Can oil, gas and coal give way to renewables? A draft COP 28 declaration on climate and health omits any reference to fossil fuels or their phase-out, something scientists say is critical to human and planetary health.

BERLIN –  A draft  “health and climate ministerial declaration” set to be released at the upcoming UN Climate Conference in Dubai (COP28) 30 November-12 December, omits any reference to fossil fuels and their health harms, Health Policy Watch has learned. 

While the declaration mentions the need for climate mitigation, as well as the related health harms of air pollution in passing, the language and commitments focus mostly on the “adaptation” of health systems to climate change.

The omission of any reference to what is widely recognized as the leading driver of climate change in the draft declaration was confirmed to Health Policy Watch by a negotiator who had seen the text, which began circulating Tuesday among UN member states. 

“Mitigation language from Intergovernmental Panel on Climate Change (IPCC) is in there, so is air pollution,” said the source, who requested anonymity. “Just nothing on fossil fuels.”

Assistant Foreign Minister, Maha Barakat unveils key messages in the COP28 declaration on climate and health

Speaking about the still-unpublished declaration at a session on “The Road to COP28” on the closing day of the World Health Summit, a senior official from the United Arab Emirates (UAE), which is hosting COP28, discussed the urgency of integrating health into climate debates.

But the comments by Dr Maha Barakat, an assistant foreign minister, also made no reference to fossil fuels – and to what scientists say is the urgent need for a fossil fuel phase-out in energy, transport systems and cities to prevent snowballing health impacts.  

COP 28 declaration: focus on health sector adaptation

The UAE is organizing a first-ever day dedicated to Health, Relief, Recovery and Peace” on 3 December. during COP28. It is also sponsoring the first-ever Health Ministerial meeting at the meeting – a much-trumpeted event in global health circles. 

Key health-related climate messages at COP28 would rather focus on more health sector adaptation to climate change;  increasing the health sector’s access to climate adaptation finance; and “mainstreaming” of health into climate policies, said Barakat, at the “Road to COP28” session, the keynote climate event at the Berlin conference.

Three actions to be highlighted in the declaration 

Drought, flooding and extreme heat are among the growing health impacts of climate change in WHO’s Eastern Mediterranean region – and at current trajectories, temperature rise could double within a century.

“I would like to highlight three key action areas of climate and health to be captured in the declaration,” stated Barakat

“First, the declaration relates to the need for stronger climate adaptation in the health sector itself. Health care makes up around 4.4% of global (climate) emissions and takes up around 10% of global GDP. Health systems will need a transformational shift in order to become climate resilient, low carbon sustainable and equitable,” Barakat said.

“Secondly, the declaration requires significant concentration on finance and at COP28, we want to increase not only the overall amount of climate financing but also the proportion devoted to public health. Today, just 2% of adaptation funding and 0.5% of multilateral climate funding, go to health. 

“And thirdly, there is the need to break down silos between health and other sectors in the climate response. We know that in order to keep people healthy, we rely on actions far beyond the health sector. Building climate resistant societies with healthy populations therefore needs better cross-sectoral collaboration and the mainstreaming of health into climate policies.”

The pre-release of the draft declaration seems to confirm mounting fears that the UAE, a major fossil fuel producing nation, will sidestep the main issue at stake in the climate debate: unsustainble oil, gas and coal production.

Urgent need for reduction in fossil fuels  

Solar panels provide electricity to Mulalika health clinic in Zambia. ‘Greening’ health facilities is important – but its not a solution on its own, advocates say.

‘The proposed commitments to fund adaptation in the health sector are certainly welcome, but if fossil fuels aren’t addressed, then the declaration is incomplete, ‘said Jeni Miller, head of the Global Climate and Health Alliance (GCHA), who said she hasn’t seen the text but knows what the science says.

“We do need greater investments in our health systems to adapt to the impacts we are feeling across the world. But we are currently feeling large health impacts at 1.1 C [of warming] in terms of extreme weather, heat and disease, while we are on track to hit 2.8 C.

“So we just don’t have the capacity to adapt to the level of warming that we are currently projected to hit based on the policies being implemented,” said Miller, speaking to Health Policy Watch. 

“Mitigation is critically important and fossil fuels are the major driver of climate change.  We have to phase out fossil fuels.  

Levels of population access to electricity, by country, 2021

“And even if some of the strategies to reduce emissions from fossil fuels were feasible, they’re not currently feasible at scale, and this wouldn’t address the other many harms of fossil fuels,” she pointed out.

Those include seven million premature deaths a year from air pollution and over 750 million people lacking household energy access – whose needs can be served more efficiently and cost-effectively by community electrification and mini-grid systems, based on renewables, as compared to conventional power plants.   

“A rapid transition to clean and renewable energy is essential to meet the energy needs of the world, while keeping our climate and environment healthy and habitable,” added Miller. “And while mitigation in the energy sector is vital, we need strong mitigation across all sectors, food systems, transportation and industry.” 

Merits to health adaptation plans 

That’s not to say that the declaration, as it stands, would lack any merit.  As health facilities are major carbon emitters, more carbon-efficient and climate-resilient facilities with greater reliance on renewable energy sources such as solar power, would set an example for other sectors to follow. 

Similarly, climate “adaptation” in the housing sector can converge with climate mitigation if strategies promote, for instance, green  building codes and ventilation standards, as well as greater use of solar and thermal power.  Housing is another target of the UAE’s COP28 climate and health declaration, said Barakat. 

“We plan to launch a set of financing initiatives on climate and housing, and to do a pipeline of climate and health investments that  have strong country ownership, and can be scaled up to save lives and safeguard health – while materially reducing carbon emissions and other forms of pollution,” Barakat declared.

The Intergovernmental Panel on Climate Change (IPCC) has long identified buildings as a major carbon emitter, highlighting the huge climate mitigation potential offered by more climate-friendly and carbon-efficient housing and domestic energy systems  – that reduce reliance on fossil fuels. 

Health benefits from climate mitigation

(L-R) (left-right) Viktor Dzau, National Academy of Medicine; Alan Dangour, Wellcome Trust; and Nísia Trindade, Minister of Health, Brazil and Dr Maria Neira, WHO discuss climate mitigation and health synergies and the need for a broader evidence base to persuade policymakers to act.

In the Berlin climate and health events, leading figures from the US National Academy of Medicine, the World Health Organization (WHO),  governments and civil society, restated these themes over and again at different sessions. They stressed the need to remake transport, energy and urban design – along with health systems- so as to reap the full range of health “co-benefits” from climate action.

“When you think about of the sectors that are impacting climate change: agriculture, transportation, energy, you name it, every one of these sectors …is where we need to mitigate, but rarely does anyone say, what does that mean for health?” said Dr Victor Dzau, president of the US National Academy of Medicine, at a Tuesday afternoon session on “Sustainable Health for People and Planet.”

UK school children protest against climate change in February 2022.

“And, in fact, very few policymaking decisions are [framed] by the sectors in terms of health.”  That, despite the fact that meat-heavy diets rich in saturated fats, for instance, typically lead to more animal and agricultural waste, which also means more emissions of methane, a powerful short-lived climate pollutant more powerful than CO2, in the near-term.

“There are many issues, but in fact, if you get it right, you get better health as well as much lower carbon emissions.”

Said Dr Maria Neira, WHO’s Director of Climate, Environment and Health, at one session: “Instead of communicating about ‘co-benefits’, I prefer to talk about health outcomes and health benefits,” underlining that the health gains from cleaner transport, energy production and cities are arguably so great that they should be able to drive a change in policy direction.

Declaration endorsed by over a dozen member states 

A press release circulated by the UAE COP presidency at the end of the Berlin summit, states that the health and climate declaration had been developed “in close collaboration” with the WHO and a dozen “country champions – including Brazil, Malawi, UK, US, Netherlands, Kenya, Fiji, India, Egypt, Sierra Leone and Germany, as well as the UAE.

“Kenya, Fiji, Liberia, Sierra Leone and Malawi also expressed their support as ‘early endorsers’ of the Declaration,” the press release states. 

But with the UAE in the driver’s seat, it’s unclear how much practical influence the global health institutions and health experts can really have on the text references to the politically charged fossil fuel debate, insiders observed.

Meanwhile, a closed-door meeting with WHO member state representatives in Berlin kicked off the arduous process of circulating and collecting country signatures to the draft Climate and Health declaration in its current form.  

