Avian influenza is spreading among US cattle, and milking machines are likely to be one source of infection.

Global surveillance of influenza viruses in animals needs to be intensified to “rapidly detect any changes to the virus that could pose a greater threat to humans”, World Health Organization (WHO) Director-General Dr Tedros Adhanom Ghebreyessus told a media briefing on Wednesday.

He also urged the media to ensure that the humanitarian crisis in Sudan, one of the worst in the world, was not forgotten.

The outbreak of H5N1 avian influenza in US dairy herds has almost tripled in the past five weeks, now affecting 92 herds in 12 states. The number of human cases has increased from one to three, and 500 people are being monitored after exposure to infected cattle.

The US H5N1 clade affecting the cattle derives from Eurasian geese and is the same clade that has affected wild birds, commercial poultry flocks and “sporadic infections in several species of wild mammals and neonatal goats in one herd in the US”, according to the American Veterinary Medical Association.

“Collaboration, communication and information sharing between the animal and human health sectors is essential in all countries. This is the meaning of One Health,” Tedros urged.

However, the WHO continues to assess the risk to public health as low because of its limited spread in humans.

“Since 2003, there have been 893 reported infections of H5N1 in humans, including 11 so far this year: five in Cambodia, three in the U.S., and one each in Australia, China and Viet Nam. In that time, the virus has not shown signs of having acquired the ability to spread easily among humans,” said Tedros.

“In recent years, H5N1 has spread widely among wild birds, poultry, land and marine mammals on several continents,” said Tedros.

Timely investigation of every human case

“WHO recommends that anyone working with any infected animals, in any country, should have access to, and use, personal protective equipment”, and urged systematic follow-up, testing and care of people exposed to the virus.

“Early medical care and support, and thorough and timely investigation of every human infection is essential to evaluate and interrupt potential onward transmission between humans.”

Dr Wenqing Zhang, head of the WHO’s Global Influenza Programme

Dr Wenqing Zhang, head of the WHO’s Global Influenza Programme, said that previous large avian flu outbreaks in seals had been contained and had not spread to humans.

While it was “too earlier” to predict the trajectory of the US cattle infection, Zhang said it was possible that it could be eliminated.

However, Dr Maria van Kerkhove, the WHO’s director of  epidemic and Pandemic preparedness and prevention, said that the WHO is concerned about the geographic spread of H5N1 and the fact that it is infecting new animal species, and put more people at risk.

“We need to be able to rapidly assess the viruses that are circulating, any changes in those viruses that are circulating, to make sure that the system that is in place so we can react as quickly as possible, should we need to produce vaccines,” she added.

“We’re not in that situation yet.”

She stressed that a lot of work needs to be done at a local level with communities using this One Health approach.

“The stronger the biosecurity we have within the farms, the earlier that we can mitigate any potential spillover into human populations and potential onward spread.”

‘Forgotten and ignored’ Sudan 

Tedros also drew media attention to Sudan, noting that this is the war the world has “either forgotten or ignored”.

“Sudan is the world’s largest humanitarian crisis, with 12 million people displaced – 10 million internally, while two million have fled to neighbouring countries.”

“More than 70% of hospitals in conflict-affected states, and 45% of health facilities in another five states are not working, and the remaining ones are overwhelmed with people seeking care,” he noted.

“Critical services, including maternal and child health care, the management of severe acute malnutrition, and the treatment of patients with chronic conditions, have been discontinued in many areas.”

He noted that insecurity and operational hurdles, such as the current break in telecommunication services, were disrupting WHO’s ability to deliver supplies and services.

A WHO team member providing nutrition support to internally displaced children in Gedaref state, Sudan, in August 2023.

Famine in Gaza

Turning to Gaza, Tedros said that the WHO welcomes the UN Security Council resolution adopted on Monday, which calls for a full and immediate ceasefire, the unconditional release of all hostages, a permanent end to hostilities, and the reconstruction of Gaza.

We urge all parties to take steps to implement the resolution immediately, and bring a permanent end to the suffering of millions of people.” said Tedros.

“A significant proportion of Gaza’s population is now facing catastrophic hunger and famine-like conditions,” he noted. “Over 8,000 children under five years old have been diagnosed and treated for acute malnutrition, including 1,600 children with severe acute malnutrition.

“Our inability to provide health services safely, combined with the lack of clean water and sanitation, significantly increase the risks for malnourished children. There have already been 32 deaths attributed to malnutrition, including 28 among children under 5 years old.”

However, due to insecurity and lack of access, only two stabilization centres for severely malnourished patients are operational, he added.

 

Image Credits: WFP/Ala Kheir, Josh Kelahan, WHO.

Monu Kumar Yadav, a street vendor sells juice at a busy Delhi road. Peak temperatures here have been hovering between 40-49° for several weeks.

A wave of record-setting heat waves, beginning in March, have led to new Government guidelines for emergency cooling including measures like heat stroke rooms. Even so, public health  experts are only beginning to grapple with the multiple ways in which heatwaves can kill – and map out mitigating measures for both healthy people as well as the more vulnerable, including people with chronic diseases. 

Under a mid-day blazing sun on a busy Delhi road, Monu Kumar Yadav tends to his cart. There’s little shade. He’s selling bael sharbat or stone apple juice, a popular summer drink. It’s 41°C but Yadav, who says he’s here from 8am to past 5pm daily, says it’s bearable. It was far worse a week ago, he says.

There have been a series of heatwaves in almost every part of the country since March and these are forecast to continue in the north throughout June. Temperatures have been as much as six degrees or more above normal and touched 50°C in several places. The capital, New Delhi, hit a record high of 49.9° C at two stations. 

Heatwaves coincided with India’s general election held across April, May and June. Hundreds of deaths have been reported, several of these related to the election. Some 33 polling staff died from the heat on the last day of voting in Bihar, Uttar Pradesh and Odisha states, according to Reuters.

Experts in the government had forecast the heatwaves and prepared response plans. This is in addition to the heat action plans in dozens of Indian cities. But local administrations and communities were seemingly caught unaware. 

Climate scientists have calculated that heat waves will only get worse with the record amount of carbon dioxide and other greenhouse gases being emitted. 

The heat wave alerts began as early as February. From early March onwards, forecasts warned temperatures could be more than 5° C above normal in parts of the country. The Indian Meteorological Department (IMD) has also warned of hotter temperatures and longer heatwaves this year.

A fortnight later the Election Commission of India announced the longest voting schedule in decades lasting 44 days; longer, if the campaign and counting days are included. 

India’s longest heatwave?

In Kishan Kunj, New Delhi, Razia splashes water on the jute bags that she has covered her roof with before she leaves for work every day. She hopes that the room below remains bearable for her two sons during the summer months.

April’s heat was alarming with a rare heatwave alert in the southern coastal state of Kerala. In eastern India, deaths began to be reported. But it was about to get a whole lot worse in May, in the north. 

A new study by ClimaMeter, a global group of scientists who provide a climate context for weather extremes, shows May’s heatwave was 1.5°C hotter than any other ever recorded in India. 

Delhi’s power demand touched a record high, its water supply ran low. The local government announced it would fine anyone wasting water, for instance washing cars with water pipes or letting tanks overflow.

Separately, the IMD told Health Policy Watch that several states in north India saw an unusually long stretch of heatwave days. The normal for May is three days for places like Delhi, and a few more for places like the desert state of Rajasthan and Madhya Pradesh in central India. 

IMD forecast the number of days could be as much as four to eight days above normal. But it turned out to be far more at about 15 days. Officials that HPW spoke with couldn’t recall a similar event in recent years though they are yet to analyse whether this is the longest stretch ever on record.  

The spell was broken by some storms and rain in early June but the heatwaves are forecast to continue in north India. 

With hotter nights, the danger is shifting indoors. The human body gets little chance to recover from the day’s heat and cool down which hits health and productivity at a “very large scale,” Sharma adds. 

