureau’s handling of the talks, with some saying too much time was spent on a few areas of disagreement such as PABS, instead of nailing down agreement on other clauses.

‘Hardcore’ Northern trade negotiators

“Part of the problem is not the differences. What’s left for the PABS right now, for instance, is really a handful of words, compared to all the other text brackets and non-consensual  clauses still out there” said James Love, Director of Knowledge Ecology International (KEI), which is a key NGO stakeholder in the talks.

“You’ve got over 30 Articles, and that is a much larger challenge.” 

Love added that “hardcore trade and foreign policy people have been running the negotiations for the North”, and they have been intent on getting precedents on issues such as intellectual property (IP) rights and technology transfer.

The governments of the EU, US, Switzerland and Japan have largely been seen to be protecting the substantial pharmaceutical industries in their countries.

According to the World Trade Organization’s (WTO) rules, countries are able to overrule IP rights in certain instances – referred to as the Trade-Related Aspects of Intellectual Property Rights (TRIPS) flexibilities.

But some countries that have planned to use TRIPS flexibilities to override patents to address health challenges have been threatened with sanction by the US and the European Union (EU) in particular, if they did.

Developing countries want a clause in the agreement – Article 4bis, referred to by negotiators as the “peace clause” –  explicitly stating that parties to the agreement “shall not challenge, or otherwise exercise any direct or indirect pressure on the parties that undermine the right of WTO members to use TRIPS flexibilities at any multilateral, regional, bilateral, judicial or diplomatic forum” . 

But this has been rejected by the EU and the US and is proving to be an obstacle to consensus. 

Ironically, the EU is in the process of adopting legislation to enable EU-wide compulsory licencing in crisis situations. Meanwhile, US security laws permit it to do just this.

Myriad of outstanding details

There are a myriad of other details in the complex agreement still to be ironed out, including on One Health – or how to address zoonotic challenges. But as other agencies such as the UN Food and Agricultural Organization (FAO) will have to be included in this, the draft agreement proposes a May 2026 deadline for sorting out the details.

The same deadline has been proposed to agree on the parameters for a WHO PABS system.

Yet even with these decisions kicked down the road, consensus within the time frame has proved elusive. 

With a single day left, negotiators are going to spend the latter part of Friday discussing a way forward for the talks.

Families flee Rafah to seek safe shelter in central Gaza, 7 May 2024.

With Gaza’s Rafah crossing into Egypt closed by an advancing Israeli incursion, and Israel’s Kerem Shalom crossing shut since last Sunday’s Hamas missile attack, Gaza hospitals have only about three days left of fuel and medical supplies, said WHO Director General Dr Tedros Adhanom Ghebreyesus Wednesday.    

The global health agency is making contingency plans for a full-scale Israeli invasion of Gaza in the wake of an impasse in Israel-Hamas talks over a cease-fire, including release of Israeli hostages. But such preparations would only be a “drop in the ocean” of human need that would follow the death and injuries incurred in such an operation, added Dr. Rick Peeperkorn, head of WHO’s office in the Occupied Palestinian Territories at the press briefing. 

“WHO has pre-positioned some supplies in warehouses and hospitals, but without more aid flowing into Gaza, we cannot sustain our lifesaving support to hospitals,” Tedros said.

Meanwhile, one third of Sudan’s population is facing acute hunger and  70% of hospitals in conflict affected areas are not functioning, Tedros noted – calling for a cease-fire in the African country wracked by a year-long civil war as well as in the war between Israel and Hamas.    

Rafah’s population fleeing and hospitals shutting down

Dr Rick Peeperkorn, head of WHO’s Jerusalem-based office of the Occupied Palestinian Territories (OPT) speaking at a WHO press briefing Wednesday

In war-torn Gaza, tens of thousands of people left Rafah’s eastern outskirts, as Israeli tanks moved in Tuesday and Wednesday through a narrow wedge of land between the city and its crossing into Egypt, taking full control of the strategic entry point for the first time since Israel’s withdrawal from Gaza in 2005.

More people were packing up and leaving by the hour, local media reported, showing scenes of advancing Israeli tanks, artillery explosions, and families pulling up tents and loading belongings onto tractors and donkeys.   

Despite the evacuations, some 1.4 million Gaza Palestinians remain in the densely populated Rafah area and “at risk”, including about 600,000 children, said Tedros. Areas designated by the Israeli military as safe zones, such as the Muwasi district westwards, near the Mediterranean Sea, are already packed with displaced Palesitnians, and lack infrastructure to accommodate tens of thousands more people, added Peeperkorn. 

Israeli evacuation order Sunday to Gazans – telling them to leave neighborhoods on the edge of Rafah (marked in red) for Khan Younis and Muwasi, skirting the Mediterranean sea, marked in yellow and beige.

One Rafah hospital, An-Najjar, has already been forced shut down since the Israeli incursion into the southernmost area of the Gaza strip overnight Tuesday – and the city’s other two hospitals are threatened with closure should the military advance further into the city core, said Peeperkorn, speaking by video from Jerusalem. 

Efforts are now being made to shift critical supplies and operations to hospitals further north, such as Nasser Medical Complex in Khan Younis and other hospitals in Gaza’s ‘Middle region’, Peeperkorn and Tedros said. Nasser hospital has recently been reopened after undergoing extensive repairs following damage in earlier phases of the seven months of war, and even just opened a dialysis center. 

Only three days of fuel left 

WHO Director General Dr Tedros Adhanom Ghebreyesus

However, if the Israeli advance continues, and key entry points remain cut off, then hospitals will have no more fuel or supplies with which to operate, Tedros warned. 