“Country endorsements of the COP28 Declaration on Climate and Health will be announced at COP28, and cover a range of areas, including cross-sector collaboration on climate and health, reducing emissions within the health sector, and increasing the amount and proportion of financing devoted to climate and health,” the UAE press release said. 

The link between climate change and health is becoming increasingly evident every day, with diseases like malaria surging as temperatures rise, and extreme weather events impacting people around the globe,” says COP28 President, Dr. Sultan Al Jaber, in the press release.

“Through the Declaration on Climate and Health, we aim to help deliver public health systems that are climate-resilient, sustainable and equitable, and we urge all nations to endorse it.”

Al Jaber also avoided any reference to fossil fuels. 

Image Credits: Mazen Malkawi/WHO, Gellscom/CC BY-ND 2.0., E. Fletcher/Health Policy Watch, UNDP/Karin Schermbrucker for Slingshot , Callum Shaw/ Unsplash.

South Sudanese Minster of Health Elizabeth Chuei receiving a COVID-19 vaccine at Juba Hospital.

Time-bound waivers of intellectual property (IP) rights and benefits for countries that share information about threatening pathogens are some of the key components of the draft pandemic accord  sent to World Health Organization (WHO) member states by the Intergovernmental Negotiating Body (INB) on Monday.

These two issues have been major bones of contention in negotiations and may well be watered down during the horse trading that will commence on the first official negotiating draft. (So far, there has been a “zero-draft” drawn up by the INB Bureau and a “zero draft +”.)

The International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), swiftly condemned the draft, describing it as “damaging” and “bad”, warning that it would have “a chilling effect on the innovation pipeline for medical countermeasures”.

Earlier in the week, German Health Minister Karl Lauterbach stated unequivocally that his country would not countenance an IP waiver in the pandemic accord.

“For countries like Germany and most European countries, it is clear that such an agreement will not fly if there is a major limitation on intellectual property rights,” Lauterbach told the World Health Summit. 

“That is a part of our DNA … we need intellectual property security in order to invest into vaccines, invest into therapeutics, diagnostics, and so forth.” 

However, Helen Clark, co-chair of the The Independent Panel for Pandemic Preparedness and Response, countered on social media that “maintaining pure adherence to intellectual property protection in a pandemic costs lives”.

Double-whammy for pharma

Article 11 contains a double-whammy for big pharma. First, it calls on parties to commit to “time-bound waivers of intellectual property rights to accelerate or scale up the manufacturing of pandemic-related products during a pandemic, to the extent necessary to increase the availability and adequacy of affordable pandemic-related products”.

Then it “encourages” patent-holders that are producing pandemic-related products “to waive or manage” royalties payment by developing country manufacturers during pandemics.

Patent holders that have received “significant public financing” to develop their products shall be “required” to waive their royalties.

“It is reassuring that, despite ferocious lobbying by pharmaceutical companies, the provision on the waiver of intellectual property is still in the text, but the current wording does not provide a significant change in the status quo,” said Mohga Kamal-Yanni, Policy Co-Lead for the People’s Vaccine Alliance.

“Making the adoption of the waiver discretionary by using qualifiers such as ‘to extent necessary’ would make it difficult to apply this provision in practice.”

R&D and transparency

The draft tries to promote transparency by calling on member states to “encourage” manufacturers in their countries to “share undisclosed information” with qualified third-party manufacturers if withholding it “prevents or hinders urgent manufacture”.

During the pandemic, for example, Moderna steadfastly refused to share its know-how with the WHO mRNA vaccine production hub in South Africa, which had found Moderna’s mRNA vaccine “recipe” online but was stymied by certain aspects of its production.

In addition, countries “shall” publish the terms of government-funded research and development (R&D) agreements for pandemic-related products, including “pricing of end-products”.

In the past, many countries have not imposed any conditions on pharma companies that have received government grants to develop medicines, leaving them to determine prices and access on their own.

But the Drugs for Neglected Diseases initiative (DNDi), which develops treatments for neglected diseases, said it was “extremely disappointed” that a provision “to attach conditions to public R&D funding” that had been in the zero draft, had been excluded.

“An obligation to publish contract terms, which we support as a separate obligation, does not ensure that public R&D funders use their leverage to attach pro-access conditions to their funding in the first place, nor ensure that recipients of funding enact pro-access activities,” explained Rachael Crockett, DNDi’s Senior Policy Advocacy Manager.

“Both are needed – transparency and conditions – to not only ensure the fast and efficient development of health tools but also to ensure equitable access,” added Crockett.

The draft also proposes “technology co-creation and joint venture initiatives” using an “open science”  approach that encourages collaboration, particularly with scientists and research centres from developing countries. 

WHO Director-General Dr Tedros Adhanom Ghebreyesus and Professor Petro Terblanche, head of the WHO mRNA vaccine development hub in South Africa.

Access and benefit-sharing

One of the trickiest sections up for negotiation is Article 12, which deals with access to pandemic products and benefit-sharing arising from sharing information about pathogens.

To address this, the draft proposes the establishment of the WHO Pathogen Access and Benefit-Sharing System (WHO PABS System) to “ensure rapid and timely risk assessment” and “facilitate rapid and timely development of, and equitable access to, pandemic-related products”.

National laboratories and health authorities will be required to upload the genetic sequences of pathogen material to “one or more publicly accessible database(s)” of their choice in “a rapid, systematic and timely manner”. 

They will need to be part of a WHO-coordinated laboratory network to receive material from other bodies and won’t be able to seek IP rights on any of the material they receive. A standard material transfer agreement (a PABS SMTA) will govern the material transfer

“Benefits, both monetary and non-monetary, arising from access to WHO PABS materials, shall be shared fairly and equitably,” the draft notes.

WHO should get “a minimum of 20%” pandemic-related products” for distribution, with 10% being donated and 10% sold “at affordable prices”.

Each country with manufacturing facilities to produce pandemic-related products “shall take all necessary steps to facilitate the export of such pandemic-related products,” the draft adds – no doubt, to circumvent a repeat of India’s refusal to allow the Serum Institute of India to export COVID vaccines during the pandemic. 

Manufacturers from developed countries should be “encouraged” to collaborate with manufacturers from developing countries “through WHO initiatives to transfer technology and know-how and strengthen capacities for the timely scale-up of production of pandemic-related products”.

The draft also proposes options such as tiered pricing and “no loss/ no profit” arrangements for pandemic products that take into account the income level of countries.

Even if a manufacturer does not opt for a PABS SMTA, if it produces pandemic-related products out of WHO PABS materials, it will be required “to ensure their fair and equitable allocation”.

Civil society groups, with UNAIDS Executive Director Winnie Byanyima, for an IP waiver for COVID vaccines

But Kamal-Yanni of People’s Vaccine Alliance said that while the language on PABS is improved, “we strongly disagree with the logic that allocating a percentage of production to WHO can ensure equitable access”.

“Sharing technology, knowledge and intellectual property by manufacturers accessing pathogens and data should be mandatory to ensure equitable access to all medical countermeasures during a pandemic,” she added.

Country obligations,

The draft also sets out countries’ obligations to prevent, prepare and respond to pandemics – finally giving weight to the pandemic cliché that “no one is safe until everyone is safe”.

All countries “shall”, for example, “detect, identify and characterise pathogens presenting significant risks” and “conduct risk assessment of such pathogens and vector-borne diseases to prevent spill-over in human and animal populations and cause serious diseases leading to pandemic situations”.

Countries are also required to strengthen animal disease preventive measures to prevent zoonotic spillover, strengthen laboratory biosafety to curtail lab accidents and address antimicrobial resistance.

To achieve this, developing countries will get “financial and technical support, assistance and cooperation” to strengthen and sustain a skilled and competent public health workforce.

Tighter language – or belonging in the bin?

Mohga Kamal-Yanni, Policy Co-Lead for the People’s Vaccine Alliance.

 

“While it is positive that many equity provisions are included, their language is inadequate and unnecessarily vague to achieve their goals,” warns Kamal-Yanni.  “The ability to apply transparency, technology transfer or intellectual property measures could be undermined by qualifiers and limiting language.”

“Provisions calling only for the promotion and encouragement of measures necessary to ensure equitable access to medical countermeasures must be transformed into obligations and commitments,” she added.

The Independent Panel’s Helen Clark welcomed the progress towards a pandemic agreement “which, together with reformed International Health Regulations, remains a unique opportunity to secure a world better protected from pandemic threats”.

“A core principle and approach in the agreement should frame pandemic preparedness and response as a global common good. This would contribute to building the regional capacity, resilience and stated commitment to equitable access that is fundamental to a transformed international system,” Clark told Health Policy Watch.

