WHO Director General Dr Tedros Adhanom Ghebreyesus describes imbalance in spending on war and health – and death of his own uncle in ongoing violence in Tigray, Ethiopia

There are emerging hopes that sometime in 2023, WHO can declare that the COVID-19 global health emergency is over, said WHO Director General Dr Tedros Adhanom Ghebreyesus, speaking at a pre-holiday press briefing on Wednesday.  

Meanwhile, however, the world continues to invest some $2 trillion in wars and “killing each other” – but not nearly enough in preparing for pandemics and humanitarian crises like SARS-CoV2 that rocked the world, said Tedros, making a plea for more investment in health, during a detailed ‘year-in-review’ briefing with other top WHO officials at the agency’s Geneva headquarters.

He later told journalists that he had almost cancelled the pre-holiday meeting after recently learning that his own younger uncle had been “murdered” by Eritrean troops during an incursion into Ethiopia’s blood-soaked Tigray region – one of the areas of the world that has been rocked by violence over the past year. Despite a November truce between Tigrayan rebels and Ethiopian government forces, Eritrean forces aligned with Addis Ababa have continued attacks in some areas.

“It was a difficult moment for me. I was struggling, but we went ahead,” he confided just before the end of the briefing.

Against that sobering personal news, however, Tedros’ comments on the declining rate of deaths from COVID, Mpox and in Uganda, Ebola, and struck some upbeat notes as the year comes to a close.    

“At this time a year ago, COVID-19 was killing 50,000 people a week.  Last week, less than 10,000 people lost their lives,” Tedros said. “There is still a lot that all countries can do to save lives. But we have come a long way.  We are hopeful that at some point next year we will be happy to say that COVID 19 is no longer a global health emergency.

“The criteria for declaring an end to the emergency will be among the topics of conversation when the [WHO] Emergency Committee meets in January,” he added.  That date will mark three years since COVID was first declared a “public health emergency of international concern” by WHO on 30 January, 2020, followed by a statement on March 11 that the virus had reached pandemic proportions.  

COVID virus is here to stay; need to manage it alongside flu and RSV 

On left: Mike Ryan, WHO executive director of Health Emergencies

That does not meet that the world has met that mark quite yet, Tedros cautioned: “This virus is here to stay, and more countries will need to learn to manage it alongside other diseases, including influenza and RSV [Respiratory Syncytial Virus], both of which are circulating intensively in many countries. 

Despite the massive global vaccine  roll-out, only one in five people in the world’s lowest income countries have been vaccinated, he added, while COVID diagnostics and treatments remain inaccessible for many in low-income countries, meaning that “the burden of long COVID is only likely to increase.” 

Big blind spots in global surveillance of emerging threats 

Surveillance for Ebola Virus a the border between Democratic Republic of Congo and Uganda – many countries lack funds to effectively track infections and variants.

Surveillance of new SARS-CoV2 as well as other disease threats also remains exceedingly weak in many countries, Tedros said. 

Some countries are even dismantling COVID surveillance systems that they had set up, with WHO support, during the height of the pandemic, because they simply cannot afford the costs, Mike Ryan, Executive Director of Health Emergencies, warned. 

“Many of the systems that we established have in some countries been dismantled,” Ryan lamented.  “Many countries have disinvested in surveillance capacity, disinvented in their genomics capacity because their systems are under such pressure because of the … energy crisis and economic crises.

“We’ve left blind spots on surveillance in different parts of the world,” Ryan added, comparing the disproportionate investments by rich and poor countries in tracking SARS-CoV2 and other emerging threats, to those of a community that puts “100 smoke detectors in one house, and no smoke detectors in the other houses.

“And that’s what we do when we increase the intensity of surveillance and genomics in an industrialized country, while leaving a gap in the South,… which is going to affect not only that country, but the whole world’s ability to react to a new signal.

“That’s the world we’re in right now. So I think we need to be really careful because if we do want to match our [new] vaccines to the circulating strains, we still have work to do, and it’s not just on vaccine development.  It’s  not losing sight of surveillance.”  

Renewed call to China to share data and research on SARS-CoV2 origins

Chinese and WHO-International team present findings February, 2021 in Wuhan, China on theirjoint study of the SARS-CoV2 virus origins – in Wuhan briefing 9 February. Since then, the narratives have diverged

Related to the emergence of SARS-CoV2, Dr Tedros also renewed his calls upon China “to share the data and the studies on the origins of this virus. 

“As I have said many times, all hypotheses remain on the table,” he added. He was referring to the still-unresolved debate over whether the virus first emerged as a result of animal transmission to humans in a natural setting or the Wuhan market that housed and slaughtered wild animals – or whether it could have somehow escaped as a result of a biosecurity failure at the Wuhan Institute of Virology, which was studying bat-borne coronaviruses, similar to SARS-CoV2. 

He welcomed, however, the collaboration displayed by WHO member states so far in the initial stages of negotiations of a new pandemic accord, or treaty.

“One of the other key lessons of the pandemic is the need for much stronger cooperation and collaboration rather than the competition and confusion that was the global response to COVID-19. 

“So, I’m very pleased that last week, WHO Member States agreed to develop the first draft of a legally binding accord on pandemic prevention, preparedness and response, based on the principles of equity, solidarity and sovereignty. Member States will begin discussing this “zero draft” of the pandemic accord, in February.”  

WHO member states have generally refrained from describing the potential agreement as a “treaty”, preferring more nuanced terms such as ‘accord’, or even ‘convention’.  However, if the new agreement is indeed binding according to international law, as the current talks suggest, then it will in fact have the force of a “treaty,” added WHO legal counsel Steven Solomon.  

War and hunger overshadow progress on mpox and Ebola, as well as COVID 

Millions of lives are at risk due to an unprecedented food crisis in the greater Horn of Africa.

Tedros also expressed hopes that WHO could pronounce an end to the Mpox global health emergency. A virus belonging to the smallpox family that was largely unknown outside of Africa, it caught the world off guard last spring, when clusters of cases first began appearing in Europe and the United States. 

Since then, “more than 82,000 cases have been reported from 110 countries, although the mortality rate has remained low, with just 65 deaths,” Tedros said. 

But number of weekly reported cases has declined by more than 90% since July, when WHO declared another public health emergency of international concern (PHEIC) for the virus.

“If the current trend continues, we are hopeful that next year we will also be able to declare an end to this emergency,” he predicted.