“Fuel that we expected to be allowed in today has not been allowed in, meaning we only have enough fuel to run health services in the south for three more days,” he said.

Already, WHO has had to suspend a number of medical missions to northern Gaza due to a lack of fuel to move EMTs, added Peeperkorn.  Israel has promised the United States that the Kerem Shalom entry from Israel would reopen Wednesday, but as of late afternoon that hadn’t happened, Peeperkorn said.

“There were discussions that fuel will come in through Kerem Shalom, but the current state is that just that there’s no fuel coming in today. So anyone with influence, it’s the biggest item that is needed. I’m not only talking about food distribution, I’m talking about fuel for bakeries, fuel for hospitals, fuel for any operations.

The WHO remarks were echoed by the UN Office for the Coordination of Humanitarian Affairs (OCHA) in a statement Wednesday: “An average of 48 trucks and more than 160,000 litres of fuel entered Gaza via the Rafah crossing between 1 and 5 May. We need that fuel to sustain our humanitarian operations.

“We are engaging with all involved on the resumption of the entry of goods, including fuel, and so that we can again begin managing incoming supplies. However, the situation remains extremely fluid, and we continue to confront a range of challenges, amid active hostilities.

“We count on cooperation and facilitation to get these crossings operational again, since stocks of critical supplies – including fuel – are being depleted by the hour.” 

‘WHO has no intention of withdrawing’

Tedros said that WHO is coordinating the work of some 20 Emergency Medical Teams in Gaza, comprising 179 internationals and 800 local staff based in 10 hospitals and five field hospitals. 

“WHO has no intention of withdrawing from Rafah and will stay and deliver alongside our partners,” Tedros asserted. 

Sudan faces humanitarian disaster after year of fighting

WHO team member providing nutrition support to internally displaced children in Gedaref state, Sudan, in August 2023 during the ongoing civil war.

As for Sudan, some 15 million people – nearly one-third of the population –  are in urgent need of humanitarian assistance and almost nine million people are displaced, Tedros said.  And even in areas where there is no active combat going on, one-half of the hospitals are not functioning.

“Those that are functioning are overwhelmed by people seeking care, many of whom are internally displaced,” he said. “Health facilities, ambulances, health workers and patients continue to be attacked, depriving entire communities of essential health services. Just last week, two of our colleagues from the International Committee of the Red Cross were killed in South Darfur.”

“The conflict has led to a devastating deterioration in food security. More than one-third of the population is facing acute hunger, and there is a risk of famine in Darfur and Khartoum. Humanitarian partners have released a famine prevention plan,” he added.

“WHO’s priority is to ensure continuity of health services to prevent and respond to outbreaks, and to provide care for those most in need, including pregnant and breastfeeding women and children under five,” he said.

Late last year, WHO launched a $US 178 million appeal for an emergency health response in Sudan.  But the agency has said little recently about efforts underway to support hospital capacity in the war-torn country. Although it does have a major nutrition stabilization effort underway, the last detailed report to Geneva media was in late February.

And Tedros didn’t provide any added details at Wednesday’s briefing, saying only: “It is imperative that all sides to the conflict provide unhindered humanitarian access to those in need, including through cross-border routes.

“Most of all, we call for a ceasefire and a comprehensive peace process for Sudan. It is time to silence the guns and raise the volume for peace. The best medicine is peace.”

Image Credits: OCHA/Olga Cherevko. , Twitter/@IDF, WHO.

Insulin supplementation is the daily reality for diabetes patients. Lower prices for insulin pens could make their everyday reality easier.

Insulin pens are more affordable and preferred by diabetics but they are available almost exclusively in high-income countries due to gross overpricing, according to a report by Médecins Sans Frontières (MSF) and T1International, a British NGO fighting for equal treatment access for people with diabetes type 1.

The research was presented on Wednesday, ahead of the fourth Symposium on Diabetes in Humanitarian Crises happening in Athens late this week, which is hosted by the International Alliance for Diabetes Action (IADA).

“In Lebanon, offering pens to people with diabetes in our care has had a significant and positive impact on their quality of life, especially for children who are more likely to stick to their treatment schedule with the easier-to-use and less painful pens,” said Dr Sawsan Yaacoub, Paediatrician for MSF in Lebanon, where insulin pens were implemented instead of the traditional treatment administering with syringes and vials of insulin.

Numerous benefits of using insulin pens instead of the traditional syringe and vial make it a preferred choice for a vast majority of patients

The pens offered many advantages, especially to young patients, MSF evaluated. They make it easier to inject insulin, calculate doses and they induce less pain during the procedure, they are also more practical in terms of transport and stocking. Thanks to their advantages, children and adolescents participating in MSF’s programme in Lebanon were more likely to stick to the prescribed injection schedule.

Growing burden

Diabetes is a chronic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin produced. 

Type 1 diabetes (insulin-dependent) is a deficient insulin production of the organism and requires daily administration of insulin.

There were 529 million people living with diabetes worldwide in 2021, as a Lancet study found. According to WHO, the number increased five-fold, from 108 million, in the four last decades.

The disease and accompanying conditions are a major cause of blindness, kidney failure, heart attacks, stroke and lower limb amputation. Diabetes and kidney disease alone accounted for two million deaths in 2019.

Inaccessible

The diabetes burden is increasing for low- and middle-income countries, but, as MSF pointed out, the treatment options offered there are limited and old-fashioned.

MSF and T1International’s survey found that 82% of over 400 respondents in 38 countries preferred insulin pens when compared with injecting insulin with a syringe.

The pens could also be a more affordable option. “We have shown that it could be more affordable to use insulin pens instead of the old-fashioned vials and syringes,” said Dr Helen Bygrave, a Non-communicable Diseases Advisor for MSF.