“I encourage member states to aim high on this aspect of the negotiations and on all others,” added Clark, the former Prime Minister of New Zealand.

“We urgently need transparency on how the barriers to equity that were so evident in the global response to the COVID-19 pandemic will be addressed,” said Aggrey Aluso, the Pandemic Action Network’s Africa Director.

“Key aspects to focus on right now are the inclusivity and transparency of the negotiating process, countries’ political engagement, as well as transparency on the pathway of transformation to address the barriers to equity,” added Aluso, who described the draft as “a good starting point for thinking about the key elements of a new pandemic accord”.

He called for all countries, regardless of their size or wealth, to have an equal voice in the negotiations, and for the drafting group negotiations to be open to civil society, organisations and other stakeholders.

But IFPMA Director General Thomas Cueni would prefer to bin the draft: “It would be better to have no pandemic treaty than a bad pandemic treaty, which the draft circulated to member states clearly represents,” said Cueni in a media statement on Tuesday.

“The ability of the private sector to develop new vaccines and treatments in response to COVID-19 was driven by decades of R&D investment and the ability of scientists to rapidly access data on pathogens. If adopted, the draft treaty would undermine both and leave us weaker ahead of the next pandemic than we were in December 2019, and we urge governments to make significant revisions to the current text.” 

* Story updated to include comment on the draft from Helen Clark, co-chair of the Independent Panel.

Image Credits: ULISES RUIZ / Getty Imageses Contributor, UNICEF, WHO, @FilesGeneva .

A Palestinian boy with his cat in the ruins of an apartment bombed by Israel.

Health workers in Gaza face “agonising choices” in the face of Israel’s order that all people evacuate the north of the territory: “abandon ill patients amid a bombing campaign, put their lives at risk while remaining on-site to treat patients or endanger patients’ lives while attempting to transport them to facilities that have no capacity to receive them”.

This is according to the World Health Organization’s (WHO) Eastern Mediterranean Region, which “strongly condemned” Israel’s “repeated” evacuation orders – including more than 2,000 patients in 22 health facilities.

“The lives of many critically ill and fragile patients hang in the balance: those in intensive care or who rely on life support; patients undergoing hemodialysis; newborns in incubators; women with complications of pregnancy, and others all face imminent deterioration of their condition or death if they are forced to move and are cut off from life-saving medical attention while being evacuated,” said WHO EMRO.

Although Israel’s evacuation deadline expired on Saturday, Israel has not yet deployed ground troops into the areas of Gaza that it ordered evacuated.  Meanwhile, some Palestinian health workers in the hospitals affected have chosen to stay with their patients, who cannot be moved in any event.

Dr Christos Christou, president of Medecins sans Frontieres (MSF), described the situation in health facilities in Gaza as “horrific and catastrophic”, with surgeons at Al-Shifa Hospital currently “operating without painkillers”.

“People are trapped, unable to escape, with absolutely nowhere safe to go. They’re deprived of essential needs – water, food, protected shelter, medicines,” added Christou. “This is unimaginable. This is inhumane. As doctors, humanitarians, human beings, we cannot tolerate this. While we are frightened of what is coming, our only hope is for humanity to prevail.”

Huge death toll

At least 2,750 Palestinians have been killed and 9,700 have been wounded in Israeli air strikes on Gaza since 7 October, the Palestinian health ministry said on Monday. This is the highest Palestinian death toll since Hamas took control of Gaza in 2007, wresting power from the Fatah-aligned Palestinian Authority in a violent takeover, after both sides failed to win a clear majority in elections, the last ever to be held. 

Israel launched unprecedently intense airstrikes on Gaza after Hamas attacked  towns, villages and collective farms inside Israel on 7 October, killing around 1,300 people and abducting 199 others, including babies, children and elderly, whom it is currently holding hostage in Gaza.

Around half the population of Gaza is under the age of 18, and the UN Children’s Agency, UNICEF, called for an immediate ceasefire last week, saying that “hundreds and hundreds of children have been killed and injured”.

UNICEF has also called for Israeli children held captive by Hamas to “be safely and immediately reunited with their families and loved ones”.

 

Palestinians killed on designated safe route to the south

Meanwhile, some 70 Palestinians were killed on Friday while trying to leave northern Gaza along one of the routes designated as safe by the Israeli Defense Force (IDF) when their convoy was bombed, according to media reports.

Amnesty International said on Sunday that it had verified six videos of the Israeli attack on a civilian convoy on Salah al-Din Road, and a follow-up bombing of ambulances that arrived to assist. IDF has denied responsibility for the attacks.

The Israeli strikes on Gaza have been unprecedented in their intensity.  Hamas has also continued to fire missiles into southern and central Israel, leading to the evacuation of Israeli communities in proximity to the Gaza border. Although most Israeli civilians have access to shelters, the total Israeli death toll so far in the hostilities has now risen to over 1400, according to Israel, including several dozen foreign workers, students and Palestinian-Israeli citizens.

White phosphorus use?

Last week, Human Rights Watch (HRW) said it had verified videos that showed Israel had fired white phosphorous “over Gaza City’s port and in two rural locations along the Israel-Lebanon border.”

“Upon contact, white phosphorus can burn people, thermally and chemically, down to the bone as it is highly soluble in fat and therefore in human flesh. White phosphorus fragments can exacerbate wounds even after treatment and can enter the bloodstream and cause multiple organ failure,” according to HRW.

“Its use in densely populated areas of Gaza violates the requirement under international humanitarian law that parties to the conflict take all feasible precautions to avoid civilian injury and loss of life,” HRW added.

However, Israeli military spokesperson Lieutenant Colonel Peter Lerner denied that the army had used the substance, saying “categorically no” in an interview with CNN. 

Gaza is without power, low on water and food 

Meanwhile, Israel has implemented a total blockade of Gaza alongside its aerial bombing and is not allowing aid trucks carrying food, water, fuel and medical supplies to enter Gaza from Egypt via the Rafah crossing.

“There is not one drop of water, not one grain of wheat, not a litre of fuel that has been allowed into the Gaza Strip for the last eight days,” said Philippe Lazzarini, Commissioner-General of the United Nations Agency for Palestine Refugees (UNRWA), at a media briefing on Sunday.

“Gaza is running out of water, and Gaza is running out of life.  Soon, I believe, with this there will be no food or medicine either.”

Gaza’s only power plant ran out of fuel Wednesday afternoon, shutting down electricity, water and wastewater treatment, according to UNICEF spokesperson James Elder.

“Most residents can no longer get drinking water from service providers or household water through pipelines,” said Elder. “At least six water wells, three water pumping stations, one water reservoir, and one desalination plant serving more than 1 million people have been damaged by airstrikes.”

In its situation report on Monday, UNRWA said that over one million people – almost half the total population of Gaza – have been displaced. 

“Some 600,000 Internally Displaced Persons (IDPs) are in the Middle Area, Khan Yunis and Rafah, of those, nearly 400,000 are in UNRWA facilities – much exceeding our capacity to assist in any meaningful way, including with space in our shelters, food, water or psychological support.    

“Despite the Israeli Forces’ evacuation order, an unknown number of IDPs remain in UNRWA schools in Gaza City and the north. UNRWA is no longer able to assist or protect them. Over 160,000 IDPs were sheltering in 57 UNRWA premises, including – but not only – Designated Emergency Shelters in these areas at the time of the Israeli evacuation order.” 

UN Secretary-General Antonio Guterres said on Monday that the UN had food, water, medical supplies and fuel in Egypt, Jordan, the West Bank and Israel that could be “dispatched within hours” but “our staff need to be able to bring these supplies into and throughout Gaza safely, and without impediment”.

Guterres also said that “all hostages in Gaza must be released. Civilians must not be used as human shields,” in a New York Times article last Friday.

“International humanitarian law — including the Geneva Conventions — must be respected and upheld. Civilians on both sides must be protected at all times. Hospitals, schools, clinics and United Nations premises must never be targeted.”

At least 14 UNRWA staff members have been killed in the past week, while the International Federation of Red Cross and Red Crescent Societies (IFRC) said that five of its members had been killed in attacks on ambulances.

“It is clear that the two sides in this conflict cannot achieve a solution without concerted action and strong support from us, the international community. That is the only way to save any chance of security and opportunity for both Israelis and Palestinians,” Guterres concluded.

Image Credits: UNRWA.

