China’s “wet markets” sell fresh meat, fish and vegetables; but the sale of exotic animals at some of them is believed to have faciliated the spread of COVID-19 from animals to humans

In a mild statement touching on a politically wired issue, World Health Organization Director-General Dr Tedros Adhanom Ghebreyesus said that the agency would step up its investigations of the original animal source of the SARS CoV-2 virus that causes COVID-19. 

His comment came in response to a recommendation of the WHO Emergency Committee that met Thursday 30 April to review the status of the COVID-19 pandemic as a ‘public health emergency of international concern.’

“We accept the committee’s advice that WHO works to identify the animal source of the virus through international scientific and collaborative missions, in collaboration with the World Organisation for Animal Health (OIE) and the Food and Agriculture Organization (FAO) of the United Nations,” said Dr Tedros, speaking at Friday’s WHO press briefing. 

The Emergency Committee had recommended that WHO “work with the OIE, FAO, and countries to identify the zoonotic source of the virus and the route of introduction to the human population, including the possible role of intermediate hosts,” and “provide guidance on how to prevent SARS-CoV-2 infections in animals and humans and prevent the establishment of new zoonotic reservoirs.”

The issue of the virus’ origins became highly politicized after US President Donald Trump claimed to have evidence that the virus had escaped from a laboratory, although he never provided any support. Trump referred again to this claim at a press briefing Friday.

Scientific assessments have generally concluded that the virus came from a natural source, most likely a bat that possibly transmitted it to a pangolin or a reptile, which are widely used in traditional medicine as well as food sources in China. 

Even so, Chinese claims that the virus first was transmitted to humans at the Wuhan, China wild animal market, seem less well-founded, insofar as some early cases had no connection to the market. 

That has led some observers to suggest that the virus, while natural in origin could have also escaped from the Wuhan Virology Institute or the Wuhan Centre for Disease Control, near the wild animal market – which had also collected bat coronavirus specimens. 

When asked about the origin of the virus, WHO’s Executive Director of Health Emergencies Mike Ryan declined to speculate on whether the virus escaped from a lab or emerged from a wet market. 

“We were assured that this virus is natural in origin, and what is important is that we establish what the natural host for this virus is,” said Ryan. “The primary purpose of doing that is to ensure that…we understand how the animal-human species barrier was breached, [so] that we can put in place the necessary prevention and public health measures to prevent that happening again. Anywhere.”

Environmental health advocates have underlined that increased contact between wild animal species and humans in developing countries of Asia and Africa, as a result of urbanization and the degradation of wild animal habitats, as well as illegal wild meat capture, containment and consumption, has led to the ever more frequent transmission of zoonotic diseases to human populations in past decades, including HIV, Ebola and Nipah virus.  

And outbreaks of new diseases will pose an even greater risk in the future if the underlying environmental health and food safety drivers are not addressed.

Dr Tedros signs the WHO-EIB Memorandum of Understanding

WHO Signs MOU With European Investment Bank

At Friday’s press briefing, the WHO Director-General also signed a Memorandum of Understanding with the European Investment Bank – which aims to inject funding into the COVID-19 response into at least 10  African countries, as well as countries elsewhere with weaker health systems. 

The EIB’s commitments include freeing at least 1.4 billion EUR to address the health, social and economic impact of COVID-19 in Africa. However, Werner Hoyer, President of the European Investment Bank, told reporters that most of the funding would be provided in the form of loans.

The funding would also support continuation of other critical health services such as malaria elimination and antimicrobial resistance. 

The EIB president declined to comment on which nations would receive funding. 

“I must disappoint you, because this communication has not gone to the respective governments yet, and therefore I for the time being cannot respond to this. Together with our delegation with WHO, we will do this within the next couple of days,”  said Hoyer.

Werner Hoyer announces the European Investment Bank – WHO collaboration

The funding is yet another gesture of support from Europe at a time when US aid has been put on hold creating a funding crisis in WHO, which receives some 15% of its budget from Washington – much of it going to WHO’s African region.

In addition the United States Agency for International Development (USAID) this week issued a directive forbidding use of its overseas funding for the purchase of personal protective gear for health workers, such as masks and gloves, or for the purchase of respirators, The New Humanitarian reported.  

The move was widely seen as a political gesture by US President Donald Trump to his domestic base of support. As one Geneva-based NGO observer, said, “I think it’s because they’re afraid of Trump’s fan base saying, ‘we’re short of PPE, why are we giving it to foreigners?’” 

USAID also is one of the world’s largest bilateral donors to health systems in developing countries.

Cases Are Doubling In Nigeria’s Conflict Zones – Even As Cases Decline Elsewhere During African Lockdowns

Conflict-ridden areas in Nigeria have witnessed an uptick in new cases over the past week even as new cases declined elsewhere across the African continent. South Africa, Ghana, Mauritius, Botswana, Mauritania and Niger, which clamped down on movement three weeks ago, saw a decrease in new COVID-19 cases, said WHO Regional Director for Africa Matshidiso Rebecca Moeti, in a regular briefing on Thursday.

On Friday, about half of the 200 new COVID-19 cases were reported in historically unstable northeastern Nigeria, where over 180,000 people remain displaced after a fresh wave of violence in 2019. A hotspot of 80 new cases was reported in the northern Kano State, as well as smaller outbreaks in northeastern states Gombe, Bauchi, Borno. There are now a total of 1932 cases in the country. Daily new cases in Nigeria doubled on Tuesday compared to Monday’s numbers.

The main challenge in conflict-ridden zones is access, said Michel Yao, WHO Emergency Programme Manager for the Africa Region, in Thursday’s briefing.

“These [historically unstable] areas are a bit far from the capital city, and is where the centralization of some of the capacities like testing should be taken in place,” Yao said.

We need to be working closely with all humanitarian partners, the International Organization for Migration (IOM) and the United Nations High Commissioner for Refugees Agency (UNHCR), to assess these unstable areas, he added. The IOM, which frequently works with refugee and asylum seekers fleeing from conflict, is bracing itself for a potentially devastating COVID-19 outbreak in northeast Nigeria.

WHO AFRO Director Matshidiso Moeti speaks at Africa Media Leader Briefing on COVID-19 on April 30, 2020

In an unusual move by the WHO, the Regional Director for Africa pointed out by name countries who had been slow to implement WHO recommended strategies to slow the spread of the pandemic.

“Tanzania took some time to implement [their strategies] particularly the physical distancing measures” stated by Dr. Matshidiso Rebecca Moeti. “While schools were closed, places of worship were kept open. The gathering of people continued to happen in closed spaces. The prevention of travel from the epicenter also took some time to happen. After the lockdown was announced, many truck drivers left the country and have spread the infection to neighboring countries.”

Tanzania has 480 confirmed cases as of Friday, although concerns about test kit shortages have many experts concerned that cases are being undercounted across the continent.

Svet Lustig Vijay, Zixuan Yang and Grace Ren contributed to this story

Image Credits: Breaking Asia.

Pregnant women remain one of the groups at highest risk of complications from malaria infection.

Reducing new cases of malaria among pregnant women remains one of the key challenges on the road to malaria elimination – a goal that was celebrated last week, on World Malaria Day, 25 April.

Although malaria deaths fell by nearly a quarter between 2010 and 2018, pregnant women remain among the groups most at risk from the parasitic disease.

In response, MMV has recently ramped up a longstanding programme (first initiated in 2014) dedicated to fighting malaria in pregnancy, naming it the Malaria in Mothers and Babies (MiMBa) initiative.

MiMBa for short, the acronym is aptly named after the Swahili word for “pregnancy.”

Every year, malaria in pregnancy causes some 10,000 maternal deaths, mostly in sub-Saharan Africa.

In areas where malaria is widespread, it is estimated that at least 25% of pregnant women are infected with malaria. And more than 11 million pregnant women were infected in sub-Saharan Africa in 2018 alone – putting a third of all future mothers in that region at risk.

During pregnancy, the disease can also cause maternal anaemia, premature labor, and low birth weight in babies – some 872,000 babies alone were born with low birth weight in 38 sub-Saharan African countries in 2018. This puts newborns, as well, at much higher risk of early death in the first 12 months of life, according to the latest WHO World Malaria Report.

“Protecting pregnant women from malaria has been a key concern of the malaria community for many years, though today in the context of a burgeoning COVID-19 pandemic the stakes are even higher,” said Dr David Reddy, MMV’s CEO. “We need to move quickly to ensure pregnant women and others at risk of malaria can access the tools they need to protect them today, particularly because access to healthcare facilities will be compromised during the COVID-19 outbreak. Beyond this immediate need, we must continue to develop the new tools they will need for the future”.

A key tool to protect pregnant women – Intermittent Preventive Treatment

A key tool to protect pregnant women from malaria in areas with moderate-to-high malaria transmission in Africa is intermittent preventive treatment of malaria during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP), which is a cost-effective intervention.

