Air pollution above India
Smoke covering Punjab, Delhi, Uttar Pradesh and Madhya Pradesh, as captured by Nasa’s Visible Infrared Imaging Radiometer Suite.

DELHI, India – As north India reels under ‘severe’ levels of air pollution for the fourth day in a row, the government has appointed a former Petroleum Ministry bureaucrat to chair a new national Commission For Air Quality – hastily set up by a presidential decree just 10 days ago.

Dr M.M. Kutty, former head of India’s Ministry of Petroleum and Natural Gas, took over as chair of the new Commission on Friday, a day when official monitors reported PM2.5 levels in Delhi as high as 953, almost 100 times more polluted than WHO’s guidelines for 24-hour particulate pollution levels.

Delhi and adjoining areas are now regularly seeing PM2.5 cross 500 micrograms per cubic metre – more than 50 times the WHO-recommended 24-hour standards – as seasonal crop stubble fires continue to burn in neighboring rural states of Punjab, Haryana, Rajasthan and Uttar Pradesh.

NASA researcher Dr Pawan Gupta tweeted on Monday that there have been more fires in Punjab in the last two months, than any other September and October in 9 years, with the exception of 2016.

Adding to the pollution mix are seasonal weather conditions -falling temperature and stagnant winds – and open wood or biomass-burning fires to heat homes. Things could get even worse in coming days and weeks if Delhi’s residents also begin setting off firecrackers that are a traditional part of the late autumn festival of lights, Diwali.

New Ordinance For An Old Problem?

The new commission actually does something significant in terms of Indian law. It replaces the 22-year-old Supreme Court-empowered Environment Pollution (Prevention and Control) Authority (EPCA), with a formal government body responsible to the central government of Prime Minister Narendra Modi.

As such, it represents the most explicit action yet by Modi to address the threat of India’s air pollution to public health – even though the Prime Minister continues to avoid the issue in his public statements.

India’s Prime Minister Narendra Modi

Although air quality experts have welcomed the creation of the new Commission, they said that the notable lack of government urgency to act in the face of another mounting air pollution crisis remains disappointing.

“A new commission, with full-time members, representation from the Centre and states, and dedicated staff is a step in the right direction,” Shibani Ghosh, public interest lawyer and Fellow at the Centre of Policy Research, told Health Policy Watch. “It could address concerns of intermittent focus on air quality, institutional capacity constraints and lack of bureaucratic coordination.”

“What the ordinance has done is replace the EPCA and the multiple other task forces with a single new commission with full-time staff, representatives from the central and state governments and significant powers,” explained Dr Santosh Harish, who specialises in energy and environment policy and air quality governance. “This could help address some of the issues in bureaucratic coordination across agencies in this region.

“However, all the major actions needed for improved air quality – tackling industrial or power plant emissions more effectively, finding a long-term solution to stubble burning, improving waste management – involve increased political willingness to impose costs on polluters. Neither the ordinance or the commission seem to solve that problem,” he added.

Quality Of Commission Members Will Be Decisive

In the absence of greater leadership from the prime minister, what will be critical to the effectiveness of this 18-member commission is the dynamism and accountability of its appointed members.

Alongside Kutty, other members are a mix of retired and serving bureaucrats and non-profits, with few technocrats or scientific experts on the new panel. This leads environmentalists to worry that the new commission may end up as yet another body of file-pushing officials.

Young people in Delhi demand action against air pollution
A long-standing issue: young protesters from the Democratic Youth Federation Of India, Delhi state, demand action against air pollution.

Those named so far include: Arvind Nautiyal, a mid-level Joint Secretary in the Ministry of Environment; Dr K J Ramesh, former head of the Indian Meteorological Department; Professor Mukesh Khare of Indian Institute of Technology-Delhi; Dr Ajay Mathur of The Energy Research Institute and Ashish Dhawan of the Air Pollution Action Group as NGO representatives.

The new commission also includes representatives from Punjab, Haryana, Uttar Pradesh and Rajasthan – which contribute to the seasonal air pollution with their crop-burning practices.

But other key stakeholders, like the Health Ministry, the Agriculture Ministry, the Rural Development Ministry and the Labour Ministry all seem to have been left out, at least for the moment.

It remains to be seen how the new commission might set measurable, time-bound goals and outcomes that could make a difference in the air pollution emissions – as well as being accountable to such targets.

If tackled systematically, these would include urban and rural measures, from shifting energy and transport policies to cleaner modes and sources to weaning farmers off of rice subsidies that leave crop residues which are easiest burned – to other, more nutritious indigenous grains and legumes that could be composted or managed more sustainably.

“A lot depends on how this commission will get constituted and the rules that are issued to enable its function,” Ghosh commented. She added: “Unless competing interests are heard and decided in a deliberative manner and the Commission is held accountable to ambitious but achievable targets for improved air quality, not much will change on the ground.”

Supreme Court Declares: No Smog in Delhi – Easier Said Than Done

Modi’s announcement of the new air quality commission followed weeks of Supreme Court pressures on his government in September and October. His government promulgated an Ordinance (which acts as law when Parliament is not in session) that brought this commission into existence via a gazette notification.

A view of Humayun's Tomb in New Delhi at various points during the air pollution season
A view of Humayun’s Tomb in New Delhi at various points during the ‘pollution season’.

The gazette notification – all five chapters and 26 sections of it – is fairly detailed and was likely in the works for some time.

The move to act, observers say, could have been prompted by any number of factors besides the Supreme Court. Those may have included US President Donald Trump’s denunciation of India’s “filthy air” in a pre-election debate, or growing public awareness of the health impacts of poor air quality, particularly during the pandemic. The gazette itself acknowledges that the number of petitions and litigations on environmental issues is skyrocketing across India’s judicial system.

On Friday, the country’s Supreme Court continued to be active on the issue. It directed the federal government to ensure that there is no smog in Delhi and neighboring areas following heightened alarm over the health hazard it poses during the coronavirus crisis, Bar and Bench reported.

The judges were responding to senior advocate Vikas Singh, representing one of the petitioners in court, who said the condition in Delhi was akin to a “public health emergency” and that “drastic measures need to be taken” to tackle the air pollution.

Environment Pollution Control Authority Dissolved by New Law

The Supreme-Court EPCA, which operated for 22 years, has meanwhile been dissolved with the publication of the new law.

The Government’s legal notification creating the new commission stated: “It is now considered necessary to have a statutory authority with appropriate powers and charged with the duty of taking comprehensive measures to tackle air pollution on a war footing and powers to coordinate with relevant states and the central government.

“The quality of air remains a cause of concern on account of the absence of a statutory mechanism for vigorous implementation of measures put in place.”

The government notice said the new body represents a “self-regulated, democratically monitored mechanism for tackling air pollution” that will lead to better “coordination, research, identification and resolution of problems surrounding the air quality index”. It is hoped this will do away with “limited and ad hoc measures.”

The commission will be empowered to direct orders to control air pollution and take cognizance of complaints. It will also have the authority to set new parameters for curbing emissions, as well as levying fines to violators. Pollution offences can invite a jail term of up to 5 years and penalties of up to $135,000, Section 14 of the new notification states.

Law Conceived Hastily – Commission Lacks Statutory Powers

Other questions revolve around why the new ordinance was so hurriedly issued by government fiat, rather than as a bill to be voted on by both houses when Parliament was in session.

“The haste in setting up this commission without any scope for public comment does not bode well for the professed objectives of increased public participation mentioned multiple times in the preambular text in the ordinance,” Harish said. “This is a missed opportunity at thinking through how to operationalise airshed level management.”

Delhi’s skyline, chronically obscured in late winter by heavy air pollution.

Experts are also annoyed at the way air pollution is being treated as a problem only in Delhi and its surrounding areas. Ritwick Dutta, an environmental lawyer, said:

“Unless the Central Government sets up similar committees in other polluted regions of the Country, it violates the right to equality under Article 14 of the Constitution and discriminates against those who are not in the NCR. Clearly, there are equally if not more polluted regions which are beyond the NCR.”

“There is disproportionate representation from agencies and ministries which are responsible for the problem,” Dutta said. “As it is currently constituted, the new Commission is neither a representative nor independent body to deal with the issue of air pollution.”

Dutta added: “The Commission has been given power similar to the one conferred on EPCA. EPCA in its 22 years rarely exercised its statutory powers and had become an advisory body to the Supreme Court. The same situation is likely to take place with regard to the new Commission.”

Still Missing – Accountability to Measurable Goals

What happens if air quality remains at the current hazardous levels in the Indo-Gangetic Plains by next winter, or even the year after?

“We certainly don’t want to be stuck with another EPCA-like authority for the next 22 years which will be as ineffective in bringing down pollution on the public payroll,” said Anita Bhargava, co-founder of Care for Air, a clean air non-profit.

