Lab technician at a pharmaceutical company conducting a test.

The new draft of the pandemic agreement “is a step backwards rather than forwards”, according to Thomas Cueni, Director General of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA). 

“It is critical that any agreement takes steps to ensure equity in access to medicines and vaccines in future pandemics, whilst preserving the innovation ecosystem that delivered a vaccine just 326 days after the SARS-CoV2 genome sequence was first sequenced,” said Cueni.

 Article 12 of the current draft proposes that manufacturers pay an annual subscription fee to a yet-to-be-formed World Health Organization (WHO) Pathogen Access and Benefit-Sharing (PABS) System.

In exchange, they would get “rapid, systematic and timely access to biological materials of pathogens with pandemic potential and the genetic sequence data (GSD) for such pathogens”.

The article also proposes that manufacturers provide “real-time contributions of relevant diagnostics, therapeutics or vaccines” with 10% free and 10% at not-for-profit prices during public health emergencies of international concern or pandemics.

‘Uncertainties will cause delays’

But Cueni was dubious: “Stringent requirements for accessing pathogen data would severely impact responses to future pandemics and basic research and development (R&D).

“Conditions, uncertainties, and negotiations surrounding pathogen access will cause delays in the developing medical countermeasures, leading to significant public health consequences, including loss of lives and unnecessary economic pressures. In the COVID-19 pandemic context, even a one-month delay could have meant an extra 400,000 lives lost.”

The pharmaceutical industry has warned that a mandatory financial contribution could dis-incentivise companies from joining the PABS system.

“The pharmaceutical industry is determined to continue to play our part in these final stages – sharing our experience, evidence and expertise to help deliver an agreement that will better protect the world when the next pandemic hits,” Cueni said.

Thomas Cueni, Director General of the IFPMA.

This week, the biopharmaceutical industry published a statement on how companies can work between pandemics – as well as when a pandemic hits – to deliver equitable access to medical countermeasures on the basis of public health risks, needs and demands.”

The statement was signed by a broad range of trade associations aside from the IFPMA, including the Developing Countries Vaccine Manufacturers Network, DCVMN, Europe (EFPIA), the US (PhRMA) and Japan (JPMA), and the Biotechnology Innovation Organization (BIO).

The companies detail the commitments to pre- and during pandemic measures.  These include improving surveillance; research on pathogens of pandemic potential; voluntary licensing and technology transfer based on “mutually agreed terms to improve geographic diversity of manufacturing”; real-time allocation of part of production, and equity-based tiered pricing.

Companies are also engaged in ongoing activities to support health system preparedness, whether by building clinical trial and regulatory capacity and harmonization, health care worker and community health worker trainings, or the continual investment needed to establish and maintain new technologies and platforms.

“With a final draft of a pandemic agreement now published, negotiators should redouble their efforts to find consensus as there is still much work to be done before an agreement can be reached, added Cueni. 

Previously, Cueni warned that “It would be better to have no pandemic treaty than a bad pandemic treaty.”

Image Credits: AMR Industry Alliance, World Health Summit.

The Bureau of the intergovernmental negotiating body session during negotiations in June 2023.

The negotiating text of the pandemic agreement (see below) landed in the inboxes of World Health Organization (WHO) member states last Friday afternoon – 10 days before the penultimate negotiation on 18 March and on the eve of the fourth anniversary of the WHO’s declaration of COVID-19 as a pandemic.

The 31-page draft was also sent to official stakeholders previously excluded, as agreed by the eighth meeting WHO’s intergovernmental negotiating body (INB).

READ: WHO Pandemic Agreement draft – negotiating text

The INB Bureau and staff only had a week to distil a mishmash of often contradictory proposals into the negotiating text, and will brief member states and stakeholders this Friday (15 March) on the revised draft and propose how the final round of negotiations will be structured.

Contested articles contain many caveats, with giveaway phrases such as “where appropriate”, “may” and “voluntary”.

What’s new? Chapter I (Articles 1-3)

Chapter I deals with terminology, aims and guiding principles. According to the note accompanying the latest text, what is new in Chapter I, are “refined textual proposals” as proposed by the INB Bureau in Articles 1, 2, and 3.

The stated objective of the WHO pandemic agreement – no longer referred to as a treaty or accord – “is to prevent, prepare for and respond to pandemics” with “equity as the goal and outcome” and recognising the “common but differentiated responsibilities and respective capabilities” of countries’ health systems.

This chapter also explicitly refers to “the sovereign right of states to adopt, legislate and implement legislation, within their jurisdiction, in accordance with the Charter of the United Nations and the general principles of international law, and their sovereign rights over their biological resources”. 

This is in response to misinformation that the pandemic agreement is a WHO power grab that will enable the global health body to impose, amongst other things, global lockdowns.

Chapter II (Articles 4-20): Site of most disagreement 

The meat of the agreement – and site of most disagreements – lies in this chapter. Its theme is “achieving equity in, for and through pandemic prevention, preparedness and response (PPPR)”.

According to the note accompanying the latest text, Articles 7, 8, 16, 17, and 18 contain refined textual proposals as proposed by the INB Bureau based on INB 8 talks.

Meanwhile, Articles 4,5, 6, 10, 11, 13, 19 and 20 contain refined textual proposals as proposed by the INB vice-chairs and co-facilitators from the work of the drafting subgroups. 

Article 4 addresses countries’ responsibilities in terms of “pandemic prevention and public health surveillance”, with countries committing to “progressively strengthen” these. It outlines  eight key responsibilities for member states to prevent pandemics including providing clean water, sanitation and hygiene; reducing the risks of zoonotic spillover and spillback; laboratory biosafety and managing antimicrobial resistance (AMR).

Article 5 sets out a One Health approach, with assistance to developing countries to prevent zoonotic spillover of diseases from animals to humans. This section has been shortened considerably over previous drafts.

Article 6 addresses health system preparedness and readiness, resilience and recovery – but once again dwells on countries’ responsibilities. Responsibilities related to health system strengthening for PPPR includes “the progressive realisation of universal health coverage”.

Article 7 deals with the responsibility of each country to sustain “an adequate, skilled and trained health and care workforce”. However, it makes a veiled acknowledgement of wealthier countries poaching skilled personnel by including a section where countries agree to “minimise the negative impact of health workforce migration on health systems while respecting the freedom of movement of health professionals”.

Article 8 deals with “preparedness monitoring and functional reviews”. Countries are to report to the WHO every five years on their PPPR.

Activists have pushed for companies that get government research and development (R&D) funding to be compelled to share their findings with countries from the global South and to publish the terms of these agreements with private companies. 

But the strongest that Article 9, which deals with R&D, gets is to state that that countries shall “support the transparent and public sharing of research inputs and outputs” from government-funded R&D pandemic-related products and publish the relevant terms of these.

pandemic
Activists want companies that get government funds for R&D to share their findings.

Article 12: PABS is the biggest bone of contention

The most contested section, Chapter II’s Article 12, addresses pathogen access and benefit-sharing (PABS). The new section contains “structural design elements as proposed by the vice chair and co-facilitators from the work of the drafting sub-group”.

This article was not included in the previous draft at INB 8 but it is virtually the same as the vice-chair’s proposal that was leaked shortly before that meeting.

Article 12 spells out the formation of a “multilateral system for access and benefit sharing for pathogens with pandemic potential: the WHO Pathogen Access and Benefit-Sharing System (PABS system)”. 

Its aim is to “ensure rapid, systematic and timely access to biological materials of pathogens with pandemic potential and the genetic sequence data (GSD) for such pathogens” to facilitate the development of products to control such pathogens.

Countries with access to such pathogens will share biological material “as soon as it is available” to one or more laboratories and/or bio-repositories participating in WHO-coordinated laboratory networks (CLNs)” and its GSD to “one or more PABS sequence databases (SDBs)”.

All users of biological materials and GSD “shall have legal obligations under PABS regarding benefit sharing”.

The WHO shall conclude legally binding standard PABS contracts with manufacturers, taking into account their size, nature and capacities.  

Manufacturers will be expected to pay annual contributions to support the PABS system and relevant capacities in countries. They will also be expected to provide “real-time contributions of relevant diagnostics, therapeutics or vaccines” with 10% free and 10% at not-for-profit prices during public health emergencies of international concern or pandemics.

Manufacturers will also be expected to make voluntary non-monetary contributions “such as capacity-building activities, scientific and research collaborations, non-exclusive licensing agreements, arrangements for transfer of technology and know-how” and implement tiered pricing.

The agreement envisages that a Conference of the Parties (COP) will govern the pandemic agreement (detailed in Article 21), and this will “regularly review the operation, monitor adherence and effectiveness of the PABS system” and “promote and support its effective and sustainable implementation”. 

Article 20: New financial mechanism

Article 13 addresses the establishment of a “global supply chain network” developed and operated by WHO in partnership countries and other stakeholders. This will identify needs during pandemics, aimed at avoiding “competition for resources amongst international procuring entities, including regional organisations and/or mechanisms”.