MSF’s research into the cost of production shows that analogue insulin pens, offering more durable insulin without having to keep it refrigerated, could be sold at a profit for $111 per patient per year, including insulin cartridge and the pen itself. 

This technology is widely used in high-income countries, contrary to the human insulin administered with syringes, which is the standard in low-income settings as it is sold for a lower price.

MSF argues that the production of analogue insulin and insulin pens is 30% cheaper than the alternative. It is the selling prices that make insulin pens inaccessible. Each long-acting analogue insulin pen costs $2.98 in South Africa, $7.88 in India and $28.40 in the US, compared to the cost-based price of $1.30.

“No matter where a person lives in the world, they should be able to have equal access to their preferred diabetes care option,” Bygrave added.

The situation is similar to that of new diabetes drugs, GLP-1 agonists, which increase the feeling of satiety, helping patients to curb obesity. 

Semaglutide, a commonly used diabetes drug, could be sold at a profit for just $0.89 per month – a daunting difference from its cost in a pharmacy: $115 per month in South Africa, $230 in Latvia, and $353 or more in the US, which is 400,000% higher than the estimated generic price.

Near-monopoly dictates prices

The main manufacturer of GLP-1 drugs, Novo Nordisk, has recently faced a hearing in the US Senate about the gigantic markup it imposes on the market.

Due to intellectual property rights restraints, only three firms are currently providing insulin: Sanofi, Novo Nordisk and Elly Lily. The two latter ones are the only producers of GLP-1 medicine.

Price comparison and the difference between the sales prices and the ones based on production costs, according to MSF’s estimates.

Numerous benefits of using insulin pens instead of the traditional syringe and vial make it a preferred choice for a vast majority of patients

Despite their limited capacity making it difficult for them to meet the demand worldwide, the firms is still blocking generic manufacturers from entering the market.

“Pharmaceutical corporations Eli Lilly, Novo Nordisk and Sanofi must drop their insulin pen prices now, and at the same time, humanitarian agencies need to start procuring insulin pens and more systematically integrating them into the diabetes care they provide,” said Bygrave. 

As gross overpricing stands on the way to improved diabetic care, the new report shows clearly the production costs are not the reason behind it.

 “There is really no excuse for today’s double standard in diabetes care to continue,” Bygrave added.

“We firmly believe that every person with diabetes should have affordable access to the insulin and delivery device that is best for their body,” Elizabeth Pfiester, T1International’s Founder said.

Image Credits: WHO, MSF.

Philanthropists gather to commit $300 million for global health research
Leading global health philanthropists gather near Copenhagen to commit $300 million for global health. From left: Mads Krogsgaard Thomsen (Novo Nordisk), Bill Gates (Gates Foundation), Catherine Kyobutungi (African Population and Health), Ismahane Elouafi (CGIAR) and John-Arne Røttingen (Wellcome).

The Novo Nordisk Foundation, Bill & Melinda Gates Foundation, and Wellcome Trust have announced a new partnership, committing $300 million over three years to stimulate innovative research in developing countries into three of the world’s most critical global health challenges and their interlinkages – including climate change, infectious diseases and antimicrobial resistance (AMR).

An additional funding stream would aim to support research for greater understanding of the interplay between nutrition, immunity, infectious and non-communicable (NCDs), and developmental outcomes. 

All of the challenges disproportionately affect people in low-and-middle income countries (LMICs).  Consequently, funding will be directed mainly to LMIC countries and communities to strengthen research and development capacities and scale “equitable access to existing tools and technologies,” the partners said. 

The announcement by the world’s biggest health philanthropy heavyweights also aims to signal the urgency of making bigger global health investments more broadly to face new and emerging threats. 

“We face huge challenges to protecting and improving physical and mental health, compounded by vast inequities globally,” said John-Arne Røttingen, CEO of Wellcome, speaking at a two-day “Global Science Summit” in Helsingør, Denmark, where the initiative was announced. 

The most effective solutions to pressing challenges often emerge from the very communities they affect,” said Dr. Catherine Kyobutungi, executive director of the African Population and Health Research Center, one of the scientific research institutions that will collaborate in the new effort. “I’m encouraged that this new partnership seeks to unlock novel ideas and support the scientists working directly with the communities that stand to benefit the most.”

Climate change, infectious disease, and nutrition-disease interactions

Girl receives oral polio vaccine, funded by Gates Foundation philanthropy
The philanthropic partnership will fund additional scientific research and vaccine development into emerging and persistent health threats.

The initiative will support interdisciplinary initiatives that advance, for instance, better collection and use of climate data, innovation in more sustainable agriculture and resilient food systems, and other measures protecting  people from climate change, according to a press release by the Bill and Melinda Gates Foundation. 

“We’re on the cusp of so many scientific breakthroughs in agriculture, health, and nutrition, and with the right support these innovations will save and improve lives around the world,” said Mark Suzman, Gates CEO. “Every sector has a critical role to play, and we hope this collaboration opens the door for other funders and partners to contribute to scaling up existing innovations and developing the tools of tomorrow.”

“Many of these challenges are overlapping and intersecting, with profound impacts on human health,” said Dr Tedros Adhanom Ghebreyesus in remarks at the two-day summit, hosted by Novo Nordisk Foundation, which ended Tuesday.  

Since the late 1990s, NCDs have overtaken infectious diseases as the world’s leading cause of premature mortality on every continent, except Africa, Tedros noted, while big gains against HIV, malaria and TB have plateaued recently. 

“NCDs can weaken the immune system, making people more vulnerable to infectious diseases. In turn, infectious diseases can exacerbate the progression of NCDs and cause complications. And the climate crisis exacerbates both of them.”