Heat and NCDs

Differentiating between heat exhaustion and more dangerous heat stroke.

Extreme heat may be a direct trigger for fatal conditions, even in the healthiest person.  The most direct impacts involve deaths from heat stroke – when the body’s core temperature shoots up beyond normal temperatures of 36.8°C . If temperatures cross 42°C or 107.6°F, cellular damage and cardiac, respiratory and kidney failure begin to occur. 

But heat can also can exacerbate pre-existing noncommunicable diseases in older people, other groups with chronic conditions, and newborns lacking poor heat regulation, also leading to death. At least 605 people died of heart attacks out of almost 25,000 “suspected” heat stroke cases in India between March and May according to government data. 

In earlier years, experts have pointed out that heat-related deaths have been under-reported, insofar as many of those who perished also suffered from other types of non-communicable diseases (NCDs), such as cardiovascular or respiratory conditions – to which their deaths were attributed.

But this season the number of heat-related deaths being reported has been frequent and high -signalling at least a new awareness of the ways in which heat can exacerbate pre-existing NCDs. Several of these have been reported from the election. However, the data remains plagued by discrepancies and confusion – which are understandable in light of the complexity of the diverse impacts of heat on healthy and more vulnerable groups.  

Heatstroke may affect both people with chronic conditions as well as healthy people, as a result of over-exertion or exposure to extreme weather conditions.

As of 1 June, the National Centre for Disease Control (NCDC) reported 56 deaths. But that excluded Uttar Pradesh, a northern state with a population larger than the UK, France, and Germany combined, where 166 deaths had been reported as of May.

About 141 deaths suspected to be heat-related were reported from the eastern, coastal state of Odisha as the polls ended. However, officials said post-mortems and investigations had shown less than a fifth to be due to heatstroke, as such.  

The capital, Delhi, too saw many deaths (24) in the last week of May, and over 120 in Rajasthan. There, in one city, newborn babies were put on dialysis because of dehydration leading to an increase in sodium levels. 

With such a devastating impact, Rajasthan’s top court called for heatwaves to be categorised as “national calamities” which would enable emergency relief as with other natural disasters, though there’s no decision on that yet.  

‘Cooling, cooling, cooling’

The response to the heatwave crisis has broadly been at two levels. Met and health experts within the government have been putting out warnings and advisories. 

Health advisories include detailed guidelines, webinars, social media posts and other outreach efforts; there was even a meeting held by Prime Minister Narendra Modi where he called for a whole of government approach and hospitals to be adequately prepared. 

Health is a state subject in India, which means that the central government can put out advisories but the states decide their policy and what to implement. One such advisory titled ‘Emergency Cooling for Severe Health Related Illnesses’ was released in March 2024. 

In February, the National Disaster Management Authority held a workshop where preparations for this year’s heatwaves were discussed by health, disaster management, met, and climate experts in the government. It showed how training had begun as early as January, that there should be a decentralised approach involving local communities and health infrastructure should be strengthened, for instance establishing cooling centres in public buildings and spaces. 

For the first time this year, such advisories called for heat stroke rooms. These are essentially places set up at healthcare centres to rapidly cool a person suffering from heat stroke, a potentially fatal condition. Doctors point out the main treatment for heat stroke or heat exhaustion is “cooling, cooling, cooling.” 

The mortality rate for delayed treatment is about 80%, but with early identification and rapid cooling, it can be as low as 10%. Symptoms of a heat stroke include a temperature of 40.5°C/104.9°F or more, throbbing headache, no sweating, and red hot dry skin among others. 

The idea is to bring the body temperature down to 39°C/102.2°F as quickly as possible. The methods prescribed include immersing a person in an ice bath or very cold water, placing ice packs on them, using wet towels, and rushing them to the hospital. 

But to what extent have these guidelines and advisories been implemented at the grassroots level? There is little data available about how many health centres, the most basic and widely spread health care facilities, in rural and urban areas were equipped to identify and treat heat stroke patients. The heat stroke room was proposed last year and implemented this season, according to a source. It is meant to be set up at all healthcare facilities but it’s unclear how many were done. 

Towards the end of May, the central health ministry asked states to take “proactive measures to prevent devastating incidents caused by extreme heat.” A substantive press note was issued two days after the election result. 

Assessing heatwave risks to health

At least three types of temperature readings may be considered for hyperlocal responses. An understanding of these can help people and authorities work out what to do in a house, in schools or offices, at construction sites, in marketplaces, and of course at public gatherings.

The first is the conventional meterological temperature. Several places and meteorological stations in the arid plains of India have crossed 50°C. Around this time, swathes of the north were forecast at 45-50°. Such temperatures, even for one day, can be fatal, depending on the person’s age, co-morbidities, and other factors. 

The scond is urban heat island temperatures. A study done in April used a thermal camera and it shows how built-up or paved areas can be much hotter than the official temperatures. In vivid visuals, these illustrate what climate scientists including the IPCC have called the urban heat island effect. If the temperature was about 40°C according to standard, official readings, it could be as high as 50-59°C depending on concrete or tarred places that trap heat.

The third is the ‘feels like’ temperature. Experts warn of another danger, particularly for low-income households.

Anshu Sharma is co-founder of SEEDS, which works with people, particularly in vulnerable communities, to build their resilience to disasters and climate change impacts. He warns that wet bulb temperatures – a factor of heat and humidity – must be monitored to provide relief.

“While temperatures will drop once the Monsoon arrives, the suffering will not go away. Indexed heat, with the addition of humidity, will make it feel worse than the current dry heat, with indexed temperatures expected to go well above 50°C,” says Sharma.

“This year’s heatwaves, characterised by hotter days, much hotter than normal nights, and longer duration of heatwaves have hit people harder than usual. Nights, especially during power cuts, are particularly unbearable for those who cannot afford air conditioning and power backups.”

Many causes or one main cause?

In eastern India, the heatwaves may have been exacerbated by anti-cyclonic circulation and the absence of thunderstorms during April, and in the northwest, the absence of western disturbances (bringing storms and rain) during May. The El Nino phenomenon has also been blamed. This is the Pacific climate pattern which tends to cause hot and dry weather in Asia and heavier rain in parts of the Americas. 

The biggest cause, however, is climate change. World Weather Attribution (WWA), at the Grantham Institute in Imperial College London, says that the heatwaves in the last two years became 30 times more likely and hotter because of human-induced climate change. 

April mean temperature 2024. The blue outline shows the region with the most extreme heat in South Asia.

Dr Mariam Zachariah, a WWA Researcher, told HPW, “While it is likely the additional heat from El Nino, a naturally occurring climate phenomenon, helped push summer temperature extremes in some regions of India to cross 50C, such episodes will become more frequent in India as the climate warms, regardless of El Nino.” 

Monu Yadav doesn’t know what makes the heat worse than earlier years but out on the roads for eight to 10 hours a day, he knows for sure that it’s hotter than anything else he’s experienced in Delhi. 

With greenhouse gas (GHGs) emissions rising faster than ever to record levels, heatwaves will get worse, but the response needs to be better. Cutting GHGs is vital, as are SOS cooling solutions for people.

Image Credits: Chetan Bhattacharji, Webinar/Ministry of Webinar on Clinical Aspects of Heat-Related Illnesses – National Programme on Climate Change and Human Health, MoHFW., Webinar on Clinical Aspects of Heat-Related Illnesses: National Programme on Climate Change and Human Health, MoHFW., World Weather Attribution.

The tobacco industry is just one sector implicated in a new WHO Europe report on the commercial determinants of health.

Just four industries –  tobacco, ultra-processed foods (UPFs), fossil fuels, and alcohol – cause over a third of all deaths globally each year, according to a new report from the World Health Organization’s (WHO) Regional Office for Europe.