Article 13 bis is a new addition, dealing with “national procurement- and distribution-related provisions”. It declares that countries “shall publish the terms of its government-funded purchase agreements for pandemic-related products at the earliest reasonable opportunity and in accordance with applicable laws” – but shall “exclude confidentiality provisions that serve to limit such disclosure”. 

Article 14 addresses countries’ regulatory systems strengthening, and Article 15 addresses liability and compensation management.

Article 16, on international collaboration and cooperation, covers support for countries to develop PPPR. Article 17 covers whole-of-government and whole-of-society approaches, and Article 18 addresses communication and public awareness geared to tackling misinformation. Article 19 addresses implementation capacities and support.

Article 20 deals with financing. It proposes the establishment of a “Coordinating Financial Mechanism” to support the implementation of the pandemic agreement and, in a new addition, also the implementation of the International Health Regulations (IHR). 

The mechanism shall include a pooled fund to provide financing to support PPPR, and this  may include “contributions received as part of operations of the PABS System, voluntary funds from both states and non-state actors and other contributions to be agreed upon by the Conference of the Parties”.

Chapter III (Articles 21-37): A Conference of Parties

Chapter III, which deals with institutional arrangements and final provisions, contains “refined textual proposals as proposed by the INB Bureau with respect to Article 21, and as proposed by volunteer delegations regarding the remaining Articles of the Chapter”, according to the INB.

It proposes a Conference of the Parties (COP) to review the implementation of the pandemic agreement every three years, based on the countries’ reports on their pandemic readiness, and take the decisions necessary to promote its effective implementation. However, the COP can also request information from countries.

The first COP will be held within a year of the agreement’s adoption. The WHO secretariat is to provide support for the COP.

The previous draft simply referred to a governing body to review the implementation of the agreement to be run by a secretariat. 

In another clarification to address misinformation, Article 24 states: “Nothing in the WHO pandemic agreement shall be interpreted as providing the Secretariat of the World Health Organization, including the WHO Director-General, any authority to direct, order, alter or otherwise prescribe the domestic laws or policies of any party, or to mandate or otherwise impose any requirements that parties take specific actions, such as ban or accept travellers, impose vaccination mandates or therapeutic or diagnostic measures, or implement lockdowns.”

Reaction: ‘Underwhelming governance’

Nina Schwalbe, CEO of Spark Street Advisors and a keen observer of the negotiations, told Health Policy Watch that “the governance section is truly underwhelming”.  

“While they do call for a Conference of Parties, there is almost no regular reporting let alone any type of monitoring vis a vis states’ compliance with their obligations. It’s not even punted to a future date – it is simply not mentioned,” said Schwalbe

Meanwhile, 58 charities, NGOs, and health experts including the Pandemic Action Network, Oxfam, African Vaccine Alliance, Innovarte, and Public Citizen have called on the US and the European Union to end their “patent hypocrisy” in the pandemic agreement  negotiations.

Pamela Hamamoto (right), lead US negotiator in the pandemic accord and Colin McIff.

While US President Joe Biden and President of the European Commission Ursula von der Leyen “have overseen ‘laudable’ proposals to step around intellectual property rules when they prevent Americans and Europeans from securing access to affordable medicines”, they “have shown a ‘double standard’ by stopping lower-income countries from doing the same thing”, according to the groups.

In an open letter coordinated by the People’s Vaccine Alliance, organisations including Oxfam, the African Alliance, Innovarte, and Public Citizen, the groups urge the EU and US leaders to support measures in the pandemic agreement “to enable lower-income countries to overcome intellectual property barriers, to make public funding of R&D conditional upon sharing pharmaceutical technology and know-how with Global South countries, and embed transparency in global health by publishing all government contracts with companies involved in public health”.

They also want the pandemic agreement to “go beyond current proposals to require a small proportion of vaccines and medicines to be set aside for the Global South, and instead ensure those at the highest risk are prioritised regardless of where they live”.

They also want  “an extension of the pandemic flu mechanism”, which guarantees that countries that share pathogen data will receive benefits in return, including “fair access to medicines produced and financial contributions”. 

‘Untenable double standard’ of US and EU

“President Biden is staking his reputation on his ability to take on Big Pharma’s profiteering. While the President is taking crucial steps to stand up to the industry domestically, his administration still holds open a door for pharma companies to profit at the expense of people’s lives in lower-income countries. He must change course from this untenable double standard,” said Peter Maybarduk, Access to Medicines Director at Public Citizen.

“Millions of people in developing countries died at the height of the COVID emergency without access to the NIH-supported mRNA vaccines that made such a difference in the United States. The world has a rare, fragile chance to do better through the Pandemic Accord. The United States has uncommon power, and therefore responsibility, to help make a strong agreement that protects lives and livelihoods at home and worldwide, with some measure of justice.”

Image Credits: WHO.

The entrance of the Sokoto Noma Hospital (also called Noma Children’s Hospital) in Sokoto, north-west Nigeria. For over two decades, the Nigerian Ministry of Health has run a specialised noma treatment programme at the hospital.

The atmosphere at the Sokoto Noma Hospital, named after the city and state in north-west Nigeria bordering the Republic of Niger, is serene. The buildings are modest structures painted in soft, earthy tones. Several large trees form lush green canopies, providing shade from the afternoon sun.

Huddled under the shade trees, caregivers — mainly mothers — engaged in quiet conversations. Their children were amongst those selected for reconstructive surgery during a two-week campaign of surgical interventions organised in February by Médecins Sans Frontières (MSF) in collaboration with the hospital.

The surgical campaigns, usually held four times a year, have been conducted since 2015, with 1310 surgeries conducted for 918 patients over the past decade.

Milestone moment 

But this year’s event came at a special moment. It was the first campaign since the WHO’s recognition of noma as a neglected tropical disease (NTD)—a category of diseases intrinsically linked with poverty.

Noma, is a deadly disease that begins as common gum sores but develops into ulcerative gingivitis that destroys the soft tissues and bones of the mouth, rapidly progressing to perforate the hard tissues and skin of the face.

It mostly affects children between the ages of two and six years, who are malnourished, live in extreme poverty and suffer from weakened immune systems.

Detected early, its progression can be halted rapidly through basic hygiene and/or antibiotics.  

Untreated, it progresses rapidly and has a 90% mortality rate within the first two weeks of the onset of the disease. This is primarily due to sepsis, severe dehydration or malnutrition.

Despite its aesthetics and functional impact, noma survivors are regarded as the lucky ones.

Sokoto state, Nigeria

A lifeline for noma patients

Mohammadu Usman, 23, a popular figure at the Sokoto Noma Hospital, counts himself amongst the fortunate. At the age of five, he became infected with the disease. While he survived, he grew up with the prominent scars that the disease left on his face — characteristic to noma survivors.

“My parents were desperate to find a treatment that would help me look normal, just like everyone else,” Usman said.

He recalled that he could not eat in public and received disparaging remarks from people who did not know about noma.

In 2017, he and his father embarked on a gruelling 14-hour journey from Maiduguri to the hospital after they heard about the free surgical treatments. Usman’s timing was serendipitous, as he was chosen for surgery around the same time he presented at the hospital.

Mohammadu Usman, a 22-year-old noma survivor, works in the Sokoto Noma Hospital as a car washer and a cleaner. He’s now a secondary school student at a local school and wants to be a doctor. ‘I strive to educate others about noma so they know, for example, that cleaning their mouths daily reduces the risk.’ May 9, 2023.

By the time Usman arrived at the hospital, he had developed trismus, a complication of noma that makes it difficult to open the mouth.

Since his initial surgery in 2017, he has undergone two more operations. The most recent one was performed last year.

“I have been told that I need another surgery,” he said.

But he is pleased with the outcome so far. It has given him a new lease of life. After his surgery, the hospital staff helped him enrol in a public school. To support himself financially, he started working as a hospital cleaner.

“This surgery has completely transformed my life. My parents, too, are happy about the changes,” he said.

MSF’s Surgical Intervention

Ummu Salma, aged 30, travelled from a village in Katsina with her eight-year-old daughter for the surgical intervention. She learned about it from a father whose son received treatment in the hospital.

This February, MSF conducted its 28th intervention at the Sokoto Noma Hospital. Over the course of two weeks, from February 11th to 23rd, MSF’s surgical team of four plastic surgeons, two maxillofacial surgeons, and five anaesthesiologists joined hands with the hospital’s staff to perform reconstructive surgeries for noma survivors.

Prior to the team’s arrival, the hospital staff conducted thorough screenings of noma patients to determine their eligibility for surgery, which is greatly influenced by their nutritional fitness. Twenty-nine patients were eventually selected to undergo surgical treatment.

Growing recognition of Noma nationally and globally 

The programme at Sokoto is the oldest in the country, and it was also the only one available before the launch of a Noma Centre in Abuja, Nigeria’s capital city, in November 2023.

The launch of the Abuja centre reflects the growing awareness about the disease across Nigeria, and more broadly in West Africa, where it is endemic.

Nigeria, with a national noma incidence ranging from 4.1–17.9 per 100,000 is amongst the eight countries with the highest incidence of noma in sub-Saharan Africa. Indeed, the countries in this region form the so-called ‘noma belt.’

