Affordable, healthy food options are key to good health.

“The bottom line is that our food environment is deeply unhealthy. And unless we change that, millions of people will suffer from avoidable illness and die early from preventable death,” Dr Tom Frieden, CEO of Resolve to Save Lives, told the World Health Summit in Berlin.

“Voluntary changes are much less likely to result in sustainable positive healthy development than a predictable regulatory framework,” said Frieden, speaking at a session on ‘Transforming Food Systems for Healthy and Sustainable Diets. 

He pointed to five areas that needed targeted action to address malnutrition – micronutrient deficiencies, artificial transfat, excessive sodium, excessive sugar and the higher cost of healthier foods.

“Let’s be clear that simply encouraging people to eat better and exercise more will not only fail, but is essentially a form of blaming the victim.

According to the WHO, 1.9 billion adults in the world are obese and 462 million are underweight. Almost 233 million children under the age of five suffer from some form of malnutrition and around 45% of deaths among children in that age group is linked to undernutrition. 


In 2019, The Lancet Commission on obesity, undernutrition and climate change identified these three issues as the biggest threats to the world, and called for significant funding to address them, including but not limited to agriculture, food production and policy, land use and environment. 

The United Nations Food Systems Summit in New York in 2021 also called for sustainable food systems and healthy diets for all, and Tuesday’s session was aimed at addressing the various commercial determinants involved in achieving this goal. 

Some countries are already reforming their food systems to deliver healthier options to their populations using measures such as investment in agriculture, tax subsidies for companies that produce healthier foods to make them more affordable and regulations ensure processed food adheres to strict health standards. 

More regulation

Government regulation of companies that manufacture processed and unhealthy foods and their marketing strategies can help the cause, according to Frieden.

“We’re not absolving individuals from responsibility. But we’re not absolving society from the responsibility of establishing the structure to make the healthy choice the easier choice either,” added Frieden, explaining that measures like front-of-the-pack warnings, increasing the price of unhealthy food and reducing the price of healthy food have helped. 

Commercial determinants of obesity and chronic diseases are very well-documented and so is the power wielded by influential processed food corporations across the world, said Dr Marion Nestle, professor of nutrition, food studies, and public health at New York University.

Prof Dr Marion Nestle
Dr Marion Nestle speaking at the World Health Summit 2022.

She pointed to the Lancet Commission’s report and stated that big food companies are not social service agencies with public health as the goal: “They’re businesses with stockholders to please. They have to put profits to stockholders as their first priority, no matter what the people in the companies think they would like to do about hunger, malnutrition, chronic disease and climate change,” she said, calling for a regulatory framework that puts all food companies on the same level playing field.

Keep companies out of public policy

One of the Lancet Commission’s recommendations was the reduction in the influence of large commercial interests in public policy development to “enable governments to implement policies in the public interest to benefit the health of current and future generations, the environment, and the planet”.

Explaining the complicated relationship many governments have with processed food companies, Nestle said that this is a difficult situation. “It’s one that public health advocates have to figure out how to deal with, which means increasing advocacy in civil society,” she said. 

“We ought to be doing what the Lancet Commission suggested, which is keeping food companies out of public policy decisions. They should not be at the table when public health policy is being discussed. They need to be regulated in terms of marketing, and in terms of what the formulation of their products is.”

Secy General IFBA
Rocco Renaldi, secretary-general of the International Food and Beverage Alliance.

However, companies that manufacture and market processed foods play a crucial role in the eco-system and should not be ignored, argued Rocco Renaldi, the secretary-general of the International Food and Beverage Alliance (IFBA).

“We made a commitment on (reducing) sodium…to achieve a global set of sodium targets for our products by 2025, and 2030. These are minimum global targets, you can go further at national level,” he said. 

He was referring to the Nutrition for Growth Summit held in Tokyo in 2021, where the member states of the WHO agreed to a 30% reduction in the global salt intake by 2025. 

While reformulation of products to reduce salt and sugar was important, demonising processed foods is not the answer, he said. “The real answer is how to rebalance the system so that different types of food occupy the right space within that system,” Renaldi argued.

Food financing

Like many other public health challenges, money is a crucial bottleneck in addressing the issue of malnutrition across the world. 

Food financing needs to be envisioned in a different way to achieve these goals, said Dr Geeta Sethi, an advisor at the World Bank. She added that the private sector has deep pockets that will help fund these goals but are deterred by perceived risks. 

“For some reason, we in the food sector have not been able to price risk in a way that allows private finance to come in. This is urgently needed.. the change agents have to be the private finance,” she added. 

“In a nutshell, food systems do not lack financing…the public support for agriculture and food is $700billion a year,” she stated, adding that if food subsidies were a country, they would be the 19th largest economy in the world. “And this is not even considering the massive spending of the private sector, which is around $2 trillion.”

Sustainable food systems

While countries like Indonesia and Bhutan are actively redesigning their food systems and production pathways, countries like Germany, Sweden and Fiji have been successful in creating sustainable food systems that are healthy for their populations. 

“We would like to establish a framework that will be tracking institutional things that are happening in the governments, but also the behavioural change that’s happening in the stakeholders and in the private sector,” Dr Stefanos Fotiou, the director of the UN Food Systems Coordination Hub said. 

The need for political will to address these challenges also came up repeatedly as various ministers shared their experiences in designing and implementing policies around the issue. 

Speaking about her experience in Germany, Dr Doris Heberle, from the federal ministry of food and agriculture said that reducing the intake of salt is not an easy task since it impacts trade-related issues like the shelf-life of food products. 

“But we are going to have more scientific advice and scientific evidence to get better targets for reduction patterns and also to attune those to the target groups which are the most vulnerable,” she added. 

Dr Ifereimi Waqainabete
Dr Ifereimi Waqainabete, Fiji’s Health Minister, at the World Health Summit 2022.

Taking public health decisions when trade is a huge factor in the economy is difficult, said Dr Ifereimi Waqainabete, Fiji’s health minister. He added that small countries like Fiji are pushed to choose between nutritious food that is expensive and cheap food that is less nutritious. 

Waqainabete added that his government had distributed seeds and plants to people during the COVID-19 lockdown to encourage local food production and the regeneration of agriculture.