A minimum of three doses of SP from the second trimester onwards prevents maternal and foetal anaemia, reduces maternal malaria episodes, and decreases the risk of low birth weight.

“IPTp has been shown to reduce negative pregnancy outcomes and if well implemented, with good coverage, these interventions can drastically reduce the malaria prevalence in these specific populations,” said MMV Director of Access & Product Management, Dr André-Marie Tchouatieu.

Intermittent treatment with sulfadoxine-pyrimethamine (SP) can help prevent malaria during pregnancy.
Scaling Up Access to IPTp

However, right now, a complete three-dose course of IPTp only reaches about 31% of the pregnant women that need the treatment, according to the latest WHO data. This year the RBM Malaria in Pregnancy Working Group, which includes MMV, has launched the Speed-up Scale-up campaign to rally a larger community of stakeholders to bring IPTp-SP to all eligible women who need it in sub-Saharan Africa.

The challenge on the ground, Dr Tchouatieu said, is to “bring these interventions as close as possible to the affected communities.”

He explained that IPTp has so far been delivered primarily in health facilities, during antenatal care (ANC) visits. However, these ANC visits typically cost women money, while malaria preventive drugs are often freely provided.

Since pregnant women often skimp on ANC visits due to limited resources, they miss out on the opportunity to get the three doses of anti-malarial preventive treatment.

As part of a Jhpiego-led consortium, MMV and other partners are exploring ways to complement the existing delivery method for IPTp by bringing treatments more directly into the communities and homes of women who need them. Under the UNITAID-funded TIPTOP project, the consortium is exploring whether community-based delivery of IPTp-SP could successfully complement ANC-based delivery.

“We are exploring how to involve community health volunteers to both deliver IPTp and encourage women to attend ANC visits,” said Dr Tchouatieu. Results from the recently wrapped primary phase of the project showed that in four pilot countries – Nigeria, the Democratic Republic of the Congo, Mozambique, and Madagascar – coverage of the second and third doses of IPTp went up along with attendance at a fourth and fifth ANC visit.

WHO currently recommends at least six ANC visits in order for pregnant women to be screened for other pregnancy-related health problems. Ideally, says Dr Tchouatieu, recommendations on IPTp might also be expanded to a monthly administration to cover women more completely during the last two trimesters of pregnancy.

Malaria – A Particular Risk in the First Pregnancy    

Malaria is a particular risk to women and their foetus during their first pregnancy. In moderate and high transmission settings such as parts of sub-Saharan Africa, women tend to naturally have a higher level of immunity to malaria due to the constant exposure to the disease; but that immunity may be depressed during pregnancy.

“There is a breakdown of acquired immunity [to malaria] that occurs in pregnancy, especially in the first pregnancy,” said Dr Tchouatieu.

That may also explain the comparatively higher rate of malaria mortality seen in teenage girls and young women in some settings, where teenage pregnancy is more common. According to WHO, malaria remained one of the top 5 killers of adolescent girls 10 to 14 years old, and maternal conditions were the leading cause of death in young women age 15 to 19 around the world in 2016.  In subsequent pregnancies, on the other hand, immunity appears to be less impacted.

Many young women also carry asymptomatic infections, Dr Tchouatieu adds. This can lead to chronic anaemia, which is caused by a low level of parasitic activity that destroys red blood cells. Women who were previously asymptomatic or slightly anaemic may develop stronger symptoms during pregnancy, and even progress to severe disease.

In addition, during pregnancy, the malaria parasites may be attracted to a new, abundant source of healthy red blood cells – the placenta. The parasites infect the placenta, a condition known as placental parasitaemia, interfering with the circulation of nutrients between the mother and foetus, leading to low birth weight, still births, or even miscarriages.

In areas of unstable malaria transmission, such as Asia and Latin America, as well as in low transmission areas of Africa, where populations have a lower level of  acquired malaria immunity, the risks of developing severe disease upon being infected by malaria can be even higher for pregnant women, said Dr Tchouatieu.

Intermittent preventive treatment during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is effective in reducing maternal malaria episodes, and may help prevent low birth weight in babies.
IPTp – Part of a Wider MiMBa Strategy

Supporting the scale up of IPTp is just one part of a wider MiMBa strategy whose ambition is to improve equity and inclusion of the needs of future mothers, mothers and their babies in malaria drug development – MMV and its partners also want to accelerate the discovery, development, and monitoring of new antimalarial options – optimized for pregnant women and lactating mothers.

As other elements of the MiMBa initiative, MMV also aims to:

  1. Fill the gaps on existing compounds to inform on their use in pregnant women and neonates;
  2. Develop new antimalarial medicines to address the needs of pregnant women and neonates;
  3. Strengthen the capture of safety data from use of antimalarials in endemic countries during pregnancy;
  4. Advocate for changes in drug development that promote the proper inclusion of pregnant women into clinical studies, with the aim of generating data to support earlier access to innovative medicines for this population.

While the current IPTp strategy is important, it can only be administered from the second trimester onward. So, development of a new treatment that could also be safely administered to prevent malaria in the first trimester of pregnancy, would represent a breakthrough.

“The face for malaria is female. The disease disproportionately affects pregnant women resulting in severe illness, deaths, loss of productivity and missed professional development opportunities,” says Joy Phumaphi, the Executive Secretary of the African Leaders Malaria Alliance, speaking at a meeting last year. “We must ensure sufficient resources are available to remove barriers to treatment and prevention, including the fast tracking of new commodities and interventions.

Image Credits: Elizabeth Poll/MMV, Karel Prinsloo-Jhpiego .

SARS-CoV-2 (red), the virus that causes COVID-19, attacking a dying cell (blue).

Preliminary results of a clinical trial released by the US National Institutes of Health (NIH) found that in patients who received remdesivir recovered faster than those who did not receive the treatment.

The largest trial to date, which followed 1063 patients, found that patients who received the drug recovered on average 4 days earlier than those who did not. Additionally, the death rate was 8% in the group that received remdesivir compared to 11.6% in the control group, although this result was not statistically significant.

“What [this trial] has proven is that a drug can block the virus,” Anthony Fauci, the director of the National Institute of Allergy and Infectious Diseases (NIAID), told reporters in a rare show of optimism on Wednesday. Fauci has emerged as the most reliable expert voice on the US national coronavirus taskforce.

He reflected that the moment he saw the results were reminiscent of the moment the NIAID reviewed preliminary results from the first large-scale study on the use of antiviral combination therapy for HIV/AIDS – the first in a series of technological breakthroughs against that virus.

“We think it’s really opening the door to the fact that we now have the capability of treating [COVID-19],” he said.

In seemingly contradictory news, a new study published Wednesday in The Lancet found that remdesivir did not significantly speed recovery or reduce deaths in patients suffering from severe COVID-19 in Wuhan, China. 

Some 14% of patients in the remdesivir treatment group died after 28 days, compared to 13% in the group that did not receive the treatment. The Lancet study followed 237 adult patients with severe COVID-19 in Wuhan, China, the original epicentre of the pandemic.

“Unfortunately, our trial found that while safe and adequately tolerated, remdesivir did not provide significant benefits over placebo”, says lead researcher Bin Cao from China-Japan Friendship Hospital and Capital Medical University in China, in a press release. The formal publication in the Lancet confirmed initial reported findings that were accidentally leaked on the World Health Organization’s clinical trials registry last week.

Independent experts have urged for continued research in order to create a larger pool of conclusive evidence to judge remdesivir’s effectiveness on COVID-19. The Wuhan study had been terminated early due to lack to new patient enrollment, resulting in a much smaller sample size.

“Each individual study is at heightened risk of being incomplete [in a pandemic situation],” wrote John Norrie, professor of Medical Statistics from the University of Edinburgh, in a separate Lancet comment. “Pooling data across several such ‘underpowered’ but high-quality studies looks like it will be our best way to obtain robust insights into what works, safely, and on whom.”

Remdesivir, a failed Ebola antiviral developed by Gilead Sciences, was tapped as one of a handful of promising COVID-19 treatments for a global Solidarity trial coordinated by WHO. It has only been available to patients under emergency or compassionate use protocols, which allow patients to access experimental medications in the absence of any known treatments for COVID-19.

WHO experts declined to pass judgement on remdesivir in a press briefing Wednesday. Maria Van Kerkhove, WHO’s Technical Lead on the COVID-19 crisis, remarked, “Typically you don’t have one study that will come out that will be a game changer. Once we look at all of the studies, and we judge them collectively we can come away with some kind of a conclusion of ‘yes we see an effect’ or ‘no we don’t.’”

WHO Executive Director of Health Emergencies, Mike Ryan, said that he had not yet read the full study, but “fervently hoped” that one of the many drugs under investigation around the world would help improve clinical outcomes. 