Not only are these industries driving ill health and premature mortality across Europe and Central Asia, but they are “interfering in and influencing prevention and control efforts for non-communicable diseases (NCDs) such as cardiovascular diseases, cancers, diabetes and their risk factors including tobacco, alcohol, unhealthy diets and obesity,” according to a press release from WHO Europe. This translates to 19 million deaths globally each year. 

WHO Europe, a vast region of 53 countries including Russia, is disproportionately affected by these industries.

The region has the highest global levels of alcohol consumption and alcohol-related harms in the world, and the highest level of adolescent tobacco use.

Non-communicable diseases (NCD) – primarily cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases – are responsible for 90% of deaths in the region. By 2017, one out of five deaths from cardiovascular diseases and cancers in the European Union were attributable to unhealthy diets.

“Four industries kill an estimated 7,400 people in our region every day. The same large commercial entities block regulation that would protect the public from harmful products and marketing, and protect health policy from industry interference,” said Dr Hans Henri P. Kluge, WHO regional director for Europe.

Figure of tobacco industry and commercial determinants of health
The private sector influences a wide range of health factors through marketing, lobbying and product design.

“Industry tactics include exploitation of vulnerable people through targeted marketing strategies, misleading consumers, and making false claims about the benefits of their products or their environmental credentials,” added Kluge. 

“These tactics threaten public health gains of the past century and prevent countries from reaching their health targets. WHO Europe will work with policymakers to strengthen tactics to protect against and reduce harmful industry influence.

“Today, we provide indisputable evidence of harmful commercial practices and products and we say: people must take precedence before profit, always,” added Kluge.

The report provides a detailed estimate of each industry’s impact on health: tobacco leads as the highest proportion of all cause death at 10.37% (nearly 1.2 million deaths in 2021), followed by fossil fuels (5.21%), alcohol (3.84%), and unhealthy foods (3.52%). “Unhealthy foods” being diets of processed meats, high sodium, trans fats, and sugar-sweetened beverages.

Corporate social responsibility and image laundering 

The WHO Europe Region has the highest rates of adult tobacco use.

Through a series of unsettling case studies, the report documents the lengths to which companies go to protect their reputations, shift blame, and take advantage of crises for profit. 

Industry corporate social responsibility (CSR) programs that appear “inherently beneficial to society” yet undermine public health efforts, were singled out as image laundering. 

“Pinkwashing” is one example. The phrase was coined by Breast Cancer Action, and refers to  groups that claims to care about breast cancer by displaying a pink ribbon while selling or promoting products that contain chemicals linked to cancer.

For example, alcohol consumption is a known risk factor for breast cancer, yet some alcohol companies fund charities that have underplayed or denied the risk of alcohol, according to the report.

“They fund charities that raise awareness of breast cancer and other dangers, while selling alcohol which causes these harms,” said Kluge.

‘Wresting power back. from industries

Table displaying statistics of the commercial determinants of health, including tobacco
Tobacco, followed by fossil fuels and alcohol, contribute to chronic diseases like obesity, cancers, respiratory illnesses, and diabetes.

“We really have to re-think,” said Belgian Deputy Prime Minister and Minister of Social Affairs and Public Health, Frank Vandenbroucke.  “For too long we have considered risk factors as being mostly linked to individual choices. We need to re-frame the problem as a systemic problem, where policy has to counter ‘hyper-consumption environments’, restrict marketing, and stop interference in policy making.

The report calls for an entire rethinking of current economic models – going beyond traditional metrics of “productivity and profit, emphasizing wellbeing over monetary return on investment.” 

It calls on member states to enforce stronger regulations on marketing of harmful products; monopolistic practices; transparency, lobbying, funding and conflicts of interest, and  taxation of multinational corporations.

It also wants vulnerable populations to be protected against exploitation during crises and funding and government support for civil society organizations to ensure their independence.

Not a new conflict

Ad for tobacco
The report notes that the conflict between industry interests and public health dates back more than half a century.

In 2023, the Lancet journal commissioned a series on the mechanisms and scope of commercial determinants of health, examining how the private sector influences health through activities like product design, packaging, supply chains, lobbying, research funding, and marketing. 

The Lancet series identified companies that “are escalating avoidable levels of ill health, planetary damage, and inequity.” These include formula milk companies’ extensive lobbying networks and “predatory” marketing tactics that derailed progress on breastfeeding education, and the palm oil industry fueling unsustainable deforestation, driving malaria risks in deforestation hotpots. 

Indeed, industry’s battles with public health can trace its roots to 1950s era tobacco press statements – the beginnings of a half-century charade to mislead Americans about the dangers of smoking.

Yet resistance from industry to change that could be health-promoting has grown more sophisticated over time, says the report. 

“Earlier efforts were exemplified by the tobacco industry denying that nicotine was addictive or that there was no evidence that tobacco was harmful to health.

More recently, in many European countries, industry efforts have challenged public health by promoting ‘harm reduction,’ where the concept does not apply across a bundle of industries taken together, thereby reducing the impact of strong regulation to promote health.” 

With these tactics in mind, “we have no illusion that one report will bring about a sea change, but we are firm in the belief that the reaction the report is getting is evidence of a groundswell of support, not just in public health practitioners, but in governments, civil society, and academia,” said Dr Gauden Galea, WHO Europe regional adviser on NCDs and Innovation.

“The report is a rallying cry in a generational struggle for health for all,” she added.

Image Credits: PAHO, The Lancet, WHO Europe, Standford School of Medicine .

Stephanie Psaki speaking about global health security at a CSIS event
Dr Stephanie Psaki at a Center for Strategic and International Studies event in Washington, D.C.

While the World Health Organization’s International Negotiating Body (INB) continues to negotiate a global Pandemic Agreement, the US has issued its own vision for global health security and expanded its bilateral partnerships with countries across the world.

Following the release of this revamped US global health security strategy, Health Policy Watch spoke with Stephanie Psaki, the inaugural US Coordinator for Global Health Security and Deputy Senior Director for Global health security and biodefense at the US National Security Council.

Health Policy Watch: The COVID-19 pandemic illustrated that weaknesses in the public health response in one part of the world can be a threat globally. Why did the US Administration release a Global Health Security Strategy now?

Stephanie Psaki: The goal is to build on and learn from the lessons of the COVID-19 pandemic. We started working on this new strategy as we emerged from the acute phase of the COVID pandemic feeling like it’s going to be enough in our rearview mirror that we can understand and learn from the lessons and have a more forward-looking approach with how we can prevent and address the next pandemic. 

We tried to not just assume that the next pandemic or the next biological threat will be the same as COVID-19 because chances are it will take a different form. We wanted to develop a system and a process that works quickly and is adaptable, depending on different threats that can easily bring in the different parts of the inter-agency that have relevant expertise to inform decision-making.

The last global health security strategy was released in the previous administration in 2019. So the idea was to build on that, five years later. Very practically this is something that was called for in a national security memorandum as well as the Global Health Security Act, passed as part of the NDAA [National Defense Authorization Act] last year. So both Congress and the President asked us to do it.

HPW: What is remarkable about the new strategy is the expansion of global partners from 50 to over 100 countries. Partners now include countries across almost all continents. How are these countries chosen?

US Global Health Security partnerships with countries abroad.

Psaki: There are a number of different criteria we use to select partners. You’ll see that some of them are countries where we’ve been working with for a while in global health broadly or global health security, specifically, and then some are countries where this is a new global health security partnership. 

Need is top of the list in terms of where there are gaps in their global health security capacity and their ability to detect, prevent, and respond to an outbreak. There also is political will. So these are partnerships that we formed with the countries – with the government directly to just make sure that there was interest, not just in getting government support, but also investing them domestically in global health security so that we can move the goal forward together.  

And then the third criterion is risk both to the United States and to the rest of the world in terms of an outbreak. So looking at countries where there’s emergence of pathogens that pose a pandemic threat or you know, otherwise have expressed concern about their own preparedness.

We also launched a website that lays out who the 50 countries are, how long we’ve been working with them, what we’re working with them on. 