“We also regenerated our ocean area by bringing back the village system and the tribal system where you have your own ‘parish’ where you fish traditionally and stop fishing at a particular time. And we found that by doing that we’re able to regenerate our ocean,” said Waqainabete.

Sweden’s Ambassador for Global Health, Dr Anders Nordström said his government only procured healthy food for the education and healthcare sectors and this ensured that the most vulnerable received the healthiest options. 

“This has been a policy for a long time… we serve about three million meals every day and this has had a dramatic positive impact. What is interesting is that (the government) has been also putting into those policies that those meals should not just be healthy, they should be affordable.”

Image Credits: Scott Warman/ Unsplash, Megha Kaveri/Health Policy Watch.

For “Nundy,” a mother of two living in South Africa’s Khayelitsha township, going to the doctor more than once a year is not an option.

She would have to pay 50% of her total household income in a month in order to see a doctor, so she saves up all of her medical questions and then makes one appointment, at which she tries to collect as much information as possible to take care of her 18-year-old son, two-year-old daughter and ailing mother.

In the meantime, she buys over-the-counter health products and tries to treat her families ailments herself.

“She told us a story of having many products and she told us all the ways she used them. And she was not sure what their expiry date was or exactly what they were for … but she knew she had to do something,” said Manoj Raghunandanan, global president of self-care and consumer experience at Johnson & Johnson.

He met Nundy a few years ago during a visit to the area.

Manoj Raghunandanan, Global President of Self-Care and Consumer Experience at J&J
Manoj Raghunandanan, Global President of Self-Care and Consumer Experience at J&J

Raghunandanan was speaking Wednesday at the launch of the Global Self-Care Readiness Index (SCRI) 2.0, the kick-off session of the Global Self-Care Federation World Congress 2022, which runs until Thursday.

“She was a consumer that deserved better,” Raghunandanan said, “someone that deserved access, affordability and the right to take care of herself, her family and her loved ones in a responsible way.”

How to improve self-care health policies and practices for people like Nundy was the topic of the congress and the focus of the SCRI report, which is published by the Global Self-Care Federation (GSCF).

The index is 89 pages long and covers 10 additional countries, which supplements the original set of countries examined in the 2021 edition and covers at least one from each of the World Health Organization’s (WHO) six regions: Africa, the Americas, Southeast Asia, Europe, the Eastern Mediterranean, and Western Pacific.

The index is supported by the WHO and forms part of the working plan between itself and GSCF. It aims to arm healthcare decision-makers and professionals with the data they need to increase self-care in their own countries and around the world.

Judy Stenmark, Director General of the Global Self-Care Federation (GSCF), speaks at the launch of the Self-Care Readiness Index 2.0 on Wednesday, October 19, 2022
Judy Stenmark, director-general of the Global Self-Care Federation (GSCF), speaks at the launch of the Self-Care Readiness Index 2.0.

Regulatory environment

The self-care industry has sometimes come under fire for making far-fetched claims about products to encourage people to spend money on things that don’t work, but GSCF director-general Judy Stenmark said that is something her organization is working to fix.

“Consumers become aware of the products or activities mainly through marketing and advertising, especially online,” she told Health Policy Watch. “We must ensure that we continue with our self-care literacy education efforts, especially in the digital sphere, including product guidance and e-labelling.”

SCRI 2.0 highlights the regulatory environment as one of the key enablers of self-care, advising countries to “focus on regulations and processes governing approval of new health products, from prescriptions to over-the-counter medications.”

Stenmark also stressed that while some people think of self-care as providing consumers with over-the-counter medicines, it is a multi-dimensional concept, which encompasses different notions, starting from self-medication to maintaining a healthy diet and raising health literacy levels.

WHO resolution by 2025

In order to help persuade policymakers of the importance of self-care, GSCF is working to have a self-care resolution adopted by WHO by 2025, something Stenmark said would provide a clear articulation of self-care and outline the value for health systems, governments and a people-centered care network.

It would also help facilitate member states’ development and effective implementation of national self-care strategies and provide them with direction on aligning resources.

“If we pass a resolution, things start to change, and then we get self-care embedded in policy,” she stressed. “That is why we want a WHO resolution. We want to build the political wheel for self-care.”

Socio-economic benefits

Currently, half the world lacks access to adequate healthcare, according to Dr Bente Mikkelsen, WHO’s director of non-communicable Diseases, who spoke at the beginning of the launch event.

According to the SCRI report, the sector could be improved by increased support and trust of self-care behaviors and products by healthcare providers, patients, consumers and regulators; increased health literacy; and policymakers’ recognition that self-care has economic value.

Low- and middle-income countries, often plagued by disease, have the highest potential to benefit from self-care policies.

Africa faces the “largest and biggest disease burden of all the regions in the world,” said Skhumbuzo Ngozwana, Chief Executive Officer of Kiara Health in South Africa. Some 90% of malaria deaths take place on the continent, tuberculous is still common and there is a “burgeoning and exploding” non-communicable disease problem,  Ngozwana said.

“Clearly Africa has a major problem,” he said. “All of this is in the context of significant infrastructure challenges, constrained budgets and that less than 3% of global healthcare workers are deployed on this continent. If people have to spend 50% of their monthly income on doctors, it makes it impossible.”

GSCF has also put out a supplementary report, Global Social and Economic Value of Self-Care,  which shows the potential socio-economic benefits of self-care around the world and specifically in sub-Saharan Africa.

If proper self-care policies were put into practice, the report showed, it would represent a $4 billion savings on annual healthcare costs in sub-Saharan Africa by 2030. Moreover, it could save individuals a collective 513 million hours in time savings and physicians 44 million hours. It would also reduce welfare spending by $31.5 billion.

Annual socio-economic benefits of self-care in Sub-Saharan Africa presented by the Global Self-Care Federation
Annual socio-economic benefits of self-care in Sub-Saharan Africa presented by the Global Self-Care Federation

Globally, the numbers are even greater: $179 billion in healthcare cost savings and $2.8 trillion in welfare spending.

“Self-care integration has significant long-term economic benefits for health budgets and health systems in general,” GSCF told Health Policy Watch. “Integrating self-care into the healthcare continuum allows for better resource allocation, alleviates burden placed on health systems, and ultimately improves the quality of care provided.”