The majority of the Nigerian cases are seen in the northern region. In 2018, a survey found that in north-west Nigeria, 3,300 out of every 100,000 children aged newborn to 15 years were affected by noma.

Estimates of global incidence are challenging due to insufficient data collected through standardised methods across the affected regions. The WHO’s global estimate of 140,000 noma cases annually, with a disease prevalence of 770,000 people, remains the most widely referenced. But that data dates from 1998. A 2023 study suggests a global incidence of 30,000–40,000 cases.

Cases are not limited to Africa. From 1950 to 2019, noma patients were reported in 88 countries. However, the number of countries reporting new cases narrowed to 23 across Africa and Asia between 2010 and 2019, with Italy being the only European country affected, according to a 2022  Lancet review. Amongst these, 11 were in West Africa, where Niger recorded the highest incidence in the sub-Saharan region, with an estimated seven to 14 cases per 10,000 children aged newborn to six years.

Exact causes of the disease remain unclear 

Although the disease is associated with extreme food insecurity, poverty, poor health, and unsanitary conditions, the exact causes are unknown.

Noma treatment depends on the disease stage. At early stages, antibiotics, better oral hygiene practices and nutritional support are effective. In advanced cases, wound care, surgical procedures and physiotherapy may become necessary.

With the backing of international NGOs and the WHO, several West African nations have successfully established specialised noma treatment centres. Since 2015, the Lausanne, Switzerland-based Fondation Sentinelles has operated a care centre in Niger and Burkina Faso, treating nearly 2,000 children affected by the disease.

Ethiopia has three major noma care centres. In Nigeria, beyond the collaboration between the Sokoto Noma Hospital and MSF, noma programmes have received support from the Dutch Noma Foundation, the German nonprofit Hilfsaktion Noma, and the Noma Aid Nigeria Initiative (NANI), with the latter two joining forces to establish the country’s second noma centre in Abuja.

Reported global occurrence of noma cases from 1950 until 2019 based on the last reported noma case in each country.

 

Number of reported noma cases and number of reports on noma cases at national and subnational levels in Africa. ADM0: national administrative division. ADM1: upper subnational administrative division.

Sokoto centre remains strategically important  

Despite the creation of the new Abuja noma centre, the Sokoto hospital will remain strategically critical due to its much greater accessibility to patients in the country’s remote northern region, which sees the highest prevalence of the disease.

The centre has also built a reputation for community outreach into the region.

Its success with outreach is associated with the hospital team’s innovative use of storytelling in their awareness-raising activities. This includes a dramatic tale about a fictional boy suffering from noma, designed to break taboos and spark conversations amongst community members.

Supported by the MSF outreach team, the hospital regularly conducts awareness-raising activities within communities in Sokoto, Kebbi and Zamfara states, all in north-west Nigeria, where noma has long been prevalent. They distribute leaflets, make dramatic presentations and educate villagers on noma recognition.

To streamline the referral process, medical staff require referring hospitals to send images of patients through WhatsApp for preliminary assessment.

The social stigma attached to noma leads to isolation, complicating case detection. To counter this, each community appoints a focal person for follow-up on referrals.

Audrey Beckers, an anaesthesiologist from the Netherlands. She had been part of MSF missions to the Republic of Congo and South-Sudan.

Surgical interventions remain critical 

Even with improved surveillance, however, the surgical interventions offered by the hospital remain critical to recovery, in light of the rapid progression of the disease.

The surgery involves creating new facial features for the patients. The surgeons reconstruct damaged noses, lips, cheeks, palates, and eyelids, and perform trismus surgery. Some procedures can last up to six hours.

The trismus release surgery to improve mouth opening poses a formidable challenge, even for the highly skilled surgical team.

“Normally, we pass a laryngoscope through the mouth to deliver general anaesthesia. With trismus, the mouth is no longer an option. So we go through the nose—a far more complicated procedure,” explained Audrey Beckers, a Dutch anaesthesiologist who is on her third MSF mission in Africa.

Given their socio-economic status, none of the noma patients could afford such care if they had to pay out-of-pocket.

“In a public hospital, where treatment is highly subsidised, each stage of the surgery wouldn’t cost less than 300,000 naira [$190]. Private hospitals could charge up to a million naira [$633] per stage. and noma patients [often] require multiple procedures,” said Jacob Legbo, the MSF surgical team leader.

“Knowing that these are poor patients, the opportunity to provide them with free treatment brings immense joy to me and the team.”

Localisation of the surgical intervention

After COVID-19 related travel restrictions disrupted the 2020 surgical intervention, MSF intensified efforts to include more national surgeons.

In the first years, MSF depended primarily on surgical team members who travelled to Sokoto from Europe or elsewhere.

However, by 2018, local Nigerian surgeons were gradually being integrated into the work. The travel restrictions imposed due to the 2020 pandemic, meanwhile, limited the participation of foreign surgeons, resulting in only one intervention held that year.

This accelerated a shift in the organisation’s approach, prioritising the further integration of Nigerian surgeons, post-pandemic. The goal was to foster an exchange of skills and experience with their international counterparts, paving the way for local professionals to eventually spearhead the missions.

Jacob Legbo, a Nigerian surgeon and the MSF surgical team leader for the intervention.

The strategy appears to be working. Currently, the pool of national surgeons and anaesthesiologists has increased to 45. For this outreach, the surgical team was predominantly Nigerian, with only two foreign anaesthesiologists participating.

Reinvigorated national efforts

The new Noma Centre Abuja located in Abuja, the country’s capital.

In 2017, the Nigerian Federal Ministry of Health (FMoH) designated November 20 as National Noma Day.

By 2019, with the backing of the WHO Regional Office for Africa, Nigeria launched its national action plan to control noma. Ten other countries with a high noma burden have also developed and implemented similar national initiatives under the WHO’s guidance.

During the 2023 national noma day celebration, a new 100-bed national noma centre was unveiled in Abuja, within the grounds of the National Hospital, a tertiary hospital in the country’s capital.

This centre is now Nigeria’s second dedicated facility for noma treatment. It was established through a collaboration between the Nigerian NGO, Noma Aid Nigeria Initiative (NANI), and the federal ministry of health, with support from the German non-profit Hilfsaktion Noma.

Funding from the WHO and MSF also enabled the Nigerian Health Ministry to provide specialised noma training to 741 primary healthcare workers from 2021 through the first half of 2022. Additionally, noma is being integrated into the training curriculum for Nigeria’s nursing and midwifery, MSF told Health Policy Watch.

Pathway to global recognition

In 2021, WHO adopted a landmark Resolution on Oral Health at the 74th World Health Assembly. It recommended that “noma should be considered for inclusion in the NTD portfolio as soon as the list is reviewed in 2023.”

In January 2023, the Nigerian government submitted an official request to WHO on behalf of 32 other member states to have noma recognised as an NTD. The request was backed up by a dossier, providing evidence on how noma meets all four criteria for neglected diseases.

The African campaign was supported by a unique constellation of global health forces in Geneva’s global health hub. This included not only WHO but also leading universities, the Hospitaux Universitaires de Geneve, MSF, Fondation Sentinelles and others.

By December 15, WHO officially recognised noma as a neglected tropical disease, increasing the number of NTDs to 21.  It is hoped that the long-awaited move will lead to more research and funding investments in the long-neglected NTD.

Significance of noma’s recognition as an NTD

In Sokoto, hospital staff are optimistic that noma’s inclusion on the WHO NTD list will drive more research, advocacy and funding.

“My joy in the WHO recognition is that noma will get more attention,” said Mulikat Okanlawon, a noma survivor who now works as a hygiene officer at the Sokoto Noma Hospital. Alongside fellow survivor Fidel Strub, Okanlawon co-founded Elysium, the first foundation for noma survivors.

“[W]hat this list does is it makes the disease legitimate in the eyes of donors to fund further research on the disease, and it brings awareness,” said Mark Sherlock, MSF Health Advisor for Nigeria, in an NPR interview.

The organization expects that the recognition of noma will attract more stakeholders at important stages of noma care: early detection, treatment and referral.

Abubakar Abdullahi Bello, chief medical director of Sokoto Noma Hospital. Sokoto. In 2023, the hospital had about 234 acute noma cases.

Despite the presence of a new facility in Abuja, the surgical interventions offered by the noma hospital in Sokoto continue to grow in popularity – due to its successful outreach activities and close proximity to communities where the disease is most prevalent.  Unfortunately, the funding has not kept up with the need for updated infrastructure.

“The [hospital] structure has been here for more than 20 years and there are some departments in the hospital that need to be upgraded, like the outpatient unit,” said Abubakar Bello, the hospital’s chief medical director.

“The state government has made some contributions, but there is still a lot left to be done,” Bello said.

That’s all the more reason why the recent WHO recognition of Noma is so important, he added, “hopefully we will see more organisations offering support in the prevention, treatment, or rehabilitation aspects of the disease.”

Nutritional support also critical 

While MSF and the state cover the cost of meals for patients during their stay at the hospital, Nigeria’s high inflation rate and associated food insecurity threaten the ability of noma survivors to meet their nutritional needs after discharge. This puts survivors at risk of relapse.

Malnutrition is commonly reported among patients admitted to the hospital, making nutritional rehabilitation a crucial part of treatment.