More equitable use of available tools also are needed

WHO Director General Dr Tedros Adhanom Ghebreyesus – innovation is an engine of global health improvements, but available health tools and strategies also are not being used well enough.

But while research and innovation have always been the “engine of improvements in public health”, Tedros also reminded his audience of donors and philanthropists that available solutions to NCDs, infectious disease and climate change also are not being harnessed. 

“The health challenges we face globally are not fundamentally scientific challenges; they are largely political, economic and social challenges,” the WHO DG asserted. “Of course, we need more technologies, but using the existing ones to the maximum is important.

“Many NCDs can be prevented through healthier diets, physical activity or by stopping smoking. Premature deaths from NCDs can be prevented with the right diagnosis and treatment.

“Most cases and deaths from infectious diseases can be prevented with vaccines, prophylaxis, bed nets or other tools to prevent exposure.

“And climate change can be reversed, and its impacts mitigated, by weaning ourselves off our addiction to fossil fuels.

“The problem is not that we don’t have the tools or the knowledge to address these threats; the problem is that those tools are not equally available, for multiple reasons.”

Emphasis on AMR

The partnership will also channel funding to infectious disease research, with an emphasis on addressing AMR, advancing disease surveillance, and developing vaccines for respiratory infections. 

Supporting new advances in detection and the development of vaccines and other tools should  help “reduce the burden of disease in LMICs and prevent outbreaks from turning into global crises,” the partners said. 

An overarching aim of the initiative is to “break down barriers between often isolated areas of work—between cardiometabolic and infectious diseases, or between scientific discovery and delivery of solutions, for example,” said Mads Krogsgaard Thomsen, CEO of the Danish-based Novo Nordisk Foundation.

Both over and under-nutrition continue to burden countries in both the global North and South. In that context, the partnership aims to support advances in nutritional science and the microbiome – the trillions of micro-organisms that co-exist in our bodies – as an avenue to tackle nutrition-related diseases. 

“It’s kind of mind-blowing how little research was going into understanding malnourishment,” remarked Bill Gates. “In some cases, for things like the microbiome, we had to fund scientific research because it was just an ignored area.” 

Faltering global health investments

Wellcome Trust CEO speaks at Copenhagen global health forum
John-Arne Røttingen, Wellcome Trust CEO, speaks the Novo Nordisk Foundation Global Science Summit in Denmark

The new initiative aims to signal that renewed global health investments are all the more important in the current post-pandemic context. 

“We have a challenging macroeconomic situation,” said John-Arne Røttingen, Chief Executive Officer at Wellcome. “We also see that the major part of global health financing is really not for science and innovation.”

After the surge in funding during the COVID-19 pandemic, national investments in health have since faltered. Governments face competing budgetary priorities in the wake of inflation and debt crises.

A recent World Health Organization (WHO) analysis of global health expenditures found that most governments fail to meet the global targets for spending of 5% of GDP and 15% of national budgets on health care. Meeting those two benchmarks indicates if a country is on track to achieve universal health coverage. Many low-and-middle income countries spend even less on health today than they did  in 2000. 

“Funding and attention for global health and development is faltering, putting progress at risk. Debt crises are forcing governments to cut funding for essential health programs; climate change and conflict are shattering communities; and progress to protect lives from diseases known and unknown is under threat. Across all of these challenges, it is the world’s poorest who are most affected,” said the Gates Foundation announcement.

New obesity drugs filling Novo Nordisk philanthropy’s coffers  

The Novo Nordisk Foundation contributed $100 million for a new global health partnership along with Gates Foundation and the Wellcome Trust

Ironically, the Novo Nordisk Foundation’s participation in the new partnership comes on the heels of the recent landslide success of the pharmaceutical firm Novo Nordisk A/S – which  Novo Nordisk Foundation controls – with the sale of two new drugs Ozempic® and Wegovy® to control obesity..

“The booming market for weight-loss drugs has pushed the assets of the Novo foundation to more than double those of the Gates foundation,” noted Bloomberg Law in a recent article.  

“In turn, the Danish organization is broadening its giving and its footprint outside its home market. The Novo foundation already backs 27% of Danish medical research, awarding a record $1.3 billion to projects related to innovation and science last year.

The partnership may be extended beyond the initial three years if successful, Novo Nordisk Foundation CEO Thomsen was quoted as saying. “To be honest, three years is a short time for making a change on global climate, agri-food systems, human health.” 

If early results are positive, he said, “the most natural thing is to continue such a relationship, of course.” 

Image Credits: CDC.

Some of the areas covered by the WHO Results Report

“The world is off track to reach most of the Triple Billion targets and the health-related Sustainable Development Goals,” said World Health Organization (WHO) Director General  Dr Tedros Adhanom Ghebreyesus. 

His comments were part of the WHO Results Report 2023 released on Tuesday.

The triple billion targets involve one billion more people benefitting from universal health coverage, one billion more people better protected from health emergencies, and one billion more people enjoying better health and well-being by 2025. 

Using data from 174 countries, the report shows some progress towards the 46 targets, however.

One billion enjoying better health? Yes

The current trajectory indicates that the target of 1 billion more people enjoying better health and well-being will likely be met by 2025, driven primarily by improvements in air quality and access to water, sanitation and hygiene measures, according to the summary.  

But the progress will be insufficient to reach all the health-related targets of the Sustainable Development Goals (SDGs) by 2030, with only one target on tobacco use likely to be met.

Tobacco use is declining in 150 countries, 56 of which are on track to achieve the global target of reducing tobacco use by 2025. There are 19 million fewer current tobacco users globally than there were two years ago.

Forty-five countries also reduced their road traffic deaths by 30% or more.