HPW: What lessons and successes has the US learned from past partnerships that have informed expanding these bilateral agreements to new countries?

CDC staff member sets up RT-PCR tests as part of CDC’s
support to Thailand’s Ministry of Public Health
COVID-19 response.

Psaki:  A long list, but I would say, you know, one of the areas that has been a priority for this administration is what what USAID [United States Agency for International Development] calls localization – really shifting the power dynamic – so that we are working in partnership with other countries rather than it being a development program or a priority that’s imposed on countries. 

The way that these partnerships are designed, and the way that we have developed, a partnership from the outset – identifying countries that have interest from the political leadership level in collaborating with the US on closing gaps that have been identified – is key to success. There needs to be political ownership at the leadership level, and then down to the level of the health workers who are working in communities. 

HPW:  The strategy also discusses evolving risks like spillover events from animals to humans, climate change, urbanization. How is One Health informing the strategy? 

Psaki: This is a really important piece of the strategy. We’ve seen that a lot of emerging pathogens are zoonotic diseases. At a basic level, in terms of how we do the work, the strategy lists the roles of different departments and agencies across the US government, and it includes US Department of Agriculture (USDA), Food and Drug Administration (FDA), and others whose primary role is animal health. That’s making sure you have the right people at the table with the right expertise and that there’s a collaborative approach to not just identifying risks, but responding to risks. 

If you take a look as well at the areas of partnership with the 50 countries, you’ll see that zoonotic disease is a common area partnership because this is something that has been identified by many other countries as well. So that includes collaboration with our traditional health departments and agencies like Health and Human Services (HHS) and USAID but it also includes technical support and assistance from USDA and some of those other parts of the government that have expertise in animal health and zoonotic disease. If you look across the departments and agencies, there’s a lot of focus on developing cohesive One Health strategies. So I know for example, the Center for Disease Control and Prevention (CDC) has a One Health office and they’ve developed a strategy on One Health to make sure that their work is informed with that perspective.

HPW: You mentioned a variety of agencies across the federal government are coordinating together. What does this inter-agency cooperation look like in the implementation of the strategy?

Five of the US federal agencies collaborating to strengthen global health security.

Psaki: Part of my role as the US Coordinator for Global Health Security is to coordinate the interagency efforts and implement the strategy. We have a structured decision-making process that has been long standing within the US government, between the agencies when we develop new policy. Much of what we spend our time on is also responding to emerging risks. 

For example, we were talking recently about the Marburg outbreak in Equatorial Guinea that happened a couple of years ago. We received identification of the risks through our CDC colleagues and also through our Embassy in Equatorial Guinea. We then worked through CDC and through USAID, which has a lot of staff and presence in the region and through the State Department and its ambassador on the ground, to engage with the government to understand what is needed to figure out how we can respond. 

That is really just pulling everyone together, having regular conversations and making sure that we’re exchanging information and leveraging the strengths of each of the different departments and agencies. 

The way that each department and agency works and even the way that we coordinate depends a lot on whether we’re responding to a threat like that or we’re responding to the need to develop a new policy. In terms of responding to threats, part of what this administration has done – and this is also quite a rigorous process – is to identify threats, assess the level of the threat and make decisions about what our response to the threat should be. And that I think is an area as a big improvement from the systems that were in place when we came in.

HPW:  Thinking more about the current Pandemic Agreement negotiations, how does the US Global Health Security Strategy fit in? 

Psaki: This strategy is really what guides the work that we are doing in global health security. It lays out a set of priorities across the administration that we are pursuing through a number of different avenues – including bilateral support. It also includes our support to multilateral institutions like Gavi, and of course, our participation in multilateral negotiations, including on the pandemic accord and the International Health Regulations. 

We’ve been really clear about what our goals and priorities are for those negotiations. Our overarching goal for our participation is protecting the American people and protecting our national security. Any decision we make, throughout those negotiations, but also through our bilateral support, is through that lens, within the pandemic accord and IHR negotiations. 

Specifically, we’re looking at a set of three key outcomes that we need to see in the final agreements and in order to support it. 

The first is to enhance the capacity of countries around the world to prevent, prepare for, detect, and respond to pandemic emergencies and provide clear, credible, consistent information for their citizens. 

Our second priority is to ensure that all countries share data and laboratory samples from emerging outbreaks quickly and transparently to facilitate response efforts, including the rapid vaccines, tests and treatments. Again, that connects directly to our bilateral support. It also connects to our national bio defense strategy, which overlays our work. 

And then the third area is to support more equitable access to and delivery of vaccines, test treatments and other mitigation measures to quickly contain outbreaks, reduce illness, and minimize impacts on economic and national security in the US and around the world. We are actively participating in these negotiations and hope that we can land the Accord and [implement] the IHR amendments to advance those goals. 

USAID global health security strategy
USAID is just one of the many US agencies coordinating for more robust global health security.

HPW:  One of the biggest points of contention in the pandemic agreement negotiations is pathogen access and benefit sharing, governing how World Health Organization (WHO)  member states share the biological material of pathogens that may cause pandemics. How has the US addressed this in its global health security strategy?

Psaki: This goes back to the point that every experience is not going to be exactly like the COVID pandemic. But if we think for example, about some of the other outbreaks that I mentioned before, Ebola, in particular, we’ve had very, very few Ebola cases in the US. It is not a major threat to the United States. And so when we are thinking about how to respond to Ebola and how to ensure that countermeasures are developed and available, to date, it has largely been to ensure that those countermeasures are available to people living in the countries where the outbreak is emerging. 

We have had a really forward leaning approach, not just in this Administration, but historically from the United States to make sure that vaccines, therapeutics and countermeasures are available when there is an outbreak based on a pathogen with pandemic potential. But also other disease outbreaks with existing vaccines, thinking about cholera, dengue, and other outbreaks around the world. 

We are by far the leading donor to respond to these outbreaks, most of which don’t have a direct impact on Americans. So when we talk about the importance of access to samples and the data early on in an outbreak, that is the quickest way to make sure that medical countermeasures are developed and available, not just to Americans but to the rest of the world. The only impact of constraining access to pathogens and data will allow the pathogen to spread more widely, and delay access to countermeasures. I would pose it the other way: what is the upside to holding back access to pathogens?

Image Credits: CSIS, US Department of State, CDC Thailand, JT Square, US Department of State, USAID .

Panelists discuss the future of global health initiatives
From left: Katerini Storeng, Justice Nonvignon, Anders Nordström, and Mercy Mwangangi discuss the future of GHIs at a Geneva Graduate Institute event.

One of the world’s largest global health initiatives (GHI), vaccine alliance Gavi, started in a UNICEF basement with a staff of five people. Nearly 25 years later, Gavi has grown into one of the most influential players on the global health stage, driving progress on key global health challenges.

Yet several experts on global health finance contend that large non-UN multilateral health organizations like Gavi and Global Fund need to gradually turn more of their functions to countries – and devolve into less costly, more country-based institutions. 

The Geneva Graduate Institute hosted a frank conversation on the future of GHIs alongside the 77th World Health Assembly and Gavi and the Global Fund’s soon-to-be launched “replenishment” campaigns.

GHIs have been accused of fragmenting global health efforts, challenging the authority of the World Health Organization (WHO) and privileging donor and private-sector interests while evading accountability.

Remarkable achievement but little transparency

Graph of GAVI's vaccine portfolio
In the nearly 25 years their establishment, global health initiatives have continued to expand their mandates.

Gavi and the Global Fund, the largest of these GHIs, “really challenged the established ways of working through the World Health Organization, of the traditional multilateral system,” said Professor Katerini Storeng from the University of Oslo’s Centre for Development and the Environment. 

“They did so specifically by giving additional seats at the table to commercial companies, civil society organizations and to philanthropic foundations,” she said. 

This novel private-public partnership “fundamentally reshaped global health governance around private sector principles like innovation, technological solutions, and the protection of intellectual property rights,” said Storeng. 