In a parallel move, Gilead unveiled early results from a trial exploring the efficacy of different durations of remdesivir treatment on Monday. The so-called SIMPLE trial found that treatment outcomes were similar in patients with severe COVID-19 receiving a 10 day course and those receiving a 5 day course. However, the Gilead trial results fail to assess remdesivir efficacy against a control group, making The Lancet study the first published RCT to explore whether remdesivir has any overall benefit to COVID-19 patients.

Findings from the Lancet Study – Small Sample Size a Major Limitation
3D molecular structure of remdesivir, an antiviral drug

The Lancet study found no significant differences in the death rate or amount of virus in the body between patients who received remdesivir and those who did not. 

Overall, 22 of 158 patients died in the remdesivir group compared with 10 of the 78 in the placebo group after 28 days. Treatment with remdesivir did not reduce the amount of SARS-CoV-2, the virus that causes COVID-19, in the body or respiratory tract compared to the control group.

However, patients who were treated within 10 days of illness onset had a slightly lower mortality rate at 11% compared to 15% in those who did not receive remdesivir. Similarly, patients who were on invasive mechanical ventilation were weaned off an average of 8.5 days earlier compared to those who did not receive the drug. No significant differences were noted between the groups in overall length of oxygen support, length of hospital stay, or time to discharge or death.

Still, the authors say that the results must be interpreted with caution due to the small sample size in the study.

“This is not the outcome we hoped for, but we are mindful that we were only able to enroll 237 of the target 453 patients because the COVID-19 outbreak was brought under control in Wuhan,” said Cao. “What’s more, restrictions on bed availability resulted in most patients being enrolled later in the disease course, so we were unable to adequately assess whether earlier treatment with remdesivir might have provided clinical benefit.”

Despite the limitations, independent experts praised the study’s protocol, including the use of a well-designed control group. All patients enrolled in the study received standard care including treatment with lopinavir–ritonavir, interferons, and corticosteroids.

“Most other released data did not have a proper comparison group, while this trial has a group given standard treatment but no remdesivir, allocated at random. The description of the methods makes it clear that this was a well-conducted trial,” said Stephen Evans, a professor in the Department of Medical Statistics at the London School of Hygiene & Tropical Medicine, in a separate comment.

WHO Director-General to Reconvene Emergency Committee for COVID-19

WHO Director-General Dr Tedros Adhanom Ghebreyesus will reconvene the emergency committee under the international health regulations on Thursday to reassess the status of the COVID-19 pandemic.

The meeting will take place three months after Dr Tedros declared COVID-19 a ‘public health emergency of international concern’ (PHEIC) on 30 January. The group of experts was deadlocked over whether COVID-19 constituted a PHEIC, the highest level of alarm the WHO can raise, in late January, meeting several times to debate the issue. 

“WHO is committed to transparency and accountability in accordance with the International Health Regulations. I will reconvene the emergency committee tomorrow,” said the Director-General on Wednesday.

However, Dr Tedros refrained from making public comment on the plans for the 74th World Health Assembly, WHO’s largest and most important annual meeting of Member States, usually planned for mid-May. Sources told Health Policy Watch on Tuesday that the Organization was considering for the first time a one-day virtual World Health Assembly on 18 May – focusing only on COVID-19. 

European Countries and US States Slowly Unwind Lockdown Restrictions – Even as the US Surpasses 1 Million Infections

The US crossed the threshold of 1 million coronavirus cases on Tuesday, confirming 1,013,168 cases and 58,368 deaths as of Wednesday morning.

Even so, many states are gearing to reopen – Alabama will replace its stay-at-home order with a safer-at-home mandate beginning Thursday, allowing employers and beaches to reopen “subject to good sanitation and social distancing rules,” Governor Kay Ivey said. Florida Governor Ron DeSantis stated on Wednesday that he will outline reopening plans during an Oval Office meeting with President Donald Trump.

Still, public health experts fear a second, deadlier wave of coronavirus in the fall. Anthony Fauci said, “I’m almost certain it will come back, because the virus is so transmissible and it’s globally spread,” during an Economic Club of Washington webinar.

Meanwhile, several European nations are eyeing a gradual end to their coronavirus lockdowns as infection rates slow and death rates decline. Swiss councillor Alain Berset announced in a Federal Council press conference on Wednesday that the country’s three-step re-opening will be sped up due to a dramatic decrease in the infection curve. The council has now authorized the reopening of more businesses than was previously allowed for 11 May, also authorizing restaurants and gyms to reopen, with appropriate sanitation and social distancing methods. Switzerland has recorded 29,407 coronavirus cases with 1408 deaths.

Spain is hoping for a return to relative normality by the end of June, said officials in Madrid, announcing a four-phase plan on Tuesday to lift the toughest set of restrictions as the daily death toll fell to 301, less than a third of a record high of 950 in early April. Meanwhile in France, widespread coronavirus testing will be launched on 11 May so that the country can slowly unwind its lockdown to avoid an economic meltdown.

Still, Europe remains the worst-affected continent, with over 1.2 million confirmed cases and more than 125,000 deaths. Spain, Italy, France and the United Kingdom are the most affected countries with 236,899, 201,505, 169,053 and 162,350 cases respectively; each has recorded over 20,000 deaths.

Total cases of COVID-19 as of 8:30PM CET 29 April 2020, with cumulative case distribution globally.

Gauri Saxena contributed to this story

This story was updated 4 May.

Image Credits: NIAID, ChiralJon – Remdesivir 3D, Johns Hopkins CSSE.

A young boy sits by an open sewer in Kibera slum, Nairobi, Kenya, where COVID-19 prevention recommendations such as social distancing and frequent handwashing are difficult to maintain.

“Epidemics, such as this one or any other, by their very nature, feed off existing inequalities and make them worse. And that’s what we see COVID-19 doing to inequalities between countries and within countries.” – Winnie Byanyima, executive director of UNAIDS. 

As the COVID-19 crisis unfolds and the global economy grinds to a halt, how has this pandemic exposed inequalities in access to medical care, employment, and countries’ abilities to protect their citizens? A panel of global health leaders and international experts tackle this question in the first ‘Global Pandemics in an Unequal World‘ webinar on Tuesday, co-sponsored by The New School and Health Policy Watch.

“As this pandemic unfolds, it has made one thing very clear. It’s unprecedented in reach and reinforcing inequality,” said moderator Sakiko Fukuda-Parr, professor and director of the Julien J. Studley Graduate Programs in International Affairs at The New School. “Not only are low income and more marginalized populations more exposed, it’s likely to deepen inequalities between countries.”

Global inequality has left entire countries’ health systems exposed to the virus. African countries, saddled by debt, are particularly vulnerable.

“30 African countries are paying more towards debt repayments today than to their health sector,” said Winnie Byanyima, executive director of UNAIDS. “That’s the situation African countries have found themselves in. Corona hits at a time when they have very little fiscal space to address a new epidemic, or even to address the existing health needs of their people.”

But the inequality can be felt within countries as well. As low-wage essential workers continue to risk exposure to the deadly virus while celebrities and CEOs retreat to private mansions and islands for self-isolation, gaps between the “haves” and the “have-nots” were brought into stark relief by the coronavirus pandemic. 

“In Italy, we have clearly seen the poisonous combination of two pandemics: the new coronavirus and the pandemic of inequality,” said Nicoletta Dentico, Italian journalist and director of the Global Health Program at the Society for International Development. “The decades of social spending cuts and the very serious problems that we’ve had with austerity measures, since the financial crisis, have devastated completely the health system.”

Likewise in New York City, the pandemic has disproportionately hit the poor, immigrant, and other marginalized communities. Over 1 million people have lost their jobs – and health insurance – during the coronavirus lockdown in the city, according to James Parrott, director of Economic and Fiscal Policies at The New School. Additionally, crowded housing in the lowest income neighborhoods in the city have elevated the risk of COVID-19 transmission in those communities.

As such, any policy solution to the pandemic must focus on the most vulnerable people at the core, said Mandeep Dhaliwal, director of HIV/AIDS and human rights at the United Nations Development Programme.

“Those most vulnerable who don’t have a right to quality basic services, health, education, social protection, social safety nets; who don’t have adequate standards of living living conditions; who don’t have access to medicines or vaccines; who don’t have access to food or don’t have access to water, how can they possibly protect themselves from [COVID-19]?” she asked. 

Manjari Mahajan, co-director of the India China Institute at The New School, added that solutions must be multi-sectoral. 

“Health has to really be embedded firmly within larger social, economic, political governance systems,” said Mahajan. “We have to stop thinking about health… as a stand alone sector where the [COVID-19] response has to be determined by health specialists, health experts, health systems and hospitals alone.”

(top, left-right) Winnie Byanyima, Sakiko Fukuda-Parr, James Parrott
(Bottom, left-right) Manjari Mahajan, Mandeep Dhaliwal, Nicoletta Dentico

Here are some more key comments from the panelists, touching on debt relief, tension between the US and WHO, and next steps to address inequality:

Winnie Byanyima, executive director of UNAIDS

Corona hits Africa at a time when they have the very little fiscal space to address a new epidemic, or even to address the health needs of their people. More than half of the Sub-Saharan African countries have some form of user fees that people have to pay to go to the clinic. So we have a situation where we have user fees that are themselves now an obstacle to diagnosis because people want to offer themselves to be tested. 

