A Palestinian boy with his cat in the ruins of an apartment bombed by Israel.

Health workers in Gaza face “agonising choices” in the face of Israel’s order that all people evacuate the north of the territory: “abandon ill patients amid a bombing campaign, put their lives at risk while remaining on-site to treat patients or endanger patients’ lives while attempting to transport them to facilities that have no capacity to receive them”.

This is according to the World Health Organization’s (WHO) Eastern Mediterranean Region, which “strongly condemned” Israel’s “repeated” evacuation orders – including more than 2,000 patients in 22 health facilities.

“The lives of many critically ill and fragile patients hang in the balance: those in intensive care or who rely on life support; patients undergoing hemodialysis; newborns in incubators; women with complications of pregnancy, and others all face imminent deterioration of their condition or death if they are forced to move and are cut off from life-saving medical attention while being evacuated,” said WHO EMRO.

Although Israel’s evacuation deadline expired on Saturday, Israel has not yet deployed ground troops into the areas of Gaza that it ordered evacuated.  Meanwhile, some Palestinian health workers in the hospitals affected have chosen to stay with their patients, who cannot be moved in any event.

Dr Christos Christou, president of Medecins sans Frontieres (MSF), described the situation in health facilities in Gaza as “horrific and catastrophic”, with surgeons at Al-Shifa Hospital currently “operating without painkillers”.

“People are trapped, unable to escape, with absolutely nowhere safe to go. They’re deprived of essential needs – water, food, protected shelter, medicines,” added Christou. “This is unimaginable. This is inhumane. As doctors, humanitarians, human beings, we cannot tolerate this. While we are frightened of what is coming, our only hope is for humanity to prevail.”

Huge death toll

At least 2,750 Palestinians have been killed and 9,700 have been wounded in Israeli air strikes on Gaza since 7 October, the Palestinian health ministry said on Monday. This is the highest Palestinian death toll since Hamas took control of Gaza in 2007, wresting power from the Fatah-aligned Palestinian Authority in a violent takeover, after both sides failed to win a clear majority in elections, the last ever to be held. 

Israel launched unprecedently intense airstrikes on Gaza after Hamas attacked  towns, villages and collective farms inside Israel on 7 October, killing around 1,300 people and abducting 199 others, including babies, children and elderly, whom it is currently holding hostage in Gaza.

Around half the population of Gaza is under the age of 18, and the UN Children’s Agency, UNICEF, called for an immediate ceasefire last week, saying that “hundreds and hundreds of children have been killed and injured”.

UNICEF has also called for Israeli children held captive by Hamas to “be safely and immediately reunited with their families and loved ones”.

 

Palestinians killed on designated safe route to the south

Meanwhile, some 70 Palestinians were killed on Friday while trying to leave northern Gaza along one of the routes designated as safe by the Israeli Defense Force (IDF) when their convoy was bombed, according to media reports.

Amnesty International said on Sunday that it had verified six videos of the Israeli attack on a civilian convoy on Salah al-Din Road, and a follow-up bombing of ambulances that arrived to assist. IDF has denied responsibility for the attacks.

The Israeli strikes on Gaza have been unprecedented in their intensity.  Hamas has also continued to fire missiles into southern and central Israel, leading to the evacuation of Israeli communities in proximity to the Gaza border. Although most Israeli civilians have access to shelters, the total Israeli death toll so far in the hostilities has now risen to over 1400, according to Israel, including several dozen foreign workers, students and Palestinian-Israeli citizens.

White phosphorus use?

Last week, Human Rights Watch (HRW) said it had verified videos that showed Israel had fired white phosphorous “over Gaza City’s port and in two rural locations along the Israel-Lebanon border.”

“Upon contact, white phosphorus can burn people, thermally and chemically, down to the bone as it is highly soluble in fat and therefore in human flesh. White phosphorus fragments can exacerbate wounds even after treatment and can enter the bloodstream and cause multiple organ failure,” according to HRW.

“Its use in densely populated areas of Gaza violates the requirement under international humanitarian law that parties to the conflict take all feasible precautions to avoid civilian injury and loss of life,” HRW added.

However, Israeli military spokesperson Lieutenant Colonel Peter Lerner denied that the army had used the substance, saying “categorically no” in an interview with CNN. 

Gaza is without power, low on water and food 

Meanwhile, Israel has implemented a total blockade of Gaza alongside its aerial bombing and is not allowing aid trucks carrying food, water, fuel and medical supplies to enter Gaza from Egypt via the Rafah crossing.