In short, while on paper it might seem as if the Commission is empowered with legal and financial resources – its real power and its own accountability to measurable goals remains to be seen.

Bhargava added: “Any responsible government should already have been at work to find some real solutions to this gigantic problem that is causing more disease, disability and death than war, terror and several communicable and non-communicable diseases put together.”

There are solutions. The problem of massive stubble burning can be solved by zero-till farming. There are new rapid composting technologies, like the Pusa decomposer. Farmers should be discouraged from growing the wrong crop in the wrong state at the wrong time of the year – like water-intensive rice in water-scarce northern states such as Punjab.

But in light of the legacy so far, environmentalists fear that the commision may lack the real authority to act, and could still end up becoming yet another body adding to an already long list: “Between the Supreme Court, EPCA, National Green Tribunal (NGT), Central Pollution Control Board (CPCB) and State Pollution Control Board (SPCB) no one is clear as to what needs to be done,” Ritwick Dutta said.

Until the creation of this Commission, only the Indian judiciary has made any significant attempt at tackling the problem of pollution, whether through banning fireworks or crop-stubble burning, or the well-intentioned but misdirected order to install smog towers, a clear case of judicial overreach. But it isn’t really the job of judges to make public policy and enforce laws. It is the job of legislators and the executive.

“We still need to see measurable goals set, and timebound, real outcomes from this Commission. And of course, transparency and accountability,” Bhargav summarised.

Jyoti Pande Lavakare is the author of “Breathing Here is Injurious to your Health: The Human Cost of Air Pollution” published by Hachette and available on pre-order.

Image Credits: Pawan Gupta, Mike Bloomberg, DYFI Delhi Twitter, Chetan Bhattacharji / Care for Air, Wikimedia Commons: Prami.ap90.

Virtual World Health Assembly nerve center at WHO’s Geneva headquarters, with only a skeletal staff around the table, due to the pandemic.

The World Health Assembly on Tuesday approved a resolution calling to strengthen WHO and global preparedness for health emergencies – with few new teeth but lots of symbolism attached.

The resolution makes a sweeping, but still largely ceremonial, call to countries and the WHO to reinvigorate systems of emergency preparedness, vulnerability assessment,  alert, response, compliance and investments, in line with the 2005 International Health Regulations (IHR), which are a binding legal framework. 

The new resolution’s major novelty is a mandate to WHO to come up with proposals by next year’s WHA for “possible complementary mechanisms to be used by the Director General to alert the global community about the severity and/or magnitude of a public health emergency, in order to mobilize necessary support and facilitate international coordination.” 

In plain language, member states have discussed adding a possible “amber alert” – like an orange traffic signal – to the current IHR system by which WHO could signal that a public health emergency is developing – even before it becomes a full blown “public health emergency of international concern”. 

Geopolitical Divide Between Reformists & Backers of the Status Quo

Tuesday’s debate between member states over the measure seemed largely to be a warm-up for the more far-reaching reform proposals that may be in the offing next year, following the completion of multiple reviews over pandemic response now underway. Those reviews are looking at countries’ and WHO’s pandemic performance; WHO’s health emergencies programme, and the IHR system itself. 

And overall, member state remarks were framed by the same geopolitical divides that plague multilateral efforts more generally – leaving questions about what kind of truly far-reaching reforms could really be achieved that might help head off a future pandemic.  

Speeches by the United States, Japan, European and other western allies, on the one hand pressded for more speed in data sharing, transparency and measures to compel member state compliance with early alert rules.  Russia, Pakistan and China, on the other hand, suggested no such changes in the IHR system are needed; and such reforms could even encroach on countries’ sovereignty.

“We need a more independent and authoritative World Health Organization with strengthened IHR implementation, including robust monitoring and evaluation,” said Australia, speaking on behalf of the reformers. “We look forward to an assessment of whether the WHO powers are sufficient to properly investigate and prevent future outbreaks.”  

A representative from Japan speaks at the resumed 73rd WHA, November 2020.

Said Japan: “IHR reform calls for clearly defined responsibilities and requirements for countries to improve their communications capacities and processes.”  

The United States, meanwhile, said there was “overwhelming agreement” between the G7 (Group of 7 most industrialized nations), “that WHO and IHR state parties must improve preparedness and response, including a ‘traffic light approach’ for declaring a public health emergency of international concern, universal review mechanisms for IHR compliance, and revising travel and trade restrictions in systematic and evidence-based way.

“The US along with its G7 partners initiated discussions on WHO strengthening and reform in early 2020,” said Garrett Grigsby, Director of Global Affairs for the US Department of Health and Human Services. “Several member states have since put forward proposals “that reflect our shared values,” he said, noting that the US had put forward a “roadmap” for reform, also being supported by Brazil. 

On the other side of the divide, Russia stated grand revisions legal mandates should be avoided:  “We need to use the experience accumulated in combating  the pandemic to strengthen existing multilateral instruments of cooperation in combating epidemics including the International Health Regulations, but not to revise them.” 

China, stepping gingerly, added, “We firmly support WHO’s leadership role and the framework of the IHR, adding only that “all parties should “effectively implement the requirements of the IHR &…work together to maintain global health security.”

China’s reprsentative speaks at the WHA73

Pakistan, which also has said that too much IHR reform could impinge on countries’ sovereignty, stressed the need for stepping up technical assistance to low-income countries and addressing fundamental drivers of pandemics, like population growth and climate change. 

“The pandemic has highlighted the need for developing IHR core capacities,” said Pakistan’s WHA representative. “The discourse on  the IHR must embed a focus on technical assistance, financing and capacity building, & trends outside the health sector, like climate change, need particular attention,” the representative said. “That there will be another pandemic is not a question of IF, but of When, in light of climate change, population growth and other global trends.”

Low- and Middle Income Countries: Investments & Technical Assistance Most Important 

Other low and middle-income countries also tended to stress the importance of gaining greater access to investments, equipment and other know-how – as compared to reforming the legal rules of the emergencies system.

Reforms in the IHR and other emergency response systems should “build on existing mechanisms to avoid running up costs,” said Kenya’s WHA representative.

Bangladesh talked about the importance of “more predictable and stable core funding” for WHO as key to improving the Organization’s emergency capacity – and thus its support to countries. 

Ghana called for a “more meaningful engagement between the International Health Regulations review and member states – particularly low- and middle income countries and small island states – to reflect all experiences.”

Investigating the Sources of the Virus 

Left-right: Bjorn Inge Larsen, Norway; Helen Johnson Sirleaf;  and Helen Clark at the virtual WHA

The member state debate followed presentations of two reviews of the pandemic response. These included reviews of WHO’s Health Emergencies programme by an Independent Oversight and Advisory Committee (IOAC), and a report by the Independent Panel for Pandemic Preparedness and Response (IPPR), just getting underway. The IPPR review is intended to take a more step-back approach, evaluating pandemic response by countries as well as by WHO.  

“It’ll be important to establish a “chronology” about what happened in the emergence and spread of the SARSCoV-2,” said Helen Clark, former New prime minister of New Zealand, in a diplomatic remark heavy with meaning. She is serving as the co-chair of the IPPR committee along with Helen Johnson Sirleaf, former prime minister of Liberia. 

Member states would also like to see yet another, new WHO committee dig more deeply in the murky history surrounding the original source of the SARS-CoV2 virus, and its origins. 

There is wide agreement among experts that those sources is a natural, animal reservoir, like bats, which are known to harbor coronaviruses in the wild. But the route by which this novel coronavirus first reached humans remains entirely unclear.  Bats found to be harboring a virus  nearly identical to SARS-CoV2 have been reported by Chinese researchers in one or two published studies, but at sites hundreds of miles away from Wuhan, China, where the first major infection cluster was reported.  

Whether the virus reached the city of 10 million people via people traveling to the city from rural China, or via another wild animal source, such as pangolins, sold in the city’s open markets there, or yet by other means [more conspiratorial theories have it escaping from a laboratory], remains a mystery.  And in light of the strict limits imposed  more generally by the Chinese government on research and information exchange, the landscape for investigating such a question is forbidding.   

A new WHO terms of reference for the virus investigation, drafted in July but only published recently states: 

 “As the information is scarce, there are limited hypotheses about how the outbreak might have started in Wuhan. It may have started from an infected individual contaminated elsewhere, from contact with an infected animal, or less likely through contact with contaminated products. The early cases in Wuhan are thought to have occurred in early December, and preliminary information from surveillance data of severe pneumonia suggest no unusual cluster or departure from trends in the weeks and months preceding the first reported case in Wuhan. 