Image Credits: The Global Social and Economic Value of Self-Care report, Screenshot.

Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization.

A shortage of cholera vaccines and a number of outbreaks have prompted the World Health Organization (WHO) to advise countries to administer single doses of the vaccine instead of the usual two doses.

So far, 29 countries have reported cholera outbreaks, with Haiti, Syria and Malawi dealing with large outbreaks. The standard preventive approach to cholera is two-dose vaccination with the second dose administered within six months of the first. The immunity of a fully vaccinated person against cholera lasts for three years. 

“The one-dose strategy has proven effective in previous outbreaks, although evidence on how long protection lasts is limited,” Dr Tedros Adhanom Ghebreyesus, the director-general of WHO told a media briefing on Wednesday. 

However, he stressed that “this is clearly less than ideal and rationing must only be a temporary solution”.

“In the long term, we need a plan to scale up vaccine production as part of a holistic strategy to prevent and stop cholera outbreaks. The best way to prevent cholera outbreaks is to ensure people have access to safe water and sanitation,” he stressed.

Stockpile depleted

Four organisations – WHO, UNICEF, Médecins sans Frontières and the International Federation of the Red Cross and Red Crescent Societies – have managed the global stockpile of cholera vaccines since 2013. 

Of the 36 million doses produced this year, 24 million doses have already been shipped to countries facing outbreaks. The International Coordination Group (ICG), a WHO group that manages and coordinates emergency vaccine supplies and antibiotics during major outbreaks, has approved eight million doses for the second round of emergency vaccination in four countries, leaving only four million doses for further outbreak management. 

This shortage has prompted the ICG to recommend that countries temporarily suspend the two-dose vaccination regime and instead follow a single-dose regime so that more people can be protected against the bacteria. 

“The one-dose strategy has proven effective in previous outbreaks, although evidence on how long protection lasts is limited,” Dr Ghebreyesus said, calling for a scale-up of vaccine production. “The best way to prevent cholera outbreaks is to ensure people have access to safe water and sanitation.”

Narrow window to prevent Tigray genocide

Tedros also called for international attention to the civil war in Tigray, Ethiopia, which has left around six million people “under siege for almost two years”.

“I’m running out of diplomatic language for the deliberate targeting of civilians in Tigray, Ethiopia,” said Tedros. “There is a very narrow window now to prevent genocide in Tigray.”

The WHO Chief quoted Antonio Guterres, the UN Secretary-General, who called for the immediate withdrawal of Eritrean armed forces from the region.

Tedros described the “indiscriminate attacks” on civilians as “war crimes”.

“There are no services for tuberculosis, HIV, diabetes, hypertension and more – those diseases, which are treatable elsewhere, are now a death sentence in Tigray…This is a health crisis for six million people, and the world is not paying enough attention,” added Tedros, who was a former health minister of Ethiopia.

“Banking, fuel, food, electricity and health care are being used as weapons of war. Media is also not allowed and destruction of civilians is done in darkness.”

Ebola and COVID-19

WHO expressed concerns about the Ebola outbreak in Uganda and added that there is a possibility that more transmission chains and contacts might be involved in the spread of the virus. 

As of Wednesday, there are 60 confirmed and 20 probable cases of Ebola in the country, with 25 recoveries and 44  deaths.

Two people with confirmed infection in Mubende district had travelled to Uganda’s capital city, Kampal,a for treatment, thus prompting fears of transmission in the capital. The Ugandan government issued lockdown orders in Mubende on 16 October. 

“The Ministry of Health is investigating the most recent eight cases, as initial reports indicate they were not among known contacts,” Tedros said. 

Meanwhile, COVID-19 remains a public health emergency of global concern as per the Emergency Committee meeting last week. WHO urged countries to strengthen surveillance, and not reduce testing, treatment and vaccination for their populations.

“While the global situation has obviously improved since the pandemic began, the virus continues to change, and there remain many risks and uncertainties.”

Cary Adams, Bente Mikkelsen, Alejandra de Cima Aldrete, Valerie McCormack, Miriam Mutebi and Olivier Michielin address the World Cancer Congress press conference.

Common cancers that can be treated successfully when they’re detected early – breast, cervical, colorectal and prostate – are causing high mortality in low and middle-income countries (LMICs) because of a lack of screening and treatment, Dr Cary Adams, CEO of the Union for International Cancer Control (UICC), told a press conference at the start of the World Cancer Congress in Geneva on Tuesday.

“We see this inequity in childhood cancer, with 80% survival rates in high-income countries and as low as 20% in low and middle-income countries,” he added at the start of the hybrid in-person and online congress, which is being attended by some 2,000 scientists, public health officials, civil society representatives and cancer control experts from 120 countries.

A new study by members of the Bloomberg New Economy International Cancer Coalition released this week calculates that at least 1.5 million deaths, representing 20% of global cancer deaths, could be avoided each year if international regulations around patient trials were more standardized and people placed on life-saving treatment immunotherapy treatments such as Pembrolizumab (for lung cancer) and Enzalutamide (prostate cancer).

Despite the US Food and Drug Administration (FDA) approval of Pembrolizumab in 2016 and Enzalutamide in 2012, neither drug is yet available in many countries and regions of the world due to “regulatory isolationism that is preventing approval and usage of these and other much-needed oncology therapies”, according to the study.

The  Access to Oncology Medicines (ATOM) Coalition, which was formed in May, has started to engage with pharmaceutical generic and biosimilar companies “to see whether we can find ways to get their medicines into LMIC countries either by increasing donations, by tier pricing or using a voluntary licence mechanism”, said Adams. 

Dr Bente Mikkelsen, director of non-communicable diseases (NCDs) at the World Health Organization (WHO), said that the WHO had private sector dialogues every six months “where we have defined asks for most of the diseases and we call for commitments to be able to increase access to medicines and devices”. 

“On cancer, our focus is now of course on the medicines that are already on the essential medicine list, but we don’t shy away from the innovative new drugs and devices,” said Mikkelsen, adding that the dialogue was a structured and safe way to discuss access to medicine.

COVID disruptions

Mikkelsen pointed out that, in the four years since the last cancer congress, 30 million people had died of cancer – and there had been disruptions to 50-60% of cancer treatments during the COVID-19 pandemic.