“There is not one drop of water, not one grain of wheat, not a litre of fuel that has been allowed into the Gaza Strip for the last eight days,” said Philippe Lazzarini, Commissioner-General of the United Nations Agency for Palestine Refugees (UNRWA), at a media briefing on Sunday.

“Gaza is running out of water, and Gaza is running out of life.  Soon, I believe, with this there will be no food or medicine either.”

Gaza’s only power plant ran out of fuel Wednesday afternoon, shutting down electricity, water and wastewater treatment, according to UNICEF spokesperson James Elder.

“Most residents can no longer get drinking water from service providers or household water through pipelines,” said Elder. “At least six water wells, three water pumping stations, one water reservoir, and one desalination plant serving more than 1 million people have been damaged by airstrikes.”

In its situation report on Monday, UNRWA said that over one million people – almost half the total population of Gaza – have been displaced. 

“Some 600,000 Internally Displaced Persons (IDPs) are in the Middle Area, Khan Yunis and Rafah, of those, nearly 400,000 are in UNRWA facilities – much exceeding our capacity to assist in any meaningful way, including with space in our shelters, food, water or psychological support.    

“Despite the Israeli Forces’ evacuation order, an unknown number of IDPs remain in UNRWA schools in Gaza City and the north. UNRWA is no longer able to assist or protect them. Over 160,000 IDPs were sheltering in 57 UNRWA premises, including – but not only – Designated Emergency Shelters in these areas at the time of the Israeli evacuation order.” 

UN Secretary-General Antonio Guterres said on Monday that the UN had food, water, medical supplies and fuel in Egypt, Jordan, the West Bank and Israel that could be “dispatched within hours” but “our staff need to be able to bring these supplies into and throughout Gaza safely, and without impediment”.

Guterres also said that “all hostages in Gaza must be released. Civilians must not be used as human shields,” in a New York Times article last Friday.

“International humanitarian law — including the Geneva Conventions — must be respected and upheld. Civilians on both sides must be protected at all times. Hospitals, schools, clinics and United Nations premises must never be targeted.”

At least 14 UNRWA staff members have been killed in the past week, while the International Federation of Red Cross and Red Crescent Societies (IFRC) said that five of its members had been killed in attacks on ambulances.

“It is clear that the two sides in this conflict cannot achieve a solution without concerted action and strong support from us, the international community. That is the only way to save any chance of security and opportunity for both Israelis and Palestinians,” Guterres concluded.

Image Credits: UNRWA.

BERLIN, Germany — Hours before the release of the second draft of the Pandemic Accord on Monday, German Health Minister Karl Lauterbach told the World Health Summit that a pandemic agreement with “major limitations” on intellectual property (IP)  rights protection will “not fly” for Germany and most of its fellow European Union (EU) members. 

“For countries like Germany and most European countries, it is clear that such an agreement will not fly if there is a major limitation on intellectual property rights,” said Lauterbach. “That is a part of our DNA … we need intellectual property security in order to invest into vaccines, invest into therapeutics, diagnostics, and so forth.” 

Lauterbach’s announcement is a victory for the pharmaceutical industry, which has been lobbying hard to influence negotiations on the pandemic treaty at the World Health Organization’s (WHO) International Negotiating Body (INB). 

“We need to be open about what can move forward and what cannot be moved forward,” said Lauterbach. 

Pharmaceutical companies like Pfizer and Moderna, which developed the most widely used mRNA COVID-19 vaccines, argue that IP protections were fundamental to them being able to take the financial risks that resulted in record-speed vaccine development at the height of the pandemic.

“The record speed at which new vaccines and treatments were developed in response to COVID-19 was the result of an innovation ecosystem, underpinned by intellectual property,” Thomas Cueni, Director General of the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA) told Health Policy Watch.  “In the first year alone, COVID-19 vaccinations saved 20 million lives.” 

Europe and the United States, home to many of the world’s largest pharmaceutical companies, are aligned in their opposition to major limitations on IP protections in a pandemic accord.

Other countries, such as India, South Africa and Brazil, argue that IP waivers are needed for equity and would have saved millions of lives during the COVID-19 pandemic.

Another non-starter for Europe and its allies outlined by the German health minister is any relinquishing of executive power to the treaty.