But adult obesity continues to rise in all WHO regions, with no immediate sign of reversal. Ambient air pollution continues to be a challenge in many areas of the world. 

One billion access to universal health coverage? No

The world is off track to meet the target of one billion more people benefiting from universal health coverage by 2025. However, 30% of countries have made progress on both the coverage of essential health services and the provision of financial protection. 

But “the overall measures of progress are largely driven by increased HIV service coverage”, according to the WHO. 

Over three-quarters of people living with HIV globally are receiving antiretroviral therapy and almost all of those who are receiving treatment are achieving viral suppression, which means that they cannot infect others. 

Global HIV services are the beneficiary of the US President’s Emergency Plan for AIDS Relief (PEPFAR), which has strengthened health systems in many countries, particularly in Africa.

However, the COVID-19 pandemic disrupted progress on childhood vaccination and tuberculosis and service coverage for malaria, non-communicable diseases and preventive services continue to lag.  

But the world’s first malaria vaccine, RTS,S/AS01, was administered to more than two million children in Ghana, Kenya, and Malawi during the biennium, reducing mortality by 13% among children eligible for vaccination. WHO’s prequalification of a second vaccine, R21/Matrix-M, is expected to further boost malaria control efforts. 

Indicators for financial hardship has worsened with 13.5% of households spending 10% or more of their income on health services (vs 13% in 2017).

Management of diabetes has also worsened. 

One billion better protected from health emergencies? No

Although the coverage of vaccinations for high-priority pathogens shows improvement since the pandemic-related disruptions in 2020–2021, it has not yet returned to pre-pandemic levels. 

But there has been a 62% increase (from 103 to 167) in the proportion of member states with genomic sequencing capability for SARS-CoV-2 between February 2021 and December 2023. Angola, Bahamas, Central African Republic, Dominican Republic, Honduras, Maldives and Sudan are among the countries that have gained a sequencing capacity.

The Pandemic Fund made its first round of $338 million disbursements to 37 countries in 2023 to assist them to bolster systems to prevent and respond to pandemics and outbreaks.

However, the Intergovernmental Negotiating Body (INB) still has not come up with a pandemic agreement, while the Working Group on Amendments to the International Health Regulations (2005) seems close to agreement on amendments to present to the Seventy-seventh World Health Assembly which starts on 27 May.

“With concrete and concerted action to accelerate progress, we could still achieve a substantial subset of [the targets]. Our goal is to invest even more resources where they matter most—at the country level—while ensuring sustainable and flexible financing to support our mission,” said Tedros.

Displaced Palestinians in Rafah huddle around a makeshift food market, facing yet another forced move as threat of an Israeli operation in the city looms.

WHO has said it is “deeply concerned” that a full-scale military operation “could lead to a bloodbath” as prospects of a major new Israeli incursion into Gaza’s southern enclave of Rafah appeared to grow over the weekend – while hopes of a cease-fire deal see-sawed wildly. 

“A new wave of displacement would exacerbate overcrowding, further limiting access to food, water, health and sanitation services, leading to increased disease outbreaks, worsening levels of hunger, and additional loss of lives,” said the global health agency.  

The WHO statement Friday was repeated Monday afternoon on X  by WHO Director General Dr Tedros Adhanom Ghebreyesus – as previously positive signs of a possible ceasefire and hostage deal between Israel and Hamas receded last week, crashed over the weekend, and then rebound slightly again Monday evening with Hamas announcing publicly that it would accept an Egyptian-Qatari mediated proposal – even as Israel launched a wave of air strikes on Rafah’s eastern neighbourhoods. 

“Only 33% of Gaza’s 36 hospitals and 30% of primary health care centres are functional in some capacity amid repeated attacks and shortages of vital medical supplies, fuel, and staff,” said the WHO statement on the health situation in the Palestinian enclave, only about 365 square kilometres in size. 

“As part of contingency efforts [for a possible operation], WHO and partners are urgently working to restore and resuscitate health services, including through expansion of services and pre-positioning of supplies, but the broken health system would not be able to cope with a surge in casualties and deaths that a Rafah incursion would cause.   

“The three hospitals (Al-Najjar, Al-Helal Al-Emarati and Kuwait hospitals) currently partially operational in Rafah will become unsafe to be reached by patients, staff, ambulance, and humanitarians when hostilities intensify in their vicinity and, as a result quickly become non-functional,” warned WHO.  

“The European Gaza Hospital in east Khan Younis, which is currently functioning as the third-level referral hospital for critical patients, is also vulnerable as it could become isolated and unreachable during the incursion. Given this, the south will be left with six field hospitals and Al-Aqsa Hospital in the Middle Area, serving as the only referral hospital.” 

Over 1 million displaced Palestinians are crowded in and around Rafah, a town hugging up against the Egyptian border, which is also heavily barricaded against crossings by Palestinians except for the seriously ill – and wealthy, well-connected families who can afford steep fixer fees to evacuate.  

Crisis began building last week 

Displaced Palestinian children in Gaza’s Rafah area play near a water pit filled by a rainstorm.

The current crisis began building up last week in the wake of a blunt series of statements by Israel’s Prime Minister Benjamin Netanyahu expressing his determination to invade Gaza’s Rafah area, whether or not a ceasefire and hostage deal is reached. 

Then on Sunday, a Hamas volley of rockets at an Israeli military base near the Kerem Shalom crossing into Gaza killed four Israeli soldiers – creating a political uproar inside Israel as it observed a national Holocaust remembrance day. Israel responded by shutting the Kerem Shalom crossing point to traffic Sunday morning  – one of the three vital humanitarian aid lifelines into the enclave.  Israeli-Hamas talks over a cease-fire and potential exchange of Israeli hostages and Palestinian prisoners held by Israel reportedly stalled – only to receive a new Monday evening with the Hamas announcement of a new offer, that Israel said it was “studying” – even as it launched a wave of “targeted” air strikes on what it claimed were Hamas strongholds east of Rafah.