Not only did GHIs introduce a private sector mentality to global health financing, but their model was “quickly embraced,” according to Storeng. One of the most recent examples of the application of the model was with the Gavi-directed global COVAX campaign during the COVID-19 pandemic.

However, Storeng noted that the pandemic reignited old debates, including around how these partnerships are dominated by a handful of powerful GHIs and “the apparent conflict of interest arising from the inclusion of for profit actors into formal institutions of global health governance.” 

Experts have reiterated calls for better coordination between global health partnerships and for their greater alignment with national health plans and priorities. While others have rejected such calls for incremental change asking for more radical reform or even present organizations to be together.

Three main developments have completely altered the GHI landscape, namely a shift towards bureaucratization, expanded mandates, and shifting cooperation with other partners, according to Antoine de Bengy Puyvallée, a PhD Fellow at University of Oslo’s Centre for Development and the Environment. 

GHIs have moved from being coalitions to completely separate organizations with increasingly broader missions. Furthermore, Puyvallée notes that budgets have grown “astronomically,” tripling from 2005 to 2015, meaning more staff and a greater physical footprint in the global health hotspot of Geneva.

Their CEOs are now public figures, and their missions now encompass a wide range of goals beyond their original mandates. Gavi, for example, has expanded its activities to include diagnostics not just vaccinations, noted Puyvallée. 

“You see this journey from vaccinating children to strengthening health systems,” he said. The problem with this growth, however, is the lack of accountability. “Are the boards in control?” 

Chart showing global health fund successes for malaria, TB, and HIV
While global health initiatives like the Global Fund have significantly contributed to global health successes, experts argue for increased self-reliance among GHI funding recipients.

“Moving forward it is wise to think of new ways to keep these partnerships accountable together – a coordination mechanism that goes beyond the traditional ways of being governed by their own boards – otherwise it’s very difficult for accountability,” concluded Puyvallée. 

The Global Fund says that its programs have saved 59 million lives since 2002, making significant strides in reducing deaths from HIV, TB, and malaria. Its 2022 numbers show that HIV prevention services increased by 22% compared to 2021, and the number of people diagnosed and treated for TB increased by 26%.

Calls for transparency and accountability

Making these GHIs more transparent and accountable requires five key strategic shifts, according to Mercy Mwangangi, director of Health Systems Strengthening at AMREF Health Africa, and former co-chair of the Future of Global Health Initiatives. 

These are: investing in primary healthcare, play a catalytic role in strengthening domestic resources, champion for equity when mandates are expanded, achieve strategic and operational coherence, and mobilize research and development. 

These five shifts were identified by the Lusaka Agenda, an international and multi-stakeholder dialogue. 

Mwangangi noted that the Global Fund and Gavi now have a joint partnership around malaria vaccine and health systems strengthening, but asked: “How do we ensure that these shifts lead to in-country implementation?” 

She stressed the need to keep country-level changes and implementation at the forefront through strengthened partnerships “otherwise we’ll just keep going round and round in circles.”

Mwangangi also called for the widespread adoption of the Lusaka Agenda to ensure that  countries have a bigger voice and agency in the GHI ecosystem, but was optimistic about GHI reform. 

“The boards have actually taken ownership of this issue and have shown interest in the Lusaka Agenda,” she added.

However, Anders Nordstrom, a founding member of the Global Fund and former WHO Director General, argued that there is much to do to improve the transparency and accountability of GHIs. 

“The board of the Global Fund should actually discuss the yearly results report. I mean, for business, that’s one of the core responsibilities of a board. You should approve the annual report. 

“That is not happening with the Global Fund. You approve the annual financial statement. There’s no link in between where you spent the money and the annual report. So in their annual report, there are no financial figures. And the annual report is very, very good, actually, but the board is not including it in discussion.”

Nordstrom went on to explain that if the boards do this, they could then “discuss the efficiency and effectiveness of the use of the money.” 

Self reliance and political responsibility

Africa CDC headquarters
Africa CDC in Addis Ababa, Ethiopia – is a promising way for countries to domestically invest in strengthening their health systems.

For countries historically on the receiving end of support from GHIs, there has been a growing concern about health systems independence. 

“Why should initiatives like Gavi buy our basic commodities?” asked Professor Justice Nonvignon, head of Health Economics Unit at Africa CDC and part of the University of Ghana’s Health Economics department. 

Nonvignon argued that countries like Ghana need to domestically fund more robust health efforts, and wean themselves off of dependency. 

Instead of a reliance on GHIs for basic needs, countries should provide domestic funds to buy these commodities, which range from syringes to drugs and vaccines, argued Nonvignon. 

These countries have the means to channel funding to health if they choose to prioritize it, added Nordstrom. 

“There are plenty of resources,” he said, noting that while working in Sierra Leone he was told that “it’s quite a rich country, plenty of diamonds and rare minerals. But where is that money?”

Mwangangi, who works closely with the Kenyan government, shared that it is incredibly difficult for African nations to transition off this dependency. 

“As long as there’s no sunset clause, as long as there’s no forced transition plans and more forced graduation plans, the Ministry of Finance will not move,” she said. 

Reducing reliance on aid, while difficult in the short-term, is a must, said Nonvignon, because it increases a country’s resilience and ability to act fast in an emergency. 

“Cholera is devastating huge populations across central and southern Africa. Where is the time to send a proposal to a fund based in Washington DC or in Geneva?” asked Nonvignon.

“Why is the Global Fund situated in Geneva and not in Nairobi? Why is the Global Fund not in Addis Ababa instead of Geneva? Because it gives a tremendous amount of power.”

In response, Nordstrom noted that much of the global health initiative ecosystem is highly political and “the power is not with the secretariat, it’s not with the directors, it’s with the governments that provide the funding.”

“I’m worried that we’ve got the epidemiology wrong… the majority of people are losing their lives to non-communicable diseases. And the global health partnerships and community are not addressing that at all,” he said, adding that the GHI community has also failed to include the effects of a changing climate. 

Sunsetting GHIs by 2030?

Nonvignon proposed sunsetting GHIs by 2030, because they have a “fundamental design flaw” in that they were established with no end date in mind. 

“We are beginning to see an increase in the desire of our member states [of Africa CDC] to  invest money…we need to push countries to take more responsibility.” 

He noted that the pandemic prompted countries to increase their domestic spending on health, which will increase their long-term financial sustainability but cautioning that reducing aid from GHIs should not mean that philanthropies fill in the gap. 

African countries must “step up,” through regional groupings such as the African Union, he added.

Putting the “onus” on countries themselves will help build global health independence – but countries need to domestically fund their own health efforts, said Mwangangi.

While a termination date for donors may seem drastic, it will at least create the space for conversation about the sustainability of GHIs, and the ability of countries to find their health financing footing.

 

Image Credits: S. Samantaroy/HPW, GAVI, The Global Fund, Africa CDC .

A health worker tests a patient for diabetes.

Like most African countries, non-communicable (NCDs) diseases, including diabetes, is increasing in Zimbabwe. And children are increasingly among the cases that go undetected or treatment until severe symptoms emerge. 

HARARE, Zimbabwe – Ten-year-old Tadisa Sayi already contends with diabetes and when his blood sugar levels spike his mother, Naume Shereketo, endures the mood swings induced by his condition.

Three years ago, Shereketo, a single mother of two, discovered the root cause of her son’s misery during a severe bout of illness.

“It was in 2021. He was weak and vomiting. When I went to the hospital with him, doctors told me he was diabetic,” Shereketo told Health Policy Watch.

“He always says: “Mama, I’m weak’, and some other time he is harsh,” said Shereketo.

Shereketo, a vegetable vendor on the streets of Harare, faces ballooning costs to attend to her son’s special dietary needs.