‘If a noma survivor, after being treated for malnutrition and infection, returns to the same living conditions that led to the disease, there’s a chance they could develop noma again.

“We cannot overlook the possibility of a noma relapse, and these are the areas where more research is needed,’ said Mohammed Abdullahi, consultant oral and maxillofacial surgeon at the University of Maiduguri Teaching Hospital, in the north-eastern region of Nigeria.

Acute need for more surveillance and research  

As many stakeholders noted, the WHO’s recognition is merely the beginning for a disease as neglected as noma – where the agency’s most recent data on global prevalence dates back to 1998. In Nigeria, research on noma has primarily been regional, focusing on northern Nigeria, where most cases are seen.

At a major noma scientific conference in Nigeria in November, Peter Ajanson, MSF Nigeria’s deputy medical director, noted an increase in reports of noma cases in other Nigerian states which were previously unaffected. However, due to limited surveillance, the real extent of noma’s impact across Nigeria remains unknown.

Like in other noma-priority countries, international aid and grants have fuelled much of Nigeria’s fight against the disease. However, local researchers like Seidu Bello from the Nigerian International Craniofacial Academy have urged Nigeria’s Federal Ministry of Health to invest more in increasing public awareness, early detection, and the national capacity for diagnosing and treating the disease

“Therefore, we advocate public awareness on the disease risk factors and prevention within the [country’s] sub-regions as well as training of primary health personnel on disease identification, primary care and nearest referral centres,” he wrote in his study on noma’s incidence and prevalence in north-central Nigeria. He argued that this will help ensure timely treatment of those most in need.

Across the hospital, Usman was sweeping off the sand and fallen leaves that had gathered on the outdoor passageway.

He was mindful of the elderly man and young child sitting nearby as he pulled the dirt across the terrazzo floor and into a small pile.

He harbours dreams bigger than his present situation. He hopes he can complete his education, improve his English and someday become a doctor.

Image Credits: Abdulrasheed Hammad , Encyclopædia Britannica, Fabrice Caterini/MSF, Galli, A., et al. The Lancet Infectious Diseases., Nigeria Health Watch, Abdulrasheed Hammad.

Center left and right, Manaouda Malachie, Cameroon’s health minister and WHO Regional Director Matshidiso Moeti hold copies of the declaration on accelerating malaria elimination, signed by African health ministers Wednesday in Yaoundé, Cameroon.

A new declaration by health ministers from African countries that have the highest malaria burden has reaffirmed the “unwavering commitment to the accelerated reduction of malaria mortality”.

The declaration, issued Wednesday by ministers convening in Yaoundé, Cameroon at an African-wide WHO conference on malaria, aims to revitalise the campaign to drive deaths from malaria further downwards – following the setbacks of the COVID-19 pandemic.  

Public health experts speaking with Health Policy Watch, however, described the declaration as largely a rehash of previous statements.  The declaration made no new commitments either to concrete targets for vaccine scale-up or health sector investments in combating the deadly disease that still kills 580,000 people annually, 95% of those Africans mostly under the age of 5.

Dr Matshidiso Moeti, WHO Regional Director for Africa, however, described the declaration as a milestone. 

“We welcome today’s ministerial declaration, which demonstrates a strong political will to reduce the burden of this deadly disease. With renewed urgency and commitment, we can accelerate progress towards a future free of malaria,” Moeti said, speaking from Cameroon to a press conference.

In 2022, some 233 million people were infected with malaria, 94% of cases in the African region. The ministers pledged to further invest in data technology, as well as malaria control efforts and elimination, and enhance malaria control efforts at national and sub-national levels. 

“This declaration reflects our shared commitment as nations and partners to protect our people from the devastating consequences of malaria. We will work together to ensure that this commitment is translated into action and impact,” said Manaouda Malachie, Minister for Health of Cameroon at the meeting.

The countries pledged “to hold each other and our countries accountable for the commitments”.

Hot air – or stepping stone?

Dr Matshidiso Moeti, WHO African Regional Director, addressing the malaria conference.

The 2023 Africa Malaria Progress report by African Leaders Malaria Alliance cited a growing number of threats to achieving the goal of eliminating malaria as a public health threat in Africa by 2030.

“Despite political will and knowing how to defeat malaria, we lack the resources necessary to fully implement our national malaria strategic plans, sustain essential life-saving malaria services, and deploy new and more effective interventions to address increasing biological threats,” the report’s foreword stated. 

The report called on African leaders “to act now to drive accountability, action, advocacy, and resource mobilisation to end this disease once and for all”. 

Just 11 African countries carry nearly 70% of the global burden of malaria, progress against malaria “has stalled since 2017” due to factors that include humanitarian crises, low access to and insufficient quality of health services, climate change, gender-related barriers, biological threats such as insecticide and drug resistance and global economic crises.

The new declaration also highlights the need to address the contributions of fragile health systems and critical gaps in data and surveillance that have compounded the challenge of controlling malaria in several African countries.

Behind the scenes, WHO and malaria implementation partners are hoping that the COVID-19 experience that demonstrated the need for more investments in healthcare, would convince the countries to willingly increase their own spending on health.

According to Moeti, the ministers and the partners in attendance understood the needs for more investment and financial resources. “We need more money to do this work.” In addition to funding, there is also the need to apply the lessons learned. “We need to apply science in a way that informs not only what we do at the national level, but very much at the local level,” Moeti stressed. 

She called for the use of data to differentiate between different situations and to be able to target and focus interventions to have the optimum impact. “We need our health system to have investments that make them more responsive, more able to deliver the services effectively, and detect cases early.”

SMART action plans 

In order to build action out of the declaration, the RBM Partnership  announced it will be convening parliamentarians, opinion leaders and civil society from high burden countries at a parallel regional forum – to discuss more concretely how to achieve their commitments and accelerate action. This is supposed to lead to the co-development of SMART action plan, RBM said in a statement. 

“Participants have also been undergoing training on the strategies, existing tools and funding for malaria control,” the RBM Partnership stated.

The partnership’s CEO, Michael Charles, noted that if so-called “High Burden High Impact” can make significant inroads, this will drive down malaria incidence globally. . 

“Collaboration plays a crucial role in promoting a coordinated African response to malaria, and we’re delighted to be working alongside partners to convene key decision makers to translate the Yaoundé Declaration into a concrete action plan that will enable these countries to quickly accelerate anti-malaria activities, stay accountable, and meet the commitments they have just made,” he said.

Consolidating progress

In spite of the bottlenecks, progress against malaria is being recorded including a number of recent malaria-free certifications by WHO, the most recent being Cabo Verde. 

With half of the world’s population at risk of malaria, however, the RBM Partnership added that biological threats and climate change are further increasing the malaria challenge, and current investment levels and coverage of malaria interventions will not be sufficient to achieve the 2025 Global Technical Strategy for malaria milestone of a 75% reduction in mortality rates and case incidence. 

It added that progress towards the corresponding third Sustainable Development Goal (SDG) 2030 targets is also “off track”. But with current tools – such as vector control, preventive chemotherapies and vaccines – the lag could be overcome, the Partnership said.  

“With a combination of efforts, it will be possible to lower malaria case incidence and significantly reduce mortality in these High Burden High Impact countries, and minimise the global threat,” it concluded.

Image Credits: World Health Organization, Malaria Ministerial Conference in Yaoundé, Cameroon, WHO/@MoetiTshidi.

Accra has reduced traffic crashes by 20% over seven years

CAPE TOWN – From Accra to Kathmandu, a global partnership of 74 cities has had remarkable success in addressing some of the key drivers of sickness and death since it was launched seven years ago.

Ghana’s capital city, Accra, has cut traffic crashes by 20%. In India, Bengaluru is virtually smoke-free – not even hookahs are allowed. Nepal’s Kathmandu has installed air quality sensors to assess air pollution while a number of Latin American cities are supporting better nutrition of their school children. 

“The Partnership for Health Cities (PHC) was formed in 2017 to address non-communicable diseases (NCDs) and injuries, which are responsible for 80% of deaths globally,” said Bloomberg Philanthropies’ Kelly Larson, welcoming city representatives to the PHC’s summit in Cape Town this week.  

“This opportunity for us to come together is very unique because we are all facing the same challenges and you can learn so much from one another. We really do believe in the power of cities to make change. We are here to support you in your efforts to know that you are leading the way on this,” added Larson, whose organisation supports the partnership, along with the World Health Organization (WHO) and Vital Strategies.

The partnership started with 54 cities but now consists of 74 cities that collectively represent over 300 million people.

Each city in the PHC chooses to work in one of six key work areas: food policy, overdose prevention, tobacco control, road safety, safe and active mobility (such as promoting cycling) or data surveillance.

The cities are encouraged to root their work in public health policies and to win as much public support as possible for these. The PHC’s  Policy Accelerator supports cities to create and implement these policies.

“Cities are a place where people are particularly at risk. There is a huge concentration of people exposed to risk of NCD and injuries,” said the WHO’s Etienne Krug.