“This is happening because the health system is actually too weak,” said Mikkelsen. “There is no [pandemic] preparedness without including cancer in universal health coverage. We will not be able to manage the new pandemic or for a humanitarian crisis unless we build stronger health systems.”

Mikkelsen added that over 70% of people diagnosed with cancer in LMICs “pay out of their own pocket for things that should be covered by the governments and this is very often the choice between food, care of the family or actual treatment and diagnosis”.

‘Financial toxicity’

Dr Miriam Mutebi, UICC Board Member and a breast surgical oncologist, said that “financial toxicity –  the fact that patients paid themselves for cancer treatment”, was a big reason why the majority of African patients are “still getting diagnosed with advanced disease and frequently not completing their care”. 

Women were particularly affected by a lack of finances as many were involved in the informal economy.

“Looking at the system’s challenges, we know in sub-Saharan Africa, women patients will see, on average four to six healthcare providers before a definitive diagnosis of their cancer, and this really underscores the need for increasing awareness, not just in the community but also amongst healthcare workers,” stressed Mutebi.

Mexico’s civil society makes cancer ‘law’

Mexican cancer survivor Alejandra de Cima Aldrete, Founder and President of Fundación CIMA, said that civil society in her country was in the process of drawing up cancer laws themselves.

“Every day I hear horrible stories about a massive shortages of medicine, about women that have to wait months before they get they get seen by a specialist, of woman that died because they didn’t have the money to continue their treatment,” said Aldrete.

“So my commitment today with my people in my country is to improve the lives of people living with cancer through changes in the legislation, the most meaningful, efficient and with the outmost reach being the general cancer law from Mexico that is currently being drawn up by 13 NGOs, mine included.”

“The cancer law would provide the very needed legal instrument that will allow us citizens to demand the policies that ensure quality and timely medical care for cancer patients. It will force also the government to comply to its sections which include amongst others, the national cancer plan and the National Cancer Registry,” said Aldrete.

A million maternal orphans

Over one million children lose their mothers to cancer every year, according to a congress paper that modelled maternal orphans for the first time using data from 185 countries. 

In 2020, an estimated 4.4 million women died from all types of cancer worldwide leaving behind 1.04 million new orphans (aged 18 and under), according to researcher Dr Valerie McCormack from the French International Agency for Research on Cancer (IARC).

Almost half the orphans were in Asia (49%), and over one-third were from Africa (35%). 

Their mothers died predominantly from breast (25%), cervical (18%) and upper-gastrointestinal cancers (13%). 

The mortality rate of cervical cancer should be reduced through screening for, and vaccinating against, the human papillomavirus (HPV), while early detection and quality treatment of other cancers was essential “to avoid the impact on on the next generation”, said McCormack.

“Orphans in some settings have lower educational levels and higher mortality than their peers. So it’s not only the women who die, we need to prevent their deaths,” she added.

WHO cancer survey

Meanwhile, the WHO launched the first global survey on Tuesday to better understand and address the needs of all those affected by cancer. 

Noting that nearly every family globally is affected by cancer, either directly – 1 in 5 people are diagnosed with cancer during their lifetime – or as caregivers or family members, the survey “is part of a broader campaign, designed with and intended to amplify the voices of those affected by cancer – survivors, caregivers and the bereaved – as part of WHO’s Framework for Meaningful Engagement of People Living with Noncommunicable diseases”. 

“For too long, the focus in cancer control has been on clinical care and not on the broader needs of people affected by cancer,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “Global cancer policies must be shaped by more than data and scientific research, to include the voices and insight of people impacted by the disease.”

Germany’s health minister, Dr Karl Lauterbach and WHO’s Dr Mike Ryan

Amid criticism that the World Health Summit was ‘speed-dating for consultants’, panellists lamented a lack of practical plans to empower local service delivery

A more empowered World Health Organization (WHO), stronger health local systems and better surveillance are some of the weapons that will protect the world against future pandemics, according to panellists at the World Health Summit in Berlin.

“The WHO needs more powers to deal with pandemics. Isn’t there something ridiculous about the fact that the International Atomic Energy Agency can go into a war zone and inspect what’s happening in a nuclear power plant and WHO doesn’t have an absolute right to get visas to go to the site of any outbreak anywhere in the world?” said Helen Clark, the former prime minister of New Zealand and co-chair of the Independent Panel for Pandemic Preparedness and Response. 

She was referring to how China denied WHO-appointed experts access to the outbreak of the pandemic in Wuhan.

“The International Health Regulations need to be made fit for purpose and empowering the WHO on very practical issues like that,” said Clark, who also asserted that “it was not the WHO that failed the world. It is member states that failed the WHO.” 

No one had a plan

Germany’s health minister, Dr Karl Lauterbach, said that when his country assumed leadership of the G7, it was clear that no country had a plan on how to address pandemics. To get a better understanding of the gaps, he convened three informal meetings of scientists.

What emerged, said Lauterbach, were two key consensus points: first, “we are lacking a workforce which is better prepared to recognise a possible pandemic and to avoid that an outbreak becomes a pandemic” and second, a lack of surveillance to identify a pandemic Lauterbach appealed for everything to be geared towards addressing these two crucial needs – and training young people to “get them interested in pandemic control”. 

“We will either spiral upwards or spiral downwards. If we spiral downwards, we will have more climate change, and more pandemics because of climate change. We will have poorer primary health because of climate change and pandemics and we will have more wars because all of this is happening.”

‘Last mile of delivery is first mile of health security’

Dr Mike Ryan, WHO executive director of health emergencies,  agreed that “without data, you’re blind and without a workforce, you have no capacity to act”.

However, he added that “95% of people who survive natural disasters survive because their neighbours and their families dig them out from under a building or pull them out of the water”. 

“That’s exactly the same principle in epidemics. It is local, community-based surveillance, point-of-care diagnostics, the ability to understand there’s a problem in the community and the rapid provision of support to a community before an outbreak becomes a national or global event,” said Ryan.

The “last mile” of health care was also the “first mile of health security” – and often the weakest link.

Describing the health summit as “speed dating for global consultants”, Ryan said that things were very different at the country level where Ministries of Health were “usually underfunded, and the weakest ministry in government”.