And meanwhile, a deadly outbreak of the Sudan species of Ebola virus in Uganda, for which no approved vaccine exists, also is fading, with no new cases in more than two weeks. 

“If no new cases are detected, the outbreak will be declared over the 10th of January,” he said. “So we end a difficult year with some encouraging news: COVID-19, mpox and Ebola are all declining.” 

However, against those successes, a series of new threats are looming, he warned. Those include an expanding band of cholera outbreaks, now affecting 29 countries, including violence-wracked Haiti which has more than 14,000 suspected cases, and 1200 confirmed. 

Severe drought in the greater Horn of Africa, is driving an acute crisis of hunger, and with that, surging disease. 

$2 trillion annually invested in ‘killing each other’ 

Tigray refugees on the move over the past year to escape Ethiopan and Eritrean forces which blockaded the region, cutting off aid.

And worldwide, wars and violence in regions across every continent are costing the global economy about $2 trillion annually, pointed out Tedros, who later mentioned that his own uncle had recently been killed during a raid by Ethiopian army on a community in the region of Tigray – despite the recent peace treaty signed between the rebel groups and the government. 

The WHO Director General has spoken out repeatedly about the conflict that led to a months-long Ethiopian blockade of the region, cutting off vital humanitarian and medical aid.

“The question is, does the world have money? The answer is yes. military expenditure is expected to cross $2 trillion a year this year,” he said. 

“Just think of it,$2 trillion US dollars of global expenditure a year to kill people, to kill each other.” he said, adding that during COVID, too, countries came up with tremendous sums to support their economies during lockdown, as well as vaccine development and rollout. 

“So there is money, the issue is commitment,” Tedros said, who admitted that he, himself, was “not in good shape” for the press briefing after hearing about the “murder” of his uncle during a raid by Eritrean forces on a village in the Tigray region. A truce between Ethiopia’s central government and rebels in the Tigray region was declared in November, but Eritrea was not party to the agreement, and its forces have continued to wage war in neighboring areas of Tigray under their sphere of influence or control.   

“We have no problem purchasing 10 years advance, an aircraft carrier, for which we’re paying  $30 to $40 billion, added Ryan. “There’s absolutely no problem whatsoever in making that decision, 10 years in advance, for an operation that’s only part of a foresight exercise. 

“And if those particular platforms of war are not used, … we declare success. We say the world is a safer place. We do not apply the same principle when it comes to protecting and securing the health and welfare of our populations against just as insidious [disease] effects.”

Strengthening finance for pandemic and humanitarian health response

However, recent moves by the UN Secretary General, the World Bank, and the G-20 to create new finance initiatives and mechanisms to fund health offer hope that more money can be mustered for preparedness, as well as  during emergencies, Ryan added. 

“I think we have to look at how to spread the burden of humanitarian response activity across the breadth of member states that we have.” While a small group of rich country donors may be criticized for shifting priorities abruptly or not giving enough “there are many other countries out there that are barely giving anything,” he noted.   

“So the fact that the G-20 has managed to get that process of the G-20 [health and finance] ministers together, with a Secretariat based here in Geneva, and that we will continue the conversation between the people that have money and the people that need to get the money, doesn’t guarantee success.  But the right conversations are happening with the right people. 

Making the health investment case to development banks; talking biosecurity to the military 

“And ín my memory, that’s the first time that’s happened, in a permanent way that’s going to continue. We’re going in the right direction; but we have to get into the development funds, the multilateral funds, the development banks have got to put pandemics and public health and health systems at the center of the investment case for societies. 

“Not just economic development, but health systems development as a central pillar for prosperity, stability, in the future.   

He added that defense departments also can and should be recruited for support – “When we make the case that protecting biosecurity, the ability for us to defend ourselves against pathogens, natural and otherwise, is  mainly mainly delivered through the health system, mainly through the public health system.

“That defense is not delivered due to military intervention. It is delivered through civilian systems. We need to be sure that the resources are there to be able to do that.” 

Image Credits: E Fletcher/Health Policy Watch, WHO Afro, Matt Taylor, @PeterDaszak, WHO/Twitter , © UNFPA/Sufian Abdul-Mouty.

Amid a worldwide surge in cholera outbreaks – a sign of poor access to clean water and sanitation – a key report released on Wednesday shows that only a quarter of countries are on track to achieve their national sanitation targets.

Meanwhile, less than half – a mere 45% – are on track to achieve drinking water coverage targets, according to the World Health Organization (WHO) and UN Water’s Global Analysis and Assessment of Sanitation and Drinking-Water (GLAAS) 2022 report involving data from 121 countries.

Three-quarters of countries also reported insufficient funds to implement their WASH plans and strategies, and few had enough staff to implement plans.

“Almost two million people are dying every year because of poorly managed water sanitation and hygiene,” said Bruce Gordon, head of the WHO’s water, sanitation, hygiene and health unit.

“The plea from WHO is that countries need to recommit to the targets they’ve already made in order to save these lives,” said Gordon.

Bruce Gordon, head of the WHO’s water, sanitation, hygiene and health unit.

Ignoring climate

But what is perhaps the most daunting is how few countries – under half – address the risk of climate change in any of their water, sanitation and hygiene (WASH) plans.

Only 20% of countries reported implementing climate change preparedness approaches for local-level risk assessment and management of WASH at a significant scale.

This is despite billions of people living in areas vulnerable to drought, wildfires, floods, coastal storms and rising sea levels.

“Climate resilience and adaptation to climate change are huge issues that are impacting all of us. And yet when we look at the policy response, whether it’s climate resilient technologies – which are simple things to avoid floods or to mitigate droughts, simple risk management and simple technologies, these are not being put in place,” said Gordon.

Dr Tedros Adhanom Ghebreyesus, WHO Director-General, said: “We are facing an urgent crisis: poor access to safe drinking water, sanitation and hygiene claim millions of lives each year, while the increasing frequency and intensity of climate-related extreme weather events continue to hamper the delivery of safe WASH services.”

Tedros called on governments and development partners to “strengthen WASH systems and dramatically increase investment to extend access to safely managed drinking water and sanitation services to all by 2030, beginning with the most vulnerable”.

Cholera outbreaks

Meanwhile, the WHO reports that 29 countries have reported cholera cases this year, including Haiti, Malawi and Syria which are facing large outbreaks. Cholera is a waterborne disease spread by eating food or drinking water that is contaminated with bacteria.