“An agreement is not likely to be successful if there is even the slightest impression that executive power moves from the countries to the agreement or the World Health Organization,” said Lauterbach. “It must be quite clear that all the countries that sign up to the pandemic agreement when there is a pandemic, their full executive power is by no means curtailed or infringed upon.

“This is an agreement on standards, on norms and on responsibilities,” he added. “Executive power is always within the countries where the action takes place.”

Big Pharma and medicines access groups deadlock on vaccines 

Hemal Shah, Gilead’s Public Policy Director, speaking at an IFPMA panel at the World Health Summit on Sunday.

Shortly after the World Health Summit kicked off in the glitzy ballrooms of the Mariott Hotel in central Berlin on Sunday,  medicines access groups and big pharma had their first major clash over vaccines. 

At a panel organized by the IFPMA, executives from Pfizer and Gilead retold a familiar story about the pandemic: Historically rapid innovation, spurred by strong intellectual property protections, saved millions of lives and restarted the global economy.

Gilead’s Public Policy Director, Hemal Shah, described the company’s antiviral remdesivir as a triumph of IP protections, arguing that the company’s ability to provide an important treatment option in the early days of the pandemic was enabled by its existing research on remdesivir’s potential antiviral activity against coronaviruses.

“[Remdesivir] is a story about how intellectual property protections enabled Gilead to provide an important treatment option … when we had no vaccines available,” said Shah. “It’s also a story of how IP protections actually enable the risky undertaking of emerging viruses research.” 

Killian Mullett, Senior Director of Commercial Supply Strategy at Pfizer, pointed to the 280 different components required to create its mRNA vaccine and the record speed at which pharma was able to mount supply chains to produce vaccines. 

“When we start looking at COVID, a lot of the supply chain had to be built up from scratch,” said Mullett. “We literally have gotten up to 4.7 million doses of the vaccine, which even for Pfizer, is an incredible amount.” 

Over the three years of the pandemic, the 20 largest pharmaceutical companies amassed profits of $455.4 billion, equivalent to nearly $5,000 every second, according to the People’s Vaccine Alliance.

Meanwhile, the People’s Vaccine Alliance released a scathing report on the eve of the World Health Summit, pointing out that the world’s 20 largest pharmaceutical companies paid out nearly as much money to shareholders and executives as they claim to have spent on developing new vaccines and medicines during the COVID-19 pandemic.

The top 20 pharma companies handed shareholders and executives more than $1 million every five minutes between 2020 and 2022, spending a combined $377.6 billion on dividends, share buybacks, and executive compensation. This adds up to more than 90% of their reported research and development spending.

“There is a rewriting of history going on here,” Anna Marriott, Senior Health Policy Lead at Oxfam International, told the panel. “There was monopoly control over the successful vaccines, and that monopoly led to pharmaceutical companies paying out a million dollars every five minutes to executives and shareholders.” 

Moderna and BioNtech, companies responsible for the two most widely used COVID-19 vaccines, reaped incredible profit margins of 51% and 54%, respectively, during the COVID-19 pandemic – far higher than any other major industry. 

In comparison, ExxonMobil, which generated record-breaking profits of $56 billion in 2022, averaged a net profit margin of just 19%. The notoriously high-profit margins of the oil and gas sector as a whole averaged 17% in 2022.

The record profits of Moderna and BioNTech have come at a time when global inequality has soared. The world’s richest 10% of people now own more than 76% of global wealth, while the poorest 50% of people own just 2%. Both the CEOs of Moderna and BioNTech were among the new billionaires minted during the pandemic.

“Corporations have never stopped trying to capture the policymaking process, using misleading arguments to enable the continuation of profiteering,” former UN Secretary-General Ban-Ki Moon said of the report.

“We see this in climate policy, with the increasing presence of fossil fuel lobbyists at COP, and we can see it in global health, with pharmaceutical companies trying to hollow out equity from the Pandemic Treaty,” said Moon, “Tackling the great challenges of our age requires standing up to vested interests and placing the needs of all humanity above the wealth of a few corporations.” 

Fighting words 

The World Health Summit kicked off on Sunday in Berlin.

In response to a request for comment on the People’s Vaccine report, IFPMA’s Cueni defended the pharmaceutical industry but did not comment on the profit margins or shareholder and executive compensation numbers highlighted by the report.

“These medical countermeasures were central to bringing to an end the pandemic which cost millions of lives and an economic cost of 13 trillion dollars,” Cueni told Health Policy Watch.  