BERLIN, Germany — Hours before the release of the second draft of the Pandemic Accord on Monday, German Health Minister Karl Lauterbach told the World Health Summit that a pandemic agreement with “major limitations” on intellectual property (IP)  rights protection will “not fly” for Germany and most of its fellow European Union (EU) members. 

“For countries like Germany and most European countries, it is clear that such an agreement will not fly if there is a major limitation on intellectual property rights,” said Lauterbach. “That is a part of our DNA … we need intellectual property security in order to invest into vaccines, invest into therapeutics, diagnostics, and so forth.” 

Lauterbach’s announcement is a victory for the pharmaceutical industry, which has been lobbying hard to influence negotiations on the pandemic treaty at the World Health Organization’s (WHO) International Negotiating Body (INB). 

“We need to be open about what can move forward and what cannot be moved forward,” said Lauterbach. 

Pharmaceutical companies like Pfizer and Moderna, which developed the most widely used mRNA COVID-19 vaccines, argue that IP protections were fundamental to them being able to take the financial risks that resulted in record-speed vaccine development at the height of the pandemic.

“The record speed at which new vaccines and treatments were developed in response to COVID-19 was the result of an innovation ecosystem, underpinned by intellectual property,” Thomas Cueni, Director General of the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA) told Health Policy Watch.  “In the first year alone, COVID-19 vaccinations saved 20 million lives.” 

Europe and the United States, home to many of the world’s largest pharmaceutical companies, are aligned in their opposition to major limitations on IP protections in a pandemic accord.

Other countries, such as India, South Africa and Brazil, argue that IP waivers are needed for equity and would have saved millions of lives during the COVID-19 pandemic.

Another non-starter for Europe and its allies outlined by the German health minister is any relinquishing of executive power to the treaty.

“An agreement is not likely to be successful if there is even the slightest impression that executive power moves from the countries to the agreement or the World Health Organization,” said Lauterbach. “It must be quite clear that all the countries that sign up to the pandemic agreement when there is a pandemic, their full executive power is by no means curtailed or infringed upon.

“This is an agreement on standards, on norms and on responsibilities,” he added. “Executive power is always within the countries where the action takes place.”

Big Pharma and medicines access groups deadlock on vaccines 

Hemal Shah, Gilead’s Public Policy Director, speaking at an IFPMA panel at the World Health Summit on Sunday.

Shortly after the World Health Summit kicked off in the glitzy ballrooms of the Mariott Hotel in central Berlin on Sunday,  medicines access groups and big pharma had their first major clash over vaccines. 

At a panel organized by the IFPMA, executives from Pfizer and Gilead retold a familiar story about the pandemic: Historically rapid innovation, spurred by strong intellectual property protections, saved millions of lives and restarted the global economy.

Gilead’s Public Policy Director, Hemal Shah, described the company’s antiviral remdesivir as a triumph of IP protections, arguing that the company’s ability to provide an important treatment option in the early days of the pandemic was enabled by its existing research on remdesivir’s potential antiviral activity against coronaviruses.

“[Remdesivir] is a story about how intellectual property protections enabled Gilead to provide an important treatment option … when we had no vaccines available,” said Shah. “It’s also a story of how IP protections actually enable the risky undertaking of emerging viruses research.” 

Killian Mullett, Senior Director of Commercial Supply Strategy at Pfizer, pointed to the 280 different components required to create its mRNA vaccine and the record speed at which pharma was able to mount supply chains to produce vaccines. 

“When we start looking at COVID, a lot of the supply chain had to be built up from scratch,” said Mullett. “We literally have gotten up to 4.7 million doses of the vaccine, which even for Pfizer, is an incredible amount.” 

Over the three years of the pandemic, the 20 largest pharmaceutical companies amassed profits of $455.4 billion, equivalent to nearly $5,000 every second, according to the People’s Vaccine Alliance.

Meanwhile, the People’s Vaccine Alliance released a scathing report on the eve of the World Health Summit, pointing out that the world’s 20 largest pharmaceutical companies paid out nearly as much money to shareholders and executives as they claim to have spent on developing new vaccines and medicines during the COVID-19 pandemic.

The top 20 pharma companies handed shareholders and executives more than $1 million every five minutes between 2020 and 2022, spending a combined $377.6 billion on dividends, share buybacks, and executive compensation. This adds up to more than 90% of their reported research and development spending.

“There is a rewriting of history going on here,” Anna Marriott, Senior Health Policy Lead at Oxfam International, told the panel. “There was monopoly control over the successful vaccines, and that monopoly led to pharmaceutical companies paying out a million dollars every five minutes to executives and shareholders.” 

Moderna and BioNtech, companies responsible for the two most widely used COVID-19 vaccines, reaped incredible profit margins of 51% and 54%, respectively, during the COVID-19 pandemic – far higher than any other major industry. 

In comparison, ExxonMobil, which generated record-breaking profits of $56 billion in 2022, averaged a net profit margin of just 19%. The notoriously high-profit margins of the oil and gas sector as a whole averaged 17% in 2022.

The record profits of Moderna and BioNTech have come at a time when global inequality has soared. The world’s richest 10% of people now own more than 76% of global wealth, while the poorest 50% of people own just 2%. Both the CEOs of Moderna and BioNTech were among the new billionaires minted during the pandemic.

“Corporations have never stopped trying to capture the policymaking process, using misleading arguments to enable the continuation of profiteering,” former UN Secretary-General Ban-Ki Moon said of the report.

“We see this in climate policy, with the increasing presence of fossil fuel lobbyists at COP, and we can see it in global health, with pharmaceutical companies trying to hollow out equity from the Pandemic Treaty,” said Moon, “Tackling the great challenges of our age requires standing up to vested interests and placing the needs of all humanity above the wealth of a few corporations.” 

Fighting words 

The World Health Summit kicked off on Sunday in Berlin.

In response to a request for comment on the People’s Vaccine report, IFPMA’s Cueni defended the pharmaceutical industry but did not comment on the profit margins or shareholder and executive compensation numbers highlighted by the report.

“These medical countermeasures were central to bringing to an end the pandemic which cost millions of lives and an economic cost of 13 trillion dollars,” Cueni told Health Policy Watch.  

“To question the very foundation of the innovation system which got us out of the COVID-19 pandemic, as the People’s Vaccine Alliance does, would severely hamper our ability to prevent, prepare, and respond to a future pandemic.” 

On Monday, BioNTech wrote down around €900mn in expected earnings from its COVID-19 vaccines due to low demand. The majority of write-offs were the result of expired raw materials needed to make the vaccines purchased during the pandemic, BioNTech said. 

To the pharmaceutical industry, BioNTech’s write-off is an example of the high-risk game of vaccine development. But to critics, €900mn is a drop in the bucket compared to the historic profits reaped during the pandemic. 

“Listening to the pharmaceutical industry, it is as though they are trying to wipe from history the decades of publicly funded research that went into COVID-19 countermeasures, and the brutal inequity of the global pandemic response,” Valentina Montanaro, global campaign head of the People’s Vaccine Alliance, told Health Policy Watch. 

“If humanity had worked together to combat COVID-19, instead of monopolising vaccine technology and withholding it from the global south, the human and economic costs of the pandemic would have been far less tragic,” said Montanaro. “Today’s panel was a masterclass in disingenuous spin.” 

Finger-pointing continues as the next pandemic looms 

A strong pandemic defence system could reduce the chance of another COVID like pandemic in the next ten years from 27.5% to 8%, according to modelling from Airfinity.

There is a 27.5% chance that a pandemic as deadly as COVID-19 will take place in the next decade, according to modelling from Airfinity, a health company that specializes in monitoring and forecasting trends in the global disease. 

Airfinity’s modelling also shows that if the original COVID-19 wild type had been as transmissible as Omicron, more than 300,000 people would have died in the UK alone, nearly three times more than the actual death toll.

Despite the looming threat, the world is not yet any better prepared than it was for COVID-19. Airfinity estimates that a “strong pandemic defence system” which enables effective vaccines to be rolled out within 100 days after the emergence of a new pathogen could decrease the threat of a COVID-19-like pandemic in the next ten years to 8.1%. 

“A robust pandemic preparedness system is the world’s insurance against a COVID-19-like pandemic or something even worse,” said Airfinity CEO Rasmus Bech Hansen. “We have calculated the real risks, but also the potential risk reduction that can be achieved. This can help inform decision-makers to the level of ongoing pre-emptive investment in the space to keep people safe.”