“Then we come in with our vertical systems and we start pushing everyone: ‘you must do this and you must do that. We have decided this is best for you’. How paternalistic is that?” Ryan said, appealing for attention to “that principle of service to the people” – and humility.

South Sudan Minster of Health Elizabeth Chuei receiving a COVID-19 vaccine after delivery from COVAX.

‘Little white, northern cabals’

He also took aim at “many unelected individuals around the world who live in their little, white northern cabals who like to sit in rooms and decide what the future of global health is going to be”.

“The reality is 194 ministers of health come together every year in Geneva, and they set out under democratic principles, what are the policies for the world and we need to continue to invest in that,” said Ryan.

“We’re a flawed organisation. But we are radically transparent and we are open. Everything we do is on the table. Everything we do is out there for criticism. I wish it were the same for other entities and institutions.”

He also blamed any failures in the global vaccine delivery platform, COVAX, on “the greed of the north”, “the greed of pharmaceutical industry” and “self-interest in certain member states” that were not prepared to share.

“COVAX went against that trend, and COVAX tried in its best way to represent that need around the world,” said Ryan, adding that he and others often worked “26 hours a day” to address the pandemic and sometimes needed to be “peeled off the wales”.

Principles not plans

Professor Lawrence Gostin from Georgetown University in the US said there was a need for “better governance” of the WHO.

“We need to have more honesty and stewardship, transparency and openness, most important, inclusive participation, effective performance monitoring benchmarks, quality improvement, accountability, and the most important thing is equity,” said Gostin.

German health ministry official Björn Kümmel, who has driven the re-financing of the WHO as co-chair of the Intergovernmental Working Group on Sustainable Financing, said that his country would like to “enable WHO not only financially but also technically, potentially legally through new mechanisms in the IHR and obviously, the pandemic treaty, and politically also vis a vie other global health agencies or other actors who are engaging in global health”. 

However, Kummel conceded that “nobody seems to have a plan”.

Discussion was largely about “principles” – such as “better governance, trust, transparency, acceptance of criticism, [ensuring] the voice of civil society, equity, community intelligence systems.

“All the big words that were mentioned here, I think it’s clear that none of us seems to have the right plan.”

Image Credits: UNICEF.

pollution
Air pollution in Delhi, India.

New evidence that exposure to air pollution can potentially contribute to obesity in women has emerged from a study by the University of Michigan

“Women in their late 40s and early 50s exposed long-term to air pollution—specifically, higher levels of fine particles, nitrogen dioxide and ozone—saw increases in their body size and composition measures,” said Xin Wang, epidemiology research investigator at the University of Michigan School of Public Health and the study’s first author. 

By cross-referencing the residential addresses of the 1,654 US women participating in the study with hybrid air pollutant concentration estimates from 2000 to 2008, the data showed exposure to air pollution was linked with higher body fat, body mass index, and lower lean mass.

But it is not all bad news. The study found that while body fat increased by 4.5%, high levels of physical activity were an effective way to mitigate and offset the effects of air pollution exposure.

Pollution and obesity: a growing link 

With an unprecedented increase in body weight issues worldwide over the last decades, numerous studies have sought to understand the complex and varied causes of obesity – and this is not the first to explore the link to air pollution.

In 2019, researchers at the University of California at Santa Barbara published the first study estimating the causal effect of air pollution on body weight based on data from 13,226 adults in China from 1989-2011. 

This period of study is unique for its historical backdrop. Across the years of the study, China’s economic explosion contributed to a rise in fine particulate matter concentration by 70%. During this time, China’s average BMI increased by 11%, while overweight and obesity rates increased from 8.57% to 32.83% and 0.48% to 4.9% respectively.

“Our study suggests that the cost of air pollution on overweight and obesity is non-trivial,” the authors state. “Although the effect’s magnitude is smaller than studies focused on other economic [and socioeconomic] variables, it is in the same order of scale.”

The International Journal of Obesity also highlighted the potential effects of ambient air pollution on child obesity development but noted evidence is still scarce.

“Early life exposure to air pollution may be associated with a small increase in the risk of developing overweight and obesity in childhood, and this association may be exacerbated in the most deprived areas,” the journal notes. “Even these small associations are of potential global health importance.”

The most striking results came from a study conducted by the Lung Care Foundation and Pulmocare Research and Education in India. The results found that while 39.8% of the children in Dehli, one of the world’s most polluted cities, were obese or overweight, this was true for only 16.4% of children in Kottayam and Mysuru, cities with significantly better air quality.

As studies continue to deepen our understanding of the toxic effects of fine particulate matter (PM2.5) on human health, the silent threat posed by polluted air has revealed itself to be more multifaceted than previously known – and extremely deadly.  

With 99% of the global population breathing air beyond the World Health Organization’s recommended quality limits, an estimated nine million deaths are caused by modern air pollution sources every year. 

New evidence of the adverse effects of air pollution is emerging at a rapid clip, but despite the economic and health implications, progress on the policy front remains slow.

Image Credits: Ella Ivanescu/ Unsplash, Wikimedia Commons: Prami.ap90.

Cancer
More than 1,500 scientists, medical specialists, NGO and civil society representatives, ministers of health, high-level United Nations representatives and people living with, or affected by, cancer are expected this week at the World Cancer Congress 2022.

A lack of expertise in geriatric oncology means that cancer in older adults is often confused with other signs of ageing and diagnosed too late.  Dr Sonali Johnson sets out a blueprint for addressing this barrier – one of the many topics to be discussed at the World Cancer Congress, hosted by the Union for International Cancer Control in Geneva, 18-20 October.

Cancer is a disease for which older adults are particularly at risk as the cells of the body are more likely to turn cancerous as a person ages, primarily as a result of greater exposure to risk factors (though this exposure can be reduced by adopting early a healthy lifestyle). In 2020, over 50% of all cancer cases were among people aged over 65 – nearly 10 million out of a total of 19.3 million – and this proportion will grow further in the coming decades, with the fastest increase occurring in low and middle-income countries (LMICs).

The treatment of cancer is more complex for older adults with co-morbidities, requiring an integrated approach. Yet a lack of expertise in geriatric oncology at different levels of the health system means that cancer in older adults is often diagnosed late as early symptoms are sometimes considered to be signs of ageing. Cancer is more complicated and invasive to treat successfully when it is detected at a more advanced stage.