“In comparison, in the previous five years, fewer than 20 countries on average reported outbreaks. The global trend is moving towards more numerous, more widespread and more severe outbreaks, due to floods, droughts, conflict, population movements and other factors that limit access to clean water and raise the risk of cholera outbreaks,” it noted.

Lebanon, which has been free of cholera for almost 30 years, reported an outbreak in October while Syria is experiencing its first outbreak since 2009.

Meanwhile, Haiti is battling a large outbreak with over 13,000 cases, its first in three years. Over 260 people have died of the disease, and the country received 1.17 million doses of cholera vaccine on Tuesday.

The vaccine (Evichol) was provided by the International Coordinating Group on Vaccine Provision (IGC), which manages the global cholera vaccine stockpile, following a request by Haiti’s Ministry of Public Health and Population. The WHO has recommended that people only get one dose of the two-dose vaccine because of a global shortage.

Off-track for development goals

“The world is seriously off-track to achieve Social Development Goal 6 on water and sanitation for all, by 2030. This leaves billions of people dangerously exposed to infectious diseases, especially in the aftermath of disasters, including climate change-related events,” said Gilbert Houngbo, chair of UN-Water, and Director General of the International Labour Organization. 

“The new data from GLAAS will inform the voluntary commitments the international community will make at the UN 2023 Water Conference in March, helping us target the most vulnerable communities and solve the global water and sanitation crisis.”  

The UN 2023 Water Conference – formally known as the 2023 Conference for the Midterm Comprehensive Review of Implementation of the UN Decade for Action on Water and Sanitation (2018-2028) – will take place at UN Headquarters in New York, 22-24 March 2023.

Image Credits: Unsplash.

South Africans campaign in favour of a tax on sugary drinks in 2017

Taxing sugary drinks can be a win for health and government revenue, according to the World Health Organization (WHO) at the launch of its first ever tax manual for sugar-sweetened beverages (SSB) on Tuesday.

“SSBs have little to no added nutritional value, but their consumption is significantly associated with tooth decay, weight gain and obesity, metabolic conditions and other diet-related non-communicable diseases,” said Dr Rudiger Krech, the WHO’s director of health promotion.

As food prices were a key determinant of food purchases, taxes on unhealthy products had proven to be a deterrent, he added.

Health promotion advocates have been critical of the WHO’s past failure to encourage SSB taxes, but the manual shows that the global body now embraces the strategy. 

“Raising taxes has proven to be the single most potent and most cost-effective strategy for reducing tobacco use, and similarly, we know that right raising taxes on alcohol beverages is also a potent and cost effective strategy for decreasing harmful use,” said Krech.

“This manual provides a practical guide to support an increasing number of policymakers from both health and finance perspectives that are contemplating the use of SSB taxation as the tool to effectively curb their consumption.

In South Africa, the mean daily sugar intake from taxed beverages fell by 37% after the introduction of a tax on sugary drinks in 2018, said Dr Francesco Branca, WHO’s nutrition director.

Last Friday, WHO launched a public consultation on its draft guidelines on fiscal policies to promote healthy diets, which strongly recommend a policy to tax SSBs, added Branca.

“The taxation of sugar-sweetened beverages is amongst the most cost-effective interventions recommended for prevention and control of non-communicable diseases,” he added.

At present, only a fraction of the WHO’s 194 member states tax sugary drinks. Eleven of the European region’s 53 countries do so, along with SSB tax pioneer Mexico, the UK, South Africa, Chile, Barbados and a handful of other countries.

The WHO’s Jeremias Paul, co-ordinator of the tobacco control economics unit, stressed that sugar has little or no nutritional value and the metabolic impact of liquid sugar was much worse than solids containing sugar as well as fibre.

“This manual essentially gives you a blow-by-blow, step-by-step way to build a case for SSB taxation,” said Paul.

“You need to determine the type of tax to impose, what are the taxable products or other or other words, what would be the coverage of products for SSBs? What will be the tax base, whether it’s going to be sugar content or the volume? What are the rates and tax administration capacity?” Paul added.

In Mexico, the government implemented an excise tax on beverages with added sugars, except for 100% fruit juices and beverages with artificial sweeteners. 

“Overall, we found reductions in purchases of taxed beverages and increases in untaxed beverages,” said said Arantxa Colchero from Mexico’s National Institute of Public Health.

“People substituted for bottled water mainly, and we found that the highest rate reductions were among low-income families, high consumers and households with children,” said Colchero.

There was no impact on employment for workers in the sugary drinks sector, either in the industry that produces SSBs nor the shops that sell the drinks, largely because the tax was “very small tax” of 5,3%, the shops sold SSB substitutes and industry also produces bottled water – the main product that consumers moved to, added Colchero.

Encouraging reformulation

UK’s Dr Victoria Targett from the Office of Health Improvement, said that her country’s tax was based on the sugar content per litre, and was  “designed to encourage reformulation” – a voluntary reduction in the sugar content of drinks by producers.

”And we have seen exactly that. In the most recent data that we published on 1 December, we saw that the levels of sugar in drinks that are subject to the levy have come down by 46%,” said Targett.

Dr Mpho Lekote from South Africa’s Treasury said that the introduction of what is termed a “health promotion levy” in his country was championed by Treasury, together with the department of health.

Although they initially proposed a 20% tax on sugary drinks, this was reduced to around 11%, with the first 4g of sugar per 100ml tax-free.

“South Africa has sugar cane growing segments, and there were concerns about the impact of the levy on the sugar cane growers,” said Lekgote, explaining why the tax had almost halved.

Revenue from the tax has dropped as producers have reformulated their drinks, he added.

Image Credits: Heala_SA/Twitter, Kerry Cullinan.

Dr Jeremy Farrar, director of Wellcome Trust

Wellcome Trust director Dr Jeremy Farrar will become the World Health Organization’s (WHO) Chief Scientist in the second quarter of 2023, according to announcements by the WHO and Wellcome on Tuesday.

Farrar’s second five-year term is ending next February and Wellcome Trust “have been planning the transition for some time, and a global search for a permanent CEO began earlier this year”, according to Julia Gillard, chair of the trust’s board.

“Jeremy’s leadership and insight have seen Wellcome achieve remarkable growth, realising ambitions in science and health on a scale not previously possible,” added Gillard.

 

“His vision has enabled Wellcome’s bold £16 billion strategy for the next decade, supporting scientific discovery and solutions to tackle the greatest health threats facing us all – mental health, escalating infectious disease and the health impacts of the climate crisis.”