“To question the very foundation of the innovation system which got us out of the COVID-19 pandemic, as the People’s Vaccine Alliance does, would severely hamper our ability to prevent, prepare, and respond to a future pandemic.” 

On Monday, BioNTech wrote down around €900mn in expected earnings from its COVID-19 vaccines due to low demand. The majority of write-offs were the result of expired raw materials needed to make the vaccines purchased during the pandemic, BioNTech said. 

To the pharmaceutical industry, BioNTech’s write-off is an example of the high-risk game of vaccine development. But to critics, €900mn is a drop in the bucket compared to the historic profits reaped during the pandemic. 

“Listening to the pharmaceutical industry, it is as though they are trying to wipe from history the decades of publicly funded research that went into COVID-19 countermeasures, and the brutal inequity of the global pandemic response,” Valentina Montanaro, global campaign head of the People’s Vaccine Alliance, told Health Policy Watch. 

“If humanity had worked together to combat COVID-19, instead of monopolising vaccine technology and withholding it from the global south, the human and economic costs of the pandemic would have been far less tragic,” said Montanaro. “Today’s panel was a masterclass in disingenuous spin.” 

Finger-pointing continues as the next pandemic looms 

A strong pandemic defence system could reduce the chance of another COVID like pandemic in the next ten years from 27.5% to 8%, according to modelling from Airfinity.

There is a 27.5% chance that a pandemic as deadly as COVID-19 will take place in the next decade, according to modelling from Airfinity, a health company that specializes in monitoring and forecasting trends in the global disease. 

Airfinity’s modelling also shows that if the original COVID-19 wild type had been as transmissible as Omicron, more than 300,000 people would have died in the UK alone, nearly three times more than the actual death toll.

Despite the looming threat, the world is not yet any better prepared than it was for COVID-19. Airfinity estimates that a “strong pandemic defence system” which enables effective vaccines to be rolled out within 100 days after the emergence of a new pathogen could decrease the threat of a COVID-19-like pandemic in the next ten years to 8.1%. 

“A robust pandemic preparedness system is the world’s insurance against a COVID-19-like pandemic or something even worse,” said Airfinity CEO Rasmus Bech Hansen. “We have calculated the real risks, but also the potential risk reduction that can be achieved. This can help inform decision-makers to the level of ongoing pre-emptive investment in the space to keep people safe.”

The Pandemic Fund, the key instrument established under the auspices of the World Bank to improve the resilience of low- and middle-income countries to the next pandemic, is vastly underfunded. It has only raised $2 billion of the $10 billion minimum annual budget it needs to meet its goals – and officials fear this could drop even further as the memory of the pandemic fades. 

“The pandemic fund is based on a recognition that the world has suffered from this cycle of panic and neglect: from SARS, to MERS, to avian influenza, to Zika, to Ebola, to COVID,” Priya Basu, executive director of the Pandemic Fund told the World Health Summit on Sunday.

“And each time we panic, and then there’s neglect. So this time around we really have to make those investments during peacetime, so to speak, so that the world is better prepared,” said Basu. 

The investment case, Basu said, is simple: the Pandemic Fund needs $30 billion per year over five years to get low and middle-income countries ready for the next pandemic. 

“That’s $150 billion over five years. Compare that with the trillions of dollars that the world just lost because we were not prepared, not to mention the millions of lives that were lost,” said Basu. “That is the investment case: the enormous economic and social returns that are produced from just getting the world better prepared.

“If any corner of the world is not prepared, then the rest of the world can suffer,” she added. 

Image Credits: World Health Summit.

WHO member states meeting to discuss a new pandemic convention in July 2022.

BERLIN  – Negotiations to produce a pandemic agreement still face a number of challenges, but some of the key negotiators in the International Negotiating Body (INB) told the World Health Summit that they are cautiously optimistic. 

As protestors gathered outside the summit venue, the JW Mariott Hotel in Berlin, to express their distrust of the pandemic agreement negotiations, panel participants addressed a session about “finding consensus” on the pandemic agreement.

Francisco Perez-Canado, the European Commission’s Advisor to the Director-General on the External Dimension of Health, underscored the erosion of trust among international partners as a result of the COVID-19 pandemic. 

“The first victim, in political terms, was trust. This erosion of trust has created a sense of urgency to establish a more reliable and legally binding framework for future responses to health emergencies,” said Perez-Canado, explaining that the accord was necessary to rebuild trust. 