“The search for the virus’s origins is a study in the compromises the WHO has made,” observed the New York Times in a damming 3 November report of how the Organization may have hindered such work, more than it  has helped.

Seafood and fresh food market in Wuhan, Hubei, China. Some early cases of SARS-CoV-2 were traced back to Wuhan’s Wholesale Seafood Market, but not all – adding to the mystery of where it first emerged.

Countries Also Say Investigation of Virus Origins Should Move Faster 

Only recently has WHO formulated the committee of international experts to probe the issue more systematically, which was mandated by the WHA in May – and only after the names were approved by Beijing. Moreover, the first, critical, elements of inquiry, to probe who were in fact the first people to become infected in China and the role of the Wuhan wild animal market, will be led by Chinese scientists.

At Tuesday’s WHA session, a number of countries expressed impatience that the quest for the virus origins needs to move ahead more aggressively. 

“The  investigation into the sources of the virus should be prioritized,” said the United Kingdom at the debate, striking a chord that the United States and other European allies also echoed.  

Underlying the comments are palpable fears that the committee’s mission could be watered down and lost at sea in the same geopolitical gulf that divides China’s controlled information regime from European and western allies. 

“The terms of reference for investigating the SARS-CoV-2 virus origins was not negotiated in a transparent way with member states,” charged the US, at Tuesday’s WHA session. 

“Member states only received TOR terms a few days ago. And it seems to be inconsistent with the mandate provided by the WHA’s member states,”  it added, referring to the  WHA resolution mandating the virus quest, which was approved by member states already in May. 

At the close of Tuesday’s WHA session, WHO Director General Dr Tedros Adhanom Ghebreyesus attempted to reassure jittery member states that the experts appointed would be serious and impartial, saying:  “The review team on SARS-CoV2 origins will be coming from the United States, Russia, Australia, Sudan, Denmark, The Netherlands, Germany, Japan, Vietnam and the United Kingdom.  

“And the TOR is now online,” he added, saying that WHO would make updates on the investigation “transparent so you can see how study of the virus origins progresses.”

Even so, sentiment that more light needs to shine on such processes also appears to be widely shared in Europe hard-hit by the pandemic – including the most progressive and pro-WHO member states. 

After lauding WHO for its “significant improvement” in handling the COVID-19 pandemic, as compared to the 2014-16 Ebola outbreak that paralyzed West Africa, Norway’s representative added, diplomatically, the following caveat:  

Norway “would have liked to have seen more WHO leadership in the early phases, including earlier WHO access to the source of the outbreak.” 

Image Credits: @ThiruGeneva, Arend Kuester/Flickr.

COVID-19 mRNA vaccine candidate developed by Pfizer and BioNTech.

A COVID-19 vaccine candidate developed by Pfizer and BioNTech has far exceeded expectations, showing a 90% efficacy rate so far among the tens of thousands of volunteers who were immunized in a clinical trial, the company said on Monday.

“Today is a great day for science and humanity. The first set of results from our Phase 3 COVID-19 vaccine trial provides the initial evidence of our vaccine’s ability to prevent COVID-19,” said Albert Bourla, CEO of Pfizer, in a press release. 

Albert Bourla, CEO of Pfizer.

In another statement Bourla added: “We are one step closer to potentially providing people around the world with a much-needed breakthrough to help bring an end to this global pandemic.”

In the trial of over 43,000 participants across six countries, there have been 94 cases of COVID-19 in people not previously infected; but fewer than 9 of those cases were in participants who received both shots of the vaccine – leading to the estimate of 90% efficacy for interim trial results, just disclosed.

The trial will continue until 164 cases of COVID-19 are recorded among trial and control arm participants, so as to confirm the efficacy rate. 

Plans are on track for Pfizer and BioNTech to apply to the US Food and Drug Administration (FDA) for an emergency use authorization in the third week of November, Bourla said. 

That will be the milestone moment when a required two months of safety data has been collected for all of those who participated in the trial. No serious safety concerns have been raised so far, the press statements said -although no breakdown by age group has been provided either. Some 42% of participants were from diverse ethnic and racial backgrounds.

The FDA previously said that a COVID-19 vaccine trial should be at least 50 percent effective, which the Pfizer and BioNTech vaccine candidate has far exceeded. 

“The big news is that we have a #SARSCoV2 vaccine with a strong signal of efficacy,” said Eric Topol, founder and director of the Scripps Research Translational Institute, on Twitter. “We’ll have at least one vaccine into Phase 1a rollout before year end, which is a stunning achievement – from virus sequence to vaccination in < 12 months.” 

“This is a victory for innovation, science and a global collaborative effort,” said Ugur Sahin, BioNTech CEO. “Especially today, while we are all in the midst of a second wave and many of us in lockdown, we appreciate even more how important this milestone is on our path towards ending this pandemic and for all of us to regain a sense of normality.” 

Avoiding the Election

Pfizer’s announcement narrowly missed the US presidential elections last week  – fulfilling the previous commitment  that the company would not be ready earlier to apply for the authorization. 

Despite the victory of Democratic contender Joe Biden, who has now been recognized as the new President-elect,  US President Donald Trump immediately took to Twitter to trumpet the vaccine breakthrough, saying: 

“STOCK MARKET UP BIG, VACCINE COMING SOON. REPORT 90% EFFECTIVE. SUCH GREAT NEWS!”

President-elect Joe Biden took a much more cautious approach, welcoming the progress as “excellent news” giving Ameicans “cause for hope” – but warning that a vaccine would only become widely available later next year. 

“Americans will have to rely on masking, distancing, contact tracing, hand washing, and other measures to keep themselves safe well into next year. Today’s news is great news, but it doesn’t change that fact,” Biden said. 

There had been concern that timing an announcement to coincide with the election might negatively influence public confidence in a vaccine, with Pfizer CEO Albert Bourla criticising President Donald Trump for politicising the vaccine timeline.

Will the Vaccine be Administered Equitably?

Although the results, should they be confirmed, are encouraging news for fighting the pandemic, the Pfizer vaccine, in particular, will pose huge challenges for distribution in low- and middle-income countries because it requires a cold storage temperature in extremes of -70°C. 

Vaccine storage containers being loaded into air cargo. Establishing temperature controlled conditions is essential to respect cold chain requirements.

In addition, there is the question of vaccine supply and distribution. Pfizer and BioNTech estimate that some 50 million vaccine doses could be manufactured by the end of 2020, enough to immunize 25 million people, and 1.3 doses in 2021. They have also said that they are positioned to manufacture more than 1 billion doses during 2021. 

Global health leaders have warned for months that initial vaccine supplies will likely be limited and need to be reserved for healthcare workers and high risk individuals around the world.  

However, Operation Warp Speed, a US government programme aiming to rush a COVID-19 vaccine to market, already signed a $1.95 billion deal with Pfizer for 100 million doses of the vaccine in July. Pfizer also has reached supply agreements with the EU for 200 million doses, covering 100 million people, as well as with the United Kingdom, Canada and Japan. 

If Pfizer’s vaccine is indeed the first to make it to market, the big question that the world will be watching is this: will the company would be obliged to begin distributing all of its initial batches in the USA and other high-income countries where it has already signed procurement deals – with remaining middle- and low-income countries served much later, and after appropriate cold-chain infrastructure is established?   

On the more positive side, the Pfizer vaccine candidate is only one among 10 other vaccine candidates in late-stage clinical trials worldwide. Moderna, a pharma company developing a COVID-19 vaccine with similar technology as Pfizer, has also announced their plans to release their interim clinical results and apply for an FDA Emergency Use Authorization by the end of November. It requires a more moderate – 20°C temperature for shipping and long-term storage.

Science of mRNA Vaccines
Description of Pfizer’s use of mRNA technology to develop COVID-19 vaccines.

Pfizer and BioNTech’s drug is an RNA vaccine. This treatment is based on a part of the virus’ genetic code – messenger RNA (mRNA) – that contains the genetic information needed to produce the coronavirus’ receptors.

If a synthetic mRNA is successfully administered to a person, their cells are then able to build proteins that mimic the receptors, triggering the immune system without causing illness.

The 90% efficacy rate was achieved 7 days after the second dose of the vaccine, which is taken three weeks after the first, totalling 28 days. It has also been shown to block nearly 20 mutated versions of the virus strain, the company said. However the duration of protection obtained remains undetermined. 

Image Credits: Pfizer, World Economic Forum, Flickr – CDC Global, Pfizer.

COVID-19 drug development
Employees at Roche, one of the companies developing monoclonal antibodies for the scheme.

A WHO co-sponsored partnership is laying the groundwork for a worldwide distribution plan of $US 6 billion worth of the most effective COVID-19 drugs, including cutting-edge monoclonal antibodies treatments if proven effective – so as to ensure that high-income countries do not snap up all available new therapies as they arrive on the market.