During the Covid-19 pandemic, Farrar led Wellcome’s advocacy for rapid investment in research on testing, treatments and vaccines. He was a participant of the UK Scientific Advisory Group for Emergencies (SAGE) from the start of the pandemic until his resignation in October 2021, and a member of the Principals Group of the WHO’s ACT-Accelerator. 

Global expertise

Gillard added that Wellcome was “delighted that the global health and science community will continue to benefit from his expertise and wisdom in his new role at the World Health Organization”.

Farrar, a clinician scientist, takes over from Dr Soumya Swaminathan in overseeing the WHO’s science division. Before joining Wellcome in 2013, he spent 17 years as director of the clinical research unit at the Hospital for Tropical Diseases in Viet Nam.

 

Farrar is a Fellow of the Academy of Medical Sciences UK, European Molecular Biology Organisation (EMBO), the National Academies USA and a Fellow of The Royal Society.

“We are living through fragile and uncertain times, with huge inequities to address,” said Farrar in a media statement.

However, he added that there had also been “breath-taking and life-changing advances in science and health” during the decade that he had been at Wellcome.

New Chief Nurse

Meanwhile, Dr Amelia Latu Afuhaamango Tuipulotu will become WHO’s Chief Nursing Officer at the start of 2023. In 2019, she became the first female Minister for Health of the Kingdom of Tonga, and before that was Tonga’s Chief Nursing Officer.

 

Previously, director of nursing at Vaiola Hospital, she was the first Tongan to receive a PhD  in Nursing. In 2019, she was appointed Honorary Adjunct Associate Professor at the University of Sydney. From May 2020 to December 2022, Tuipulotu was a member of the WHO Executive Board.

As WHO’s Chief Nursing Officer, Tuipulotu will “champion, nurture and support nurses and midwives to ensure that their skills and experience are being well-utilized to strengthen health systems and to bolster their critical role in bringing patients, communities and national health systems closer together”, according to the WHO.

“I am delighted that Jeremy and Amelia will join WHO at a critical time in global public health when investment in both the health workforce and science is imperative to strengthening health systems and outbreak preparedness and prevention,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus.

“As Chief Scientist, Jeremy will accelerate our efforts to ensure WHO, its Member States and our partners benefit from cutting-edge, life-saving science and innovations. As Chief Nursing officer, Amelia will ignite the all-important need not only to fill the gap in health workers worldwide but also to ensure they receive the support they need and deserve.”

Paul Schreier, Wellcome’s Chief Operating Officer, has been appointed interim CEO from 25 February 2023. 

Image Credits: Megha Kaveri/Health Policy Watch .

Testing a patient for hypertension. Two-thirds of Africans with high blood pressure are unaware of this.

Africa’s limited pharmaceutical industry, high costs of raw materials, and dependence on imported medicines have long hampered citizens’ access to the medicines they need. 

The challenges the continent faces are daunting. They include poor supply chain systems, lack of government investment in the pharmaceutical sector, unfavourable manufacturing conditions, limited health workforce, lack of sustainable health financing mechanisms or infrastructure and technical know-how, low investment in research and development, and circulation of fake medicines. 

Rectifying these problems is where the African Medicines Regulatory Harmonization (AMRH) programme comes in. Five years after the inaugural AMRH Week in Kigali, Rwanda in 2018, experts gathered in Ghana last week to discuss the AMRH’s potential to address these gaps, drive change for the African continent, achieve Universal Health Coverage, and galvanize resources to meet the continent’s health needs.

The week brought together African leaders and policymakers, members of the AMRH steering committee and technical committees,  regional economic communities, the AMRH Partnership Platform and other partners and stakeholders.

Safe medicine

“At its core, the mission of the AMRH is to facilitate the harmonization of medicine regulation and to create the desired outcome of access to quality, safe, efficacious and affordable medicine for the African continent,” said Mimi Darko, CEO of Ghana’s Food and Drugs Authority. “There are many reasons this is critical but in recent times nothing has brought this home but the ravages of the COVID-19 pandemic.”

COVID-19, she said, helped to shift the attention of many African countries from the short-term, urgent needs of their populations to building long-term resilience for the continent.

“It is no surprise that vaccine production is at the centre of initiatives culminating in the partnership for the African Vaccine Manufacturing, the first ever kind of collaboration for Africa,” added Darko.

This year’s focus was on regulatory processes, harmonization and strengthening National Regulatory Authorities (NRAs) across Africa and other low- and middle-income countries facing challenges in ensuring access to quality-assured medical devices, in-vitro diagnostics, personal protective equipment (PPEs) and other health products.

European Medicines Agency offers support

Dr Matshidiso Moeti, WHO Regional Director for Africa.

Emer Cooke, executive director of the European Medicines Agency (EMA), said it was critical for Africa to develop its medicines agency to gain control over regulatory and price mechanisms for the continent.

“The EMA’s support for the region during the pandemic was enormous through the EU-AU partnerships and the Africa CDC. But what is critical now is the efforts to establish the African medicine agency initiative,” Cooke said. “This will help coordinate, facilitate and harmonize access to medicine for disease cohorts in the region.”

The EMA pledged to give the AMRH steering committee technical support to address some of the challenges highlighted.

Slow pace of ratifying AMA

Dr David Mukanga, deputy director of African regulatory systems at the Gates Foundation and chairperson of the AMRH Partnership Platform, said member states’ delays in ratifying the AMA treaty was the main challenge so far.

“The rate at which we’re moving as a continent in signing and ratifying the AMA treaty is of great concern. This is because ensuring that medicine and medical products are available for everyone is a huge task and we need to move faster in professing solutions by turning our ideas into products for our people and the delays are not helping” he stressed.

In the long term, Mukanga said leveraging the scarce resources of the continent to create the AMA would help to  will deliver universal health coverage.

Dr Matshidiso Moeti, the World Health Organizations’ (WHO) Africa regional director, said in a statement to the meeting that substantive strides have been made by the AMRH to develop the regulatory framework to oversee pharmaceutical products, capacity building and technical support for member countries.

The AMRH strategy, which is operating in five regional and economic committees, has been able to deliver positive results by helping countries to access a robust legal framework and to harmonize regulatory requirements, standards, processes and capacity building.  

However, she urged the extension of regulation from generic medicine to cover new chemical-entity vaccines, medical devices and in-vitro diagnosis, hinting that $1 million has been allocated for the AU-WHO joint work plan to  establish and operationalise the AMA.