She struggles to provide the specific foods required for her son’s health. For Sayi, a grade four learner, fruit, vegetables, milk and high-fibre foods, have become a regular but costly part of his diet, costing his mother between $60 and $80 monthly.

Shereketo is puzzled about her son’s diabetes. No one else is diabetic in her family or the boy’s paternal side.

Dr Life Zambezi, the boy’s doctor, confirmed that Sayi had Type 1 diabetes, and said that this can be challenging to manage in young children due to limited support at the community level as well as the difficulty of maintaining strict insulin routines.

Type 1 diabetes, which causes glucose (sugar) in one’s blood to become too high, happens when a person’s body cannot produce a hormone called insulin that controls blood glucose.

Changes in diet also cause rise in Type 2 diabetes

While Type 1 diabetes is generally the result of a genetic condition, children also are being increasingly affected by Type 2 diabetes, as a result of changing diets and lifestyles, according to the UN children’s agency, UNICEF.

Type 2 diabetes typically develops as a result of sedentary lifestyles, obesity and unhealthy eating habits, Zambezi notes. While it’s on the rise in most African countries, and usually associated with adults, he’s seeing more such cases among children.

“Of late, children are also getting Type 2 diabetes, mainly caused by the changes in lifestyle. There is a rise in poor eating habits among children. In most cases they eat processed and unhealthy food leading to childhood obesity and eventually type 2 diabetes,” said Zambezi.  

But diabetic children like Sayi are too often only diagnosed only when they have developed a severe crisis, such as a diabetic coma.

“NCDs in children result from a combination of genetic, environmental and behavioural factors,” Health and Child Care Deputy Minister Dr John Mangwiro explained at the launch. “When a young child is diagnosed with a non-communicable disease, this implies long-term treatment.”

Dr Life Zambezi says that the high cost of insulin has made life miserable for people with diabetes, many of who cannot afford the life-saving medication.

Diabetes incidence in Zimbabwe soaring – although data remains spotty  

Approximately 537 million people worldwide are living with diabetes, according to the according to the International Diabetes Federation (IDF), an umbrella organisation of over 240 national diabetes associations in 160 countries and territories globally.  That includes 422 million people worldwide suffer from type 2 diabetes, the majority living in low- and middle-income countries, according to WHO, of the disease that kills 1.5 million people every year.

That includes approximately  106,400 adults in Zimbabwe living with diabetes Type 1 and 2, a prevalence of 1.5% in the adult population of about 7.1 million, according to the International Diabetes Federation (IDF), an umbrella organisation of national diabetes associations in 160 countries and territories.  

However,  IDF’s local member, the Zimbabwe Diabetic Association, says that’s a woeful underestimate. It estimates that as many as 10 out of every 100 people in Zimbabwe’s population of 17 million had diabetes, including children, as of 2017. But many cases go undiagnosed until the child or adult in question becomes seriously ill.

A 2014 meta-analysis also suggests diabetes incidence has grown exponentially. Prior to 1980, the prevalence of diabetes in Zimbabwe was just 0.44 %, while after 1980 the prevalence was 5.7 %, according to that systematic review. By 2018, prevalence was estimated at 8.5%, according to yet another study. 

As of 2016, Zimbabwe had the third highest estimated per-person cost of diabetes care in sub-Saharan Africa. Insulin’s exorbitant prices also cause many to miss out on essential medication, exacerbating their condition and long-term health risks, Zambezi said.  

Treatment at primary health care level is spotty

Treatment in primary health clinics remains spotty, the studies also suggests.  One small study comparing treatment in primary versus hospital facilities  in Harare, the capital city, found that more patients treated at hospital outpatient clinics ahd received some form of diabetes self-management education (DSME), and had higher levels of diabetes knowledge, as compared to those treated in primary care facilities.  At the same time, people who had consulted a dietician had the best levels of diabetes knowledge and self-care routines. 

“Dietitian-led interventions significantly improved both knowledge and practices, highlighting a need to scale up dietetic intervention, particularly in primary clinics where limited interventions occur,” concluded the July 2019 study led by a researchers at the University of Cape Town and the University of Zimbabwe’s  Department of Community Medicine.

“Though improvements have been made in self-management therapies, there seems to be a high prevalence of hospital admissions with relapse of symptoms in Zimbabwe. Relapse in diabetes predicts poor prognosis,” concluded another, 2021 study, led by the University of Zimbabwe’s Department of Nutrition.

Recognizing those gaps, UNICEF in 2022 launched an initiative in five countries including Zimbabwe, to focus on NCD prevention, detection, treatment and support, particularly in children and young adults.

As part of the grant, funded by the pharma firm, Eli Lilly, Zimbabwe’s Ministry of Health received $2.5 million to educate community health workers and increase support and understanding of various NCDs including diabetes in children.

Late detection and poor management results in adult complications 

Diagnosed with diabetes 20 years ago, 30-year-old Tariro Chiripanyanga is now contending with end-stage kidney disease as a result of poor management of her diabetes.

But until earlier detection and prompt treatment become more of the norm, many children will continue end up with severe complications in early adulthood, Zambezi observed.

One such case is Tariro Chiripanyanga. The youngest of four siblings, Chiripanyanga was diagnosed with Type 1 diabetes at the age of 10.

Today Chiripanyanga is now facing end-stage kidney disease, although she is only 30 years old.

“I was still too young to understand what it meant or how it would affect my life, but that’s when my life changed forever,” Chiripanyanga told Health Policy Watch.

Apart from living with diabetes since childhood, Chiripanyanga was diagnosed with kidney disease six years ago. She needs $30,000 for a kidney transplant, a financial burden neither she nor her family can bear. 

Chiripanyanga’s diabetes has already led to partial blindness, forcing her to drop out of university.

“My life depends on peritoneal dialysis which costs $1,750 monthly,” Chiripanyanga said. “I depend on dialysis until I can get money for a transplant which costs an estimated $30,000 in India.”

Image Credits: Muhidin Issa Michuzi, Jeffrey Moyo.

For many, access to assistive technology can enable independent everyday life.

Only one in five of the people in need of hearing aids and prostheses worldwide can access them, according to a new report by ATscale, a global partnership for assistive technologies and the Clinton Health Access Initiative (CHAI).

Assistive technology (AT) is any device and related systems that can help with everyday activities, improving or restoring the capabilities of a person’s body, ranging from eyeglasses, access ramps, prostheses or smartphones for functionalities such as the text-to-speech option.

The report, issued on the first-ever Day for Assistive Technology, aims to make assistive technology markets more transparent and easier to navigate for the public sector and producers. 

The hope is that comprehensive information will facilitate the choice of quality products, especially for governments in low- and middle-income countries, and encourage companies to expand their reach to new regions of operation, explained Pascal Bijleveld, CEO of ATscale in an interview for Health Policy Watch.

“It’s really about addressing one of the bottlenecks to access, which is the lack of transparency in the markets about what products are available, what are the price ranges, what’s the quality, and so on and so forth,” Bijleveld said.

Many governments lack the capacity to analyse and understand each of the markets and may make sub-optimal product choices.

It is also essential to raise awareness about the benefits of assistive technology and to start public and private initiatives to ensure more people, especially in low-income countries, can attain the AT they need. 

Large gap in access

Getting a AT of need is often the key to a more independent, full life for people with disabilities, unlocking a possibility to live independently, meet with family and friends, study, or work.

Globally, 2.5 billion people need at least one assistive product with the number expected to reach 3.5 billion by 2050 as the world population ages, WHO’s and UNICEF’s report shows. Even though 90% of people in need of an AT in high-income countries can access it, the number drops drastically to only 10% in low- and middle-income countries.

There is a nine-to-one return on investment from providing AT, thanks to unlocked educational outcomes, better paid employment and lower longer-term healthcare costs, an ATscale study from 2022 highlights.

The report systematically analyses markets for several most popular technologies: wheelchairs, glasses, augmentative communication, screen readers, and smartphones. 