We have a situation where country debt repayments have been deferred by the G20, but not canceled. It’s a good start, but it’s not enough, because you just have a little space now in six months to spend a little more. The World Bank, the Regional Development Banks, they too need to take action.

We will win this battle on the ground. We must empower communities, center them in shaping and leading responses. We must be data-driven and evidence-based; we cannot win when we are not focusing on what works. And I add global coordination – strong coordination and sharing of resources. Lastly, we must tackle these inequalities that existed before in order to build a better world afterwards. As Antonio Guterres said, in our interconnected world, we are only as strong as the weakest health systems.

Mandeep Dhaliwal, director of HIV/AIDS and Human Rights at the United Nations Development Programme

The crisis of COVID-19 also comes crashing into the crisis of inequality and the climate crisis. The policy solutions need to address multiple crises. but not in the way we’ve done them in the past where we trade off a health benefit for an economic benefit, or we trade off an economic benefit for an environmental sustainability benefit. We need solutions that actually address the drivers and the consequences of three profound crises coming together.  

I imagine in refugee camps, these COVID solutions of ‘shelter in place,’ and ‘wash your hands’ and physical distancing are meaningless in many ways. I think solutions need to really be adaptable to the most vulnerable. And this is not impossible. This is not our first pandemic; the HIV pandemic showed us that global solidarity, led by the people who are most vulnerable and most effective can drive incredible positive change and policy solutions. So I think we need integrated solutions. 

Nicoletta Dentico, journalist, director of the Global Health Program at the Society for International Development (SID)

We are now in the midst of a very delicate and very thorny, complex transition…of exiting the national lockdown. We lost 27,000 people – which is something totally unheard of. The elderly people have been abandoned where the hospitals could not absorb the affected people anymore. There will be a long term effect on the younger generations who have lost their grandmothers and grandfathers without saying goodbye. This is an intergenerational shock that we will have to coexist with.

In Italy I think one of the most difficult issues has been that we have a national health system, but it is the regions that are in charge of their people at the regional level. There is a disparity already between those regions that are wealthy enough to maintain a health system and those that cannot. So, the disease has hit the hardest where health was most systematically placed in the hands of the private sector. The fragmentation of the health system has created a lot of inefficiencies, a lot of delays, a lot of problems that finally resulted in losses of lives. 

Manjari Mahajan, associate professor of International Affairs & Starr professor and co-director of the India China Institute at The New School

Emergency discourse around any epidemic makes it seem as though the response has to be about short term measures, whereas what really determines outcomes is the investments in resilient egalitarian health systems, over a long term. The second thing is that we have to stop thinking about health as a standalone sector – health has to really be embedded within larger social, economic, political governance systems. This kind of cross-sectoral response really determines the long term success of various countries.

In India for example, a very strict lockdown was announced with four hours notice, without taking into account the wage laborers who need to earn money on a daily basis to buy food, making hunger a big issue. It did not take into account that people live in extremely congested, cramped quarters without access to clean water and sanitation systems, or how populations need to invest in harvest and planting today to ensure their livelihoods tomorrow.

James Parrott, director of Economic and Fiscal Policies, Center for New York City Affairs at The New School

In the United States we’ve been tremendously affected by the incapable leadership that we’ve had at the national level. What our president has done is inadvertently made the UN a lot more relevant. In a normal period, the United States might be providing international leadership on this or any crisis. It’s just totally not doing that right now, it’s doing the opposite. 

It’s been very clear that the healthcare system is so inadequate in the United States, despite all of the resources we heaped upon it. The pandemic has played out in very polarizing ways, both in terms of the economy and the health effects. The response of the federal government has not been to assure employers that they should keep their workers fully on the payroll, so that when the public health crisis eases, they can return to work. The response takes the form of laying workers off so they become economically displaced. And the hospitalization impact of this pandemic has been very concentrated in the poorest neighborhoods in under-resourced public hospitals. Hopefully out of this, we will have a spirited national conversation about a sort of health care system we need, as well as a thorough response to the raft of inequities that we’ve seen exposed.

New Webinars in the ‘Global Pandemics in an Unequal World’ Series

The Tuesday event was the first in a series of four webinars, co-sponsored by The New School and Health Policy Watch, with the Centre for Development and Environment at the University of Oslo joining as a partner. The following webinars will be covering these themes:

27 May –  Inequality and access to diagnostics, vaccines, and medicines for COVID-19

24 June – Digital technology and Inequality in the COVID-19 response

22 July – COVID-19 inequalities and the environment

 

Image Credits: Wikimedia Commons.

Dr Tedros speaks at the 27 April WHO COVID-19 press briefing

When the World Health Organization sounded the alarm by declaring a ‘public health emergency of international concern‘ on 30 January, “the world should have listened,” said WHO Director General Dr Tedros Adhanom Ghebreyesus, in his strongest response to date, to repeated allegations by the United States that WHO failed to act quickly enough in the early days of the coronavirus pandemic.

“The world should have listened to WHO carefully then, because the highest level of global emergency was triggered. This was on January 30 when we only had 82 cases and no deaths in the rest of the world,” said Dr Tedros, repeating even more adamantly messages he delivered on several occasions last week, “We advised the whole world to implement a comprehensive public health approach; find, test, and do contact tracing.

“You can take for yourselves countries who followed [our advice] are in a better position than others. This is fact,” he added.

Although the Director-General refrained from pointing fingers at specific nations, his response was clearly aimed at  US President Donald Trump, who bitterly attacked the agency for allegedly being China-centric and failing to provide sufficiently early warnings, and then suspended nearly US$ 500 million in funding – which represents some 15-20 percent of the WHO’s 2020-2021 budget. The US has now become the new epicentre of the COVID-19 pandemic – after Trump initially downplayed the risks posed by the virus and even praised China’s management.

“We don’t have any mandate to force countries to implement what we advise them,” Dr Tedros said. “WHO gives the best advice we can based on science and evidence, and it’s up to the countries to reject or accept.

“But what we have seen so far is that some countries accept [our advice] and some may not. At the end of the day, each country takes its own responsibility.”

Some 75% Of All COVID-19 Deaths Reported in Just Six Countries – Led by United States
United States tops the list of six countries with the most COVID-19 fatalities. (University of Oxford, CEBM). Orange bar indicates initial dates of state lockdowns.

In fact, some 75% of all COVID-19 deaths were reported in only 6 countries – with the United States at the top of the charts – a new analysis from researchers at the University of Oxford found. 

As of 24 April, there had been some 54,941 deaths in The United States, which suffered the biggest toll,  followed by Italy, Spain, France, the United Kingdom, and Belgium. 

These six countries together accounted for 155,457 of the 206,008 global deaths reported in the period – although they comprise only 7.5% of the global population. The sobering numbers come even as countries are slowly easing lockdown measures as new infections decrease, hoping that they have weathered the peak of the epidemic. 

New Drug Trial Results Sparks Hopes for Tocilizumab Therapy; Outcomes for Hydroxycholorquine and Remdesivir Less Positive 
How Tocilizumab may calm the “cytokine storm” provoked by immune overreaction to COVID-19

An antibody therapy used to treat inflammatory conditions associated with rheumatoid arthritis – tocilizumab – showed promising results in small, preliminary trials on COVID-19 patients in France, researchers at the Assistance publique – Hôpitaux de Paris, reported on Monday.

Given the pandemic context, “the investigators and sponsor felt ethically obligated to disclose this information,” said the investigators in a press release from the Assistance publique – Hôpitaux de Paris.

“These results should be confirmed independently by additional trials,” said a statement from the hospital press release, which was initial posted and then blocked, after having been widely reported in French media. 

The drug, produced by Roche Pharmaceuticals, is rapidly gaining attention as a potential COVID-19 therapeutic, with another Phase III clinical trial, approved by the US Food and Drug Administration, underway in the United States.

In the French trial, a 14 day course of tocilizumab was found to significantly reduce the proportion of moderate or severe COVID-19 patients who required more intensive ventilator support, or died.  

The drug works by preventing IL-6 cytokines from binding to immune cell receptors. In many severe COVID-19 cases, an overreaction of the immune system to the SARS-CoV-2 virus unleashes a wave of cytokines and immune cells, causing massive damage to the lungs that can lead to acute respiratory failure. Some scientists have posited that blocking the so-called “cytokine storm” could prevent massive lung damage. 

The trial observed 129 patients with moderate or severe COVID-19 in a multicenter randomized control trial conducted across several French hospitals. The specifics of the study will be submitted to a peer review journal pending longer follow-up in the patients.

The new US FDA-approved study on tocilizumab will enroll 330 patients in a randomized controlled trial run by Roche, the company that produces the drug, and the US government entity, Biomedical Advanced Research and Development Authority (BARDA), a branch of the US Health and Human Services Department.