Pledging the WHO’s support for the AMA, she called for local investments in the regulatory systems and its processes to safeguard it.

Image Credits: Hush Naidoo Jade Photography/ Unsplash.

COVID-19, conflicts and climate change are posing additional challenges to efforts to achieve universal health coverage (UHC) in the Eastern Mediterranean region (EMRO), the World Health Organization (WHO) acknowledged on the eve of Universal Health Coverage (UHC) Day on Monday.

“The COVID-19 pandemic demonstrated the vulnerability of our health, social protection and economic systems,”  Dr Ahmed Al-Mandhari, WHO EMRO regional director told a media briefing on Sunday at the start of a three-day regional UHC meeting.

“Half of all countries in our region are experiencing protracted conflicts and humanitarian crises. Eight of them have reported outbreaks of cholera and acute watery diarrhoea. Extreme climate events, like the floods in Pakistan and drought in the Horn of Africa, are leading to acute hunger and health crisis.”

Dr Ahmed Al-Mandhari, WHO EMRO regional director

Cholera outbreaks signal weak systems

Lebanon had been cholera-free for the past 30 years until a few months back when it reported an outbreak, indicative of challenges to its water supply amid the country’s weakening economic crisis, according to Dr Rana Hajjeh, WHO EMRO director of programme management.

“Cholera is not only a repercussion of climate change,” said Hajjeh. “It is evidence of weak and fragile health systems. We have two countries in the eastern Mediterranean region suffering from cholera at the moment in addition to the six countries where it is endemic. 

“Cholera in Syria and Lebanon is a very grave sign as it is linked to the collapse of the infrastructure, not only the health of infrastructure but also all that is relevant for the cleanliness of water and securing of clean water and services for citizens.”

However, climate change was having a huge impact on the region, Hajjeh acknowledged. The floods in Pakistan, one of the biggest EMRO member states, had disrupted the country’s health systems, while Somalia was in the midst of a very severe drought, and was in a grave food crisis in Somalia “and may be encountering starvation”.

The WHO had developed guidelines for member states on climate change and would assist them to address its impact.

Dr Suraya Dalil (left) and Dr Rana Hajjeh, WHO EMRO director of programme management.

Primary Health Care

“Primary health care is the most cost-effective way to bring services or health and wellbeing closer to individuals and communities. Reorienting our health systems towards the primary health care approach means engaging in multisectoral action, ensuring community engagement, increasing equitable access to quality health services and strengthening public health functions, added Al-Mandhari.

UHC Day is an official United Nations designated day that marks the anniversary of a unanimous decision seven years ago to endorse UHC as an essential component of international development, and work towards achieving this globally by 2030.

“UHC means that all individuals and communities receive the health services they need without suffering financial hardship. It includes the full spectrum of essential quality health services across the life course from health promotion to prevention, treatment, rehabilitation and palliative care,” added Al-Mandhari.

Meanwhile, the WHO plans to mark UHC Day with an event at the FIFA Fan Festival in Doha, Qatar, on the eve of the World Cup semi-finals on Tuesday. 

The WHO also issued its UHC service Package Delivery and Implementation Tool aimed at supporting countries to design and implement comprehensive health service packages to meet the needs of their populations on Monday.

It also launched a digital knowledge hub for the public called, ‘Your life, your health: Tips and information for health and wellbeing,’ to provide people with trustworthy health information.

Image Credits: UN-Water/Twitter .

Babies under 28 days are particularly vulnerable to AMR-resistant infections.

Leading public health experts are calling for urgent action to develop antibiotics for newborn babies, a population that is particularly vulnerable to antibiotic resistance. 

Each year, there are an estimated three million cases of neonatal sepsis causing up to 570,000 deaths, many due to a current lack of effective antibiotics, according to a paper published by international experts in the field of antimicrobial resistance (AMR).

Last Friday, the World Health Organization (WHO) released a report that shows a high level of antibiotic resistance from a number of bacteria that cause life-threatening bloodstream infections, and increasing resistance from bacteria that cause common infections. 

The Global Antimicrobial Resistance and Use Surveillance System (GLASS) report shows high levels (above 50%) of resistance in the largely hospital-acquired bacteria, Klebsiella pneumoniae and Acinetobacter spp. These require treatment with last-resort antibiotics such as carbapenems, but 8% of bloodstream infections caused by Klebsiella pneumoniae were even resistant to carbapenems.

Meanwhile, over 60% of Neisseria gonorrhoea isolates showed resistance to a common oral antibacterial ciprofloxacin. Over 20% of E.coli isolates – the most common cause of urinary tract infections – were resistant to both first-line drugs (ampicillin and co-trimoxazole) and second-line treatments (fluoroquinolones). 

Few drug trials for newborn antibiotics

Despite the rising number of newborn deaths caused by AMR, very few effective antibiotics have been studied to treat serious bacterial infections such as neonatal sepsis. 

Of the 40 antibiotics approved for use in adults since 2000, only four have included dosing information for newborns in their labels, according to the AMR experts.

In addition, far fewer trials investigating new antibiotics are currently being conducted in neonates than in adults: six neonatal trials compared with 43 adult trials.

“On any given day, up to 40% of infants admitted to a neonatal intensive care unit are prescribed antibiotics, with an estimated 90% exposed to antibiotic medications over the duration of their stay in the intensive care unit,” according to the paper.

“Many of these antibiotics are prescribed off-label because of the perceived or documented need for empiric or targeted therapy of MDR pathogens. Such prescribing risks reducing efficacy or increasing toxicity be – cause of under- or over-dosing; it also increases the potential for antimicrobial resistance selection pressure because of suboptimal dosing.”

Inter-disciplinary network

The experts, including researchers from the Global Antibiotic Research & Development Partnership (GARDP) and Penta Child Health Research, propose an international, inter-disciplinary network to accelerate the development of antibiotics for newborn babies.

“There is an urgent need to identify high-priority antibiotics to understand which ones work best and safely in children, and then make them available where they are needed,” said Mike Sharland from St George’s, University of London, and a member of the Antimicrobial Resistance Programme at Penta.  

According to recent estimates, about 2.3 million newborns die of severe bacterial infections each year.  An increasing number of babies under 28 days’ old are becoming resistant to currently used antibiotics.  Over the last decade, AMR has worsened to the point that around 50-70% of common pathogens exhibit a high degree of resistance to available first- and second-line antibiotics.  