The proposed basket of medicines would be procured under the auspices of the World Health Organisation’s (WHO) co-sponsored ACT Accelerator: a collaboration with seven other UN and global health agencies and philanthropies, including Unitaid and The Wellcome Trust, to provide equitable access to COVID-19 drugs.

The scheme requires more than US$6 billion – $750 million of which is required by February 2021, according to the plan. Due to be released in the coming week, it is currently under review by the ACT Accelerator’s Facilitation Council, co-chaired by Norway and South Africa, represeneting both donor countries and as well as low- and middle-income countries (LMICs) that would benefit from reduced prices and drug reserves.

The new procurement scheme is being supported by Bill and Melinda Gates Foundation and Mastercard Impact Fund – which banded together with Wellcome in a COVID-19 Therapeutics Accelerator to provide funding and support for the drug procurement effort.

Partners of the WHO co-sponsored Act Accelerator.
Procurement Plan Includes Monoclonal Antibodies, but Excludes Remdesivir – Due To Lack of Proven Benefit

More than half of this investment would go to procuring and distributing monoclonal antibodies, as part of what is referred to as the Therapeutics Pillar – 1 of 4 pillars of the Accelerator scheme, alongside vaccines, diagnostics and health systems.

Monoclonal antibodies appear to be a promising treatment: these artificial antibodies are manufactured copies of those created by the body to fight invading viruses. The emerging  treatment would join key approved treatments – like the steroid dexamethasone – in the medicine basket.

A Unitaid spokesperson, speaking on behalf of the ACT-A Therapeutics pillar, told Health Policy Watch that the procurement plan is being developed as part of the “investment case” for the ACT-Accelerator therapeutics pillar – which will then be shared with donors to recruit the needed $US billion in funding.

“What this investment case is doing is preparing the ground so that when a certain drug is proven to be effective and when it gets the go-ahead from the WHO, we are ready to go.”

The spokesperson added: “The ACT-Accelerator Therapeutics Pillar (co-convened by Unitaid and Wellcome) analysed the treatment pipeline to identify promising treatments with strong clinical safety and efficacy data that could be scaled up. Following this analysis, monoclonal antibodies (mAbs) and proven repurposed therapeutics like corticosteroids (dexamethasone and hydrocortisone) are the most promising options so far. The pillar is preparing different pathways to support access to mAbs as well as monitoring the pipeline and maintaining flexibility to invest in and support other promising therapeutics.”

She stressed that the plan would only be executed with drugs that are actually approved by regulators and the WHO. “Everything is evidence-based and the fundamental principle is to ensure that LMICs don’t lose out.”

Roche Also Confirms Contact With Act Acccelerator

Drugmakers Novartis and Roche are both developing monoclonal antibody treatments; Roche has collaborated with Regeneron to develop and manufacture an antibody treatment known as REGN-COV2.

A spokesperson for Roche told Health Policy Watch: “As part of our commitment to addressing the pandemic, we’ve had preliminary discussions with partners of the ACT-Accelerator about the access plan for REGN-COV2 antibodies.

“These discussions were in the context of development and production of COVID-19 therapeutics, which could eventually inform planning of the ACT-A Therapeutics Partnership,” the spokesperson added. “It is too early to speculate on future decisions, but we will continue working with them and other groups regarding REGN-COV2.”

On the other hand, Remdesivir, a drug approved by the United States Food and Drug Association (FDA), will not be included following a WHO study that found almost no evidence for reduced mortality. WHO announced it was issuing guidance on using remedesivir, but this information is yet to be published.

Cheaper Drugs for LMICs; Equitable Distribution Could Prevent 60% of Deaths

The aim is to ensure that LMICs receive access to these drugs, preventing pre-orders for supplies being locked-up by rich countries.

A recent model, created by researchers at the Northeastern University MOBS Lab, Massachusetts, found that distributing vaccines equitably based on population size could prevent up to 60% of deaths, highlighting the benefits of a scheme like the ACT Accelerator.

The scheme is intended to keep a consistent flow from research and development, to distribution and the administration of the vaccine. Drugmakers Novartis and Roche, both developing monoclonal antibodies, are confirmed to have had contact with WHO regarding the scheme.

Roche has collaborated with Regeneron to develop and manufacture REGN-COV2. A spokesperson from Roche told Health Policy Watch that approximately 2 million doses were projected to be supplied within the first half of 2021.

 

Image Credits: Roche.

Research into mRNA vaccines
The study found that if a vaccine was equitably distributed by population, 65% of global COVID-19 deaths could be averted.

Rather than hoarding vaccine supplies, rich countries that ensure global access to a new COVID-19 vaccine will pave the way to a larger reduction in pandemic related deaths worldwide, according to a new model developed by the Boston-based Northeastern University.

Their findings reinforce the argument the World Health Organization and other global health leaders that vaccine nationalism will boomerang, slowing down the progress combatting the pandemic.

Researchers at the Northeastern University MOBS Lab created two model scenarios: one in which 2 billion doses of a vaccine is monopolised by 50 high-income countries, and one in which the drug is distributed based on a country’s poupulation.

Both scenarios were run with two vaccines: one that had 80% and one 65% efficacy in terms of protective potential. A vaccine with a minimum efficacy of 50% could provide herd immunity, according to a separate study published in The Lancet.

The Northeastern University model found that if the 50 wealthiest countries stockpiled a vaccine with 80% efficacy, only 33% of the deaths that would otherwise occur that year could be averted, compared to 61% if the vaccine were to be distributed equitably. The same findings occurred in the case of the less efficient vaccine, where by hoarding would prevent 30% of deaths as compared to worldwide distribution, which would prevent 57% of deaths.

The study indicates that the planned COVAX vaccine facility, co-sponsored by Gavi, The Vaccine Alliance and the World Health Organization, could be an effective means of minimising the total number of coronavirus deaths across all countries.  See more details here.

 

Image Credits: Moderna, INC.

Vulnerable populations in Africa face falling through the cracks as resources continue to be focused on COVID-19, Matshidiso Moeti WHO Regional Director for Africa fears.

BRAZZAVILLE – The COVID-19 pandemic has dealt a heavy blow to key health services in Africa, raising worries that some of the continent’s major health challenges could worsen.

A preliminary analysis by the World Health Organization (WHO) of five key essential health service indicators finds a sharp decline in these services between January and September 2020 compared with the two previous years. The indicators included numbers of: outpatient consultations, inpatient admissions, births by skilled birth attendants, treatment of confirmed malaria cases, and provision of the combination pentavalent vaccine (a vaccine protecting against five diseases including tetanus and hepatitis B) in 14 countries.

The gaps in services provided this year and in previous years were the widest in May, June and July, corresponding to the period when many countries had imposed lockdowns to check the spread of COVID-19. During these three months, services in the five monitored areas dropped on average by more than 50% in the 14 countries surveyed, in comparison with the same period in 2019.

COVID-19 responders learn how to properly don and doff protective gowns in Kenya, May 2020.

“The COVID-19 pandemic has brought hidden, dangerous knock-on effects for health in Africa. With health resources focused heavily on COVID-19, as well as fear and restrictions on people’s daily lives, vulnerable populations face a rising risk of falling through the cracks,” said Matshidiso Moeti, WHO Regional Director for Africa at a press conference on Thusdsay.

“We must reinforce our health systems to better withstand future shocks. A strong health system is the bedrock for emergency preparedness and response. As countries ease COVID-19 restrictions, we must not leave the door open for the pandemic to resurge,” said Dr Moeti. “A new wave of COVID-19 infections could further disrupt life-saving health services which are only now recovering from the initial impact.”

Even prior to the COVID-19 pandemic, maternal mortality in sub-Saharan Africa was higher than almost any other region of the world, accounting for about two-thirds of global maternal deaths in 2017. During the pandemic, skilled birth attendance in all 14 countries surveyed dropped, an indicator of increased risks to mothers giving birth. In Nigeria, for instance, over 97 000 women gave birth somewhere other than health facilities and over 193 000 missed postnatal care within two days of giving birth. There were also 310 maternal deaths in Nigerian health facilities in August 2020, nearly double the figure in August 2019. 

An additional 1.37 million children across the African region missed the Bacille Calmette-Guerin (BCG) vaccine which protects against Tuberculosis (TB) and an extra 1.32 million children aged under one year missed their first dose of measles vaccine between January and August 2020, when compared with the same period in 2019.

Immunization campaigns covering measles, yellow fever, polio and other diseases have been postponed in at least 15 African countries this year, but the introduction of new vaccines has been halted and several countries have reported running out of stocks.