Meanwhile, new results on hydroxychloroquine and remdesivir, two of the therapeutics tapped for the World Health Organization’s Global Solidarity Trial, have not so far made strong showings, in the preliminary results of human trials which have recently been reported – although these studies also have have significant limitations. 

Preliminary results of a small remdesivir study in China, accidentally posted by the World Health Organization last week, showed no significant differences in mortality after 28 days of treatment, among patients who received the drug and those who did not. In a screenshot captured by STAT News, the trial results also reported that 11.6% of the patients who had received remdesivir also stopped the drug early due to adverse effects. The trial results were quickly removed from the Clinical Trials Registry site, with WHO saying that the results were not yet conclusive. 

Screenshot of WHO Clinical Trial Registry capturing remdesivir trial results, captured by STAT News

In a statement released on Thursday, Merdad Parsey, chief medical officer of Gilead said the trial had been terminated, but expressed hopes that other studies might yield a more positive picture: “The study was terminated early due to low enrollment and, as a result, it was underpowered to enable statistically meaningful conclusion,”  Parsey said.  He claimed that “trends in the data” could indicate that remdesivir may have clinical benefit when given to patients in earlier phases of the disease.

In early February, remdesivir showed promising results against the COVID-19 virus, SARS-CoV-2, in a Chinese cell culture study. However, these results have not been replicated in human studies.

As for hydroxychloroquine, a number of recent studies and warnings have emerged to the effect that the high doses required to combat the virus may also prove fatal to some patients.  Those include a study in Brazil, which was terminated early due to adverse effects.

Last Thursday, a retrospective analysis of outcomes among some 368 US patients treated with the drug, or with the drug in combination with azithromycin,  found “no evidence that use of hydroxychloroquine, either with or without azithromycin, reduced the risk of mechanical ventilation in patients hospitalized with COVID-19.”  The study of patients treated in US Veterans Health Administration medical centres, also found an association of increased overall mortality in patients treated with hydroxychloroquine alone.

At the same time, researchers have not given up on the drug. A 400-person Phase III Clinical trial was announced last week by Swiss authorities for the hydroxychloroquine as well as the HIV drug lopinavir/ritonavir. The trial is to be run by the Geneva University Hospitals, Basel University Hospital and the Swiss Tropical and Public Health Institute. There are currently over 60 clinical trials of various drug combinations underway in Switzerland.

Global Trends

Switzerland began today its first phase of a three-stage re-opening. Hospitals resumed all medical procedures, including elective surgeries. Caps on funerals, which were restricted only to close family members, were lifted. Businesses offering low levels of direct contact, such as hairdressing salons, massage practices, tattoo and cosmetic studios, florists, garden centres, and DIY stores, were reopened. 

Similarly New Zealand’s Prime Minister Jacinda Arden, who has been praised for her handling of the pandemic, announced Monday that the country was deescalating from a level four to level three emergency as new infections dropped into the single digits.

Yesterday, the Italian Prime Minister Giuseppe Conte announced that the country will deescalate into phase two. From May 4th, businesses such as catering services, manufacturing, construction, real estate, wholesale trade, and sports activities can resume operations. An additional $55 billion is pledged to support families, workers, and businesses struggling due to the pandemic. 

Meanwhile a new Swiss biosensor could be used to detect the COVID-19 virus, SARS-CoV-2, in public spaces like hospitals or train stations, Swiss authorities reported last Thursday. The biosensor, which was developed by the Swiss Federal Laboratories for Materials Science and Technology (EMPA) in collaboration with Zurich’s Federal Institute of Technology (ETHZ), can help contain outbreaks in public spaces by detecting ‘hotspots’ of viral genetic material floating in the air.

In the United States, the nursing home industry sought immunity from lawsuits after lawmakers  appealed to the CDC and CMS to disclose information on infections in nursing home facilities. Nursing homes have emerged as outbreak hotspots in most hard-hit countries. Hans Kluge, Regional Director for WHO Europe, told reporters last Thursday that almost half of the COVID-19 deaths across the WHO European region were in nursing homes.

In an interview with Financial Times, Bill Gates announced that the Bill and Melinda Gates Foundation (BGMF) would “almost entirely shift” to work on COVID-19 related problems, even in the non-health sectors such as education, where the Foundation has become involved in online learning.

Meanwhile, the CDC added six more symptoms to COVID-19, including chills, repeated shaking with chills, new loss of taste or smell, sore throat, headache, and muscle pain. 

In a video conference today with the Chief Ministers of the Indian states, Prime Minister Narendra Modi claimed that ‘the lockdown has yielded positive results’ and that ‘the country has managed to save thousands of lives in the past 1.5 months.’ 

Modi’s remarks coincide with the Indian Ministry of Health and Family Welfare’s new guidelines for home isolation of very mild/pre-symptomatic COVID-19 cases released today. The recommendations include mandating that caregivers and patients wear a triple-layered medical mask and disinfecting the used marks with 1% sodium hypo-chlorite solution before discarding.

Total cases of COVID-19 as of 6:31PM CET 27 April 2020, with active case distribution globally. COVID-19 cases exceed 3 million mark.

Tsering Lhamo and Svet Lustig Vijay contributed to this story.

Image Credits: University of Oxford/CEBM , Journal of Translational Medicine, WHO Clinical Trials Registry, captured by STAT News.

Soweto, South Africa. Poverty and crowded conditions make lockdowns doubly difficult.

As the COVID-19 pandemic unfolds, it continues to reveal and reinforce deep inequalities within and between countries, where low income and marginalized populations pay the highest price and suffer the most.

On Tuesday 28 April, a Panel discussion on ‘COVID-19 And Global Inequality’ will zoom into the issues even more deeply, with featured speakers including Winnie Biyanyima, executive director of UNAIDS, Mandeep Dhaliwal, of the UN Development Programme (UNDP), as well as voices from academia and civil society. The event is being hosted by the New-York based Julien J.Studley Graduate Program in International Affairs, in collaboration with Health Policy Watch.

The event, at 3 p.m. GMT time (11 EDT/17 CET), is the first in a series on Global Pandemics in an Unequal World webinar, which will address how public policymakers and civil society can change the dominant discourse of many policy debates by prioritizing health, sustainability and egalitarianism.

“Inqualities are deeply driven by the entrenched structures of health systems and the global economy. And after this pandemic is over, these are likely to be even more riveted onto the social fabric of societies – unless we get the right policies in place,” said Sakiko Fukuda-Parr, Professor and Program Director of International Affairs at the New School in New York, who will moderate the webinar. The series will continue over the summer, looking at other themes related to COVID-19 and health inequalities.  

Along with Biyanyima, and Dhalilwal, director of HIV/AIDS and human rights at UNDP, Tuesday’s panel will also include:

  • Nicoletta Dentico, journalist and director of the Global Health Program at the Society for International Development (SID) and;
  • Manjari Mahajan, associate professor of international affairs & Starr professor and co-director of the India China Institute at The New School

Link here to register for the event. Follow the livestream here:

Image Credits: Matt-80.

Sky clears up in New Delhi, India.

“I am not celebrating the fact that people can see the Himalayas or that the air quality is better in Madrid coming out of this virus, but what might come out of it is an awareness of how much human beings have contributed to the ongoing damage to people’s lungs, to our ability to drink clean water, to the harmful algae blooms in the Great Lakes, to the hurricanes and intense storms in the Midwest. Maybe it’ll be a wake-up call,” – Gina McCarthy, president and CEO of the Natural Resources Defense Counsel (NRDC) and former US Environmental Protection Agency Administrator.

As skies clear and waterways clean up due to widely adopted lockdowns and quarantines all over the world, three prominent environmental health scientists and policy experts, Maria Neira, the World Health Organization’s Director of Environment, Climate Change and Health; Gina McCarthy, administrator of the US Environmental Protection Agency under Barack Obama; and Aaron Bernstein, Director of the Center for Climate Health and Global Environment at the Harvard T. Chan School of Public Health, explored how environmentally unsustainable policies have predisposed vulnerable communities to COVID-19, at a webinar hosted by Harvard University last Monday in recognition of Earth Day.

Air pollution, mainly due to fossil fuel burning, makes people more vulnerable to serious illness from respiratory infections. In the case of COVID-19, emerging evidence is also revealing far higher death rates among people infected with COVID-19 and living in highly polluted cities. 

As economies start to open up, the experts urged governments to take time to rethink their priorities and offered a roadmap to invest in more sustainable transport, energy and urban policies that would make societies healthier as well as more resilient. 

“We have to use [the pandemic] to create a healthier society better prepared for emergencies, no doubt, more investment on our epidemic preparedness and response capacities at all levels,” said Maria Neira.

Maria Neira, WHO Director of Environment, Climate Change and Health

The pandemic has also underlined how both health, climate and environmental hazards in one part of the world can affect people on the other side of the planet, said Bernstein, a paediatrician by training.  