Hearing aids, glasses and other assistive technologies can be prohibitively expensive. Taken for granted in wealthy countries, these simple technologies are out of reach for millions globally.

It lists the product types available, describes market specifics and enumerates some of the most important features. For hearing aids, for example, approximately 20 million units are sold annually, with the main market drivers being the ageing population. 

When picking the right device, it’s important to consider its ability to manage background noise and acoustic loops, its resilience against mild shocks, dust or rain, volume control and overall design. Those and other features are tested by several control agencies; to help navigate the market, the report provides a comprehensive list of producers and certificates held by their devices.

The report is only the first step, Bijleveld said and will be changed over the next couple of months into “a web-based platform that will be continuously updated”.

 Producers themselves will want to keep this interactive source of information up to date as a potential advertisement for their products and a guide to the overall market situation.

Raising awareness about the benefits of ATs is on the top of ATscale’s agenda. ”People need to get the word out there,” Bijleveld stressed.

Image Credits: CC.

Drug-resistant bacteria have developed from years of over-prescription of antibiotics.

With less than four months to the United Nations High-Level Meeting (HLM) on Antimicrobial Resistance (AMR), global leaders have proposed a variety of measures to address the growing threat of pathogens that are resistant to antibiotics.

The recently published zero draft of the political declaration for the meeting aims to reduce global deaths caused by bacterial AMR by 10% by 2030 (using 2019 as the baseline).

Mia Mottley, Prime Minister of Barbados and chairperson of the Global Leaders Group on AMR, called for “adequate, predictable and sustainable financing” to address the problem,  including financing for research and development for new antibiotics and the implementation of national action plans on AMR, especially in low- and middle-income countries. 

“Fundamentally, we must focus on prevention across all sectors – clean water, safe and effective sanitation, food security, infection prevention and control in all settings,” Mottley told a lunchtime roundtable during last week’s World Health Assembly.

Prime Minister of Barbados Mia Mottley, who chairs the Global Leaders Group on AMR

“I believe that we should establish an independent panel to monitor and report on the science and the evidence to facilitate collaborative and coordinated action against AMR,” She also called for the quadripartite joint secretariat on AMR to be formalised and adequately resourced. This is made up of the World Health Organization (WHO), the UN Food and Agriculture Organisation (FAO), UN Environment Programme (UNEP), and the World Organisation for Animal Health (WOAH).

The agricultural sector is responsible for the vast majority of antibiotic overuse, leading to drug resistance. 

Threatens to ‘unwind century of medical progress’

“In 2019, 1.3 million deaths resulted directly from bacterial AMR, more than two every minute,” WHO Director-General Dr Tedros Adhanom Ghebreyesus told the meeting.

“AMR threatens to unwind the century of medical progress and also threatens animal health, global food production, food security, and the environment.”

Dr Jean Kaseya, Director-General of Africa CDC, noted over one million deaths in Africa were associated with AMR and 250,000 caused by ARM. 

“Only 1.3% of our labs in Africa are able to perform bacterial resistance testing. It means this data that I’m sharing with you is an underrepresentation of the reality in Africa,” said Kaseya.

Four years ago, the African Union Assembly established a task force to control AMR and recommended that all member states implement national action plans.

“But less than 10% of a member states have national action plans that are fully funded and implemented,” he added.

Kaseya appealed to The Global Fund to expand its mandate from HIV, TB, and malaria to include AMR.

Professor Sally Davies, UK Special Envoy on AMR

Professor Sally Davies, the UK Special Envoy on AMR and a member of the Global Leaders Group, called for the high-level meeting to “truly address the needs of the most vulnerable communities, offering clear support to low and middle-income countries” that carry the greatest burden of this antibiotic emergency and need fair and equitable access to antibiotics and diagnostics.

Surviving AMR

Vanessa Carter developed a drug-resistant infection after a car crash cost her an eye.

South African Vanessa Carter, chair of WHO Taskforce of AMR Survivors, shared her nightmare of being unable to shake an infection after being seriously injured in a car crash in Johannesburg and losing her right eye. 

The infection turned out to be the drug-resistant Methicillin-resistant Staphylococcus aureus (MRSA). Hospital patients, people with wounds, and those who have surgery and medical devices implanted in their bodies are particularly at risk of MRSA.

Carter, who spent a month in hospital, had a prosthetic eye inserted and a number of surgeries.

“In my sixth year of surgeries, and my fourth prosthetic [eye], I went out shopping one day, I came back to the car and I felt moisture on my face. When I pulled down the rearview mirror, I saw this pus seeping out of the cheek of the prosthetic,” Carter told the roundtable meeting.

Her doctor told her she needed emergency surgery, but two weeks’ later the infection came back again.

“I was under the care of different types of specialists, an ENT surgeon, ophthalmologist, plastic surgeon, maxillofacial surgeon, each of them prescribing antibiotics during surgeries,” she added.

After almost a year of continued infections, doctors removed the prosthetic eye and sent it for testing and it was found to be contaminated with MRSA. What followed was a long and harrowing process during which the infection got into Carter’s bones before she was finally cured.

“I’ve been an advocate for the last 11 years and, most recently, we’ve established the WHO Task Force of AMR Survivors,” said Carter.

“Our biggest objective is to bring the human impact. When policy makers and members of the public understand exactly what it is, we can we can empower them. One of the documents we have worked on is a strategic technical guidance document for meaningful patient involvement. I would encourage you to go take a look at it.”

Votes to move to a secret ballot broke down along almost the same geopolitical lines – with 14 opponents (voting here) versus 17 supporters.

The World Health Organization (WHO) Executive Board on Tuesday voted to recognize the US-based Center for Reproductive Rights (CRR) as a non-state actor “in official relations” with it, in a motion carried by a narrow 17-13 margin, with four abstentions.

After multiple rounds of voting, the final vote was by way of a secret ballot.

The decision to grant WHO recognition to the Center, which supports access to sexual and reproductive health services, including abortion, was a hard-won victory for European, Asian and Latin American countries.  But the victory may be  short-lived.

Egypt, backed by a coalition of Middle Eastern and Islamic nations, as well as the 47-member WHO African Group, pledged to  “escalate” the issue to the World Health Assembly (WHA), a promise that it reaffirmed shortly after the vote in the WHO governing body, calling the vote a “politicization” of the global health body.

Egypt’s delegate to the EB (back left) pledges “to pursue” the controversial issue at the World Health Assembly.

“We would like to repeat what we have mentioned yesterday,” said Egypt’s delegate. “That we will pursue reopening of the discussions on this agenda item within the wider quorum of the organization during the upcoming WHA”.

He added that, at the national level, the decision ” is of no weight…  we will not abide by it, and will not consider it in any means”.

“Also, we will join the Russian Federation on their query, which is ‘how could we avoid the repetition of such unpleasant situation?’.. We need the good offices of the WHO in order to avoid the politicization of this organization as it has been experienced frequently in the past few days. “

“The text that was adopted today will not be implemented in Senegal, unless it is compatible with our laws, traditions and values,” said Senegal’s delegate, echoing sentiments expressed by Yemen, Kuwait, Somalia, and other member states in the post-vote discussion. 

National context still prevails

The Netherlands: WHO recognition of non-state actors does not commit member states where, “the national context prevails.”

Member states that supported the move by the 34-member governing body noted that other nations are in no way obliged to cooperate with the Center, or with any other non-state actor, which they oppose.

They stressed that the recognition was being extended solely by the WHO Secretariat, which maintains a wide network of official relations with over 200 non-state actors from civil society, industry federations and professional associations in line with a Framework for Engagement with Non-State Actors (FENSA) approved by the World Health Assembly in 2016.

The vote also awarded WHO recognition to a second non-state actor, Rare Diseases International, whose candidacy was never opposed by member states.