“Now that countries are easing their restrictions, it’s critical that they implement catch-up vaccination campaigns quickly,” said Moeti. “The longer, large numbers of children remain unprotected against measles and other childhood diseases, the more likely we could see deadly outbreaks flaring up and claiming more lives than COVID-19.”

WHO has issued guidance on how to provide safe immunization services, including ways to conduct vaccine campaigns while avoiding transmission of COVID-19.  The Central African Republic, the Democratic Republic of the Congo and Ethiopia have already carried out catch up measles vaccination campaigns. Thirteen other African countries aim to restart immunization campaigns for measles, polio and human papillomavirus in the coming months and WHO is providing guidance on COVID-19 prevention measures to keep health workers and communities safe, WHO said in a press release.

WHO has also provided guidance to countries on how to ensure the continuity of other essential health services by optimizing service delivery settings, redistributing health work force capacity and proposing ways to ensure uninterrupted supply of medicine and other health commodities.

As part of the COVID-19 response, health workers have received extra training in SARS-CoV-2 infection, prevention and control, and laboratories have been strengthened and data collection and analysis improved. These efforts support the fight against the virus while also building up health systems.

Image Credits: Twitter: WHOAFRO.

Schoolgirls line up to receive the HPV vaccine in Central Primary School in Kitui, Eastern Kenya.

Health experts will meet at the upcoming Geneva Health Forum to discuss the World Health Organisation’s (WHO) new roadmap for the elimination of cervical cancer. Hopes are high for funding to expand services in countries where they are needed the most.

At Newlands Clinic in Harare, Zimbabwe, the waiting room is always busy with women waiting to do a simple cervical cancer screen as part of the routine package of available reproductive and sexual health services. HIV positive women can receive free screening, and follow-up treatment if they are found to be at risk of cervical cancer, which is the most common form of cancer among women living with HIV.

Newlands is one of a growing number of clinics across Zimbabwe and other countries in sub-Saharan Africa that have started to incorporate cervical cancer prevention, screening and treatment services, into their women’s health programmes. The countries with the highest incidences of cervical cancer – Malawi, Mozambique, Comoros, Zambia and Zimbabwe – also have a high prevalence of women living with HIV/Aids, which makes rolling out these services all the more urgent.

Even so, the lack of public awareness and an equally large dearth of funding and international support have created challenges against making such services more mainstream.

“HIV, TB, Malaria – those are major killers so they tend to get the lion’s share of the attention,” says Dr Cleophas Chimbetete, deputy director of Newlands Clinic, who is one of a number of experts speaking at a keynote session on Cervical Cancer Elimination at the upcoming Geneva Health Forum running from 16-18 November.

“Cervical cancer can only be addressed if we have more international organisations coming in to assist, to make noise, and to make cervical cancer programmes. Because [at the moment] most cervical cancer screening is linked to HIV programmes.”

He and other experts gathering at the forum hope that a new global strategy from the WHO to eliminate cervical cancer as a public health problem will give more impetus to donor action. The WHO strategy sets out a roadmap for expanding vaccination, screening and treatment worldwide by 2030.

A Preventable and Treatable Disease

Cervical cancer is still the fourth most common form of cancer among women in the world, despite being one of the few malignancies that is preventable and highly treatable providing it is diagnosed and managed early.

The cancer also reflects global inequity, as its burden is greatest on low- and middle-income countries (LMICs) where access to public health services are limited. In 2018, nearly 90% of all cervical cancer-related deaths worldwide occurred in LMICs, where the proportion of women who die from the disease is greater than 60%. This is more than twice the number than in many high income countries.

The tools to prevent, detect and treat the disease already exist, yet developing countries face a number of challenges in expanding vaccination and screening programmes. The WHO’s strategy, therefore, marks a long overdue call to the global community to put the elimination of cervical cancer higher on their agenda, ensuring that all countries have the necessary policies, health services and funding in place.

Rolling out the Vaccine

As of 2020, less than a quarter of low-income countries have introduced the HPV (human papillomavirus) vaccine, a safe and effective way to protect women from a key cause of cervical cancer, into their national immunisation schedules.  In contrast, more than 85% of high-income countries have done so.

In recent years, however, more and more LMICs have taken steps to roll out the vaccine.

In Zimbabwe, where cervical cancer is the leading cause of cancer-related deaths among women, the country introduced the HPV vaccine into its national immunisation programme in 2018 with funding from Gavi, the Vaccine Alliance, which allocated funds sufficient to reach over 800,000 girls aged 10-14.

Gavi has been supporting the vaccine’s gradual roll-out to LMICs since 2013. That has enabled Dr Chimbetete’s clinic in Harare to offer the vaccine to adolescents, as well as screening and treating older women.

“Once people are aware, the uptake is good, but there still needs to be a lot of work to highlight the importance of HPV vaccination among the general population,” he says.

Beating the Stigma in Cameroon

Like Zimbabwe, Cameroon introduced the HPV vaccination onto its national immunisation programme last month following a six-year long pilot phase.

Completion of the pilot, first launched in 2011, faced many challenges. Dr Simon Manga, a reproductive health specialist for the Cameroon Baptist Convention Health Services (CBCHS), explains that parents initially were reluctant to have their children vaccinated, thinking it would make them sterile.

Now the national immunisation programme is getting started, some communities that initially accepted the vaccine earlier this year have later refused it, due to an unfounded belief that it is in fact an experimental COVID-19 vaccination. Misinformation has been rife on local and social media during the pandemic, with Gavi CEO Seth Berkley describing the situation in one article as “the worst I have ever seen.”

Dr Manga said: “People are afraid that they want to sterilise their girls, and worst of all it coincided with the period of COVID-19, so there’s an idea that the white man wanted to come and test the COVID-19 vaccine in Africa. There’s currently a lot of resistance.”

Dr Manga is a member of the National Planning Committee for the vaccine programme. He still hopes that with the help of the government and cooperation from community leaders, vaccine uptake will expand. A nationwide campaign is currently being organised to raise awareness about the importance of the vaccine and to quash the rumours that have been circulating.

Inexpensive Cancer Screening with Novel Methods

Dr Manga also supervises the CBCHS’ Women’s Health Programme (WHP) which offers cervical cancer screening as well as breast examinations as part of its other reproductive health and family planning services.

Like most facilities rolling out these services in Africa, the screening method used is not the traditional “pap smear” that requires expensive laboratory analysis, but rather an on-the-stop visual inspection of potential abnormalities on a cervix dabbed with acetic acid, and then exampled with the help of new digital cervicography. Here, too, HIV positive women are prioritised due to their increased vulnerability to cervical cancer.

Unlike the vaccine, there is no national programme for free screening services, and Dr Manga explains this is a major barrier for women. When the CBCHS have trialled free services before, the uptake has been unsurprisingly high.

In addition, encouraging those women who show signs of pre-cancer or cancer to return for follow-up treatment is also a challenge. Dr Manga explains many women do not understand the seriousness of the need for follow up, are put off due to the additional cost, or are advised not to return by faith healers in their communities.

Despite this, Dr Manga says the programme hopes to expand their services, increasing their use of mobile clinics and developing a “centre of excellence” by which local healthcare workers can gain training from different organisations and experts that they can use in their facilities. As with screening services, however, more funding is needed.

“One of the things that is slowing down our rapid expansion is funding – if we start getting funding then we can expand rapidly,” says Dr Manga. “[The WHO’s strategy] gives me hope that very soon there will be a lot of funding.”

Like in Cameroon, Costs are a Barrier to Treatment – More Funding is Needed

Because Dr Chimbetete’s clinic is funded by the Swiss-based Ruedi Lüthy Foundation, he has the mandate to provide the screening and treatment services free for HIV positive women. However this is not the case at public primary care clinics across the country.

At those clinics, while screening is widely available, follow-up treatment services generally come at a cost. Dr Chimbetete explains that the cost – which usually includes travel to a central facility that offers treatment as well as the treatment itself – prevents many women returning for follow-up, even when they know they have or are at risk of developing cervical cancer.

“Anything other than screening is not free, even in patients who are diagnosed with cervical cancer,” he explains. “Cost becomes an issue … especially now when we are going through economic challenges, it may not be a priority. So even though as a nation we are offering cervical cancer screening we still see very high incidences of cervical cancer because of all these issues.”

“Cervical cancer can only be addressed if we have more international organisations coming in to assist,” concludes Dr Chimbetete. “People need to make more noise. Noise has helped with HIV, noise has helped with TB, but I don’t think in my view we have made enough noise around cervical cancer. And now, because COVID has become such a huge global issue, there is a fear that everything else becomes insignificant. So some people really need to make noise around cervical cancer.”

Geneva Health Forum 2020 logo

This story was published in collaboration with Geneva Solutions – a new platform for peace & humanitarian, climate, global health, sustainable business & finance, and technology.