“We need this pandemic agreement because this is how we can rebuild trust in the need for pandemic preparedness and response, and this trust is based on far-reaching obligations for low- and middle-income countries to be empowered towards equity for them to extend their R&D and manufacturing capacity through either voluntary or compulsory tech transfer,” Perez-Canado said. “We must remember that this Pandemic Accord is not about charity but about solidarity.”

Equity at the forefront

WHO Principal Legal Officer Steven Solomon

Steven Solomon, WHO’s Principal Legal Officer, who has been intimately involved in the INB processes, believes that the May 2024 deadline is doable provided the negotiations continue to be as intense as he and other facilitators witness them to be.

“If member states have the political will to agree on this treaty faster, then it is doable by May 2024,” Solomon said. “There are four key areas to focus on towards operationalizing equity.” 

First, a meaningful sharing of pathogens data and tools: finding combined obligatory sharing of pathogens data and sharing of benefits such as tools should be on an equal footing between the global north and the global south. 

“Finding mechanisms to exchange genetic sequence data of pathogens and in return pandemic response products such as vaccines, diagnostics, and treatments should be obligatory,” Solomon said. 

Second, a crucial aspect of the proposed agreement is the building of sustainable and geographically distributed production capacity for vaccines and other pandemic products. 

“It’s widely acknowledged amongst the negotiating parties that countries need to work together to enhance their capacity to produce essential medical supplies,” Solomon said. “This includes addressing issues related to intellectual property rights and ensuring that production is not solely based on purchasing power but also on public health needs.”

Third, national health capacities need to be strengthened, and this involves improving health systems, health and infectious disease surveillance, enhancing risk assessment capabilities, securing supply chains, and bolstering regulatory mechanisms towards real-time supply – as needed – of pandemic response products without any delay, which can happen only when regulatory mechanisms strengthen the global supply chains. 

“All of these should aim to operationalize equity by ensuring that all countries have the capacity and access to respond effectively to health emergencies,” Solomon said. “Access to diagnostics, treatment options, and vaccines are like justice – it means when delayed, it is actually denied.”

Fourth, governance, financing, and political will: effective governance is essential for the success of any international agreement. It should be inclusive, transparent, and promote accountability. Additionally, financing mechanisms must be sustainable, and there must be a strong political will to ensure that the agreement’s provisions are implemented and enforced. 

“Therefore, the need to address the risk of political amnesia and potential shifts away from multilateralism is also acknowledged by the negotiating bodies,” Solomon said.

Progress and challenges 

The negotiations to create this binding instrument for pandemic preparedness have had their share of challenges. Initially, there were ideological differences among negotiating parties, according to the panellists. However, informal sessions and mediated discussions have helped bridge these gaps, where participants in the negotiation process have started to recognise the urgency of creating legally binding obligations, according to the panellists.

“Work on negotiations in the informal discussions has actually pushed the negotiation discussions further,” said Perez-Canado.

Maria Juliana Tenorio Quintero, a representative of the Colombian Permanent Mission in Geneva and one of the facilitators of the negotiations, added that participants have shifted from general statements to focusing on concrete provisions that will ensure equity. 

“The negotiations have reached a stage where they can have meaningful discussions about legally binding obligations,” she said. 

Member states’ negotiations on Article 9 of the Zero Draft, which focuses on fair, equitable and timely access and benefit-sharing, are basically “done”, she added.

However, when questioned about the optimism about the negotiations, the panel flagged some of the remaining difficulties. 

These include intellectual property waivers, voluntary or compulsory tech-transfer between countries that discover pandemic response products, how to include the OneHealth approach, incentivisation of technology co-creation and strengthening joint venture initiatives.

The panellists conceded that the deadline is just around the corner and that unless these issues are agreed on, the divide between the global north and south could widen. 

“Thanks to the work of the facilitators of negotiations, there’s a greater understanding between the negotiating parties of the need for the components of all the articles the Zero Draft highlights,” Solomon told Health Policy Watch. “However, fulfilling the mandate for a strengthened International Health Regulations, operationalized by the pandemic treaty, is only achievable with political will.”

One of the panellists, who asked not to be named, told Health Policy Watch: “Should the political will and momentum we see is real and kept up, we can – and we have to – deliver the agreement by May 2024. 