Earlier on Monday Israel’s military issued orders to some 100,000 Palestinian civilians in parts Rafah close to the Israeli border to begin evacuating from the area, dropping leaflets in the targeted areas. The Israeli move, and its potential to expand to a larger attack, was decried by UN Human Rights Chief Volker Türk, who called Israel’s Rafah threat “inhumane” as well as by countries ranging from France to Saudi Arabia.  

“Gazans continue to be hit with bombs, disease, and even famine. And today, they have been told that they must relocate yet again as Israeli military operations into Rafah scale up,” the High Commissioner said. Israeli air strikes on homes in Rafah were reported to have killed over two dozen more people, including women and children over the past 24 hours, Turk’s office added. 

On Monday evening, air raid sirens were again sounding in Israeli communities around the Gaza perimeter – while Israel’s military spokesperson Daniel Hagari stepped up calls on Israeli television for Palestinians in “designated areas” of Rafah to move north and westward to the area of Al Mawasi, and northwards towards Khan Younis – in advance of planned Israeli operations got underway later Monday night. 

Some 400,000 displaced people are already located in Al-Mowasi, said Louise Wateridge, a spokesperson for the UN agency for Palestinian refugees, UNRWA, speaking from Rafah in a Geneva press briefing on Monday afternoon. 

Dashed hopes

Louise Wateridge, spokesperson for the UN agency for Palestinian refugees, UNRWA.

“There was really a lot of hope over the last days that there would be a ceasefire,”  Wateridge said. “So, we’re genuinely devastated to wake up today and have the reality that is the [Israeli] leaflet drop and you know, reports of evacuations beginning.”  

“Nobody has a clear path where to go, there is no advice on where to go, there is no safety to be led to,” she added. “So, in each circumstance, in each family, now it’s a lot of panic and a lot of chaos, because even though we’re hearing the evacuation orders are confined to a small area in Rafah, in the east of Rafah, you can imagine as people start to move, the panic is going to spread. 

“Already outside the window here, we’re in more central Rafah, people are beginning to take down shelters and leave.”

In the wake of the closure of Israel’s Kerem Shalom crossing into Gaza, Egypt’s Rafah checkpoint also remains the only reliable source of food aid – now threatened by a looming Israeli operations, she pointed out. Food supplies had only recently begun to rebound parts of Gaza, like Jabalya, where there has been more commercial food on the market, which is really promising to see,” Wateridge said. But in parts of northern Gaza, which UN humanitarian aid convoys have been unable to reach, “the situation remains just devastating.”

Inside Israel, families of hostages who had been hopeful last week of a possible deal to release the remaining women, elderly and ill who remain amongst the estimated 100 people still held captive by Hamas blocking a main highway in Tel Aviv, calling on Netanyahu to “stop playing with the lives of our children”.  

Israeli protestors block main highway in Tel Aviv, calling on government to put hostage release over military operation in Rafah.

UN Secretary General Antonio Guterres meanwhile called upon Israel and Hamas to ‘go the extra mile needed’ to finalise a deal in a statement Monday evening.

“The Secretary-General is deeply concerned by the indications that a large-scale military operation in Rafah may be imminent,” said UN spokesperson Stephane Dujarric in a statement. “The Secretary General reminds the parties that the protection of civilians is paramount in international humanitarian law.”

Some 1,139 Israelis, mostly civilians, were killed and another 252 people taken captive by Hamas on 7 October, with 105 hostages released in late November as part of a week-long ceasefire, and seven more unilaterally by Hamas or by Israeli operations, while around 267 more Israeli soldiers have died in the ensuing six months of conflict. Meanwhile, over 34,000 Palestinians have been killed during Israel’s prolonged invasion of Gaza, according to Gaza’s Hamas-controlled Health Ministry. Most of the victims are reported to be women and children, but Hamas data does not distinguish between civilian and military casualties.  

Image Credits: OHCHR , UNRWA , Channel 11, Israel TV.

Mechanical milking machines may be facilitating the fast spread of H5N1 avian flu in dairy cows in the US.

Although cows have been infected with avian influenza subtype H5N1 for the first time and viral remnants have been found in milk, the World Health Organization (WHO) and the US Centers for Disease Control and Prevention (CDC) characterise its current risk to humans as “low”.

The risk for people exposed to infected birds and other animals is low to moderate, they add.

So far, there have been no cases of avian flu being transmitted from person to person in the current outbreak – only from infected birds and animals to humans.

The last human-to-human transmission of avian flu was detected in 2017 and involved infections between a small group of health workers.

Only one person has been infected in the current outbreak in US dairy herds, a man working on a Texas dairy farm who developed conjunctivitis. Swabs of the man’s throat and eye tested positive for H5N1, but he had mild symptoms and did not infect anyone in his household.

Meanwhile, some 220 workers who work at the 36 US dairies affected by the H5N1 outbreak have been screened, but none has been infected with the virus, according to the US CDC’s Dr Todd Davis, speaking at a WHO Information Network for Epidemics (EPI-WIN) briefing on Monday.

“After sequencing several hundred viruses from cattle, we don’t see any molecular changes that would indicate increased possibilities of infection or transmission from person to person,” said Davis. 

“So we still consider this public health risks to be quite low. I think some of the exceptions may be prolonged unprotected exposure to infected dairy cattle, so there are some likely risk associated with occupational exposure.”