Image Credits: Keystone / EPA / Karel Prinsloo / GAVI, Geneva Health Forum.

US eleciton 2020 campaign signs
Signs supporting Biden and Trump split various small towns in Delaware County, upstate New York. The liberal state’s rural leanings have divided opinion.

While President Donald Trump’s mismanagement of Covid-19 may help Democratic contender Joe Biden turn the final corner in a tight US election, identity politics and the economy have loomed as bigger factors than health in voter choices. Voters in key battleground states, like Michigan and Nevada, explain why.

The United States election came just as the country was racking up some of the highest-ever daily rate of new coronavirus infections in the world. But in comparison to the economy, COVID-19 and health care issues still ranked lower on Americans’ priorities when people finally turned out to the polls.

US election 2020 signs
Signs supporting Biden and Trump split various small towns in Delaware County, upstate New York. The liberal state’s rural leanings have divided opinion.

All in all, the pandemic threat has failed to generate the kind of landslide support for the Democratic contender Joseph Biden that some had hoped for, or even anticipated – even if the vote count overnight early Thursday saw him inching his way toward victory.

Even so, “identity politics” – including a gaping rural-urban divide – remain more dominant factors in the campaign than the COVID pandemic that has transfixed the world.

Nor did health care seem to rate as high a concern either – even though some 20 million Americans stand to lose their health care coverage if the Affordable Care Act is finally overturned by a second-term Trump administration either through action in the US Supreme Court or Congress.

Massive ‘COVID Rebuke’ Didn’t Happen

While the mounting toll from the coronavirus has certainly played a role in a greater show of support among retirees and suburbanites for Biden in some places, a huge COVID-driven “rebuke” of Trump just did not occur at the magnitude that Democrats had expected.

This was already apparent in the early hours of Tuesday evening, before returns began to flow. A CNN exit poll found that about one-third of Americans considered the economy the most critical election issue. Only 1 in 6 voters considered the pandemic and 1 in 10 cited health care policy or violence, as their top issues. One in 5 people cited racial inequality.

Those attitudes were all the more apparent in the tsunami-like changes in early election results seen in key US “battleground states”, reflecting the log-jammed political divide between urban and rural voters, with suburban areas as wild cards.

Overnight Wednesday, mail-in ballots were still being counted in key states where battles raged,while a complicated calculus of 270 state “electoral college” votes, not the popular vote, determines the final outcome.

“There was a lot of energy and expectation – on the Democratic side and I would say even in America – that there was going to be a surge, a rebuke of Trump, particularly over the virus,” said political analyst, David Gregory, speaking to CNN.

“And what we’re seeing so far is that has not been the case. It’s a really tight race. We’re even seeing some evidence out of exit polling that a lot of voters out there are saying ‘hey, it’s really important we get this economy open, even if the virus spreads a little bit more.’”

Reported COVID-19 cases the day after the US election
A state-by-state map of US COVID-19 Cases Reported to the Centers for Disease Control over the Last 7 Days, as of 7pm CET, 4 November 2020.

 

Biden Benefits from “COVID” Vote but Only Marginally

That’s not to say that there was no ‘COVID factor’ at all.  More people from key demographic groups, like seniors and suburbanites, shifted significant votes to the Democrat’s Biden – as compared to Hillary Clinton four years ago. That surge of support was being felt in Michigan and Wisconsin, as well as in expanding suburban regions of sunbelt cities in Arizona and Nevada – making these states the major players in the final election outcome.

Polling stations were fitted with sanitizing stations.

“A lot of seniors don’t feel like he’s handled this very well – because literally they’re dying… people are legitimately dying I mean,” said one Nevada resident, a construction worker whose 64 year-old wife’s pre-conditions puts her seriously at risk from COVID-19.

Adding to the uncertainty in all of these states was the fact that unprecedented numbers of voters cast their ballots by mail, and those ballots were being counted last, rather than first, creating a dizzying set of ups and downs in the results.

Amidts pandemic concerns, however, another systemically hot issue in US politics – abortion – was a countervailing factor keeping many people loyal to Trump – virus or not.

“Abortion is a HUGE factor, I have heard many people say it alll comes down to who ‘will save the babies’,” said one businesswoman in Ann Arbor Michigan, who voted for Biden, where Biden was hanging onto a slight lead Wednesday evening.

“I honestly don’t get it,” she added. “No thoughts or consideration to helping the babies after they are born, but the pro-lifers are faithful in their voting. I’m seriously thinking of moving to Canada.”

“As far as I can tell, people care about healthcare but apparently believed the false dichotomy Trump presented of pandemic lockdown or the economy, and many preferred the latter,” a New York City public health expert said. “When Trump says that he did everything he could about the pandemic, and it was all China’s fault anyway, his supporters and apparently many other people believe him… After almost four years, you’d think people would have learned.  But he’s very good at what he does.”

Identity Politics Overwhelms COVID – No Matter Who Wins

In Trump strongholds like eastern Tennessee’s Putnam County, nestled in the foothills of the Appalachian mountains, a local store that sells Trump memorabilia just opened, and pickup trucks have been parading around downtown shouting the president’s praises, relates a prominent lawyer with deep roots in the community:

Nominee Joe Biden and Senator Kamala Harris as the latter accepts the Nomination for Vice President of the Democratic Party, 19 August 2020.

“One of the trucks carries a big flag with Trump’s sagging jowly face placed on top of Rambo’s body, firing an M-60 machine gun. And he drives around the Square yelling ‘Trump Trump Trump’. A disturbing number of people honk in support of him. From my window, Trump support has nothing to do with rationality,” said the attorney, who asked not to be named.

“Trump is a cult figure in red states like Tennessee,” he added. “He received 71% of the vote in Putnam County. We were reliably 55% Democratic until the 2010 election.” This was when local politics flipped during Barack Obama’s presidency – as racist rumors about the president’s origins and religious persuasion became rampant.

“Trump’s supporters share his fears and hatreds. More ‘bad others’ – illegal immigrants, rioters, black people and the much-feared and utterly non-existent ‘ANTIFA’ – dominate their fears. Trump rails against them and tells these people that they are right, they are smarter than people with education, than people with money, than these bad others. He makes their irrational prejudices into virtues. And they love him for it,” he added.

“A huge number of Americans simply do not understand the connection between government and their lives. Government is a ‘bad other’: the enemy, something to be mistrusted and opposed at all costs.

“So the Trump voter doesn’t give a flip about health care when they walk into the voting booth.  They do not believe that the government could ever provide them decent health care.

US President Donald Trump at recent rally. Supports are not wearing masks.

“They ‘know’” Obamacare has failed and is bad – even though it only ‘failed’ because the GOP congress wouldn’t fund it or implement it. The Trump voters vote on issues like their professed opposition to abortion and transgender rights, and their support for gun rights. Their vote for Trump has nothing to do with their own economic interests, except to the extent that their information system has told them that socialism is bad. And a vote for Trump is a vote against the undefined bad other, socialism.

“As for COVID, the Trump voters mostly do not believe it is real. They won’t wear masks. They assemble in groups, at churches and proms. Our hospital numbers are through the roof, but they don’t believe it, because their information sources tell them, doctors overreport COVID to get money – ‘those educated greedy doctors again.’

“And they chuckle to themselves, congratulating themselves on how they’ve seen through the liberal conspiracy, because at least THEY aren’t falling for this COVID nonsense. This is from people who have family members who have died with COVID. The denial is astounding, and inexplicable to me. But it is as real as the coffee in my cup.”

Conservatives See the Robust Trump Support Very Differently

Scott Jennings, a Republican campaign adviser from Kentucky, argued that Trump’s base of support had, in fact, expanded in this election to include new African American and Latino voters in areas like Miami-Dade county, where Trump had campaigned heavily and did even better than he had in 2016 against Hillary Clinton.

The COVID-driven “rebuke” anticipated by the Democrats did not happen quite as expected.

Jennings said in an interview with CNN: “Republicans are pretty well stunned at how well Donald Trump did.

“There has been a clear realignment here for the Republican party to attract new working class voters of all races. When you look at the resilience of the Republican party in all these states with these large rural areas, among working class voters, the attraction of some new hispanic voters, even some African American voters.

“I also think there has been a rejection of the Democratic party, and in some cases the media, of the liberal elites in rural America. They feel like they are held to different rules: double standards. They’ve been browbeaten for their support of Donald Trump, and they turned out in droves yesterday to let folks know it. It’s not all bad for the party right now.”

Atmosphere of fear

Yet, despite the positive spin of some conservative pundits, Americans of all persuasions were bracing for Trump’s legal challenges, possible violence and more uncertainty, while a decisive vote still remained elusive.