He described how he visited a family’s home, fully suited in protective gear, to examine a child suspected of being infected in the early days of the US epidemic. 

“As I walked into the room, dressed in my alien suit, and touched that child’s hand through the barrier of a synthetic rubber glove. It occurred to me – that child’s hand could connect me to a bat living in Asia. By the way, I work in Boston.” 

In looking forward into the future, the panelists emphasized that this pandemic, despite its devastation, does present a ‘shock’ that could change our economic system. Here, the Bernstein emphasized a transition into a green economy, and considered the present inequities between not just the global South and the global North, but within countries where the poor and marginalized often share an unequal burden of disease. 

“We cannot get out of this crisis at the same level of environmental pollution that we went in. Even before the crisis we were having 7 million primitive deaths caused by air pollution and we were very much vulnerable today. Our health was very vulnerable to climate change and the responses we need to provide are more important than ever,” said WHO’s Maria Neira.

Boys play on a beach in Kiribati, an island nation threatened by rising sea levels due to climate change.

As part of a Health Policy Watch’s continued coverage on COVID-19 and climate, here are some key excepts from the Q&A:

Air Pollution Predisposes Vulnerable People to Negative COVID-19 Outcomes

Q – Is there a link between air pollution and the severity of coronavirus? Do most polluted cities experience more severe coronavirus epidemics?

Aaron Bernstein – “For every small increment in air pollution [in long-term studies], there’s a substantial increase in death from COVID-19…This kind of air pollution makes people more vulnerable to respiratory infections and makes them more likely to die. You could pick any city in the world and expect to see an effect of air pollution on people’s risk of getting sicker with coronavirus.”

Maria Neira – “The evidence we have is pretty clear. And on top of that, of course, within those cities [that are more polluted], the people who are most at risk are people who are already sick, people who are poor, and in the United States, the evidence is strongly suggesting minority communities of color.”

Gina McCarthy – “We have to look at low income [groups] and we have to look at people of color, who are in this COVID-19 exposure. Actually, we’re seeing African Americans die at much higher rates than others in part because of their exposure to air pollution…they are already predisposed [due to high air pollution levels]; this is adding another layer of burden on their bodies. And they just can’t fight equally.” 

 Q – Considering that the southern hemisphere is moving towards winter shortly, could a colder climate be expected to increase the transmission of COVID-19 and /or its lethality? And if so, what would be the recommendation to scientists and policymakers?

Aaron Bernstein – “We don’t have clarity about what temperature means for the virus. It’s been thriving and warmer temperatures and colder temperatures as it is. And so I think the best thing we need to do is to have surveillance in place and the ability to test people at a broader scale as possible. And particularly in many cases among the poor.”

Aaron Bernstein, Director of the Center for Climate Health and Global Environment at the Harvard T. Chan School of Public Health

Addressing Climate Change To Better Mitigate Public Health Crises – A Holistic Approach Is Key

Q – If the coronavirus shows how effectively we can mobilize to confront a public health crisis, what does framing climate change as a public health crisis look like? 

Gina McCarthy – “We have to figure out how we can live healthy lives. We know now that we have a problem, not just with our ability to treat, but with our ability to prevent and that needs to be invested in. We have to get people to understand that…if you invest in stopping people from getting sick, which is what all environmental protection is about, then you save enormous money in lives, from having to spend the money to treat them on the back end.”  

Maria Neira – “Climate change is creating the conditions for the population to be extremely vulnerable and we cannot leave this crisis by not joining forces between all the efforts: the law, the legislation, the enforcement, the demands by the environment community and [through community mobilization]…We need to prove to the population that this is not a completed agenda….Our lungs have been made very vulnerable by the levels of exposure to pollution that we had for many years.” 

The COVID-19 Pandemic: A Strategic Opportunity To Promote A Green Recovery

Although it is “very difficult” for humans to learn lessons from the past, Maria Neira is “very optimistic” that the “new society” can do the right thing.

Q – How should countries limit air pollution to reduce the impact of coronavirus?

Maria Neira – “We need to avoid the temptation [of going back to] intensive use of fossil fuels or again intensive use of traffic, private cars, or going back to activities that will be considered as important to recover the economy…It has to be a green recovery, it has to be an investment, this time on maintaining the commitments for tackling climate change, on moving into a green and renewables and stopping the use of fossil fuels, and working as well on healthy cities, better urban planning and in the mobility of the new society….One of the most important benefits of this type of healthy planning on this new transition will be by the reduction of air pollution. So, this will require a lot of work from the scientific community, from the climate change, air pollution, energy, and sustainable development community, a community. We need to have a common narrative. We need to be very strategic.”

Q – What steps should governments take to reduce air pollution and prevent future pandemics like COVID-19? 

Gina McCarthy – “My biggest concern has been the stimulus dollars [to address the economic effects of the pandemic in the USA]. How you spend this money is going to be usually important. We know climate change and the challenges we face on air pollution are going to cost money, but they are also going to prevent public health damages, and we have to invest in a better future, and not go backwards.”

Gina McCarthy, president and CEO of the Natural Resources Defense Counsel (NRDC) and former US Environmental Protection Agency Administrator.

Investment in Education, Science and Prevention: An Awakening For Governments ?

Q – Clearly, climate friendly policies can provide long term improvements to public health, but what would you say to local officials and governors coming out of COVID-19, what should be the first priority of local official and governance? Where should the priorities be in the first 12 to 24 months to address both COVID-19 and climate change?

Gina McCarthy – “[Governments] need to make science-based decisions, and they need to look at what healthy air and clean water looks like. And they need to use the laws that are in the books and create more to make sure that we’re protected.”

Maria Neira – “One of the lessons of this horrible shock is that the investment on the health systems, investment on education, investment on researchers and scientists is definitely a non-regrets investment. I mean having a very strong health system, well prepared to respond to this type of public health crisis has proved to be fundamental…This crisis is once again demonstrating how much the government needs to take the right decisions to protect people’s health…[we need to] invest in primary prevention [and build] a very good health system, trying to reduce as much as possible those horrible inequalities that are bad for the population, for the health of the people, but they’re very, very bad for the economy of the country as well.”

This story was published as part of Covering Climate Now, a global collaboration of more than 250 news outlets to strengthen coverage of the climate story, co-founded by The Nation and Columbia Journalism Review.

Image Credits: Maria Neira, WHO.

Ursula von der Leyen, European Commission President, speaking at the virtual launch of the Access to COVID-19 Tools (ACT) Accelerator virtual launch

In the largest global collaboration to address the COVID-19 crisis so far, the World Health Organization, European Commission, and other partners including the Bill and Melinda Gates Foundation (BMGF), launched a new campaign to accelerate development of COVID-19 diagnostics, drugs, and vaccines – and just as critically ensure that they are affordable and accessible worldwide.

The European Commission will be hosting a rolling pledging campaign, beginning 4 May, to raise the 7.5 billion Euros to bankroll the massive effort, said Ursula von der Leyen, EC President.

In a striking display of multi-lateral unity, launch of the new ‘Access to COVID-19 Tools’ (ACT) Accelerator was made in a WHO public webcast featuring UN Secretary General Antonio Guterres, Melinda Gates, 11 heads of state, including Germany’s Angela Merkel, France’s Emmanuel Macron, and South Africa’s Cyril Ramaphosa, as well as other leaders across Africa, Asia, and the Americas, and Europe.  

Strikingly absent were the United States and China, which have been locked in bitter dispute with each other over the management of the COVID-19 crisis. But Macron specifically addressed the political tensions, saying he hoped to “be able to reconcile this initiative” with both superpowers.

“I hope that both of these countries will be able to fight against COVID-19 by developing vaccines together,” said Macron. “There should not be any divisions between countries, we need to join forces.” Clinical trials for five of the seven leading vaccine candidates identified by the WHO are being conducted in either the United States or China. 

“Human health is the quintessential global public good, and today we face a global public enemy like no other. COVID-19 requires the most massive public health efforts,”  said Guterres in prepared remarks. “For too long we have undervalued, underinvested in global public goods. Data must be shared, production capacity prepared, resources mobilized, and politics set aside.”

UN Secretary-General Antonio Guterres calls into the ‘Access to COVID-19 Tools’ (ACT) Accelerator launch event.

“The ACT Accelerator brings together the combined power of several organizations to work with speed and scale,” added WHO Director-General Dr Tedros Adhanom Ghebreyesus at a 90 minute virtual launch, co-hosted with French President Emmanuel Macron and the BMGF. “Each of us are doing great work, but we cannot work alone. We’re coming together to work in new ways to identify challenges and solutions.” 

Leaders of other global health organizations echoed Guterres’ and Tedros’ calls urging countries to collaborate in the pandemic response.

Melinda Gates, co-founder of the BMGF, said “COVID-19 knowns no borders, and defeating it will require action across sectors and countries.”