Working together collaboratively could speed up both development and access to urgently needed antibiotics for newborns. 

“By bringing together academic clinical trial networks, international research networks, regulators, donors, government and industry sponsors, these public-private partnerships can leverage their multi-disciplinary expertise and funding to speed up access to antibiotics and facilitate the update and routine implementation of global treatment guidelines,” said Carlo Giaquinto, President of the Penta Foundation.    

The paper outlines how a stakeholder group could work together to define a Neonatal Priority Antibacterial List, and to standardise regulatory criteria.     

“We need to move fast to develop guidelines and protocols on the use of antibiotics, as well as develop new antibiotics,” said Professor Sithembiso Velaphi, Head of Paediatrics at the Chris Hani Baragwanath Academic Hospital in Soweto, South Africa. 

“We have the opportunity to prevent more unnecessary deaths of babies from these severe and preventable infections by intervening, quickly, equitably, and safely.  It is also critical that all efforts must be made to prevent these infections by ensuring that all healthcare facilities and providers adhere to infection prevention and control protocols.” 

GARDP, Penta, St George’s, University of London (SGUL) and other key partners are partnering on an upcoming clinical trial starting in South Africa in the next few months before being expanded to other countries to evaluate more effective neonatal treatment regimens to overcome resistance to current treatments, especially in low- and middle-income countries. 

Image Credits: 20 May 2021South AfricaKL Schermbrucker/GARDP.

chronic disease
Two women walk through the streets of Aleppo, an ancient Syrian city reduced to rubble by war.

On the occasion of Universal Health Coverage Day, thought leaders on the front lines outline the challenges and opportunities of health systems in conflicts.

The last decade of 12-year-old Zaynab’s life has been spent in an informal settlement in Lebanon, after her family fled from the Syrian conflict. She shares a three-room tent with her parents, grandparents and six siblings. 

Since leaving Syria, Zaynab has been diagnosed with type 1 diabetes and controlling her blood sugar level requires taking insulin several times a day. Zaynab is not the only one in her family with a long-term health condition – her father and grandmother are living with type 2 diabetes.

Managing an NCD like diabetes is tough for any child – but for Zaynab and her family, buying insulin and blood sugar testing strips has been an ongoing challenge.

She and her family members have often delayed, reduced, or completely missed out on treatment because of the cost. For people living with type 1 diabetes, their life depends on sustained access to insulin – a century old drug that remains costly and hard to access in many settings like Zaynab’s refugee camp.

Conflict, health emergencies and the climate crisis continue to impact lives across the world, with an estimated 103 million displaced persons in 2022. The conflict in Ukraine has driven one of the largest exodus of people since World War II and it remains, alongside Syria, one of the largest refugee and displacement crises of our time.  However, those crises are only the tip of the iceberg. 

Eight out of every ten displaced persons live in low- and middle-income countries, where people are also  disproportionately at risk of premature death from chronic, or noncommunicable, diseases (NCDs).  

When a humanitarian emergency strikes, many people affected or forced to flee live with pre-existing chronic health conditions that are exacerbated by the accompanying stress and difficulties in accessing scarce or disrupted medical care. Persons living with a chronic disease, including those with hypertension and type 2 diabetes – the most common among Syrian refugees – are more vulnerable in humanitarian emergencies, as they need continuous access to essential health services, including affordable and available medicines and testing equipment adapted to crisis settings and climate extremes. 

Care that leaves no one behind

Zaynab’s father doesn’t have regular work, and her mother earns less than the cost of feeding the family a simple diet of potatoes and pulses. As one of several humanitarian agencies operating in Lebanon, the International Committee of the Red Cross (ICRC) has stepped in to guarantee the family’s medicines and supplies, including Zaynab’s life-saving insulin treatments. However, the family still faces the expense of buying healthy food and challenges in applying other medical recommendations, such as regular physical activity.

If the world is to achieve universal health coverage (UHC) – in which no one is left behind – finding solutions to challenges faced by individuals like Zaynab and her family must form part of the discussion. Recent years have seen increased attention to address the specific challenges of people living with NCDs in humanitarian settings. World Health Organization (WHO) Member States, for example, have adopted the NCD Compact to protect the lives of 1.7 billion people living with NCDs the world over by 2030, including during humanitarian emergencies. For that to happen will require strong leadership, reliable data and an efficient multi-disciplinary and multi-stakeholder approach.

While operational considerations proposed by a set of humanitarian agencies around NCD prevention and care in humanitarian settings are yet to be widely implemented in the way HIV/AIDS guidelines for humanitarian settings have been, encouraging progress is being made.. A new set of recommendations on the issue was  approved by WHO Member States at the World Health Assembly earlier this year and it is hoped there will also be progress made on the issue through a series of WHO meetings on the topic in 2023 as well as through next year´s UN High-Level Meeting on UHC.

The path towards universal health coverage

An ‘informal tented settlement’ in Lebanon’s Bekaa valley. The mountains in the background form the border with Syria, just a few miles away.

Fundamentally, all countries need to be working towards achieving UHC, including countries impacted by humanitarian crises. Lebanon for example is a country of fewer than seven million inhabitants and is hosting nearly one million registered Syrian refugees. This has increased the country’s population by 15%, placing enormous pressure on its infrastructure, including the health system.

All efforts towards achieving UHC must include the integration of NCD services into community services and primary health care (PHC) facilities to ensure people living with NCDs have access to quality services across the continuum of care, and avoid the need for costly and time-consuming travel to distant hospitals and overburdening secondary and tertiary care. Local nurses and community health workers are indispensable: with appropriate training, they can manage many conditions in collaboration with primary care doctors, facilitate referrals, and support continuum of care and adherence to treatment.

Increasingly, people live with more than one health condition: for instance, hypertension, diabetes and mental health conditions are often interlinked. Person-centred care building care around the person and their family, their needs and perspectives can be achieved through an integrated service approach. People living with NCDs usually require care throughout their lives, including regular follow-up to prevent long-term complications, such as diabetic foot ulcers or terminal kidney failure. Therefore, they need to be empowered to manage their health, to engage proactively with and help shape health services, and incorporate treatment into daily life and make the healthiest possible choices.  

Person-centred care in humanitarian crises

The smoke of the Beirut harbour explosion spreads over the skies of Lebanon. In their journey to seek safe new homes, many displaced persons find themselves in countries with their own set of problems and challenges.