Age isn’t everything

IUCC
More than half of all people who have cancer are over 65 years old, and this number is predicted to rise as populations age globally. Yet, many health systems are not prepared to address the specific needs of this population.

Older adults are not a uniform group and age alone is a poor predictor of an individual’s health. They can have widely varying physical and mental health at a similar age, with the presence or not of co-morbidities. They may or may not have a strong social support network. They may have considerable or, on the contrary, very limited financial means. Each of these factors will shape if and how an older adult engages with the health system, therefore their preferences and needs should be individually assessed. 

To do so effectively, we need to improve our data on the prevalence of co-morbidities amongst adults aged over 65. Many health policies have been developed and implemented with partial information and in silos, addressing diseases separately. There is an opportunity here for cross-sectoral and multisectoral coordination and integrated approaches that lay the groundwork for patient-centred care.

There is also a need to train health staff in geriatric care to correct the misconceptions that often surround health and ageing – stereotypes, assumptions and prejudices that mask the diverse nature of older populations and the contributions of older adults to society.

Patient-centred care also means removing age limits in clinical trials and the inherent biases in research programmes to make them more inclusive. Currently, doctors and regulators may have little precise knowledge of how older adults react to certain treatments or how cancer medicines may interact with other medications they are taking, since these have not been tested.

Countering misperceptions that older adults themselves may have about clinical trials (e.g. fear of mistreatment, being used as a ‘guinea pig’) is also essential to improve access to services and research. Other limitations also need to be addressed, such as hearing or transportation difficulties.

Only if older adults are proportionately well represented in clinical trials and research can doctors have more insight into the efficiency and side effects of cancer treatments for people over 65.

Caring for older cancer patients is a surmountable challenge

Cancer
Estimated increase in cancer incidence and mortality (2020 data: Globocan / 2030 previsions: AIRC)

The Union for International Cancer Control (UICC) has made cancer and ageing a focus area of its work, supporting the advocacy efforts of UICC member organisations in LMICs working to improve access to cancer services and care for older adults

Initiatives in El Salvador, Guatemala, Kenya, Mongolia and Tajikistan have been set up in partnership with Sanofi, to improve the training of healthcare practitioners in geriatric care; include cancer and ageing strategies in national cancer control plans and universal healthcare packages; ensure cost-free access to cancer medicines for people aged over 65, and increase the availability of palliative care specifically tailored to the needs of older adults.

To improve cancer care for older adults at the international level, the International Society of Geriatric Oncology has developed the Top Priorities Initiative to identify global priorities for progress and development in geriatric oncology and translate these priorities into tangible actions.

The American Society of Clinical Oncology (ASCO) has issued recommendations for geriatric assessments, a tool to understand an older person’s physiological and socioeconomic situation to inform the most effective and appropriate course of care.

These are being adopted by several health systems, for instance in Chile, where the Arturo Lopez Perez Foundation (FALP) created an oncogeriatric unit to provide a comprehensive geriatric assessment of older adults with cancer.

Caring for older adults is not about prolonging life at all costs – and it is not an insurmountable challenge. Neither does it necessarily involve investing significantly in additional resources or diverting resources from other priorities.

It is, ultimately, about ensuring that the clinical expertise exists to identify the specific needs of older adults and offering them the same opportunities for diagnosis and treatment as other populations enjoy, in line with their wishes and particular situation.

Sonali Johnson is Head of Knowledge and Advocacy at the Union for International Cancer Control (UICC), which is hosting the World Cancer Congress in Geneva, 18-20 October.

Vaccine deliveries by the global COVAX facility.

Midway through last year, the head of the Africa Vaccine Acquisition Task Team, Strive Masiyiwa, angrily accused the global COVID-19 vaccine acquisition platform, COVAX, of misleading African countries about its ability to procure vaccines for them.

Masiyiwa’s bitter remarks came after months of Africans watching Europeans and North Americans being vaccinated against COVID-19 while no vaccines were available for them – even if their governments had the money to pay for them.

By the end of last year, a special meeting of the World Health Assembly had resolved to set up an intergovernmental negotiating body (INB) to negotiate an accord to guide future pandemics, and all member states agreed that it needed to be based on equity. The INB is expected to submit a draft accord to be negotiated at the 77th World Health Assembly in 2024.

This week, an independent evaluation of the Access to COVID-19 Tools Accelerator (ACT-A), COVAX’s parent body concluded that “a different model for pandemic response will be needed in future”.

The review – which combined interviews with over 100 key informants, a survey and a review of documents – comes as the World Health Organization’s (WHO) INB is preparing a “zero draft” to kick off negotiations on the pandemic accord. 

The ACT-A comprised three pillars – diagnostics, therapeutics, vaccines (COVAX) and a fourth cross-cutting pillar, the Health Systems and Response Connector (HSRC), which was viewed as a flop. 

COVAX ‘too ambitious’

Interestingly, the review’s main criticism of COVAX is that its global scope as the key vaccine-purchasing agent for the world was “too ambitious” and that a “more targeted approach” would have been more useful. 

This observation is based on the failure of high-income countries to go through COVAX to buy its vaccines, meaning that COVAX was “unable to play the market shaping role it first envisioned”. 

The crux of any successful pandemic accord will be to ensure that wealthy countries don’t hoard all the available diagnostics, therapeutics and vaccines to fight the next killer pathogen – an almost impossible task.

Instead of expecting wealthy countries to subject their procurement to a global body, it might be more effective for a future pandemic body to “focus on a smaller set of lowest-income countries”, according to the review.

Despite the criticisms, COVAX’s performance in improving access to COVID-19 vaccines in the 92 Advanced Market Commitment (AMC) countries was ranked 7.5 out of 10, the highest survey rating.

By 15 September, it had delivered 1.72 billion doses although massive vaccine inequalities persist. 

Barbados receives 33,600 doses of COVID-19 vaccines, its first shipment through the COVAX facility, in April 2021

Unsuitable operating model

Almost two-thirds of respondents thought that ACT-A’s operating model should not be replicated, citing problems including “insufficient accountability, limited meaningful engagement of low- and middle-income countries (LMIC) and regional bodies, and an insufficient focus on delivery”.

Prioritising speed and using existing global health agencies to respond to the pandemic had “compromised accountability and transparency”, according to the review. 