“The Framework of Engagement with Non State Actors (FENSA) is one of WHO normative guidelines, which has been negotiated and agreed by all member states,” The Netherlands pointed out.  “Questioning any non-state actor about its eligibility for admission into an official relationship with WHO after the organization passed the Secretariat’s criteria, undermines a great procedure and sets a harmful precedent for the future agreements.

However “the national context prevails over WHO engagements with non state actors,” she emphasized. 

FENSA framework is supposed to be neutral

The FENSA framework sets out a set of generic criteria for organizations “in official relations” to engage in collaborations with WHO, serve on technical groups and be recognized as “observers” with the right to speak at the annual WHA.

The aim of FENSA, which took years to negotiate and approve, was to create an even playing field in the much-coveted “official relations” designation that would side-step vested interests, particularly of industry or lobbying groups, that contravened WHO aims and priniciples.

Since the approval of FENSA, the handful of recommendations made by WHO each year to the Executive Board, to approve new NSA’s in official relations with WHA, or renew the terms of others, are usually just a matter of protocol, following WHO review and due diligence.

But there is growing pressure on the UN from socially conservative nations to roll back its activities on sexual and reproductive health in a period where many conservative nations still ban abortions, limit access to contraceptives and  criminalize the LGBTQI community.

Proposed WHO Recognition of Center for Reproductive Rights Provokes Storm at WHO Executive Board

As member states pointed out, the CRR has long been recognized by the UN’s Economic and Social Council (ECOSOC),  highlighting how the controversy over its recognition by WHO is a sign of the times, with intensive pushback not only in major powers such as the US and Russia, but also in international forums against the recognition of reproductive health rights long taken for granted in many societies.

Multiple votes are worrisome precedent for WHO governing body

Poland pledges to uphold the “consensus” around the FENSA framework for engagement with non-state actors.

For the EB members, themselves, the repeated votes, including by secret ballot, was yet another worrisome sign of the growing fracture between WHO member states in Europe, the Americas and Asia, which tend to identify themselves as socially and politically liberal, and developing nations in Africa as well as Russia, and the Middle East – where more conservative worldviews prevail.

The result, most member states agree, is the creeping “politicization” of global health agendas and issues. And while everyone also has a different point of view about what is political, it’s clear that it is leading to fewer decisions by consensus and more by lengthy, and often bitter, rounds of votes.

“After a record number of votes in the last week, we are alarmed by the notion that this is now becoming the default way to solve difficult issue,” said Poland’s delegate. “We would like to remind everyone that we adopted the FENSA by consensus, and we should respect it subtle equilibrium for the sake of our collective interests.

Matthew Wilson (center): “What you did was democracy”

“It is essential to preserve the independent, transparent, technical and evidence based role of the World Health Organization. We highly appreciate the efforts of the direct chair and other member states in trying to find a solution we could have all subscribed to. Poland remains committed to decision-making by consensus in this organization, and rejects the notion that the voting is now mainstream. We will spare no effort in supporting effective multilateralism and fostering consensus – with all due respect for different contexts of different countries.”

New EB Chair, Matthew Wilson, who sought to strike a more consensual note after the vote, declared: “What you did was democracy, and that’s not a bad thing.”

A baby gets vaccinated against polio thanks to su

With the first-ever malaria vaccines rolling out across Africa and a next-generation tuberculosis (TB) vaccine in testing, scientific advances are driving an unparalleled expansion of vaccine development. But vaccines in development don’t become immunizations that protect our health without concerted efforts by global initiatives like Gavi, the vaccine alliance, that help bring these life-saving products to the world’s poorest countries.

Next month, Gavi will kick-off a campaign to raise several billion dollars to deliver on its new strategy. The stakes are high: falling short of its target could delay delivery of vaccines to those most in need.

But amidst a rapidly changing global landscape, Gavi’s leadership and board must look inwards and seize the opportunity to reform by adjusting its operational model, addressing how it delivers vaccines in humanitarian and conflict settings, sustaining the impact of its investments, and aligning with other global health initiatives to respond to country priorities.

By Gavi’s own count, it has helped immunize more than a billion children since its launch in 2000. But underlying this remarkable impact is a stark reality: millions of women and children continue to miss out on vaccines. Perhaps most staggering is the fact that close to 15 million children around the world still do not receive basic childhood vaccines, leaving the poorest and most vulnerable susceptible to preventable diseases.

Significant gaps in accessing newer vaccines also exist. Only 20% of girls worldwide have received the human papillomavirus (HPV) vaccine, which protects against the leading cause of cervical cancer.

As Gavi’s leadership and board finalize a new strategy that will cement its priorities over the next five years, we urge attention to three areas to ensure that every child, everywhere, has access to vaccines. 

Rethink criteria for selecting countries

First, Gavi should update how it deems which countries receive support. Since its early days, Gavi has channeled financial support for immunization, based on national income per capita, to the poorest countries that also showed the biggest gaps in immunization access. The model is simple: if national income per capita is below the eligibility line, a country can receive full Gavi support; if it is above the line, then no support is given. But almost 25 years later, it’s time to refine how this works. 

 As a growing number of countries face economic headwinds and stagnating vaccination rates in the post-COVID era, Gavi needs to better match support with a country’s ability to pay for vaccines. And as new vaccines – including for TB – become available, Gavi’s model needs to align with the burden of leading infectious killers. 

As one case in point: four of the highest TB burden countries – India, Indonesia, China, and the Philippines – are no longer or were never eligible for Gavi support. But ironically, they are eligible for financial support for TB diagnosis and treatment from Gavi’s sister organization, The Global Fund for AIDS, TB, and Malaria. This policy mismatch could limit the impact of a new vaccine against a major infectious killer.

Invest more in vaccine delivery innovation

Second, Gavi should play a bigger role in scaling innovations to address the barriers that deter vaccine delivery. COVID-19 laid bare just how critical health systems infrastructure is to stopping disease outbreaks in their tracks. It also proved how useful innovations like digital immunization records can be in boosting vaccine uptake.

 With dedicated resources, Gavi can support partner countries to scale proven innovations for immunization systems they want and need. This could include solar panels for electrification of health clinics, unmanned drones for vaccine delivery, and digital immunization records.

While each of these innovations has been proven to work, Gavi’s investments would fill a critical gap in providing financing to scale, thereby leveraging at-risk early funding by other partners. Gavi’s track record in innovation, including financing mechanisms to scale new vaccine introductions, makes it well placed to do so.

Pilot new financing to ensure country control

Lastly, Gavi should pilot new ways to channel financing to partner countries that puts them in the driver’s seat and respond to national priorities. This is especially timely amidst growing calls to shift the center of gravity for decision-making to countries. 

How can this be achieved? One idea is for Gavi to test a new approach that provides a consolidated envelope of resources to each country, scaled to specific criteria including population size.

One portion could be dedicated to vaccine purchasing, enabling countries to base decisions on their own priorities. The second portion could be carved out for technical support and grants for health systems strengthening. With the 2030 deadline of the Sustainable Development Goals in sight, now is the time to experiment. 

Our collective ability to end the scourge of vaccine-preventable diseases is within reach. And Gavi – provided it is able to reform – remains one of our best bets to get there. At this crucial juncture, its leadership, board, and donors must ensure that Gavi has a fit-for-purpose model with adequate resources to deliver on the unfinished immunization agenda in a shifting global landscape.

Janeen Madan Keller is deputy director of the Global Health Policy Program and a Policy Fellow at the Center for Global Development (CGD), where she leads policy-oriented research focused on the economics of global health challenges. 

Orin Levine has worked to accelerate the introduction of, and access to, vaccines and other proven health interventions in low- and middle-income countries for the past 30 years. He served as a member of Gavi’s board for almost nine years, representing the Bill & Melinda Gates Foundation. He currently serves as a member of the Board on Global Health for the US National Academy of Medicine, and on the Board of Directors for the National Foundation for Infectious Diseases.

 

 

Image Credits: Gavi/Karel Prinsloo 2017, Gavi, the Vaccine Alliance.