US CDC’s Todd Davis

Milk and meat risks

About 20% of milk samples collected by the US Food and Drug Administration (FDA) tested positive for H5N1 viral RNA, said Dr Richard Webby, director of the WHO’s Collaborating Centre for studies on the ecology of influenza in animals and birds.

Meanwhile, a smaller sample set targeted at the states where outbreaks had occurred found  40% of the milk products contained viral remnants,  added Webby, who is based at St Jude Children’s Research Hospital in Memphis in the US.

“There has been a relatively large number of samples tested, but so far from a safety perspective, it does look like the pasteurisation process is removing viable virus from those samples,” added Webby.

Dr Moez Sanaa, head of the WHO’s Standard and Scientific Advice on Food Nutrition, confirmed that while viral RNA has been found in pasteurised milk, none of this was live virus “suggesting that the pasteurisation process effectively inactivates H5N1,” said 

“Preliminary results [of ongoing studies] indicate that virus is inactivated by heat treatment similar to pasteurisation,” said Sanaa, but added that more studies of milk with higher viral loads was still needed. He warned people to avoid raw milk.

Meanwhile, last week the USDA’s Food Safety and Inspection Service (FSIS) announced that all 30 samples of ground beef from retail outlets in the states with infected dairy cattle herds tested negative for H5N1. These results reaffirm that the meat supply is safe.

Webby’s group has also tested eggs and found them to be free of H5N1.

Richard Webby, Director of the WHO’s Collaborating Centre for studies on the ecology of influenza in animals and birds

Cow transmission: mechanical?

From the genomic analysis, it appears that the outbreak in the dairy farms stemmed from “a single introduction” but that “the moving of dairy cattle has spread that to multiple farms and different locations”, according to Dr David Swayne, a US influenza veterinarian.

Swayne added that as transmission seemed to occur “in the unique environment of a dairy parlour”, there were two leading hypotheses about how the rapid transmission was taking place.

One was that there was “mechanical transmission” with infections being spread via milking machines, for example.

The other was that transmission occurred during the “continual cleaning” in dairies that enabled viral spread through “large droplets produced from that washing down process”. 

Meanwhile, Dr Aspen Hammond from WHO’s Global Immunization Programme (GIP) said that H5N1 had been found in other animals near the affected dairy cattle herd, including cats, raccoons and wild and domestic birds nearby.

‘One Health in action’

Dr Maria van Kerkhove, the WHO’s acting head of Epidemic and Pandemic Prevention and Preparedness (EPP), described the outbreak as “one Health in action”.

“You cannot look at human health risk without looking at the risk in animals,” said Van Kerkhove, stressing that partnerships with bodies in the animal health field were essential.

“Right now, there’s a lot of focus on the US but we are seeing a global epizootic of avian influenza, and we’ve seen H5N1 infection in wild birds and poultry and marine mammals and land mammals,” she said.

“But what is concerning is that we are seeing new species that are being infected… We need much stronger surveillance in animals globally, not just in the US, looking at the species that we know can be infected with H5N1, but also in humans at the animal-human interface. “

She urged those doing surveillance to continue to sequence and share those sequences to enable regular assessments of the viruses as well as “what any changes in these viruses mean, in terms of transmissibility in terms of severity.”

Van Kerkhove also stressed that occupationally exposed people needed to be protected from infection, including by using personal protective equipment and washing hands frequently, “because prevention is key”. 

She also said that, while it was not yet necessary, the current H5N1 flu was covered by the candidate vaccines in the influenza prevention pipeline.

Image Credits: pxfuel, Charyse Reinfelder.

A Zimbabwean health worker administers an HIV test.

HARARE, Zimbabwe – Michelle and Michael Mutsvaki were infected with HIV at birth, but while their parents have  shunned antiretroviral (ARV) medicine to treat their HIV, the siblings opted for treatment in their teens.

The siblings, now aged 22 and 24, learnt about their HIV status from their mother, but she assured them that their faith would protect them from succumbing to the disease.

However, faith did not save their father. Instead, they watched him die of HIV complications a decade ago despite the intervention of faith healers. 

Meanwhile, their mother, a follower of the African indigenous Johane Masowe Church, still clings to her religious beliefs and concoctions instead of taking ARVs.

But after Michelle and Michael learnt about the importance of taking antiretroviral treatment from HIV/AIDS activists who visited their school in 2017, they made one of the most important decisions of their lives, opting to take ARV treatment despite their parents’ advice. Seven years on, they are doing well. 

The siblings were both born at home without the assistance of nurses because their parents avoided clinics and hospitals due to their religious beliefs. 

Labour and birth is a risky time for newborn babies born to mothers with HIV who are not on ARVs with suppressed viral loads as they can be exposed to the virus in bodily fluids.

But mother-to-child HIV transmission, also referred to as vertical transmission, is rare nowadays as pregnant women with HIV take ARVs to ensure that their viral load is undetectable before giving birth, meaning that the virus is untransmissible (referred to as U=U) . Newborns are also given ARVs at birth to prevent infection.

Unfortunately, being born at home without medical help, Michelle and Michael contracted HIV at birth.

Citizens embrace ARVs

Zimbabwe’s adult population has come to embrace HIV treatment. The Zimbabwe Population-based HIV Impact Assessment Survey conducted in 2020 revealed 86.8% of adults living with HIV knew their status, and of those who were aware that they were living with HIV, 97% were receiving antiretroviral treatment.

About 1.4 million people in Zimbabwe are living with HIV, and the health ministry says that some 1.2 million Zimbabweans are on ARVs.

The huge uptake of ARVs has been the main reason for a 50% decline in the national HIV incidence over the past 10 years, according to a report from UN Development Programme (UNDP), which works with the health ministry and the Global Fund to prevent HIV.