“Insufficient manufacturing capacity, unhelpful member state responses to COVID-19, and issues around ‘last mile’ implementation were the three factors that had the biggest impact on ACT-A’s ability to deliver on its targets,” according to survey respondents. 

Civil society organisations and academics listed the lack of technology transfers and the management of intellectual property as the most significant challenges. 

“Going forward, a new platform should be established that involves all key R&D partnerships and coordinates R&D across product types and diseases,” the review recommends.

Three-quarters of survey respondents supported joint resource mobilisation instead of uncoordinated fundraising.  ACT-A raised $23.5 billion, two-thirds for COVAX, but fundraising was too slow, and respondents supported a pandemic advance commitment facility with access to credit. 

The World Bank has already heeded this, and last month it set up the Financial Intermediary Fund (FIF) for Pandemic Prevention, Preparedness and Response (PPR) to “provide a dedicated stream of additional, long-term financing to strengthen PPR capabilities in low- and middle-income countries and address critical gaps through investments and technical support at the national, regional, and global levels”. 

The lack of manufacturing capacity, and weak country health systems are key challenges to address before the next pandemic. 

High-level political leadership

Finally, the review advocates for the creation of a high-level political body to keep pandemic preparedness and response high on the global agenda, track overall progress and provide high-level political guidance. 

Previously, the Independent Panel for Pandemic Preparedness and Response (IPPPR) proposed that a council for pandemic preparedness, made up of senior political leaders, be established under the United Nations General Assembly.

Meanwhile, WHO suggested establishing a Global Health Emergency Council and a Committee on Health Emergencies of the World Health Assembly.

ACT-A was guided by a facilitation council chaired by Norway and South Africa, but the co-chairs lacked global clout and spent a lot of energy appealing to world leaders of wealthy countries to share their pandemic products with others.

Image Credits: Gavi , @CEPI , PMO Barbados.

The drought in the Horn of Africa has caused famine in Somalia.

Over 90% of appeals for urgent hunger-related funding made through the United Nations humanitarian system were not fully funded in 2021, according to a report produced by Action Against Hunger.

While global funding has increased by 233% over the past decade, overall humanitarian needs are up 500%. 

“This means that 42% fewer UN appeals are being fulfilled,” the report stated.

In an analysis of the response to ‘crisis’ levels of hunger experienced in 2020 in 13 countries, less than 8% of food security appeals were fully funded while none of the appeals for support of water, sanitation, and hygiene (WASH) programs were fully funded.

Moreover, more than six out of ten of hunger-related appeals were not even funded to the halfway point while countries that experienced the greatest hunger crises received less hunger funding (by percentage of appeals filled) than countries with half the rate of hunger.

Michelle Brown, Action Against Hunger USA’s advocacy director, described the findings as alarming and called on the global community for more funding to combat hunger, especially in places where the crises are severe.

“While donors have increased their funding, they haven’t increased their funding to the necessary level to actually meet all of those needs,” Brown told Health Policy Watch. “As needs continue to go up, humanitarian funding continues to go up as well but not at the same level. We’re seeing a really significant gap between what the needs are and what the funding levels are.” 

Moreover, she said the report did not take into account the impact of the Ukraine crisis on food prices and the humanitarian response: “What we’re going to see are even greater levels of need, and for similar funding levels that aren’t able to meet those needs.”

It is still possible to end hunger in our lifetimes

In spite of the burgeoning hunger-related crisis and the worsening risks posed by conflicts and climate change, the report notes that it is still possible to end hunger “in our lifetimes”. This, it said, is based on a number of factors including progress made so far. 

Currently, about 828 million people (one in ten worldwide) are undernourished and 50 million people in 45 countries are on the verge of famine, yet between 2005 and 2014, the number of undernourished people dropped from 806 million to 572 million. This represents a reduction of nearly 30% within the period alone. 

The report also noted that the world has enough food and funding to meet the UN Global Goal of Zero Hunger by 2030. But it warned that this goal cannot be achieved without closing the hunger funding gap.

“We have the ability and we have the compassion that’s needed to finally solve hunger. Right now, especially when you look at what’s happening in East Africa, the needs are enormous and we have an opportunity to save lives. We’ve seen in the past that humanitarian assistance can save lives, it can prevent a famine and…this time around, [we need] to ensure that we don’t find ourselves in a famine situation,” Brown told Health Policy Watch.

Image Credits: UN-Water/Twitter .

AMA Treaty approved by South Africa
South African Health Minister Mathume Joe Phaahla affirms support for the AMA at a February 2022 visit of WHO Director General Dr Tedros Adhanom Ghebreyesus.

In a major step forward for the new regulatory alliance, Africa’s third-largest economy, South Africa is now moving to join the African Medicines Agency. 

South Africa’s Cabinet has approved the signing of the African Union treaty establishing the African Medicines Agency (AMA) and submitted it to Parliament for ratification, according to a government statement on 23 September. 

“Cabinet approved the signing of the Treaty for the Establishment of the AMA and its submission to Parliament for ratification,” the statement reported.

“This will give effect to the treaty that was adopted by the African Union Assembly in 2019. The treaty formally establishes the AMA for the continent. The agency will regulate medical products and improve the safety and efficacy of the medical products for the continent.

“The signing and ratifying of this treaty will advance South Africa’s global and continental commitment toward strengthening the continental regulatory system on its health products,” the statement added.

If the South African Parliament ratifies the treaty, South Africa will be the 34th country to swing behind the AMA since the treaty took force in November 2021 with the ratification of the first 15 African countries to get behind the initiative. 

AMA Countdown – status as of 11 October 2022

Public health officials welcome South African move

Zimbabwean public health specialist Dr Nokuthula Kitikiti, who is of South African origins, described the development as “great news”.  She noted that South Africa’s move holds special relevance since its national regulatory agency is one of the few in Africa that has achieved the milestone of being designated as “maturity level 3” (ML3) by WHO. 

“Smaller and less developed agencies can benefit from their participation in the AMA by building capacity through joint reviews and understanding the process at the South African Health Products Regulatory Authority (SAHPRA) and other ML3 agencies,” she told Health Policy Watch.

As a key regional manufacturing centre for vaccines and the site of the World Health Organization’s (WHO) mRNA vaccine hub, Kitikiti said it is is vital for South Africa to be involved in AMA as Africa builds its vaccine manufacturing capabilities. 