“But the reality of the agreement is not up to the negotiators, rather their bosses that deliver the agreement. Articles of the Zero Draft that are the heart of the negotiations, are Articles 9, 11, 12, 13, OneHealth, and negotiators are still finding it difficult to come to terms with some of the terms under most of these Articles.”

Asked whether there is a Plan B if the negotiations are deadlocked by the self-imposed deadline, Solomon said, it is up to the negotiating member states. 

However, Perez-Canado said, “Until the pandemic agreement is enforced, we do not have Plan B because this is too important to fail at this juncture.”

The World Health Organization (WHO) has announced a technical advisory group that will advise it on pricing policies for medicines, particularly the prices of medicines on the essential medicine list (EML).The 17-member Technical Advisory Group on Pricing Policies for Medicines (TAG-PPM) will support WHO to help strengthen policies, improve transparency about prices and improve access to medicines.

“One of the group’s key initial functions will be providing technical advice and assistance to WHO regarding the role of price and cost in the selection of essential medicines and beyond the EML,” said WHO spokesperson told Health Policy Watch.

The EML provides guidance to national health authorities on the products and services that should be prioritised.
The group will also identify economic data that can assist the EML expert committee in their decisions.

“What health economic data would be most meaningful for decision-making about essential medicines? What methodologies and metrics would be appropriate measures of affordability? This input could then be taken into account by WHO for the revision of the process for updating the WHO Model Lists,” the WHO spokesperson said.

Countries have often asked the WHO to provide policies and rules to make essential medicines more affordable and accessible.

In October 2021, an expert committee proposed the creation of a working group for the EML to advise the WHO on ways to make highly-priced essential medicines more affordable and accessible.

“Two years later, the WHO has yet to establish the standing EML Working Group on pricing. However, it appears that the newly formed Technical Advisory Group on Pricing Policies for Medicines (TAG-PPM) has subsumed the role of a standing EML working group on pricing. It remains to be seen if this new WHO pricing group will identify policy interventions, including compulsory licensing, that could facilitate relevant and rapid decreases in prices to reach universal access,” said Thiru Balasubramaniam, Geneva Representative of Knowledge Ecology International (KEI).

The EML, first published in1977, is updated every two years in consultation with experts worldwide but many drugs are left out because of their high cost. This year, for example, some effective cancer drugs for the treatment of lung and breast cancer were left out because of their high cost.

WHO has said it will share more information on TAG-PPM’s agenda and workplans on its site soon. 

An unprecedented number of attacks happened in healthcare facilities and against health workers in 2022, according to a report published by Safeguarding Health in Conflict, Coalition and Insecurity Insight this year.

These attacks were the topic of a recent episode of the Global Health Matters podcast with Garry Aslanyan. The guests – health workers on the frontlines of the current conflict in Sudan, an independent advocate and a senior adviser at Physicians for Human Rights – discussed the circumstances and risks faced by health workers in conflict settings.

According to the Safeguarding Health in Conflict report, there were more than 700 incidents where health facilities were damaged in 2022, and almost 300 health personnel were kidnapped.

“In Sudan alone, just in the first six months of 2023, there were 93 attacks on health,” said guest and advocate Susannah Sirkin. “And so this kind of violence is devastating to health. So, of course, there are many acute and, of course, long-term impacts of this, including on the structure of the health systems themselves.”

Where do these violations and attacks occur?

She said these kinds of violations and attacks on health occur in various contexts, including civil unrest and insecure or volatile environments. She said there could also be the diversion of care and support for health workers in facilities for political reasons. In situations of full-out internal and international armed conflicts, such as in Syria, Yemen, Sudan, or most recently, Ukraine and Ethiopia, health workers are among those fleeing bombing and other attacks.

“In these conflicts, there are often military incursions or militia incursions into health facilities themselves, and they can assault patients and health workers using weapons,” Sirkin said. “We see everything from the detention, torture, and even killing of many health workers. And then, of course, the bombing of hospitals, raids on health facilities and utter damage and sometimes the destruction of hospitals.

“And in some countries, literally hundreds of health workers have been targeted, arrested, sometimes, as we’ve seen in Syria, and we know in other countries, they die after years languishing in prison,” she continued. “And it’s really a terrible, terrible environment. In almost every continent, health care can be under threat in this big range of situations.”

‘Building clinics in caves’

Samer Jabbour, a Syrian cardiologist and professor of public health, noted how often these health workers continue to provide care and set up alternative settings. At the same time, their hospitals and clinics are taken over.