The Pandemic Fund, the key instrument established under the auspices of the World Bank to improve the resilience of low- and middle-income countries to the next pandemic, is vastly underfunded. It has only raised $2 billion of the $10 billion minimum annual budget it needs to meet its goals – and officials fear this could drop even further as the memory of the pandemic fades. 

“The pandemic fund is based on a recognition that the world has suffered from this cycle of panic and neglect: from SARS, to MERS, to avian influenza, to Zika, to Ebola, to COVID,” Priya Basu, executive director of the Pandemic Fund told the World Health Summit on Sunday.

“And each time we panic, and then there’s neglect. So this time around we really have to make those investments during peacetime, so to speak, so that the world is better prepared,” said Basu. 

The investment case, Basu said, is simple: the Pandemic Fund needs $30 billion per year over five years to get low and middle-income countries ready for the next pandemic. 

“That’s $150 billion over five years. Compare that with the trillions of dollars that the world just lost because we were not prepared, not to mention the millions of lives that were lost,” said Basu. “That is the investment case: the enormous economic and social returns that are produced from just getting the world better prepared.

“If any corner of the world is not prepared, then the rest of the world can suffer,” she added. 

Image Credits: World Health Summit.

WHO member states meeting to discuss a new pandemic convention in July 2022.

BERLIN  – Negotiations to produce a pandemic agreement still face a number of challenges, but some of the key negotiators in the International Negotiating Body (INB) told the World Health Summit that they are cautiously optimistic. 

As protestors gathered outside the summit venue, the JW Mariott Hotel in Berlin, to express their distrust of the pandemic agreement negotiations, panel participants addressed a session about “finding consensus” on the pandemic agreement.

Francisco Perez-Canado, the European Commission’s Advisor to the Director-General on the External Dimension of Health, underscored the erosion of trust among international partners as a result of the COVID-19 pandemic. 

“The first victim, in political terms, was trust. This erosion of trust has created a sense of urgency to establish a more reliable and legally binding framework for future responses to health emergencies,” said Perez-Canado, explaining that the accord was necessary to rebuild trust. 

“We need this pandemic agreement because this is how we can rebuild trust in the need for pandemic preparedness and response, and this trust is based on far-reaching obligations for low- and middle-income countries to be empowered towards equity for them to extend their R&D and manufacturing capacity through either voluntary or compulsory tech transfer,” Perez-Canado said. “We must remember that this Pandemic Accord is not about charity but about solidarity.”

Equity at the forefront

WHO Principal Legal Officer Steven Solomon

Steven Solomon, WHO’s Principal Legal Officer, who has been intimately involved in the INB processes, believes that the May 2024 deadline is doable provided the negotiations continue to be as intense as he and other facilitators witness them to be.

“If member states have the political will to agree on this treaty faster, then it is doable by May 2024,” Solomon said. “There are four key areas to focus on towards operationalizing equity.” 

First, a meaningful sharing of pathogens data and tools: finding combined obligatory sharing of pathogens data and sharing of benefits such as tools should be on an equal footing between the global north and the global south. 

“Finding mechanisms to exchange genetic sequence data of pathogens and in return pandemic response products such as vaccines, diagnostics, and treatments should be obligatory,” Solomon said. 

Second, a crucial aspect of the proposed agreement is the building of sustainable and geographically distributed production capacity for vaccines and other pandemic products. 

“It’s widely acknowledged amongst the negotiating parties that countries need to work together to enhance their capacity to produce essential medical supplies,” Solomon said. “This includes addressing issues related to intellectual property rights and ensuring that production is not solely based on purchasing power but also on public health needs.”

Third, national health capacities need to be strengthened, and this involves improving health systems, health and infectious disease surveillance, enhancing risk assessment capabilities, securing supply chains, and bolstering regulatory mechanisms towards real-time supply – as needed – of pandemic response products without any delay, which can happen only when regulatory mechanisms strengthen the global supply chains. 

“All of these should aim to operationalize equity by ensuring that all countries have the capacity and access to respond effectively to health emergencies,” Solomon said. “Access to diagnostics, treatment options, and vaccines are like justice – it means when delayed, it is actually denied.”

Fourth, governance, financing, and political will: effective governance is essential for the success of any international agreement. It should be inclusive, transparent, and promote accountability. Additionally, financing mechanisms must be sustainable, and there must be a strong political will to ensure that the agreement’s provisions are implemented and enforced. 

“Therefore, the need to address the risk of political amnesia and potential shifts away from multilateralism is also acknowledged by the negotiating bodies,” Solomon said.

Progress and challenges 

The negotiations to create this binding instrument for pandemic preparedness have had their share of challenges. Initially, there were ideological differences among negotiating parties, according to the panellists. However, informal sessions and mediated discussions have helped bridge these gaps, where participants in the negotiation process have started to recognise the urgency of creating legally binding obligations, according to the panellists.

“Work on negotiations in the informal discussions has actually pushed the negotiation discussions further,” said Perez-Canado.

Maria Juliana Tenorio Quintero, a representative of the Colombian Permanent Mission in Geneva and one of the facilitators of the negotiations, added that participants have shifted from general statements to focusing on concrete provisions that will ensure equity. 

“The negotiations have reached a stage where they can have meaningful discussions about legally binding obligations,” she said. 

Member states’ negotiations on Article 9 of the Zero Draft, which focuses on fair, equitable and timely access and benefit-sharing, are basically “done”, she added.

However, when questioned about the optimism about the negotiations, the panel flagged some of the remaining difficulties. 

These include intellectual property waivers, voluntary or compulsory tech-transfer between countries that discover pandemic response products, how to include the OneHealth approach, incentivisation of technology co-creation and strengthening joint venture initiatives.

The panellists conceded that the deadline is just around the corner and that unless these issues are agreed on, the divide between the global north and south could widen. 

“Thanks to the work of the facilitators of negotiations, there’s a greater understanding between the negotiating parties of the need for the components of all the articles the Zero Draft highlights,” Solomon told Health Policy Watch. “However, fulfilling the mandate for a strengthened International Health Regulations, operationalized by the pandemic treaty, is only achievable with political will.”

One of the panellists, who asked not to be named, told Health Policy Watch: “Should the political will and momentum we see is real and kept up, we can – and we have to – deliver the agreement by May 2024. 

“But the reality of the agreement is not up to the negotiators, rather their bosses that deliver the agreement. Articles of the Zero Draft that are the heart of the negotiations, are Articles 9, 11, 12, 13, OneHealth, and negotiators are still finding it difficult to come to terms with some of the terms under most of these Articles.”

Asked whether there is a Plan B if the negotiations are deadlocked by the self-imposed deadline, Solomon said, it is up to the negotiating member states. 

However, Perez-Canado said, “Until the pandemic agreement is enforced, we do not have Plan B because this is too important to fail at this juncture.”

The World Health Organization (WHO) has announced a technical advisory group that will advise it on pricing policies for medicines, particularly the prices of medicines on the essential medicine list (EML).The 17-member Technical Advisory Group on Pricing Policies for Medicines (TAG-PPM) will support WHO to help strengthen policies, improve transparency about prices and improve access to medicines.

“One of the group’s key initial functions will be providing technical advice and assistance to WHO regarding the role of price and cost in the selection of essential medicines and beyond the EML,” said WHO spokesperson told Health Policy Watch.

The EML provides guidance to national health authorities on the products and services that should be prioritised.
The group will also identify economic data that can assist the EML expert committee in their decisions.

“What health economic data would be most meaningful for decision-making about essential medicines? What methodologies and metrics would be appropriate measures of affordability? This input could then be taken into account by WHO for the revision of the process for updating the WHO Model Lists,” the WHO spokesperson said.

Countries have often asked the WHO to provide policies and rules to make essential medicines more affordable and accessible.

In October 2021, an expert committee proposed the creation of a working group for the EML to advise the WHO on ways to make highly-priced essential medicines more affordable and accessible.

“Two years later, the WHO has yet to establish the standing EML Working Group on pricing. However, it appears that the newly formed Technical Advisory Group on Pricing Policies for Medicines (TAG-PPM) has subsumed the role of a standing EML working group on pricing. It remains to be seen if this new WHO pricing group will identify policy interventions, including compulsory licensing, that could facilitate relevant and rapid decreases in prices to reach universal access,” said Thiru Balasubramaniam, Geneva Representative of Knowledge Ecology International (KEI).

The EML, first published in1977, is updated every two years in consultation with experts worldwide but many drugs are left out because of their high cost. This year, for example, some effective cancer drugs for the treatment of lung and breast cancer were left out because of their high cost.