“But cities are a particularly good place to think about interventions for a number of reasons,” he added. “First of all, they enforce national laws but they can also enhance these with additional regulations. City leaders are geographically close to their populations. It is easier for multi-sectoral approaches than at national level.”

Bengaluru: A model smoke-free city

Bengaluru in India has become a model smoke-free city

India’s Dr Vishal Rao has been an advocate for smoke-free laws for a number of years in Bengaluru (Bangalore) and its state, Karnataka. This is hardly surprising as a head and neck surgical oncologist at a cancer hospital and has treated numerous tumours in the thyroid, parotid, and salivary glands caused by tobacco use.

“We first prioritised creating a policy framework around smoking, and have built this policy around the three R’s – making somebody responsible, have it reviewed and reported,” Rao told Health Policy Watch.

Dr Vishal Rao from Bengaluru

“We prioritised smoke free policy because we realised that Bengaluru is a cosmopolitan  economic hub with a very vibrant culture of pubs, clubs, cafes, bars and restaurants, all of which were rampantly violating the smoke free laws,” said Rao, who is also a member of the Karnataka government’s High Power Committee on Tobacco Control.

“Reducing and protecting the non-smokers required a comprehensive approach of policy intervention which is why the mayor and the [state] commissioner came out with the government order completely banning smoking in hotels, bars, restaurants, clubs, pubs and cafes unless they have a designated smoking room which is compliant with the law,” said Rao.

The requirements for these designated smoking rooms were so onerous – including no sales or services of any sort being allowed – that most places opted not to set them up.

A couple of weeks back, the state government also banned hookah bars – including hookah with tobacco, flavoured and herbal hookah – becoming the first state to do so. The pushback has been immediate, with the Hookah Association lodging around 12 litigation cases against the new laws, said Rao.

For Rao, the partnership is less about the grants cities get and more about sharing strategies, tactics and “allowing champions to emerge” to promote the various themes – his city won an award at last year’s summit for its efforts.

Accra: All the laws but little implementation

Rita Agyen Takyi is an advisor to Accra’s mayor on international affairs

Rita Agyen Takyi is an advisor to Accra’s mayor on international affairs and the city’s focal person on road safety, the issue her city has chosen.

“Ghana has all the laws. But we needed enforcement, implementation and public awareness,” Takyi told Health Policy Watch. Accra’s Bloomberg Road Safety initiative started in 2015 and it joined the partnership at its launch in 2017.

Over half the city’s road traffic deaths involved pedestrians, cyclists and motorcyclists. Public awareness campaigns have included encouraging the use of seat belts and helmets, speed limit signs and speed detectors for traffic police, direction signs painted on roads and fixed painted bollards to prevent motorcyclists from entering pedestrian crossings.

“We have reduced traffic crashes by 22% since 2021/22,” said Takyi, who also credits this success to Accra bringing different stakeholders “out of their silos” and into one forum with a common goal.

Latin American cities prioritise food policy

Five cities in Latin America have chosen to focus on food policy. Quito in Ecuador is concerned with the nutrition of children, the city’s Marysol Ruilova told the Cape Town summit.

Quito has developed a policy requiring only healthy foods to be advertised near and at schools, and is also providing clean free water in 20 pilot schools.

However, since the COVID-19 pandemic, there has been an increase in child malnutrition so the city has focused on school feeding schemes.

Cordoba is focusing on school nutrition, including promoting water

Similarly, Córdoba in Argentina is preparing to restrict the sale and advertising of unhealthy food and beverages in schools and requiring healthy alternatives, while 

Cali in Colombia is also ensuring that scholars have access to nutritious and wholesome meals during school hours.

Lima in  Peru is also working to create healthier school environments through enforcement of a new policy that restricts sales and advertising of unhealthy products. Montevideo in Uruguay is incentivizing food services to provide healthier meals to public sector workers, through its “Healthy Canteens” initiative.

Cape Town: Socio-economic determinants of health

Cape Town mayor Geordin Hill-Lewis addresses the opening of the summit.

Host city Cape Town has been involved in tobacco control and food policy-related initiatives while part of the PHP.

“Against the backdrop of incredibly challenging national economic circumstances and very deep and wide local poverty, our city is still demonstrating progress,” Mayor Geordin Hill-Lewis told the summit.“But you cannot build a prosperous city or achieve our dream of a city of hope without also focusing on public health in a serious way.”

One of the things that Cape Town is currently focusing on is identifying and addressing the socio-economic determinants of health in the city and addressing these through infrastructure planning, service provision and job creation.

“Cape Town has a very high burden of NCDs and other preventable deaths. And, while we have a good understanding of the various factors that contribute to that burden, this programme will provide crucial information that can help determine strategies going forward,” according to Councillor Patricia Van der Ross.

Image Credits: Partnership for Health Cities, Kerry Cullinan.

Dr Ahmed Ogwell Ouma, Africa CDC’s outgoing acting deputy director general, confirms that he is leaving Africa CDC – won’t take a post in another African Union institution.

Acting director of the Africa CDC, Dr Ahmed Ogwell Ouma, on Thursday confirmed that he is leaving the agency at the end of the month. He denied, however, earlier reports that his departure was tied to African CDC age or geographic restrictions in the recruitment of a permanent candidate, but rather attributed the decision to “personal reasons”.

“It has not been an easy decision considering my love and commitment to Africa, but the time has come for me to pursue my professional and personal growth elsewhere. I also confirm that my decision is not in any way related to, nor motivated by any of the ongoing recruitment processes within Africa CDC or the African Union,” Ouma stated in a post on LinkedIn.

The official AU announcement for the position in September 2023 encouraged candidates from “less represented countries within the African Union” – although it did not specifically exclude Kenyans.

But in an X post in December, the CDC’s new director general, A Jean Kaseya made it even more explicit. He said the “ideal candidate” for the deputy director general position should be “under the age of 55” years and from one of the AU’s 32 under-represented countries – effectively excluding Ouma on two counts. 

Kaseya, when he assumed the post of Africa CDC director general following his February 2023 election by AU heads of state, said that he wants Africa CDC to reflect the continent’s diversity. Effectively, however, the recruitment conditions Kaseya cited also clear the table of previous leadership that could challenge Kaseya politically and institutionally in his new role.  In the year prior to Kaseya taking office, Ouma was acting director of Africa CDC.

Ouma’s departure from Africa CDC described as a big loss by some

Ouma described his experience at Africa CDC as one of “honour and privilege to serve my continent Africa,” he said in his LinkedIn post. “I have served with passionate professionals, learnt from seasoned leaders, energised by the vigour of African youth, and blessed with the wisdom of African elders. I have also had the privilege of working with partners (I call them Friends of Africa!) as they supported our work and contributed to our vision of a New Public Health Order.” 

The announcement was met with accolades for Ouma – and some predictions that the departure of the veteran health official is not only a loss, but an institutional setback, as the agency tries to establish itself as an autonomous continental health agency.

David Adetula, Co-Founder and Executive Director, Public Health Interest Group Africa (PHIGA), described Ouma as “a huge inspiration to me, and millions of young Africans who are passionate about fixing the continent’s health systems. Your contribution, to bringing youths to the table, stands tall.”

Ouma’s legacy at Africa CDC

Ouma led the continent through the final stages of the COVID pandemic as well as the 2022 global mpox health emergency.  In both episodes he quickly made a name for himself, asserting a strong role for the Africa health agency.

He argued with WHO over the right of Africa CDC to  declare continental health emergencies – in cases where WHO’s own legal powers relate solely to global health emergency declarations. Ouma also demanded more mpox diagnostics and vaccine allocations for Africa – where the disease is endemic but medical tools to prevent and treat it remain largely unavailable.

Dr Ahmed Ogwell Ouma at press briefing in June 2022 as Africa CDC’s acting director asserts the continent should be top priority for vaccine doses for monkeypox.

Kaseya acknowledged Ouma’s remarkable tenure at the Africa CDC, stating that he was instrumental in navigating the center “through unprecedented times”, including the COVID-19 pandemic. Kaseya also recognized Ouma’s  critical role in laying the groundwork for the AU decision in February 2022 to elevate Africa CDC’s status from a technical arm of the AU to an autonomous public health agency.

Ouma, joined Africa CDC in September 2019 as deputy director, a position he held till May 2022 when he became the acting director following the departure of John Nkengasong for a job in the United States as head of PEPFAR, the US President’s Emergency Plan for AIDS relief. Nkengasong built the agency from an AU department into a quasi-autonomous entity, a pathway that Ouma continued in his year-long tenure.

After Kaseya, a Congolese national, took on the post as Africa CDC’s director in mid-2023, Ouma then became acting deputy director once again.  Prior to arriving at Africa CDC, Ouma held several leadership positions in the World Health Organization, including as a senior advisor to WHO’s Director General on non-communicable diseases. 

Last week, Ogwell was at Harvard completing a Rockefeller Foundation seminar on “executive leadership”.

Reflecting and looking ahead

Speaking to Health Policy Watch on the sidelines of the recently held third International Conference on Public Health in Africa (CPHIA 2023), Ouma expressed pride in the current status of Africa CDC, noting its evolution into a globally trusted leader in pandemic response. 