To ensure person-centred care during situations of displacement, the continuum of care must be protected. Authorities could explore the option of providing information about possible access points to be consulted during a person’s onward journey.

Alternatively, individuals could be offered larger quantities of medication and care supplies to cover periods where it will be difficult to access a health facility, as well as information on self-management of their conditions, including clear guidance on any red flags that signal the need to seek in-person medical care.

Building a bank of evidence-based research would help us understand how to best improve care for people living with NCDs under very challenging circumstances. Also, the private sector could and should play a larger role when it comes to identifying solutions that meet the needs of people with NCDs affected by humanitarian crises.

Finally, the importance of community support for displaced people and those living in humanitarian crises – both practically and emotionally – cannot be overemphasized. 

In Zaynab’s family for example, there are in fact now three people living with diabetes; they support one another in adhering to treatment plans, and in self-care. Supporting families and peers to manage healthcare in their own communities may improve  more self-reliance, while also giving them a greater sense of stability, empowerment and purpose.

Overcoming the challenges faced by people living with NCDs under very difficult conditions extends far beyond access to medication. It is about how health systems under serious stress can be strengthened to provide continued, affordable access to NCD prevention and treatment. Until this is achieved for the most vulnerable groups of people, including those living in humanitarian settings, there can be no Universal Health Coverage. 

About the authors

Éimhín Ansbro is the Deputy Director of Centre for Global Chronic Conditions and NCD in Humanitarian Settings Special Interest Group Lead at the London School of Health and Tropical Medicine.

Micaela Serafini is the Head of Health Unit at the International Committee of the Red Cross.

Nicolai Haugaard is the Vice President and Global Head of Access to Care at Novo Nordisk.

Peter Klansø is the Director of International Department at the Danish Red Cross.

Grace Dubois is the Policy & Research Manager for the NCD Alliance.

Image Credits: UK DFID.

Margaret Gyapong, director of the Institute for Health Research at the University of Health and Allied Sciences in Ghana, with her research team.
Margaret Gyapong, director of the Institute for Health Research at the University of Health and Allied Sciences in Ghana, with her research team.

Whether researchers provide good quality data or not, healthcare systems will continue to function. In this episode of the “Global Health Matters” podcast, Margaret Gyapong, director of the Institute for Health Research at the University of Health and Allied Sciences in Ghana, tells host Garry Aslanyan that this has been a hard lesson that has shaped her career.

Joining the podcast is also Lee Hampton, vaccine preventable disease surveillance and vaccine safety focal point at Gavi, the Vaccine Alliance based in Switzerland.

According to Gyapong, the drive to better serve healthcare providers has pushed her to ensure that she works on projects that are relevant and to consider them as true partners.

This approach has been crucial in the development and deployment of the new malaria vaccine.


“Just recently, the World Health Organization made their official recommendation to widely use the long-anticipated malaria vaccine,” Aslanyan notes. “This recommendation was based on research evidence from a pilot programme in Ghana, Kenya, and Malawi that reached more than 800 000 children since 2019. This is an excellent example of how evidence, based on implementation research, tells us whether the health interventions, such as vaccines, will be effective in real life beyond the laboratory.”

Focusing on health workers

Gyapong, who has been involved in the process, shares some of her experience.

“Many times when we are delivering a new intervention, we think that we should focus all our attention on community members because they have low levels of literacy,” she says. “But then one of the things I have realized from the introduction of the new malaria vaccine is that we need to have a better understanding of our health care providers and the way they think.”

“We found out that the health workers at the lower level who were going to be the frontline workers to deliver the vaccinations had a shorter period of training than those at the higher level, and the health workers complained bitterly,” Gyapong adds, pointing out that the need for better training is relevant also for COVID-19 vaccine’s deployment.

Asked about what researchers working in different settings and areas should do, the scientist encourages them to understand “the situation on the ground” and “the needs of your stakeholders.”

Different communities have different needs

One of the challenges in deploying new vaccines is the expectation that strategies that are developed and tested in a specific society, often a high-income one, can be applied to other places, Hampton tells Aslanyan.

“We have a strong tendency to try to apply the game plans and the experience that worked in those countries that had the resources to first do the development everywhere,” he points out. “But then we run into trouble.”

Understanding the needs and characteristics of each community is crucial for a successful vaccination campaign. Hampton offers the example of the newly developed typhoid conjugate vaccine, which they expect will help prevent tens of thousands of cases and potential deaths.

Image Credits: Courtesy of TDR.

Vaccines
A United States delivery of 655,200 COVID-19 vaccine doses through COVAX to Ethiopia on September 23, 2021.

Gavi, the Vaccine Alliance, has pushed back on media reports that its board has decided to end COVID vaccine support for 37 middle-income countries next year – and end altogether the dedicated COVAX vaccine facility, supplying free vaccines to some 92 low- and middle-income countries, in 2024.

A high-ranking official at Gavi told Health Policy Watch that its Board’s approval Thursday in principle of a plan to end the free provision of vaccines to the 37 countries – including Egypt, Indonesia and Argentina – is neither final nor definitive, and would not in any case affect vaccine deliveries in 2023. 

Other officials, meanwhile, said that if funding cuts for middle income countries are made in 2024, the money saved would be shifted to a pandemic pool to confront new, and more dangerous SARS-CoV2 surges or similar future threats. 

Even so, no changes to Gavi’s support of some 92 middle and low income countries for COVID vaccines through the COVAX facility’s Advance Market Commitment (AMC) will be made in 2023, said Dr Derrick Sim.  A final decision on the shape the COVAX facility takes in 2024 will not be voted on until June of 2023, he added, following consultations with countries themselves. 

“We are not changing the approach for 2023, all AMC countries including AMC-supported middle-income countries will be supported to get fully-funded doses and delivery support,” said Sim, who is the Acting Managing Director of the Gavi-led COVAX facility, which has rolled out some 1.8 billion COVID vaccines to 146 low and middle income countries over the past two years.  

“Looking forward to 2024, every scenario we are considering involves some support for middle-income countries, and no decision will be taken until at least next year after countries have been fully consulted – and it will be based on the state of the pandemic at that time,” he added. 

New pandemic pool aims to correct problems in COVID vaccine rollout 

A lack on on-hand funding at the onset of the COVID pandemic hamstrung Gavi’s ability to respond in the early stages of the outbreak.