WHO has said it will share more information on TAG-PPM’s agenda and workplans on its site soon. 

City of Berlin lights up the Brandenberg Gate in honor of the 75th anniversary of World Health Organization, co-hosting the World Health Summit.

BERLIN – The health and humanitarian crisis triggered by Hamas attacks on Israeli towns and villages a week ago took center stage at the opening of the World Health Summit (WHS) on Sunday evening, drawing sharp remarks by German Health  Minister Karl Lauterbach who denounced the “barbaric” Hamas attacks, 7 October, which led to the deaths of over 1,200 men, women and children and the kidnapping of another more than 150 people. 

“We cannot  look at the world these days without deep dismay,” said Lauterbach, describing the early morning incursion by armed gunmen into some 22 Israeli towns and villages as “inhumane brutality that is deeply shocking.”

“Let me use this opportunity to condemn this barbaric attack, which is in contrast to all we stand for and want to celebrate at this important meeting, which is a defense of human rights,” Lauterbach said. 

WHO Director General – also gravely concerned about Israeli attacks on Palestinian civilians

Speaking remotely from Manila, WHO Director General Dr. Tedros Adhanom Ghebreyesus also called on Hamas to release the Israeli hostages.  But he added that he was also “gravely concerned about Israeli attacks on Palestinian civilians” in the pounding Israeli air raids that have followed in response to the initial Hamas attacks and more than a week of constant Hamas missile fire across Israel. Gazan authorities say some 2,750 Palestinians have died in the intense Israeli bombings of the densely populated Gazan enclave. 

Israel’s recent order to over 1 million Gazans “to move from north to south Gaza in such a short window, creates a humanitarian tragedy,” Tedros said. “The forced evacuation of patients and health workers will further worsen the humanitarian and public health catastrophe.

“WHO calls on Hamas to release civilian hostages, and we continue to appeal to Israel to abide by its obligations under international law to protect civilians and health facilities. We also call for the restoration of electricity and water and to allow the immediate and safe delivery of food, medical supplies, and other humanitarian aid.”

In a tweet Sunday, Israel’s Foreign Ministry retorted:  “@WHO you have the wrong address,” claiming that Hamas was using Gazan health facilities as shields for more attacks against Israel.  

Coming together during conflict and crisis

Karl Lauterbach, Federal Minister for Health, Germany at the opening of the World Health Summit.

WHS, co-sponsored by WHO and the German government is one of the premier events in the global health calendar, drawing thousands of people together from government, multilateral organizations, development banks, civil society, academia, and industry. 

Its packed three day agenda touches on most of the burning issues in the global health world – from the climate crisis to the negotiations over a new WHO pandemic accord that aims to improve global preparedness and response to emerging crises in the wake of the COVID pandemic.  

Every single one of those challenges are laced by geopolitical rivalries and divides that seem only to have grown more acute since the end of the pandemic. 

“We come together at a time of conflict and crisis,” Tedros observed. “And as we all know, this [Gaza-Israel] conflict is only the latest conflict to erupt. 

“In our fractured and divided world. We must continue to seek common ground and common good. The only solution is dialogue, understanding, compassion, and these are exactly the conditions in which WHO was founded 75 years ago, when the nations of the world came together in the wake of …Second World War.”

Climate and ecosystems as another fulcrum point 

World Health Summit President Axel Pries in opening remarks.

“Here at the World Health Summit, we cannot solve political problems,” said WHS President Axel Pries, who laid out the context for the conference in his opening remarks. 

“But ….during the COVID crisis, we used to say no one is safe until everyone is safe. And that is true right now. And it’s more true than ever.

“The ecosystem of the world is in crisis. And this crisis is affecting plants, animals and humans alike. And the challenge to mankind is bigger than anything we face in the past.

“It’s up to us. We as a world wide global health community can give a positive example by working together overcoming this paralysis, and enforce the spirit of international cooperation.”

The boat is on fire 

Ayoade Alakija,World Health Summit moderator, with WHO DIrector General Dr Tedros Adhanom Ghebreyesus, speaking from Manila, The Philippines.

A pandemic accord and the climate crisis are amongst the key issues featured at this year’s conference. They rank equally high as priorities for the coming year, said Ayoade Alakija,  WHS moderator and Nigeria’s former chief humanitarian coordinator at the opening night event. 

She recalled attending her very first World Health Summit only two years ago, “and the reason I was coming from Nigeria was because too many people I knew, I had seen die for lack of access to oxygen, lack of access to medical countermeasures.  And we cannot allow that to happen again. 

“Let’s put our differences aside and come together. Let us remember that we’re in the same boat. And as we talk about that boat, that boat is also on fire. 

A witness to sea level rise in the Pacific Islands

“I’m somebody who comes from Africa, but also I’ve spent much of my life living in the Pacific Islands. I have a Fijian daughter and a Fijian husband. Many of the islands that we used to go to when she was a child have completely disappeared.

“To me climate change is not a myth. It is an absolute reality. I remember crouching in the basement of our house during Cyclone Winston, praying that the house would still be there,” she said referring to the 2016 storm that was, at the time, the most intense tropical storm ever to have been recorded in the southern hemisphere. “It was the sound of seven 747 [jets] going on above my head. I’ve never hear anything like it before.  

“We now have dengue in France, we have dengue and malaria in Spain and all of these places.  We need to take action;  we are still in that same boat.”

Midway through the Agenda 2030 for sustainable development

Opening night at World Health Summit, which has some 3,000 registered attendees.

As the world hits the mid-way point on the 2030 Agenda for Sustainable Development, global health officials need to reflect on how far the health-related goals of that agenda, including universal health coverage, have progressed, noted Lauterbach. 

“It’s good news that there is way more attention to global health,” Lauterbach said, noting that September’s UN General Assembly meeting saw three high level meetings on health-related topics, UHC, pandemic preparedness and tuberculosis. 

“But we nevertheless have to consider the question are we successful?  Unfortunately, if you look, for example, at one of the topics of the high-level meetings, tuberculosis, we aren’t. 

“We want to eradicate tuberculosis by 2017 and technically, it is quite feasible. But 1.6 million people are still  dying from tuberculosis every year, and we see more resistance against the drugs that we do have. And so if we are not more forceful, we may come to a time when most of our drugs are no longer working. We may lose the golden opportunity that we have in the next seven years. 

Investing in UHC instead of fossil fuels

Similarly, in the case of SDG goal for achieving universal health coverage (UHC), the world will fall well before the goal at the present pace, Lauterbach warned. 

“If we are not faster, we will miss the target by 50% which is a huge margin.”

He added that the world could afford to invest in UHC if just a small proportion of the $US 7 trillion currently invested in harmful fossil fuel subsidies was rechannelled to health. 

“If you take into consideration how much it would take to provide everyone with universal health coverage and compare this with the subsidies for fossil fuels, it would take only 7% of what we spend in terms of subsidies for fossil fuels to eradicate the global health threats,” Lauterbach contended.

“So we are vastly under spending here and this is a threat to our economy. Because if we have more pandemics, we have more global health crises and the economic damage, by far, goes beyond what we ever were supposed to spend [on UHC].” 

WHO pandemic accord negotiations

Lauterbach also expressed concerns that the negotiations over a WHO pandemic accord may not come to their hoped-for conclusion by May 2024, in line with the timeline set by WHO member states at the November 2021 World Health Assembly. 

“Pandemic preparedness, pandemic prevention, which we discussed at the last (2022) Summit, where are we? 

“Well we are still working towards a pandemic agreement. But currently we don’t have it and it is not quite clear whether we will have it by May next year or not. I think it will be a catastrophe from a public health perspective if we will not come up with a pandemic agreement. … and we will be worse protected than we were last time. 

“So this meeting is also an very important forum for us to stress our commonalities, to stress our common goals and to work towards a pandemic agreement.” 

–Updated on 16.10.2023 with report of latest Palestinian casualties in Gaza. 

Image Credits: WHO/VIsmita Gupta Smith, E. Fletcher/Health Policy Watch.

An unprecedented number of attacks happened in healthcare facilities and against health workers in 2022, according to a report published by Safeguarding Health in Conflict, Coalition and Insecurity Insight this year.

These attacks were the topic of a recent episode of the Global Health Matters podcast with Garry Aslanyan. The guests – health workers on the frontlines of the current conflict in Sudan, an independent advocate and a senior adviser at Physicians for Human Rights – discussed the circumstances and risks faced by health workers in conflict settings.