He also highlighted the institution’s growth from humble beginnings to its central role in leading public health responses on the continent, while also spearheading partnerships and initiatives such as Saving Lives and Livelihoods partnership between Africa CDC and the Mastercard Foundaiton which sought to scale up COVID vaccination on the continent, and lay the groundwork for local vaccine manufacturing.

Ouma emphasized the importance of building and maintaining public health capacity on the continent, with the Africa CDC facilitating coordination and networking among African countries. He noted progress in establishing Public Health Emergency Operation Centers at the country level to ensure real-time information access, laboratory readiness, and expert deployment. Ouma stressed the need to reinforce these efforts to enhance Africa’s preparedness for future outbreaks.

“Africa CDC’s role is to ensure that countries are networked. Having a public health emergency operation center is a sure way for countries to maintain the infrastructure developed at Africa CDC,” Ouma told Health Policy Watch.

Looking ahead, Ouma stated that Africa CDC’s experiences during the pandemic provide valuable lessons for future interventions. He emphasized the organization’s aim to continue building resilience, prioritizing local needs, and selecting appropriate implementing partners to strengthen health security in Africa.

He also emphasized the importance of not waiting for everything to be in place before taking action.  

“Don’t wait for everything to be in place before you act. When you want to save lives, you start saving lives with what you have, and you fix it as you go along,” he said.

Image Credits: Paul Adepoju.

HPV vaccine
The WHO set an ambitious goal of having 90% of girls vaccinated against HPV by 2030

Eliminating cervical cancer is within reach, thanks to new commitments by governments, donors and other partners, including pledges of almost $600 million, made at the first-ever global forum on cervical cancer in Cartagena de Indias in Colombia.

Every two minutes, a woman dies from cervical cancer, although vaccination against human papillomavirus (HPV), the leading cause of cervical cancer, can prevent the vast majority of cases. 

Cervical cancer is the fourth most common cancer in women worldwide, but disproportionately affects women and their families in low and middle-income countries (LMICs). 

Less than 5% of women in many LMICs are ever screened for cervical cancer, and over 90% of the 348 000 cervical cancer deaths in 2022 took place in LMICs. 

Furthermore, only one in five adolescent girls were vaccinated against HPV in 2022. 

Country commitments

global cervical cancer mortality heat map
Low and middle income countries experience the highest burden of cervical cancer

However, a number of countries stepped up at the forum. These include the Democratic Republic of Congo (DRC), which has committed to introduce the HPV vaccine as early as possible, targeting girls aged 9 to 14 years.

Ethiopia aims to reach at least 95% of all 14-year-old girls with the HPV vaccine this year, and screen one million eligible women every year for cervical cancer and to treat 90% of those screened who present with positive precancerous lesions. 

Further, HPV single dose has been approved to be introduced this year and scaled up as part of the country’s Expanded Program on Immunization plans.

Africa’s most populous country, Nigeria, has committed to vaccinating 80% of girls 9 to 14 years old by 2026, including those who are no longer at school.

The nearly $600 million in new funding includes $180 million from the Bill and Melinda Gates Foundation, $10 million from UNICEF, and $400 million from the World Bank. 

Elimination of a cancer

Press conference at the global cervical cancer elimination forum
Experts gathered in Colombia to discuss global collaboration for cervical cancer elimination

“If these ambitions to expand vaccine coverage and strengthen screening and treatment programs are fully realized, the world could eliminate a cancer for the first time,” according to the World Health Organization (WHO).

In 2022, the WHO revised its HPV vaccination recommendation from two to one-dose of the HPV vaccine, making it much easier and cheaper for countries to reach those who need it.

The WHO Americas region made a similar recommendation 2023, and WHO’s African regional just followed suit with its own recommendation. 

“We have the knowledge and the tools to make cervical cancer history, but vaccination, screening and treatment programmes are still not reaching the scale required,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. 

“This first global forum is an important opportunity for governments and partners to invest in the global elimination strategy and addressing the inequities that deny women and girls access to the life-saving tools they need.” 

However, many LMICs face an uphill battle. Malawian Minister of Health Kandodo Chiponda described the challenges her country faces at the forum’s opening plenary. 

Some 60% of Malawi’s population of over 20 million is under 35, and cervical cancer is the highest cancer burden, with the incidence rate as high as 70 per 100,000. Mortality figures are 52 per 100,000, said Chiponda, who also announced the opening of the first ever cancer center in Malawi. 

Chiponda noted that women have limited time and resources to seek care, limited access to screening and diagnostic services, and are subject to misinformation about vaccinations. 

She emphasized the need for cross-sector collaborations and the strengthening of primary healthcare to reach women and girls in remote areas.

‘Miracle of modern medicine’

WHO director general
“Cervical cancer is a disease of inequity” – Dr. Tedros Adhanom Ghebreyesus, WHO Director-General

“The HPV vaccine is one of the most impactful vaccines on the planet and has already helped save thousands of lives,” said Aurélia Nguyen, Gavi’s chief programme officer. 

Despite the efficiency and safety of the HPV vaccine, high costs, supply chain issues, and difficulties in reaching remote populations keep the vaccine out of reach for many.

“More girls urgently deserve the same protection, which is why in partnership with countries, Gavi has set an ambitious goal to help vaccinate 86 million adolescent girls by 2025. With bold commitment and decisive action, we can look forward to a future where cervical cancer has been eliminated for good.” 

Describing HPV vaccines as “a miracle of modern medicine”, Dr Chris Elias, the Bill and Melinda Gates Foundation’s president of global development, said that there is “no reason why women should die from cervical cancer.”

“Now is the time for governments and partners around the world to increase HPV vaccine access and protect future generations from cervical cancer.” 

Image Credits: Unsplash, IARC/WHO, Global Cervical Cancer Elimination Forum, GCCEF/WHO.

WHO surveys destruction around northern Gaza hospitals last week, in one of the first relief missions to reach the area in over a month.

A United Nations report released Monday said there are “reasonable grounds” to believe that multiple incidents of sexual violence, including rape and gang rape of Israeli women, occurred during the Hamas-led incursion into some 22 Israeli communities near the Gaza border on 7 October. More than 1,200 people were killed in the incident, mostly civilians. 

Meanwhile, Dr Tedros Adhanom Ghebreyesus described “grim findings” of severe malnutrition and  “children dying of starvation” during the first World Health Organization visit to a children’s hospital in northern Gaza since October 2023. He appealed to Israel to permit more regular deliveries of humanitarian aid to the area, still cordoned off by Israeli troops to supply routes from the south.   

“Kamal Adwan Hospital is the only paediatrics hospital in the north of Gaza, and is overwhelmed with patients. The lack of food resulted in the deaths of 10 children. The lack of electricity poses a serious threat to patient care, especially in critical areas like the intensive care unit and the neonatal unit,” Tedros said in a statement posted on X. 

“We managed to deliver 9,500 litres of fuel to each hospital, and some essential medical supplies. This is a fraction of the urgent lifesaving needs,” said Tedros, referring to a parallel relief mission to Al Awda hospital in northern Gaza’s Jabalya neighbourhood.

“We appeal to Israel to ensure humanitarian aid can be delivered safely and regularly,” Tedros said. 

In just the past several days, WHO teams also managed to access northern Al Shifa hospital, the biggest health facility in the Gazan enclave, for the first time in over a month, delivering 19,000 litres of fuel and treatments for 50 children suffering from acute malnutrition.  

“The level of destruction around the hospital is beyond words. Ceasefire,” Tedros said in another statement.

“Hospitals in Gaza continue to face severe disruptions in providing health care,” reported the UN Office for Coordination of Humanitarian Affairs (OCHA) on Tuesday.

In most incidents, Israeli victims were raped, then killed

Aerial view of one of the sites of the October 7, 2023 assault by Hamas gunmen on the Nova music festival near Kibbutz Re’im in southern Israel along the Gaza border, where a UN mission said it found credible reports of sexual violence against some of the festival-goers and other Israeli victims of the day’s attacks.

In terms of the UN mission report on sexual violence in Israel and the occupied West Bank, released Monday, the expert team that made a two-week visit from 29 January to 14 February, described “a pattern of victims, mostly women, found fully or partially naked, bound, and shot across multiple locations” in the wake of the 7 October Hamas attack. 

The best evidence of the assaults emerged from victims found around the site of the all-night Nova music festival close to the border, which was overwhelmed early Saturday morning by swarms of Hamas-led fighters; along a major regional road, Route 232, by which festival goers tried to escape, and at Kibbutz Re’im, stated the report of the expert team, led by UN Under-Secretary General and Special Representative on Sexual Violence in Conflict, Pramila Patten. 

With respect to the 253 Israeli and foreign hostages initially taken to Gaza, some of whom have since been released, the mission team found “clear and convincing information that some have been subjected to various forms of conflict-related sexual violence including rape and sexualised torture and sexualised cruel, inhuman and degrading treatment and it also has reasonable grounds to believe that such violence may be ongoing.”

In visits to the West Bank, the UN team also interviewed representatives of the governing Palestinian Authority, as well as Palestinian civil society and several detainees.