Under the proposal approved by the board on Thursday, any money saved on procuring vaccines for the 37 middle-income AMC countries would instead go to funding a new pandemic finance pool, which could be rapidly and flexibly deployed to confront surges of new SARS-CoV2 variants, or similar threats, added Olly Cann, Gavi’s director of communications.

“The idea behind it is, can we learn the lessons from 2020?,” said Olly Cann, Gavi’s director of communications.

During the early stages of the COVID vaccine rollout, Gavi and COVAX were heavily criticized for over reliance on just one vaccine supplier, the Serum Institute of India, which then froze its shipments when India faced a major COVID surge. 

The problem, widely acknowledged later, was that Gavi had no cash in hand at that time  to seal deals with some of the other large vaccine manufacturers, like  Pfizer, Moderna and Johnson & Johnson, for advance vaccine purchases. So it was forced to the back of the vaccine procurement line. 

New strategy part of scenario planning 

The new strategy approved by the Gavi Board Thursday is anchored in alternative scenarios for COVID’s evolution, developed by the World Health Organization, which leads the policy side of COVAX. 

WHO has defined three scenarios for the evolution of the SARS-CoV2 virus and pandemic: a worst case surge of new or existing variants; a medium case; and a best case, in which mortality from SARCoV2 continues to decline as virus mutations become less deadly. 

Only in the ‘best-case’ scenario would the COVAX programme of free vaccines and vaccine distribution support to the 37 middle income countries be replaced with a more step-wise approach, officials said. 

Under the new approach, the countries would be able to receive a “catalytic grant” – a one-time payment covering 50-60% of the estimated cost of the jabs needed to immunize health workers, older people and other vulnerable groups. 

In a medium or worst-case scenario, assistance to these middle-income nations would be increased accordingly.

Integration of COVID vaccines into routine countries may be preferred  

COVAX deliveries arrive in Sudan, August 5, 2021.

In best-case scenarios, the COVAX facility might foreseeably dissolve its emergency operations and integrate COVID vaccine distribution – into routine national vaccination programmes, officials also admitted.  

However, regardless of whether COVAX is dissolved entirely, or not, the progressive main-streaming of Covid vaccinations into national vaccine delivery programmes is in line with good practice – and what countries want.  

“Countries are finding it administratively burdensome to administer COVID vaccines as an entirely separate emergency programme,” one Gavi official said, speaking on condition of anonymity. “They would rather see vaccine distribution integrated into ongoing routine vaccination programmes.”

“COVAX’s planning is driven by countries’ needs and what we are hearing,” Sim added.  “They want to find ways to integrate COVID-19 into existing programmes in a way that benefits both, and reduces the administrative burdens of running a separate emergency programme in a time of other competing priorities, from routine immunization to outbreak response.” 

The Pandemic Vaccine Pool is the long-term strategy 

Under one of the scenarios included in the proposal approved by the Board on Thursday, any savings in supplying free vaccines to the 37 middle-income AMC countries, that would be channelled into Gavi’s new Pandemic Vaccine Pool – so as to have cash in hand for any new SARS-2 surge, or other future pandemic threat. 

The Pandemic Vaccine Pool created by the Gavi Board in April is a critical, new part of Gavi’s long-term pandemic preparedness strategy, Sim said. The aim is to ensure ready funding that would allow the Alliance to be on proactive footing should another deadly variant or virus emerge. 

“The Pandemic Vaccine Pool helps us have funding on hand to act immediately if there is a need, for example, for new vaccines,” he explained. “Gavi put in place this contingency measure based on COVAX learnings from the beginning of the pandemic that the course of the pandemic can change suddenly and delays can occur due to lack of available financing.” 

Middle-income countries normally do not qualify for Gavi support

Arrival of the first COVAX package to Argentina, comprised of Oxford/AstraZeneca vaccines.

Gavi officials also stressed that prior to the COVID pandemic, Gavi’s remit was limited to assisting the world’s 54 lowest-income countries, as defined by World Bank economic data. Middle income countries were eligible only for targeted funding, upon request, and not free vaccines as such. 

But the historic nature of the Covid emergency led to an expansion of eligibility for countries that qualified for free vaccines and support. And thus for COVID vaccine rollout purposes, some 37 middle income countries, as well as India, were included to the Gavi “Advanced Market Commitment (AMC)” scheme – making for 92 countries eligible for free COVID vaccines as well as distribution support.  

“These middle-income countries normally run their own routine vaccination programs, without Gavi support except for one-off targeted interventions,” Sim said. “When COVAX was set up, it exceptionally included a larger group of countries given the unique challenges of equitable access in a supply-constrained pandemic environment.”

In effect, then, any policy change in 2024 would revert Gavi’s scope to what it was pre-pandemic: a system of free vaccines and distribution support for 54 of the world’s lowest-income countries – and targeted support to middle income countries in need, he said. 

Proposal not related to vaccine contracts

Gavi also pushed back on reports by the New York Times that the draft proposal, approved by the Board, is reflective of financial pressures resulting from Gavi being overcommitted to vaccine purchases for which there is now no demand. 

In fact, Gavi’s fixed purchase commitments for 2023 amount to only 150 million vaccine doses, one Gavi official told Health Policy Watch – while the rest are simply “options to buy”.

At the same time the existing list of AMC countries have already expressed interest in twice as many doses – 300 million in total for 2023 – and that is only after a polling of half of the eligible countries.    

 Global demand for vaccines has indeed fallen significantly as the world’s population already builds immunity, the Gavi official added.  For instance, some 52% of people in low income countries have at least had a primary vaccine dose – a far higher proportion than six months or a year ago. And countries have some 400 million doses in stock, as well. 

As a result of declining demand trends, Gavi had earlier renegotiated a number of fixed-order commitments in its portfolio to become options – orders they can fulfill if demand jumps.

But these negotiations had already happened before this week’s board meeting. 

And between a replenishment for the 2021-2025 period that exceeded Gavi’s request for $7.4 billion, reaching $10.5 billion, and the $4.8 billion committed by world leaders at the COVAX AMC summit in April, the alliance’s financials are in order.

“The focus is on increasing coverage rates, protecting high-risk groups including with boosters, and laying the foundation for integration into existing programs,” said Sim.

 “Budget isn’t a problem, and supply isn’t a problem,” Cann said. “The biggest problem is we have no idea what 2024 will look like.”

 

Image Credits: US State Department, Nana Kofi Acquah, Argentina Health Ministry.