“Beating coronavirus will require sustained actions on many fronts,” said von der Leyen, president of the European Commission. “This is a first step, only, but more will be needed in the future.” 

Search for a Vaccine Dominates

As new COVID-19 cases continue to rise in newly affected hotspots, and some states begin to weigh the risks of a resurgence as cases plateau, there was wide agreement among the leaders that developing and deploying an effective COVID-19 vaccine was the priority. Von der Leyen and Chancellor of Germany Angela Merkel called for such a vaccine to be treated as “a universal public good.”

Hope of curbing the pandemic was pinned on a vaccine just as early COVID-19 drug trial results, revealed that remdesivir, the most promising therapeutic so far, may not be as effective as initially suspected. The pre-print study was accidentally posted by WHO and obtained by STAT News.

“COVID-19 is not a human endemic infection, this will not disappear. The only true exit strategy is science,” said Jeremy Farrar, director of the Wellcome Trust.

“Finding and distributing the vaccine is the only way to win this battle,” said Guiseppe Conte, president of the Council of Ministers of Italy. “The role of governments is to promote good governance, transparency, and mutual accountability to ensure universal, equitable access to the vaccines.”

Guiseppe Conte, president of Council of Ministers of Italy, speaking at a virtual ACT Accelerator launch

So far, vaccine developers have reported that an acceleration of funding is required to bring candidates through later clinical trials and market approval. The Coalition for Pandemic Preparedness and Innovation (CEPI), which has been supporting three of the six vaccine candidates that have entered clinical trials around the world, is still facing a US $1 billion shortfall to bring a successful vaccine candidate to market.

“The establishment of the ACT Accelerator is a watershed moment in the world coming together to develop a global exit strategy from the COVID-19 pandemic,”  said Richard Hatchett, CEPI CEO. “Everyone must have access to the tools and countermeasures, including vaccines, that we will develop through the Accelerator.”

Hatchett’s comments were echoed by several heads of state and leaders of global health organizations from around the world, who stressed the importance of making any new COVID-19 tools accessible in an equitable way.

“We must commit to a system of clear global access goals as long as the virus is active somewhere. We are all at risk. The fight against COVID-19 must leave no one behind,” said Prime Minister of Norway, Erna Solberg.

Erna Solberg, PM of Norway, speaking at a virtual ACT Accelerator launch

But while the search for a vaccine dominated the discussion, other speakers reaffirmed the importance of supporting a holistic COVID-19 response, focusing on providing equitable access to diagnostics, therapeutics, and strengthening the public health system for future pandemic threats. The standing president of the G20 group of most called pandemic preparedness the “smartest investment for us to make today.”

“We might face a similar threat in the future,” said G20 president and Minister of Finance of Saudi Arabia, Mohammed bin Abdullah Al-Jadaan. “In order to deal with future pandemics effectively, we have to invest in strengthening our preparedness  and response systems. G20 is working with relevant organizations to assess that gaps with the view to establish a global mechanism for response.”

Key Commitments Under the ACT Accelerator

Under the ACT Accelerator, 11 major global health agencies, organizations, and pharma industry representatives made five major commitments in a statement released Friday:

  1. Aim to ensure equitable global access to innovative tools for COVID-19 for all;
  2. Commit to an unprecedented level of partnership to proactively engaging stakeholders and existing collaborations to align and coordinate efforts;
  3. Commit to create a strong unified voice to maximize impact;
  4. Build on past experiences towards achieving this objective;
  5. Stay accountable to the world, to communities, and to one another.

Some 11 heads of state including the United Kingdom’s first Secretary of State Dominic Raab, Spain’s President Pedro Sánchez Pérez-Castejón, Chairperson of the African Union Commission Moussa Faki Mahamat, Malaysian Prime Minister Muhyiddin Mohd Yassin, and Rwanda President Paul Kagame, among others spoke at the launch event to support the collaboration. Costa Rica President Carlos Quesada Alvarado, who called on WHO to create an accessible pool of COVID-19 intellectual property rights, also called in to support the launch. 

The initial group of collaborators includes the Bill & Melinda Gates Foundation (BMGF); the Coalition for Epidemic Preparedness and Innovations (CEPI), Gavi, the Vaccines Alliance; the Global Fund for HIV/AIDs, Tuberculosis and Malaria; UNITAID; the International Red Cross and Red Crescent Movement, and the Wellcome Trust.

Pharma industry representatives including the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA); the Developing Countries Vaccine Manufacturers’ Network (DCVMN); and the International Generic and Biosimilar Medicines Association (IGBA) have also joined as founding members of the Accelerator.

The World Health Assembly in Geneva, Switzerland.

In the wake of the COVID-19 pandemic, there could be “a window of opportunity… that would be suicidal to miss” to revise the International Health Regulations that govern countries’ behaviour during health emergencies, said Gian Luca Burci, former World Health Organization head legal counsel and now professor of international law, at a panel hosted by the Geneva Graduate Institute and Global Health Centre.

The present system may have led to delays in ramping up levels of alert at key points in the crisis to an international health emergency, Burci suggested at Tuesday’s panel entitled “What’s law got to do with COVID-19.”

“The system of alert right now is either we have an emergency or we have nothing. There is a growing consensus [that this system must be replaced by] something much more incremental,” Burci said.

The International Health Regulations (IHR), the legal framework for WHO’s emergency coordination and countries’ response, also has a “very weak” system for commanding sovereign states’ compliance with its provisions to prevent, prepare and respond to infectious disease outbreaks, Burci underlined.

But it remains up to Member States of the World Health Assembly to decide whether the WHO should wield more power, said Steven Solomon, principal legal officer for governing bodies at the World Health Organization.

As the only binding international law that governs international and member state response, and last updated in 2005 under very different global conditions, it is time for IHR to be revised, agreed Solomon and Gian Luca Burci. The question is how? 

The World Needs The WHO For Leadership And Coordination 
Top: Steve Solomon, current WHO Principal Legal Officer.
Bottom: Gian Luca Burci Former WHO Principal Legal Officer and Professor of International Law.

“To respond with two words, what can be done now [by WHO within the IHR system]…is leadership and coordination”, said Solomon.

Yet despite WHO’s attempts to coordinate such outbreak response for the world, countries have not always complied.

Export restrictions, which can block critical supply chains for essential products like personal protective equipment or medicines, have been adopted by 28 countries despite WHO guidance that such barriers impede efficient emergency allocation of resources, said Sueri Moon, Co-Director of the Geneva-based Global Health Centre.

“While many recommendations by the WHO have been implemented at the national level,” said Burci, the same level of adherence has not been observed in the international arena, with regards to trade, travel and related areas, “and we have to wonder why,” said Burci.

Countries have not complied because they simply do not have the incentive to do so under the current IHR rules, he added. 

“The system of accountability is weak. States can do whatever they want, without much accountability and with impunity,” Burci said. “There is resistance [by the WHO] to naming and shaming. There is no system of assessment of compliance [decreasing incentive for members to comply]”, he added.

Needed: “Agile” System For Resolving Trade Desputes

To address some of the trade barriers that have emerged during the emergency, the IHR would also requrie an ‘agile’ mechanism for settling trade disputes. The current system is “very weak”, and with countries shutting down their exports in a desperate attempt to prioritize sovereign supply, such revisions have become more important than ever. 

“There is no system of dispute settlement. The one we have is very weak. Look at what’s happening now, with border closures and trade limitations. These are the seeds of major dispute…There are evident gaps in travel restriction and trade restriction policies,” said Burci. 

At the broader level, a stronger compliance assessment system, integrated into the IHR, could make Member States more likely to comply with WHO recommendations because their responses to outbreaks would be evaluated and communicated to the public, agreed Solomon and Burci.

Public scrutiny, or ‘naming and shaming’, could be a useful tool to improve the WHO’s capacity to lead and coordinate an effective response at an international level.

An enforcement compliance mechanism can be created if Member States were interested in creating one, suggested Solomon. The WHO would also be ready to support countries if they decided on a new Mandate for that within the IHR context.

“Member states or countries decide…[if] something needs to be changed; that’s certainly an area where WHO would support, but that mandate has to come from Member States. That mandate can only be provided from the countries themselves,” he said.

The IHR revisions mentioned by Solomon and Burci, ranging from a compliance assessment to an improved trade dispute resolution mechanism, are not, however, compatible with the current architecture of WHO financing.  When most of its budget is controlled by a handful of large stakeholders, WHO’s hands are often tied in terms of inspecting, auditing or compelling countries to adopt emergency measures. 

Legal Experts Call For Sustainable WHO Financing Mechanism 

Top contributors to WHO’s Budget (2018)

Funding was dramatically highlighted last week when US President Donald Trump decided to suspend US funding, which amounts to about 15% of WHO’s annual budget. In addition, the regular annual “assessed” contributions of member states comprise only about one-fifth of the total WHO budget, while the rest comes from national “voluntary” commitments, which may be short-lived and are often earmarked for specific purposes.  