With Michigan and Wisconsin finally swinging toward the Democratic contender Wednesday evening, the projected electoral college count for Biden stood at 253 out of the golden 270 votes needed. But large final counts of the mail-in vote remained outstanding in key states like Pennsylvania, Arizona and Nevada; wins in just two of the three would clear his path to victory.

From New York City to Washington DC and Dearborn, Michigan, more and more storefronts were being boarded up in the anticipation of potential violence from both left and the alt-right – depending on the way the election falls.

Supporters of President Donald Trump at a “Make America Great Again” campaign rally last week without masks in Phoenix Arizona. The state flipped in Biden’s favour in 2020.

The electric tensions were being fuelled by Trump’s comments already on election night. Appearing at about 2:30 a.m. Wednesday morning at a White House party of some 250 campaign supporters, Trump claimed victory and said that he would contest the continued tabulation of mail-in ballots still underway in many states.

“We want all voting to stop.  We don’t want them to find any ballots at 4 o’clock in the morning and add them to the list, OK,” Trump said in his televised remarks protesting the counting of mail-in ballots, as districts in key states around the country tried to process huge ballot backlogs.

“This is a fraud on the American public… an embarrassment to our country.  We were getting ready to win this election. Frankly we did win this election,” he said. “So our goal now is to ensure the integrity for the good of this nation. This is a very big moment… We want the law to be used in a proper manner. So we will be going to the US Supreme Court.”

People in rural and working class neighborhoods who bucked trends to support Biden have been keeping their heads particularly low – as Trump supporters roam their neighborhoods demonstrably, sometimes visibly armed.

The Reno construction worker who voted Biden said he had been afraid to post a campaign sign on his lawn for fear of violent reprisals. He is fearful that roaming brigades of Trump supporters parading through his neighborhood might also somehow finger him as a target – and has alerted a police officer just in case.

“They’re not hard to identify,” he said. “They drive around in jacked up pickup trucks with tattered American flags hanging out. It’s really sick what they have done with our flag.

“Our flag is considered a symbol of freedom and democracy and they’ve turned it into a symbol of racism and hatred and bigotry.”

Kerry Cullninan and Raisa Santos in New York City contributed to this story.

This story was published in collaboration with Geneva Solutions – a new platform for peace & humanitarian, climate, global health, sustainable business & finance, and technology.

Image Credits: Kerry Cullinan, Adam Schultz/Biden for President/Flickr, GPA Photo Archive/Flickr, Gage Skidmore/Flickr.

The White House, Washington DC. There is currently no clear winner for President
The morning after election day, the winner is still unclear.

With the winner of the presidency and party control of the Senate still unclear the morning after Election Day, the future of the nation’s health system remains uncertain. At stake is whether the federal government will play a stronger role in financing and setting the ground rules for health care coverage or cede more authority to states and the private sector.

As of 4pm CET, Biden has a small lead of 227 electoral votes – compared to Trump’s 213 – having overtaken the incumbent president in key states Michigan, Wisconson and Arizona. Pennsylvania, North Carolina and Georgia are undeclared.

US Presidential Nominee Joe Biden.

Should President Donald Trump win and Republicans retain control of the Senate, Trump still may not be able to make sweeping changes through legislation as long as the House is still controlled by Democrats. But — thanks to rules set up by the Senate GOP — the ability to continue to stack the federal courts with conservative jurists who are likely to uphold Trump’s expansive use of executive power could effectively remake the government’s relationship with the health care system even without signed legislation.

The president has also pledged to continue his efforts to get rid of the Affordable Care Act, and if the Supreme Court overturns the sweeping law as part of a challenge it will hear next week, the Republicans’ promise to protect people with preexisting medical conditions will be put to the test. In a second term, the administration would also likely push to continue to revamp Medicaid with its efforts to institute work requirements for adult enrollees and provide more flexibility for states to change the contours of the program.

If former Vice President Joe Biden wins and Democrats gain a Senate majority, it would represent the first time the party has controlled the White House and both houses of Congress since 2010 — the year the ACA was passed. A top priority will be dealing with the COVID-19 pandemic and the economic fallout. Biden made that a keystone of his campaign, promising to implement policies based on advice from medical and scientific advisers and provide more directives and aid to the states.

Current US President Donald Trump.

But also high on his agenda will be addressing parts of the ACA that haven’t worked as well as its authors hoped. He pledged to add a government-run “public option,” which would be an alternative to private insurance plans on the marketplaces, and to lower the eligibility age for Medicare to 60.

While Democrats will continue to control the House, the final makeup of the Senate is still to be determined. And even if the Democrats win the Senate, they are not expected to come away with a majority that would allow them to pass legislation without support from at least some GOP senators, unless they change the Senate’s rules. That could lower expectations of what the Democrats can accomplish — and may lead to some tensions among members.

But who controls Washington, D.C., is only part of the election’s impact on health policy. Several key health issues are on the ballot both directly and indirectly in many states. Here are a few:

Abortion

In Colorado, a measure that would have banned abortions after 22 weeks of pregnancy — except to save the life of the pregnant person — failed, according to The Associated Press. Colorado is one of seven states that don’t prohibit abortions at some point in pregnancy. It is also home to one of the few clinics in the nation that perform abortions in the third trimester, often for severe medical complications. The clinic draws patients from around the nation, so residents of other states would have been affected if the Colorado amendment passed.

In Louisiana, however, voters easily approved an amendment to the state constitution to say that nothing in the document protects the right to, or requires the funding of, abortion. That would make it easier for the state to outlaw abortion if the Supreme Court overturns Roe v. Wade, which makes state abortion bans unconstitutional.

Medicaid

The fate of the Medicaid program for people with low incomes is not on the ballot directly anywhere this election. (Voters approved expansions of the program in Missouri and Oklahoma earlier this year.) But the program will be affected not only by who controls the presidency and Congress, but also by who controls the legislatures in states that have not expanded the program under the Affordable Care Act. North Carolina is a key swing state where a change in majority in the legislature could turn the expansion tide.

Drug Policy

In six states, voters are deciding the legality of marijuana in one form or another. Montana, Arizona and New Jersey were deciding whether to join the 11 states that allow recreational use of the drug. Mississippi and Nebraska voters were choosing whether to legalize medical marijuana, and South Dakota became the first state to vote on legalizing both recreational and medical pot in the same election.

Magic mushrooms are on two ballots. A measure in Oregon to allow the use of psilocybin-producing mushrooms for medicinal purposes passed, and a District of Columbia proposal to decriminalize the hallucinogenic fungi was leading.

Also approved was a separate ballot question in Oregon to decriminalize possession of small amounts of hard drugs, including heroin, cocaine and methamphetamine, and mandate establishing addiction recovery centers, using some tax proceeds from marijuana sales to establish those centers.

California

As usual, voters in California faced a lengthy list of health-related ballot measures.

For the second time in two years, the state’s profitable kidney dialysis industry was challenged at the ballot box. A union-sponsored initiative would have required dialysis companies to employ a doctor at every clinic and submit infection reports to the state. But the industry spent $105 million against the measure. The measure failed, according to AP.

Voters were also asked to decide, again, whether to fund stem cell research through the California Institute for Regenerative Medicine via Proposition 14. Voters first approved funding for the agency in 2004, and since then, billions have been spent with few cures to show for it. The measure was winning in early returns.

California has been at the forefront of the fight over the so-called gig economy, and this year’s ballot included a proposal pushed by ride-hailing companies like Uber and Lyft that would let them continue to treat drivers as independent contractors instead of employees. Under Proposition 22, the companies would not have to provide direct health benefits to drivers but would have to give those who qualify a stipend they could use toward a premium for health insurance purchased through the state’s individual marketplace, Covered California. The measure was approved.

Finally, voters in the Golden State were asked whether to impose higher property taxes on commercial property owners with land and property holdings valued at $3 million or more, which could help provide new revenue earmarked for economically struggling cities and counties hit hard by COVID-19, as well as K-12 schools and community colleges. Community clinics, California nurses and Planned Parenthood jumped into the thorny political battle over Proposition 15 — taking on powerful business groups — eyeing revenue to help rebuild California’s underfunded public health system. The measure was too close to call in early returns.

Democrats in California, who control all statewide elected offices and hold a supermajority in the legislature, have been positioning for a Biden win, and some were already penning ambitious health care legislation for next year. Should Biden win, they said they plan to crack down on hospital consolidation and end surprise emergency room bills, and some were quietly discussing liberal initiatives such as pursuing a single-payer health care system and expanding Medicaid to cover more unauthorized immigrants.

 

KHN (Kaiser Health News) is a nonprofit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation), which is not affiliated with Kaiser Permanente.