“Stakeholders raised concerns about cruel, inhuman and degrading treatment of Palestinians in detention, including the increased use of various forms of sexual violence, namely invasive body searches; threats of rape; and prolonged forced nudity,” the team stated.  

Other UN entities are now investigating those allegations further, it said, adding that “since 7 October 2023, the detaining authorities have severely limited the access of independent humanitarian bodies to detention facilities to monitor the conditions of detention and address any abuses.”  

‘Limited survivor and witness testimony due to large number of casualties

In terms of the 7 October violence, the expert team that visited Israel also cited “credible” witness testimony and digital phone or camera evidence for some of the rape incidents, including at Kibbutz Re’im and along Route 232. 

The team acknowledged, however, that there was  “limited survivor and witness testimony … due to the large number of casualties and dispersed crime scenes in the context of persistent hostilities … the prioritisation of rescue operations and the recovery, identification, and burial of the deceased in accordance with religious practices, over the collection of forensic evidence. 

“Further, a significant number of the recovered bodies had suffered destructive burn damage, which made the identification of potential crimes of sexual violence impossible.”

Key findings included: 

  • “At the Nova music festival and its surroundings, there are reasonable grounds to believe that multiple incidents of sexual violence took place with victims being subjected to rape and/or gang rape and then killed or killed while being raped. Credible sources described finding five murdered individuals, mostly women, whose bodies were naked from their waist down – and some totally naked – tied with their hands behind their backs, many of whom were shot in the head.   
  • “On Road 232, credible information based on witness accounts describe an incident of the rape of two women by armed elements… The mission team also found a pattern of bound naked or partially naked bodies from the waist down, in some cases tied to structures including trees and poles, along Road 232. 

In the case of several other border communities, the team said that while it could not verify sexual violence reports, while conceding that “available circumstantial evidence may be indicative of some forms of sexual violence.” 

It said “female victims were found fully or partially naked to the waist down with their hands tied behind their backs and shot,” in the case of Kibbutz Kfar Aza for instance, suggesting  “potential sexualised torture”. 

Hamas denied allegations, Israel welcomed UN report 

Hamas leaders have as previously denied the rape allegations, while the UN report said that it was impossible to pinpoint who was responsible for individual attacks given the diversity of individuals and armed groups that crossed into Israel from Gaza on the day of the attacks.  Israel’s Foreign Ministry welcomed the report for recognising “that the crimes … point to a pattern of rape, torture and sexual abuse.” 

However, the haste and chaos of the Israeli rescue efforts, the natural reluctance of survivors to come forward, and the deep well of Israeli mistrust of UN institutions in the wake of the 7 October Hamas attacks, were all noted as factors impeding the team’s enquiry. 

“Overall, the mission team is of the view that the true prevalence of sexual violence during the 7 October attacks and their aftermath may take months or years to emerge and may never be fully known,” said the report.

Image Credits: Times of Israel , WHO .

The European Parliament is to vote on a regulation to allow compulsory licencing during crises.

The European Parliament has been challenged to amend a proposed law to enable  countries outside the European Union (EU) to benefit from medical products produced under compulsory licences during crises.

The proposed regulation aims to ensure that, “during specific crises or emergencies”, the EU can issue a compulsory licence to enable the production of certain products – such as vaccines and medicines during a pandemic.

A compulsory licence gives governments the power to allow a third party to use a patent without the authorisation of the patent-holder, subject to certain conditions. 

“Compulsory licensing can therefore complement current EU efforts to improve its resilience to crises,” according to the EU.

But the draft regulation currently prohibits the export of any products produced under compulsory licences outside the EU.

On Tuesday, a group of over 70 influential civil society organisations and academics wrote a letter to the European Parliament challenging them to “support crucial amendments allowing the export of medical tools to third countries in the proposed Union Compulsory License”.

“The COVID-19 pandemic has made clear that major health emergencies need to be addressed at local, national, regional and global level and showcased that the EU’s advanced industrial capacity can be used to help protect EU citizens while also aiding and supplying non-EU countries, aligning with the principle that “No one is safe until everyone is safe”,” the letter notes.

“It is therefore disheartening to note that, when preparing for the next crisis, the EU risks turning its back on the rest of the world, including non-EU countries in Europe, with this compulsory licence proposal,” it adds.

EU harmonisation

Impetus for the new regulation stems from the fact that there is “no EU-wide harmonisation of compulsory licensing for the domestic market”, according to the EU, which adds that the new regulation has two main objectives.

“First, it aims to enable the EU to rely on compulsory licensing in the context of the EU crisis instruments. Second, it introduces an efficient compulsory licensing scheme, with appropriate features, to allow a swift and appropriate response to crises, with a functioning internal market, guaranteeing the supply and the free movement of crisis-critical products subject to compulsory licencing in the internal market.”

The letter’s signatories, including Médecins Sans Frontières, Health Action International (HAI) and Oxfam, state that they support EU compulsory licences as they have “the potential to foster a more effective response to public health challenges”.

But by prohibiting exports, the current draft – which has been put forward for a plenary vote of the European Parliament – goes against flexibilities enshrined in the World Trade Organization (WTO) Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS Agreement), according to the letter.

“This limitation is problematic, especially considering the use of a Union compulsory license would likely be triggered by situations that would affect not only EU countries but also countries outside of the EU, either in the region or globally,” they add.

Pandemics ‘don’t respect borders’

Making exports available under an EU compulsory licence “is not just a matter of international solidarity but is also in the EU’s interest” as it could “help in controlling potential outbreaks and emergencies that could spill over into the EU, allowing EU-based manufacturers to respond promptly to the needs of non-EU countries”.

“This vote is important for a number of reasons,” according to HAI Senior Policy Advisor Jaume Vidal.

“Embracing TRIPS flexibilities is, of course, a welcome step, but the current proposal risks becoming an ‘EU First’ response when it comes to pandemics and health emergencies, reminiscent of the inequities seen during the COVID-19 pandemic.

“Secondly, at a time when countries are negotiating a pandemic accord, a restrictive use of the proposed Union compulsory license that would limit exports would be sending an ominous message to negotiators. Finally, in times of greatest need, the EU would do well to remember that pandemics don’t respect borders or blocs,  and that no one is safe, until everyone is safe.”

Image Credits: Thijs ter Haar.

Charles Akim, a refugee from Sudan living in nothern Kenya, gets high blood pressure medication at Kenya’s Natukobenyo Health Center, as a result of a partnership between UNHCR, the Kenya government, Novo Nordisk Foundation, and others.

COPENHAGEN –  In Lebanon, international donors are supporting a network of public primary health care centers to test for diabetes and other noncommunicable diseases (NCDs), offering treatment equally to Lebanese nationals and Syrian refugees who are unlikely to return anytime soon to their war-torn homeland. 

In Kenya, a new national insurance law aims to make health insurance mandatory and accessible both to unemployed Kenyans as well as to the estimated 625,000 refugees that have been living in the country for 30 years or more. And a much-touted “Shirika” initiative aims to integrate refugee communities into the health workforce, as well as the broader economy. 

In both Moldova and Jordan, refugees fleeing war-torn Ukraine and Syria were immediately brought into the national health systems of their respective host countries at the height of the crisis.  That allowed international aid to be targeted to supporting refugee’s direct medical costs and even expanding national health system capacity, rather than building up a parallel system for the refugee communities.   

As humanitarian crises become more complex and more protracted, extending not years but decades, host governments, as well as United Nations aid agencies and major donor groups, are shifting tactics in an effort to extend to refugees a more holistic range of health services. The effort is particularly relevant when it comes to NCDs, which are often more expensive to diagnose and treat. And such services are not always widely available yet in many low- and middle-income countries that also host tens of millions of the world’s refugees. 

As such, policies and funding plans that simultaneously bolster NCD services for refugees as well as in national health services available to all citizens, may be particularly effective in closing multiple gaps simultaneously. 

The issue of integration was a key theme on the closing day of a three day meeting in Copenhagen on Noncommunicable diseases in Humanitarian Settings; Building Resilient Health Systems, co-organized by the World Health Organization (WHO) and UNHCR, the UN refugee agency.

‘Converging efforts’ is key, says WHO’s Santino Severoni (centre); on left Allen Maina (UNHCR) and on right, Waheed Arian, British radiologist and Afghan refugee.

“It’s paramount when you start a humanitarian response to look at the end system setting for the long term answers,” said WHO’s Director of Health and Migration, Dr. Santino Severoni, speaking Thursday in the closing hours of the event. 

“We see that all in those countries where there is a political commitment, where the political sensitivities about refugees have been diffused and the country is moving on with a rational approach, what is important is to provide support in order to converge efforts, expanding domestic capacity to finance access.  

“Every time we keep the situation in a protracted emergency. Every time we keep funding operations, not directly funding the country’s financial capacity, we are actually postponing the capacity of the country to be more effective.”

Extending Kenya’s social health insurance system to refugees means better NCD coverage

Elizabeth Onyango, Kenya Ministry of Health: Shirika means refugee inclusion, it is also a Swahili word that means coming together.

In Kenya, such an approach has led the government to extend the benefits of a new social health insurance fund intended to cover jobless Kenyan citizens to the country’s 625,000 refugees, who hail mainly from Somalia and Uganda, as well as South Sudan.