HIV prevalence in adults (15-49 years) has fallen from its peak of 26.5% in 1997 to 11% in 2021. In 2022, the incidence rate of new infections was at 0.17%, and there was a decline in new HIV infections for all age groups. 

Meanwhile, AIDS deaths have also plummeted over the past 20 years. In 2002, an estimated 130,000 people died of HIV-related complications whereas by 2021, the death toll was around 20,200, according to a UNICEF report.

People living with HIV wait to collect their share of free life-prolonging ARVs at Sally Mugabe Hospital in Harare.

Treatment holdouts

Yet as the southern African nation registers success in combatting HIV/AIDS, other people living with the disease have remained adamant they will not take treatment.

Susan Mutsvaki, Michelle and Michael’s mother, has openly expressed contempt for ARV drugs, citing her faith as a barrier to taking modern medicines for any form of illness

Mutsvaki, aged 47, says she has lived with HIV for the past two decades without taking any treatment or ARVs. Instead, she firmly believes that a concoction of water and pebbles that she was instructed to drink by her bishop at her church a decade ago, has helped keep her safe while living with HIV.

Mutsvaki is a member of the Johane Masowe Church, which traditionally worships at open-air gatherings with all congregants donning white garments.

Mutsvaki operates a market stall at the Rezende Bus terminus in central Harare, where she  sells fruit, vegetables, popcorn and cigarettes. 

She keeps a white bag with her that contains a 750 ml bottle of water mixed with pebbles, which she sips from, as told by her religious leader whom she refers to as a “prophet”.

“I have not been sick at all from HIV. This bottle and the stones in it are my prayers from our prophet and I believe these are making wonders for me as you see how fit I look,” Mutsvaki said.

While Zimbabwe prides itself of achieving success in preventing HIV/AIDS, there are a few holdouts who have pulled in the opposite direction.

Hector Chinopa is one of these. When he contracted COVID-19 in 2020, he asked staff at the Wilkins Hospital in Harare for an HIV test, which came out positive.

But barely four years after surviving the coronavirus, 36-year-old Chinopa has been dodging antiretroviral drugs.

Like Mutsvaki, he reasons that he has not been ill since contracting COVID so he hasn’t felt a strong need to seek treatment.

“I’m not sick. Do I look sick when you look at me? No, I’m not sick,” Chinopa told Health Policy Watch.

Zimbawe’s death toll has plummeted since introducing ARVs

Teen sons may have died of HIV

Linet Gavi, 41, who tested HIV positive two years ago, also has not taken any treatment. But she is uncertain about whether her two teenage sons, who passed away in 2019, were living with HIV.

The boys, aged 15 and 18 at their deaths, suffered from severe headaches and coughing, and had bouts of diarrhoea, according to their mother. They vomited often and they both lost their hair and weight during the time of their illness.

At that stage, Gavi was in the dark about her HIV status. Since she was diagnosed, she wonders whether she might have passed the virus to them at birth.

But Gavi is resistant to taking ARVs because she claims she has witnessed friends and family becoming seriously ill after beginning ARV treatment.

“I don’t want to die by taking ARVs. I had relatives and friends who took ARVs after suffering from HIV, but they are no more today. I’m fine without treatment and I have not been sick. I just eat some crushed garlic to boost my immune system,” Gavi claimed.

Chinopa, Gavi and Mutsvaki all said they have not dared seeking treatment from government clinics after testing positive for HIV although the Zimbabwean government has been making urgent calls for all HIV patients to be placed on treatment.

Zimbabwe’s prevention of mother-to-child HIV transmission programme has been operational since 2002, transitioning from a pilot program in 1999 to a national initiative. Children born since then, such as Michelle and Michael, could have been spared HIV infection if their mothers consulted clinics and gave birth in health facilities.

International help

Between 2003 and 2022, the Global Fund has invested $1.8 billion in Zimbabwe’s HIV programme and recently approved a three-year HIV grant of  (2024-2026) $437 million.

Despite a few people refusing ARVs to this day, Zimbabwe has made significant strides in prevention and treatment.

An official from Zimbabwe’s Health Ministry, who declined to be named, told Health Policy Watch, that ARVs were available for everyone who tested postive for HIV and were willing to take the treatment.

“Those people you say are refusing treatment are making their own decisions not to have the ARVs, but I can tell you the treatment is available for all who test positive for HIV,” said the government official, who was not authorised to speak to the press.

Although some Zimbabweans are resisting HIV treatment, late last year authorities announced that 95% of its HIV-positive population reached undetectable levels of the virus. 

In November 2022, the Ministry of Health’s Dr Chiedza Mupanguri told a media briefing that 95% of Zimbabweans living with HIV had reached undetectable viral loads, meaning that the level of virus in their bodies is so small it cannot be transmitted to others.

This year, Zimbabwe became the first country in Africa, and the third in the world behind Australia and the US, to approve CAB-LA, a long-acting injectable medication that prevents HIV.

CAB-LA acts as a pre-exposure prophylaxis (PrEP) and is recommended by the World Health Organization (WHO) for those at high risk of contracting HIV.

While the country has pledged to target the entire population in its battle against HIV, individuals like Chinopa, Gavi, and Mutsvaki remain steadfast in their refusal to participate. 

HIV/AIDS activists attribute the current deaths to those living with the disease for rejecting treatment due to myths suggesting that the drugs intended to help them actually hasten their demise.

“Many getting killed by AIDS these days are either defaulting on treatment or not on treatment at all,” Moris Mukundu, an AIDS activist in Harare, told Heath Policy Watch.

 

Image Credits: UNICEF Zimbabwe.