According to the Safeguarding Health in Conflict report, there were more than 700 incidents where health facilities were damaged in 2022, and almost 300 health personnel were kidnapped.

“In Sudan alone, just in the first six months of 2023, there were 93 attacks on health,” said guest and advocate Susannah Sirkin. “And so this kind of violence is devastating to health. So, of course, there are many acute and, of course, long-term impacts of this, including on the structure of the health systems themselves.”

Where do these violations and attacks occur?

She said these kinds of violations and attacks on health occur in various contexts, including civil unrest and insecure or volatile environments. She said there could also be the diversion of care and support for health workers in facilities for political reasons. In situations of full-out internal and international armed conflicts, such as in Syria, Yemen, Sudan, or most recently, Ukraine and Ethiopia, health workers are among those fleeing bombing and other attacks.

“In these conflicts, there are often military incursions or militia incursions into health facilities themselves, and they can assault patients and health workers using weapons,” Sirkin said. “We see everything from the detention, torture, and even killing of many health workers. And then, of course, the bombing of hospitals, raids on health facilities and utter damage and sometimes the destruction of hospitals.

“And in some countries, literally hundreds of health workers have been targeted, arrested, sometimes, as we’ve seen in Syria, and we know in other countries, they die after years languishing in prison,” she continued. “And it’s really a terrible, terrible environment. In almost every continent, health care can be under threat in this big range of situations.”

‘Building clinics in caves’

Samer Jabbour, a Syrian cardiologist and professor of public health, noted how often these health workers continue to provide care and set up alternative settings. At the same time, their hospitals and clinics are taken over.

The Syrian medics went as far as building clinics in caves to resist the bombings of hospitals, he said.

How do these workers build resilience?

“The inspiration and the resilience that I’ve seen has come from the health workers who are together, support each other in the time, in these grave situations and who resort to their deep understanding, based on their training, based on their ethics, based on their codes, based on their sense of themselves as professionals and based on their deep humanity, which in many cases is what drives someone to become a health professional in the first place,” Sirkin said. “Face-to-face with their patients, understanding that they are … they are looked up to as leaders, as change-makers in their community, and so in the face of that, time and time again, they rise to that occasion.

“And that is, I think, the depth of the human spirit that’s just so inspiring, as well as the satisfaction of saving lives through health care.”

Added Jabour: “The real heroes are those in conflict zones responding.”

To listen to more episodes of Global Health Matters on Health Policy Watch, click here.

Image Credits: Global Health Matters Podcast.

Russia
A Ukraine operating theatre destroyed by a Russian airstrike.

On the morning of October 10, 2022, Russia launched a barrage of over 100 cruise missiles and suicide drones at Ukraine’s power grid and water supply, striking civilian areas across the country.

One of the first targets hit were the streets around Kyiv City Clinical Hospital 5, a medical facility with hundreds of beds in the heart of the Ukrainian capital.

“We were running down the corridor, falling down on the floor at every explosion,” Dr Yaroslav Basarab, medical manager for Ukraine at the AIDS Healthcare Foundation (AHF), told Health Policy Watch. “To be honest, it was barely running, because there were patients with us who could not move by themselves.”

On that cold October morning in Kyiv, doctors and nurses raced patients to safety as missiles rained down around the hospital, shattering windows around them. The patients had to be moved on foot: the elevators were unavailable due to the risk of power outages caused by Russia’s assault on the Ukrainian grid.

“We did not even think to leave the patients,” said Basarab. “We had to take our patients and 300 more people down to the bomb shelter.”

“The doctors and nurses did their best,” Basarab recalled. “They provided psychological assistance, they supported the patients, calmed them down, and helped them to the bomb shelter.”

Kyiv City Clinical Hospital 5, Kyiv, Ukraine.

Across Ukraine, doctors, nurses, and health workers like those at Kyiv City Clinical Hospital 5 continue to risk their lives to keep the country’s health system running.

In villages near the frontlines, doctors donning bulletproof vests and helmets ride bicycles to set up mobile health clinics for patients who cannot reach the few remaining health facilities.

Others accompany rescue teams beyond the line of contact to rescue civilians. Nurses fight through gruelling hours to provide essential health services to civilians and soldiers.

Their bravery has made them a symbol of Ukrainian resilience at home and abroad. 

“The secret to our resilience is Ukrainian doctors, who have become a [symbol] for our country and for the whole world,” Maryna Slobodinchenko, Ukraine’s deputy minister of health for European integration, told a panel organized by the AIDS Healthcare Foundation (AHF) at the Lithuanian Permanent Representation to the European Union last month.

“We never stopped medical services,” said Slobodinchenko. “During blackouts, the catastrophic consequences of the explosion at the Kherson dam of the threat of nuclear disaster, we never stopped.” 

The panel organized by the AIDS Healthcare Foundation (AHF) sought to draw lessons about the resilience of health systems from Ukraine’s experience of the war.

Russian strikes on health facilities in Ukraine have killed at least 107 health workers and patients, according to the World Health Organization (WHO). 

The WHO’s Surveillance System for Attacks on Healthcare, which tracks attacks on health infrastructure and staff around the world, has documented over 1,100 attacks on health facilities across Ukraine. One in five ambulances in Ukraine’s medical fleet was damaged or destroyed as of May 2023. 

“In wartime, people put their personal lives and affairs on hold to save their families and country, and to be a shield to European families and countries,” said Slobodinchenko. 

“Our doctors continue their work irrespective of the circumstances.”

Lessons in resilience: Ukraine averts HIV catastrophe 

Ukraine has been battling a severe HIV epidemic for decades. Nearly 250,000 people in Ukraine live with HIV, the second-highest number of cases in Eastern Europe and Central Asia, after Russia.

Ukraine made significant progress in tackling HIV before the Russian invasion. More than 130,000 people living with the virus were receiving antiretroviral therapy (ART) and viral suppression rates at 96%. Viral suppression means that the amount of HIV in a person’s blood is so low that it cannot be transmitted to others.

Russia’s invasion put all of Ukraine’s progress in tackling HIV at risk. Within two months, more than 40 health facilities that offered treatment, prevention, and care for HIV patients were forced to close. 

The United Nations Joint Program on HIV/AIDS (UNAIDS) warned in April 2022 that the war risked a “humanitarian catastrophe” for people living with HIV.

“The situation for people living with HIV in Ukraine is desperate,” Dmytro Sherembel, head of the Coordination Council of 100% Life, Ukraine’s largest organization of people living with HIV in Ukraine said at the time. 

“We are trying to deliver medicines, food and other emergency assistance to people in need, but the work is dangerous and volunteers are putting their lives at risk,” Sherembel warned. “If we don’t get more help, I am not sure how much longer we can continue, especially reaching people in the front-line zones.” 

Despite the immense strain placed upon it by the war, Ukraine’s health system has – so far – managed to avoid the impending catastrophe for patients with HIV.

As of February 2023, the latest official data available, only 12,000 fewer Ukrainians living with HIV were receiving ART than before the war. 

Dr Yaroslav Basarab, AHF Ukraine medical coordinator, on the ground in Ukraine.

In August 2022, 3,529 Ukrainians were receiving their ART treatments abroad, Dr Yaroslava Lopatina, AHF country programme director for Ukraine told Health Policy Watch. 

“This is 3% of all those receiving treatment in Ukraine,” said Lopatina. “The main burden continues to be borne by Ukrainian doctors.” 

In fact, despite the pressures of war, more patients began taking pre-exposure prophylaxis (PrEP) — a daily pill that can be taken to prevent HIV infection — in Ukraine in 2022 than in any of the four years before Russia’s invasion. 

“Some doctors worked 24 hours a day. Active fighting was happening near their houses, and some of the territories [they worked in] had been occupied,” said Basarab. “Patients needed ART medicines and laboratory tests. They needed psychological help and support.” 

Aid from civilian organizations like AHF and 100% Life, Ukraine’s largest NGO fighting HIV, and financial and medical aid from international organizations like the WHO, the Global Fund, and PEPFAR, were critical in helping Ukraine avert a disaster for HIV patients during the war.

AHF provided flashlights, power banks, and lighting to HIV facilities vulnerable to power outages, while 100% Life ran nearly 40 mobile clinics to reach HIV patients out of reach of medical facilities.

The Global Fund, WHO, and PEPFAR rushed to donate ART treatments, helping to avert a disaster for HIV patients. At the onset of the war, Ukraine had just one month’s worth of ART treatments left in its major cities and as little as two weeks in some rural regions. 