Solomon and Burci advised Member States to invest in a “sustainable financing mechanism” with a view to strengthening public health systems in the long-run.

“It’s irrational to have an organization like the WHO funded at 82% with voluntary contributions. You cannot have a fire brigade that has to raise money when it catches fire, that is irrational.”

Furthermore, it is important that funding be directed more strategically toward long-term strengthening of core capacities of public health systems like prevention, surveillance and response to disease outbreaks, the two legal experts said.

“Investments cannot immediately respond to a short term profit or political gain…Long term investment in public health care [is needed]…I hope that the WHO would play a role in that”, said Burci.

“It is not a do it once and it’s done”, said Solomon. “Maintaining core capacities is much more like brushing your teeth. It needs to be done every single day in a determined way”.

Image Credits: WHO/L. Cipriani, WHO .

Polymerase Chain Reaction (PCR) test for the virus that causes COVID-19 respiratory disease, SARS-CoV-2.

With COVID-19 pandemic curves beginning to flatten out in many parts of the Europe, Health Policy Watch presents a snapshot of infection and death trends in WHO’s European region through graphs that tell the story, using up-to-date data from the COVID-19 tracker of the Geneva-based Foundation for Innovative New Diagnostics (FIND).

Notably, some striking, but little discussed, differences in deaths, disease incidence and rates of testing exist among Switzerland, Czechia, Denmark, Norway and Sweden – countries with similar population sizes and age demographics, quality health systems and high development indices.While a great deal of attention has been focused on the situations faced by Europe’s big powers, including the United Kingdom, Italy, France and Spain, on the one hand, and Germany on the other, trends in these smaller, central and northern European countries are also revealing -with death rates in Czechia particularly low, followed by Norway and Denmark.

While it will take more time and expert review to etch out the basket of policies that worked best together, the snapshot of trends is suggestive of questions that will have to be asked and the mix of policies that may or may not be most effective.

The lesson in the data seems to indicate that there is no one policy that works on its own, but rather an integrated package  – as the World Health Organization has long stated. And countries that test more and test earlier have better curbed the spread of the virus, as well as deaths resulting from COVID-19 infection.

See below the three key indicators in data: death rate, testing and number of reported COVID-19 cases. Note these are presented in per million,  to make comparisons more equal.

Death Rates – The Ultimate Indicator
(HPW/Svĕt Lustig): Sweden’s death rate due to COVID-19 is much higher than Norway and Denmark. Based on national data collected by FIND (finddx.org), 20 April, 2020.

Death rates, if reported accurately, are the ultimate indicator of a country’s outbreak response policies – at least among countries with similar age demographics and underlying health conditions. Death rates can be seen to reflect the success of the whole range of measures taken, including testing and contact tracing and the quality of hospital care as well as physical distancing through quarantines and lockdown measures.

Whatever the combination of policies that worked and did not, it remains striking that deaths, per capita, have been much higher in Switzerland and Sweden as compared to Denmark, Norway and Czechia, which also tested more aggressively in the early days.

Denmark, Norway, and Czechia also cancelled mass events, closed leisure facilities and restaurants for dining, adopting strict social distancing measures comparatively early on in the initial epidemic surge, while Switzerland took those same measures more gradually and comparatively later in its outbreak, which began to spill over from Italy already in late February.

Czechia closed its borders early on, and ordered universal masking of its citizens. So did Czechia’s extraordinary measures keep its case load and death rates particularly low? And on the other hand, could it be that Norway’s more aggressive testing policies, also helped contribute to significantly lower mortality trends, much in the spirit of WHO’s admonition to “test, test, test”?

Sweden, which experienced relatively higher mortality, left most restaurants and shopping malls open throughout. Sweden’s ‘voluntary’ physical distancing measures were also much milder than those adopted in Norway and Denmark.

Israel, also a member of WHO’s European Region, is another country with very low death rates comparable to Czechia’s. Like Czechia, Israel adopted strict social distancing, quarantine and travel restrictions early on, although experts have also attributed the low death rate to the country’s comparatively younger population – an average age of about 30 as compared to 40-something averages of the the central and northern European countries featured here.

Countries That “Test, Test, Test” Can Reduce Death Rates – But Follow-Up Also Essential

WHO has stressed that testing lies at the heart of containing infectious disease outbreaks and helps save lives by allowing authorities to trace and isolate infected people accordingly.

“All countries should be able to test all suspected cases, they cannot fight this pandemic blindfolded, they should know where the cases are, and that is how they can take decisions,” WHO Director-General Dr Tedros Adhanom Ghebreyesus has stated repeatedly at WHO’s COVID-19 press briefings.

In Scandinavia, Sweden has lagged far behind Norway and Denmark in implementing widespread COVID-19 testing, a key World Health Organization-COVID-19 control strategy. Sweden has paid the price of low testing with significantly higher death rates.

Norway, on the other hand, has been the European country that consistently tested the most, from the early days of the epidemic until now. Norway’s testing rates were three times more than those in Sweden, while Norway’s deaths were only about one-fifth of its next-door neighbor. Denmark also tested twice as much as Sweden, while its death rate was less than half.
Switzerland has also tested more aggressively than any other country, just behind Norway. Despite having one of the highest ratios of cases, per capita, its death rate has been almost the same as Sweden. Once again, differences in testing may help explain these trends, as testing can help in case identification and reporting that reduces mortality. There are signs that Sweden has come to this conclusion too. The country plans to expand testing now by a factor of six to 100 000 tests a week, targeting ‘key roles’, such as policemen, firefighters, and healthcare workers, said Swedish Health Minister Lena Hallengren last Friday at a press conference. 
(HPW/Svĕt Lustig): Sweden focused less on testing than its neighbors. Based on national data collected by FIND (finddx.org), 22 April, 2020.
But testing is merely the first step in an outbreak response, public health experts have stressed.

“Testing is a hugely important central piece of surveillance, but we need to train hundreds or thousands of contact tracers [to follow up on positive cases and contacts]. We need to be able to find cases, we need to be able to isolate cases who were confirmed,” said WHO Executive Director of Health Emergencies Mike Ryan. 

In Norway and Denmark, the widespread availability of testing as part of a comprehensive ‘package’ of policies, has allowed authorities to quickly identify and quarantine people to effectively reduce deaths – although again, these measures were also accompanied by quarantines and physical distancing.

Drop-in testing clinic outside a health clinic in the ultra-orthodox city of Bnei Brak – one of Israel’s virus hotspots

Norway and Denmark are not the only European countries that have seen the fruits of testing.  Despite being hit by heavy waves of cases from Italy and France, Switzerland has had comparatively high testing, which could have helped fend off an even wider outbreak as it faced the onslaught of cases imported from Italy, which was Europe’s virus epicenter.

“Testing is important in fighting COVID-19. Switzerland is testing more and more”, said Swiss Federal Councillor Alain Berset, in a tweet in late March.

Israel has also ramped up testing capacity recently to one of the highest in Europe – aggressive testing along with precision case tracking and isolation has been viewed by experts there as key to “lockdown exit” strategies – and its army has even taken on a central role, mapping disease incidence house by house in the most heavily infected, ultra-orthodox towns and neighborhoods.

Case Rates Per Capita Across Europe
(HPW/Svĕt Lustig): Sweden, Denmark and Norway have similar case numbers. Based on national data collected by FIND (finddx.org), 20 April, 2020.

Experts have warned that reported cases may not reflect the true picture of disease spread – due to the very different rates in testing that countries have practiced.  Strikingly, Switzerland has one of the highest numbers of reported cases, per capita, in Europe, outpacing even those of neighboring Italy and double those of Sweden. However as one of the countries testing most aggressively, it may be that Switzerland has also simply been more diligent about case tracking and reporting, while cases that passed under the wire elsewhere. In light of its high case rate, the comparatively lower mortality may be a qualified success.

Clearly, however, Switzerland’s proximity to Italy and France, as well as the fact that lockdown measures may have been implemented later in the epidemic surge than in the other countries noted here, may have also played a role in high case incidence.

Czechia Gets The Highest Marks Across The Board – So Far
Homemade mask production for members of the public have become a big part of Czechia’s containment strategy.

At the very other end of the scale, Czechia has reported the lowest number of cases, per capita. And while Czechia’s testing rates are not as high as other countries like Israel or Norway, Czechia also has one of the lowest mortality rates in Europe.

Strikingly, it is also one of the few countries in Europe that has made mask use mandatory in public spaces from the early days. Is it possible that along with the travel restrictions and lockdown measures, widespread and mandatory mask use helped Czechia slash the number of infected people to a minimum, as well as the death rate resulting from the disease?

Given that the Czech public was widely engaged in home-fashioned mask making, it is also likely that priority populations like healthcare workers did not lack access to masks. Last week, Czechia began lifting its lockdown.

Image Credits: Mehr News Agency, Israel Ministry of Health, Pavlina Fojtikova.