Image Credits: Library of Congress/Carol Highsmith, Mike Beaty/Flickr, Gage Skidmore.

Protestors stuggle for universal access to anti-retroviral treatment and against AIDS denial, in Cape Town, 2002.

IBADAN, Nigeria – In the wake of George Floyd’s death in June 2020, the decentralized protests initially organized by the Black Lives Matter (BLM) movement triggered an awakening and an echo that has reached well beyond the borders of the United States.

Protest at the 3rd precinct in Minneapolis for the murder of George Floyd by four police officers.

What started as a non-violent movement protesting against incidents of police brutality and racially motivated violence, has also inspired people around the world, including scientists to take a closer look at how colonialist attitudes and structures continue to influence their institutions and career paths. For individuals from comparatively disadvantaged countries, these attitudes often make it difficult or even impossible for them to enjoy equal opportunities and mutually favorable metrics in their chosen careers.

And this is true for global health too. “Little or no attention is being given to the issue. This isn’t something people are funded to look at. Doing it in of itself comes from a position of privilege,” says Dr Mishal Khan, Associate Professor at the London School of Hygiene and Tropical Medicine (LSHTM).

While decolonisation has been discussed in an educational context in the past, in terms of curriculum choices as well as well as the preference of western to indigenious professionals, Khan argues that the fundamental structures underpinning global health should also be closely examined.

“It’s not really researched or taught as much as it should be, and this is why people often don’t think about it so much,” she says, noting that while relics of colonialism remain and debates continue across sectors, the issue has been far less discussed in the context of global health. “The implicit assumption is certain groups are more knowledgeable and better than the others.”

The topic of ‘decolonizing global health’ will be a featured topic on the Geneva Health Forum’s agenda, taking place 16-18 November, where Dr Khan will be a keynote speaker.

“In global health there is an additional element,” Khan adds. “By nature, global health is about higher income countries trying to support low-income countries. It’s not just about teaching global health, but also the practice.”

UN Born With First Decolonialist Wave

According to the United Nations, fewer than 2 million people now live under colonial rule in the 17 remaining non-self-governing territories. out of which only one – Western Sahara – is in Africa.

“The wave of decolonization, which changed the face of the planet, was born with the UN and represents the world body’s first great success,” the UN stated.

HIV activists protesting against patent laws that pushed up costs of essential medicines, in Cape Town, 2014.

The UN’s key global health agencies, such as the UNICEF and the World Health Organization were born in the post-World War II era of 1946-48, in the waning years of colonialism. UNAIDS, on the other hand, came much later, during the worldwide AIDS pandemic, as states in the global south asserted the need for affordable solutions and more recognition of their health challenges. While these international organisations continue to champion and foster partnerships toward achieving global health goals, they are also implicated in these discussions.

In a September 2019 commentary, Richard Horton, editor of The Lancet medical journal said the success of any western institution that was more than hundred years old was built on the savage legacy of colonialism – even if the institution claims to stand for peace and justice.

“Perhaps we deal with uncomfortable pasts by burying them, excusing them, or atoning for them,” Horton wrote.

In their recent commentary on decolonising global health for the British Medical Journal, Ali Murad Büyüm and colleagues noted that histories of slavery, redlining, environmental racism and the predatory nature of capitalism underpin the design of global and public health systems, resulting in structural, racial and ethnic inequities within Black, Indigenous and People of Color (BIPOC) communities globally.

Connecting the inequities to the COVID-19 pandemic, the authors noted that exclusionary colonialist patterns that centre around Euro-Western knowledge systems have also shaped the language and response to the pandemic, which in turn can have adverse health outcomes.

“Decolonising global health advances an agenda of repoliticising and rehistoricising health through a paradigm shift, a leadership shift and a knowledge shift,” the authors state. “While the global response to COVID-19 has so far reinforced injustices, the coming months present a window of opportunity to transform global health.”

The Genesis Of Misconceptions

For her part, Khan notes that the emergence of developed countries as the worst hit by COVID-19 (contrasting earlier predictions that countries in Africa would be the worst hit) is an indication that there is imbalance in the flow of knowledge and resources in global health.

“That was the mindset with which the global health organisations were working: ‘we need to do something to help these countries or they will crumble. But you can see how countries like Nigeria have brilliantly handled things. The political leadership has been much better’,” Khan says.

A map indicating Africas comparatively low number of cumulative COVID-19 cases.

She adds that the experience of African and Asian countries that are avoiding poor outcomes in COVID-19 are not included in the writings and independent reviews on COVID-19 – often because the authors of such publications are largely people in the Global North: “It is as if the reality can be ignored. Those expertise and the skills are there and there is a lot to learn in both directions, rather than in just one direction.”

Questionable metrics for Public Health Careers

Beyond ignoring and under-representing the achievements of low-income countries in the fight against COVID-19, the need for decolonisation is also evident in the attachment of institutional brand names to successful careers in public health.

Lilian Mutua, WHO Kenya Health Promotion Coordinator, reaching out to nomadic communities to ensure people know how to protect themselves from COVID-19 in May.

Khan notes that young scientists in developing countries have to incur exorbitant costs to be able to afford an education

that would bring them closer in line with their contemporaries in Western countries.

“For instance, the schools of global public health, and the brands that are associated with them, are largely concentrated in western countries. Employers look for those names,” Khan says.

“If you don’t have the brand name from one of those top universities, it’s much harder to progress. People from low-income countries have to pay massive fees, advancing the cycle of inequality.”

In a similar vein, she argued that papers submitted by individuals from developing countries who are not products of the elite institutions will be judged much more harshly by white reviewers.

“You will get more scrutiny, you might not be able to write very well, you might not get invited for presentations: those things that grant you credibility as an expert are much harder for people of color. So those structures are there,” Khan tells Health Policy Watch. “To get promoted, they ask for how many papers published, how many grants. Naturally, people of color will have less because to have one paper, you have to work much harder to get one grant.”

She also drew attention to the existence of an unchallenged system that ensures that people of color do not progress as quickly as their colleagues from elsewhere: “When you look at organisations, there are a lot more people of color at the bottom doing the groundwork than people at the top in senior positions.”

Changing the status quo – Equity in Career Advancement Metrics

In spite of evidence that supports of the existence of unfavorable metrics that disenfranchise BIPOC and other marginalised groups from making bigger impact in global health, there appears to be a deafening silence among the key organisations in the ecosystem – a development Khan attributed to those in charge of the organisations who favour the status-quo.

Dr Mishal Khan spoke to Health Policy Watch on decolonisation in global health.

“For a long time, they’ve been able to get away with not addressing it. If you’ve got a leadership that is predominantly white and not from the country you serve, you think that’s not important. If that’s what you like because if it benefits you, why would you change it?

“There has been a lot of media attention lately so there has been a lot more scrutiny. We need to create the incentives for change,” Khan argues. “I don’t think the incentives are necessarily in there, we need to know that the change will be opposed. Nobody gives up power willingly.”

One of the changes that Khan is advocating for is a comprehensive review of the metrics being used for career advancement in global health. She tells Health Policy Watch that current metrics are such that certain people will rise to the top and others will struggle to rise to the top.

“The system doesn’t value skills,” she notes. “A good example is connection with the local context in which research or service delivery work is being conducted. Being able to speak the local language – being from the country – is given a lot less rating than it should, whereas being able to write and speak really well in English is given a lot more. And that’s why certain people will score more highly than the rest. I think the metrics do matter.”

Timing concern and what can work

The deafening silence from those who would be beneficiaries of moves to decolonise global health raises concern regarding the timing of the call, especially considering the global health ecosystem is largely preoccupied with controlling COVID-19. But Khan said the situation will not change unless it is compelled to change:“The people in power are essentially not going to change the metrics and therefore reduce their power so it favors people that do not look like them.

“I think we have to be conscious of that. People will not consciously or unconsciously reduce their own power,” Khan affirms.

To truly decolonise global health, Khan is calling for a review of the governance system in a number of global health organisations. “Broader than issues of racism and decolonisation, we are also seeing massive governance failure in terms of sexual abuse of some to these international organisations. That’s another symptom that there are people who are being exploited within these organisations that are supposed to be believing in justice and implementing justice. It just has to be done with political will,” Khan says .

Although it would take a while to systematically uproot colonisation, Khan argues that individuals have roles to play to address the narrative.

“One thing about COVID-19 is that it has shown us that if you’re okay in your bubble while other countries are not okay, it will soon spread to your little bubble,” Khan tells Health Policy Watch.

“We need resources to be spread out more equitably.”

Geneva Health Forum 2020 logo

Image Credits: Louis George 2011 , Jenny Salita, Louis George 2011 , Johns Hopkins University and Medicine, WHO African Region, Geneva Health Forum.