“Given the desperate circumstances, it could’ve – and very well should’ve – been much, much worse,” Rama Hailevish, Ukraine country Director for UNAIDS, told Wired.

“Undoubtedly, living under life-threatening conditions has an unfavourable effect on medical personnel,” Dr Yaroslava Lopatina, AHF country programme director for Ukraine told Health Policy Watch. “These courageous people have to treat and support patients and never show how hard and scary it is for them.”

Ukraine’s mental health crisis deepens as war rages on

Two residents stand in the ruins of homes in Borodianka in the Kyiv region.

The resilience of the Ukrainian people and health system in the face of the Russian invasion masks the trauma and growing mental health burden placed on millions across the country. 

Nine million people are expected to suffer from common mental health disorders and two million from severe mental health disorders as a result of Russia’s invasion, according to a report published by Health Trauma International in April 2023.

The Ukrainian Ministry of Health estimates four million people need psychotropic medication and up to 15 million need other psychological support. 

“We have implemented a full-scale program of psychological support for our citizens, which is available at every level of medical care,” said Slobodinchenko, speaking at the AHF event in Brussels.

Mental healthcare was significantly underfunded in Ukraine before the war, with only 2.5% of healthcare expenditure – around $6 per capita – allocated to mental health. This is a fraction of what high-income countries spend, which average $58.71 per capita – in peacetime.

Mental health needs also vary widely across Ukraine, with those on the front line, in areas that have experienced Russian war crimes, and in areas impacted by weapons with wide blast radiuses more likely to have experienced trauma, the Health Trauma International report found. 

“The war in Ukraine has created a huge need for psychological support ranging from psychological first aid to comprehensive psychological care,” Médecins sans Frontières (MSF) Ukraine said in August. “People have experienced fear, trauma and isolation and are showing symptoms of anxiety, depression and stress. 

People facing the aftermath of a missile strike may experience shock, panic attacks, changes in appetite and sleep patterns, and withdrawal from daily activities, while displaced people may experience anxiety, intrusive thoughts, trauma, and stress management problems.

“One of the challenges of this war was the thousands of internally displaced people, who were in need of medical care,” said Slabodinchenko. “During the first period of invasion, we arranged temporary medical facilities in various places like sports gyms, schools, primary schools, recreational facilities and even theatres.” 

‘How are you?’: Overcoming stigma in times of crisis

Mental health is an acute and sensitive subject in Ukraine. Historically, discussion on mental health has been stigmatized.

But as families, health workers, and civilians across the country try to cope with lost loved ones and new lives as refugees after their homes were destroyed, the stigma is starting to break.

In March 2023, Ukrainian First Lady Olena Zelenska launched the “How Are You?” campaign, encouraging Ukrainians to talk to each other and reach out to loved ones about the difficulties of war.

On a podcast appearance in June, Zelenska noted that the reluctance to discuss mental health amongst Ukrainians can be traced back to Soviet-era attitudes when people who held dissenting political views were locked up in mental institutions for “psychiatric problems”. 

“This fear still exists,” said Zelekska. “But people need to understand that it is no longer the case. It’s different now. That’s why we need to inform people and help them understand about mental health care. It is not scary.” 

Stigma and self-stigma remain one of the main barriers to Ukrainians accessing psychological support, according to MSF Ukraine.

“Although MSF counselling is available for everyone, most of our patients are older women,” MSF Ukraine said in August. “Men also feel powerless, helpless, and it of course affects their mental health.”

Ukraine’s resilience hinges on continued international support

Ukrainian President Volodymyr Zelensky meets NATO Secretary-General Jens Stoltenberg at NATO headquarters in Mons, Belgium.

Ukraine’s resilience in the face of Russia’s invasion has been remarkable. But as the war drags on, an uncomfortable truth is becoming apparent: the resilience of Ukraine – and its health system – hinges on continued international support.

Ukraine’s path to military victory is narrowing, according to military experts. Delays in U.S. military aid due to congressional gridlock, the election of a Ukraine-skeptic party in Slovakia, and clashes with neighbour Poland over grain exports put into question the long-term reliability of its closest allies. 

In a somber speech to NATO leaders on Thursday, President Volodymyr Zelensky warned that Ukraine’s military is “scraping the bottom of the barrel” and needs more weapons and ammunition.

While ammunition, mortars, artillery shells and tanks fetch the headlines, international aid also props up Ukraine’s health system and the people brave enough to continue working in it. 

How long they will be able to keep up their lifesaving work if foreign aid dwindles is unknown.

“Our priority now is in prosthetics,” said Maryna Slobodnichenko, Ukraine’s deputy minister of health for European integration. “We have over 90,000 amputations. We also need professionals in this field.”

“The secret of resilience is in unity and in people,” said Slobodnichenko.

Image Credits: Matteo Minasi/ UNOCHA, UA, UA.

Part of the Global Health Matters “Dialogues” series.

“We make choices about who we take care of, and we make choices about who we neglect,” says author Daisy Hernández about health systems around the world.

A guest on a recent episode of the Global Health Matters podcast‘s “Dialogues” program, Hernández shared her personal experience with Chagas disease and the journey she undertook to understand it while writing her book “The Kissing Bug: A true story of a family, an insect and a nation’s neglect of a deadly disease.”

Hernández is an essayist, memoirist, journalist, and a professor of creative writing at Northwestern University in the United States. Her work focuses on the intersections of race, ethnicity, immigration, class and sexuality. Chagas is a disease caused by the parasite Trypanosoma cruzi, which is transmitted to animals and people by insect vectors and is found only in the Americas.

Hernández’s Auntie Theodora was diagnosed with Chagas in the United States when Hernández was very young.

“I grew up in the shadow of Chagas disease, and I say in the shadow because it’s been so neglected that we thought it was a very rare disease,” Hernández said. “We had no idea about the millions of people who have this disease around the world, mostly from Latin America.”

In her book and the discussion with host Dr. Garry Aslanyan, Hernández describes how, in the U.S., as recently as 10 years ago, it was almost impossible to know where to get tested for the disease, let alone treated. She also walks through some of her interviews with doctors,
biologists, infectious disease specialists and entomologists, and shares stories of other families.

Hernández’s research took her across the United States and Columbia.

“You describe how pathogens don’t care about bank accounts, national boundaries, tax returns, yet not all health care systems are equipped to deal with a disease such as Chagas,” Aslanyan points out. Then he asks: “How do you see this playing out across different places and maybe even Colombia? How did that play out.”

Hernández describes how, in Columbia, they have a much greater awareness than in the United States about Chagas disease. However, still, there was a divide between the rural areas and cities.

“I met this doctor, a young, young doctor right out of medical school, born and raised in the city, in the capital, and he was doing his one-year commitment of going out into rural areas to provide care,” Hernández recalls. “Chagas disease was entirely new for him, and he made such an impression on me because he was so eager to learn everything. He created his textbook on Chagas disease that he showed me. He had several patients infected and was resourceful, a really incredible person.

“But it really also reminded me of what I was seeing in the U.S., which was the individual doctors ending up with their patients and realizing like, okay, I didn’t learn this in medical school 20 years ago, in some cases, 30 years ago or longer, I need to learn about it now and taking the initiative to learn about the disease, to educate their colleagues as well, in some cases to go out into the community to do testing as well.”

Today, she compares what her family went through then and what she learned in the book to what America saw around COVID-19.

In the U.S., at least in the early days, testing sites sprung up in very wealthy neighborhoods when they were desperately needed in poor areas where people had to go to work and couldn’t work from home, for example.

It took Hernández seven years to complete the book, and she said she saw much more awareness of Chagas in the last seven to 10 years in the United States.

“I keep saying still a long way to go, but again, it’s also really determined by where you live,” she said. “There’s been a lot of activism in L.A. County, and so I think if you’re in L.A. County, everyone knows, oh, there’s a particular cardiologist devoted to this. The same thing is in Florida; we have an infectious disease specialist working on Chagas disease. So people within the community they know, and then the upside, of course, is Google. People get online, and you can also track down folks that way.

“It’s been really incredible to see awareness amongst healthcare professionals,” Hernández concluded.

To listen to more episodes of Global Health Matters, click here.

Dialogues is a new series from the Global Health Matters podcast that includes interviews with some of the world’s sharpest global health minds and brightest thinkers. The goal of each Dialogue is to go beyond the echo chambers that exist in global health and to have in-depth conversations with guests who have explored global health issues from their multi-disciplinary perspectives.

Image Credits: Global Health Matters podcast.