After overcoming several court challenges, this year’s plan rollout will extend coverage to tens of thousands of refugees living for decades in the Dadaab and Kakuma camps in the country’s remote northern and northwest regions. It also coincides with the government’s launch of the Shirika Plan, which calls for transitioning the sprawling camps into more open settlements.

“Shirika is an acronym which means social, economic hubs for integrated refugee inclusion,” said Elizabeth Onyango, who heads NCD Prevention and Control at the Kenyan Ministry of Health. “It also is a Swahili word that means coming together.

“So what does the government of Kenya envision? It envisions a situation where the refugee and host communities get together; they can work, play, and even love together. It is multi-agency and multi-sector” – including the health sector as part of the coordinating secretariat.

“For health, the Shirika plan wants to focus on enhancing access to comprehensive health services, including services for NCDs. Secondly, we also want to focus on building or improving the capacity or human resources to deliver the services, including the refugee and the host population, into the country’s social health insurance funding structure,” she said. “And lastly, we focus on preventing people from promoting health, preventing disease and disease surveillance in these regions.”

Integration of refugees will be enabled by the extension of the new Kenyan Social Health Insurance programme to all of the country’s residents.

The new initiative will ensure that primary health care is “free to anyone in Kenya, including refugees,” said Onyango. At secondary and tertiary levels, refugees will be able to obtain a social insurance card for a nominal payment on the same basis as Kenyan citizens, granting them free access to services.

In terms of health facility infrastructure in and around refugee communities, the emerging model is a hybrid with UNHCR, Kenyan county governments and NGOs working in partnership to ensure that health facilities in refugee communities can “provide a wide range of services from preventive promotive of primary health care all the way to tertiary and tertiary care,” Onyango said.

Refugees as part of the health workforce solution 

Charles, a Congolese refugee living in Nyankanda refugee camp in Burundi. He was diagnosed wih high blood pressure in 2017, and now works as a community health worker for the newly established NCD clinic.

Experts have applauded another critical element of the Kenyan plan: capacity-building in the refugee communities – to train a new generation of health workers.

This shifts refugees from being victims and recipients of aid from their host country to being an integral part of the solution. And it addresses the common problem of health worker migration from rural areas, where the most prominent camps are located, to the cities.

“We want to support [refugee] students with scholarships so they can get into medical training colleges,” said Onyango.

“Because one of the things we suffer is the retention of health worker staff; most staff are from other regions. Conversely, if more refugees from the far-flung camps are educated as health workers, she said it’s more likely they’d be willing to return to work in their home communities. She added that bolstering local capacity can help ensure that a full spectrum of NCD services are available in the communities.

“We want to ensure that we have the specialists who can go and mentor the healthcare workers, and at the same time, support groups established by people with lived experience, who can empower people to take charge of their health and ensure better management of their conditions,” she said.

Jordan – health enabling policies and programmes for everyone   

Dr Anas Almohtaseb director of the NCD Directorate in Jordan’s Ministry of Health (left) with Elizabeth Onyango, Kenyan Ministry of Health.

Jordan, host to one of the largest refugee populations in the world, is another country that has prioritised the integration of refugee health into the mainstream health services of the country.  

The country of 11 million people hosts nearly 760,000 refugees and asylum seekers registered with UNHCR. These are mostly Syrians who fled the country since the beginning of the civil war in 2011, but also Iraqi, Yemeni and Sudanese.  And that is not including some 2.3 million Palestinian refugees from the 1948 and 1967 Arab-Israeli wars, who hold Jordanian citizenship but are also registered with the UN refugee agency for Palestinians, UNRWA.  

While there are some health clinics run by UNHCR, UNRWA or affiliated charities, most are served in Jordan’s national system “available to all registered refugees from all nationalities at the non-insured Jordanian rate at public health centres and governmental hospitals”, according to UNHCR. 

“When the Syrian refugee crisis came, and they are our neighbors by the way, the services were provided free of charge for several years,” said Dr Anas Almohtaseb director of the NCD Directorate in Jordan’s Ministry of Health, speaking at the conference, which was co-sponsored by the Hasemite Kingdom, as well as Kenya and Denmark. 

Particularly in terms of NCD-related policies, many government initiatives “related to strengthening the healthcare system, will also strengthen the services provided for refugees,” Almohtaseb stressed, and vice versa. 

As an example, he cited tobacco cessation clinics – which are free and available to everyone, regardless of nationality.  Similarly, in terms of nutrition, Jordanian government plans to supplement basic goods like flour with critical vitamins would benefit the micronutrient status of everyone.   

Jordan also is in the process of updating its guidelines on cardiovascular disease prevention, diagnosis and care to align with the WHO HEARTS protocol, released in 2020. 

“Once we have these unified guidelines, this will help improve the services for every patient, whatever his nationality, said Almohtaseb. “And also we have the implementation of community engagement programmes, such as mental health care clinics, which will be inclusive for the whole population,” he said. 

Finally, digitisation of healthcare services, including better tracking of patients’ diagnoses and treatment, can help improve NCD coverage for refugees, who may be more mobile as they seek work and better living conditions, he pointed out. 

“Ultimately, the refugees affect the whole healthcare system. And for this reason, while NGOs are very important, we have to also be dependent on the public health system – that is crucial to the sustainability of the healthcare system in Jordan.”

New direction for the international health and development community 

Bent Lautrup-Nielsen, head of global advocacy for the World Diabetes Foundation (WDF).
Bent Lautrup-Nielsen, head of global advocacy for the World Diabetes Foundation (WDF).

Strategies that advance the integration of refugee health services with national health systems of host governments represent a “significant improvement” to the traditional approach to health emergencies, said Bent Lautrup-Nielsen, head of global advocacy for the World Diabetes Foundation (WDF).

“This is relatively new to the international health and development community,” Lautrup-Nielsen observed, noting that historically, institutional and funding drivers tended to foster more siloed approaches.

“For many years, the international system of humanitarian response has had its own mechanisms of funding – for example, through appeals by UNHCR, the Red Cross and many others,” and that led to focused emergency health efforts, more siloed approaches, he observes.

Over a decade ago, however, some organisations, including the World Diabetes Foundation, began to see that refugee health issues, with all of the urgency those often implied, could also be an essential entry point for boosting capacity for sorely needed NCD services in affected host countries.

“What we’re saying is that if you’ve got a refugee situation, then the donors should target the whole NCD population – not only refugees but also the host communities. If you start distinguishing between the refugee population and the local population, you risk creating uneven health access and inequities.”

In Lebanon – the refugee crisis led to new primary healthcare investments

Lautrup-Nielsen cites the Foundation’s experience supporting refugees in Lebanon, who fled to the country in the first phases of the Syrian civil war, as one example.

Public health clinics have traditionally played a relatively minor role in Lebanon’s largely privatised health services. However, these clinics became more critical due to the domestic economic crisis and the refugee inflow.

The new healthcare demands stimulated by the refugee crisis ultimately prompted a group of donor organisations, including WDF, the Danish Red Cross and Novo Nordisk Foundation, to support the expansion of NCD services in over 200 public primary health clinics nationwide, serving refugee and host populations. They are rolling out services for cardiovascular disease, diabetes and other conditions, including mental health.

“Building that as an integrated, basic package that wasn’t there before was a benefit to both Lebanese and refugees living in Lebanon,” Lautrup-Nielsen said.

But he notes that integration cannot be a one-size-fits-all approach. “Of course, there are acute emergencies at times that demand a dedicated humanitarian approach. We have a lot of that right now.

“But that cannot be separated from a long-term perspective,” he added. “And the COVID-19 pandemic crisis, which was considered a health emergency, showed that those who suffer the most are people living with NCDs.

“What came out of COVID was that realisation that you have to build resilient health systems that are meaningful in any context and serve everybody.”

Convergence instead of silos 

“Many [high-income] governments and private sector donors and foundations have willingly supported dedicated health services in response to humanitarian crises and emergencies – and for good reason. But this can also create imbalances or a lack of equity in a protracted situation.”

The inequities may also go both ways. In some low-income host countries, UNHCR-provided health services in refugee camps might even be regarded as “better” than what might be available in the local communities, Lautrup-Nielsen pointed out.

“But governments also wish to build equitable health systems, whether for refugees or local communities.

“Amongst the more than 150 countries represented at the conference, many are hosting refugees, and they are also appealing for a balanced international system, combining humanitarian response support in acute emergencies with protracted, long-term national health system strengthening.

“At the same time, most premature deaths from NCDs, before the age of 70, now occur in low- and middle-income countries of Asia, the Americas, the Middle East and Africa – and the disease burden is huge and growing fast.

“Five or ten years ago, this conference probably would not have been possible. But the thinking has matured a lot due to COVID and other things, not the least, because of the NCD agenda,” said Lautrup-Nielsen.

“To put things in a positive light, we are seeing a convergence within the health and development space and with other spaces like humanitarian response.”

Image Credits: UNHCR/Sala Lewis, UNHCR/Mia Bulow-Olsen , E. Fletcher/Health Policy Watch , E Fletcher/Health Policy Watch , UNHCR , Jesper Westley.