“South Africa also has a vibrant patient and civil society community that I am sure will enrich the continent-wide discussions on how to involve the public and patients in a more meaningful way in health products regulations as the AMA takes shape. We are still very nascent in this compared to other regions. After all, we are all doing this to make medicines safer and more accessible for patients,” she added.

Key country in operationalizing AMA 

South Africa has been one of the big country holdouts on treaty ratification – along with Nigeria in West Africa and Kenya in East Africa. 

 

This is despite pledges from South Africa’s political leadership that it supported the AMA dating back as far as 2017 when the AMA’s first stakeholder consultative meeting was held at the South African historical city of Johannesburg.

Senior South African government officials have repeatedly stated that they had no hesitation regarding being a part of the AMA. In February 2022, South Africa’s Health Minister, Dr Joe Phaahla affirmed the country’s support for the continental-wide medicines regulatory authority, and said the government would sign the treaty.  

“There is no, in principle, hesitation. It’s more operational in terms of making sure that we do sign the treaty on the AMA,” the minister said, during a tour by WHO’s Director General of Cape Town’s new mRNA vaccine R&D hub.

Treaty ratification by parliament remains critical next step for South Africa – also for Kenya  

The front page of the AMA Treaty

Even so, ratification of the AMA treaty by the South African parliament remains a critical step before the deal is sealed. Following that, the treaty ratification then needs to be formally deposited with the African Union. 

Kenya’s parliament has remained stalled on the treaty ratification already for the past five months ever since the cabinet signalled its approval of the treaty in May. 

In Kenya, the National Assembly officially received a memorandum proposing ratification of the AMA in June 2022 but nearly four months later, parliamentarians are yet to vote on the treaty. 

According to the memorandum that presented the treaty to the parliament, the signing and ratification of the treaty by Kenya will “demonstrate Kenya’s commitment to the continent’s collective action to the improved regulation of medicines, medical products and technologies… Ratification will bring about positive consequences both to the country and States Members.”

However, Kenya held national elections in August, leading to a Supreme Court challenge of the election of President William Ruto, whose election was ultimately upheld. The ensuing political uproar, however, likely also delayed the parliamentary move. 

East African countries urged to sign the treaty 

The treaty has long been a topic of discussion in regional African political forums, including at events such as the Commonwealth Speakers and Presiding Officers’ Conference held in November 2021 in Rwanda and attended by both Kenya and South Africa. 

South Africa approves AMA Treaty.
(On right) Amos Masondo, head of the South African delegation to the Commonwealth Parliamentary Conference in Rwanda in November 2021.

At that conference, the leader of South Africa’s delegation Amos Masondo, urged parliamentarians across the continent to “accelerate the ratification” of the treaty.

“Establishment of an AMA [will] help regulate products; help invest more in research and development, [and help countries] to build their own vaccine production while fighting to address vaccine nationalism that disadvantages the African continent,” Masondo said.

Nigeria another holdout – could be a costly delay  

In West Africa, meanwhile, Nigerian global health equity advocate Ifeanyi Nsofor told Health Policy Watch the continual delay in the treaty’s ratification and full implementation could create confusion in the pharmaceutical landscape on the continent as countries that have already signed and submitted the treaty may have a different policy direction from those that haven’t. 

He added that the delay could also have impacts on plans to scale up vaccine manufacturing on the continent.

“Of importance is the way it could delay plans to manufacture vaccines in Africa. Infectious diseases do not care about politics. Ultimately, Africans would suffer from this reluctance. It’s a matter of life and death,” Nsofor told Health Policy Watch.

Lesotho and Mozambique the latest formal AMA entries

In spite of holdouts, the number of countries in Africa that have swung behind the treaty has continued to grow – and now constitutes a two-thirds majority of the African Union’s member states.  

On 1 September, the Kingdom of Lesotho became the latest Member State to ratify and deposit the AMA Treaty instrument.

Prior to that, the Republic of Mozambique also signed the treaty on 8 August but it has yet to ratify the treaty and deposit the ratified instrument with the African Union as per the formal required procedure. 

Regarding the holdouts, the official AU line continues to be “countries have different ratification processes at the national level … However, the AU Commission continues with advocacy efforts to encourage more member states to ratify the Treaty.”

At the same time, AU Special Envoy to the AMA, Michel Sidibé, and the AMA Treaty Alliance (AMATA) are also engaging patient groups, industry, academia and civil society to support the AMA treaty and its operationalization. 

Sidibé, who also is the former Executive Director of the Joint United Nations Programme on HIV/AIDS (UNAIDS), described the success of this approach as reliant on “partnerships with stakeholders across the health ecosystem”.

“It is very important to not lose momentum…We don’t have another way to do it except making sure that we maintain and sustain our advocacy — and we mobilize political leaders,” said Sidibé in one recent Health Policy Watch interview. 

AMA will be enlisted in African Union’s battle against drug resistant microbes 

AMA advocates have continuously underlined the knock-on benefits the new regulatory agency would have in terms of not only harmonising the approval of new medicines – but also thereby ensuring more access to affordable quality medicines. 

This, in turn, can help fight worrisome trends like antimicrobial resistance (AMR) – which the continent has little capacity to track or tackle right now, according to one recent study of 14 countries.

According to a new African Union Framework for AMR Control, the nascent AMA will promote a common scheme for prohibiting the sale of non-standard antimicrobials, whose use can foster drug resistance, backed by post-marketing surveillance. 

In the context of the framework, the AMA will contribute to strengthening laboratories for drug quality control and promote the education of pharmacists in identifying sub-standard or falsified drugs, using innovative tests to measure drug quality, while also encouraging policies that promote the availability of genuine, safe and effective products at competitive prices.

The Framework also promotes collaboration with governmental and non-governmental partners (including community groups) to increase awareness amongst not only clinicians and pharmacists but also veterinarians and animal and crop producers about substandard and falsified antimicrobials.

For full coverage on the development of the African Medicines Agency, see our AMA Countdown Page here: 

African Medicines Agency Countdown

-Kerry Cullinan contributed to the reporting on this story.

Image Credits: @elmimuller, Kenyan Parliament website, South African Parliament.