The Syrian medics went as far as building clinics in caves to resist the bombings of hospitals, he said.

How do these workers build resilience?

“The inspiration and the resilience that I’ve seen has come from the health workers who are together, support each other in the time, in these grave situations and who resort to their deep understanding, based on their training, based on their ethics, based on their codes, based on their sense of themselves as professionals and based on their deep humanity, which in many cases is what drives someone to become a health professional in the first place,” Sirkin said. “Face-to-face with their patients, understanding that they are … they are looked up to as leaders, as change-makers in their community, and so in the face of that, time and time again, they rise to that occasion.

“And that is, I think, the depth of the human spirit that’s just so inspiring, as well as the satisfaction of saving lives through health care.”

Added Jabour: “The real heroes are those in conflict zones responding.”

To listen to more episodes of Global Health Matters on Health Policy Watch, click here.

Image Credits: Global Health Matters Podcast.

Part of the Global Health Matters “Dialogues” series.

“We make choices about who we take care of, and we make choices about who we neglect,” says author Daisy Hernández about health systems around the world.

A guest on a recent episode of the Global Health Matters podcast‘s “Dialogues” program, Hernández shared her personal experience with Chagas disease and the journey she undertook to understand it while writing her book “The Kissing Bug: A true story of a family, an insect and a nation’s neglect of a deadly disease.”

Hernández is an essayist, memoirist, journalist, and a professor of creative writing at Northwestern University in the United States. Her work focuses on the intersections of race, ethnicity, immigration, class and sexuality. Chagas is a disease caused by the parasite Trypanosoma cruzi, which is transmitted to animals and people by insect vectors and is found only in the Americas.

Hernández’s Auntie Theodora was diagnosed with Chagas in the United States when Hernández was very young.

“I grew up in the shadow of Chagas disease, and I say in the shadow because it’s been so neglected that we thought it was a very rare disease,” Hernández said. “We had no idea about the millions of people who have this disease around the world, mostly from Latin America.”

In her book and the discussion with host Dr. Garry Aslanyan, Hernández describes how, in the U.S., as recently as 10 years ago, it was almost impossible to know where to get tested for the disease, let alone treated. She also walks through some of her interviews with doctors,
biologists, infectious disease specialists and entomologists, and shares stories of other families.

Hernández’s research took her across the United States and Columbia.

“You describe how pathogens don’t care about bank accounts, national boundaries, tax returns, yet not all health care systems are equipped to deal with a disease such as Chagas,” Aslanyan points out. Then he asks: “How do you see this playing out across different places and maybe even Colombia? How did that play out.”

Hernández describes how, in Columbia, they have a much greater awareness than in the United States about Chagas disease. However, still, there was a divide between the rural areas and cities.

“I met this doctor, a young, young doctor right out of medical school, born and raised in the city, in the capital, and he was doing his one-year commitment of going out into rural areas to provide care,” Hernández recalls. “Chagas disease was entirely new for him, and he made such an impression on me because he was so eager to learn everything. He created his textbook on Chagas disease that he showed me. He had several patients infected and was resourceful, a really incredible person.

“But it really also reminded me of what I was seeing in the U.S., which was the individual doctors ending up with their patients and realizing like, okay, I didn’t learn this in medical school 20 years ago, in some cases, 30 years ago or longer, I need to learn about it now and taking the initiative to learn about the disease, to educate their colleagues as well, in some cases to go out into the community to do testing as well.”

Today, she compares what her family went through then and what she learned in the book to what America saw around COVID-19.

In the U.S., at least in the early days, testing sites sprung up in very wealthy neighborhoods when they were desperately needed in poor areas where people had to go to work and couldn’t work from home, for example.

It took Hernández seven years to complete the book, and she said she saw much more awareness of Chagas in the last seven to 10 years in the United States.

“I keep saying still a long way to go, but again, it’s also really determined by where you live,” she said. “There’s been a lot of activism in L.A. County, and so I think if you’re in L.A. County, everyone knows, oh, there’s a particular cardiologist devoted to this. The same thing is in Florida; we have an infectious disease specialist working on Chagas disease. So people within the community they know, and then the upside, of course, is Google. People get online, and you can also track down folks that way.

“It’s been really incredible to see awareness amongst healthcare professionals,” Hernández concluded.

To listen to more episodes of Global Health Matters, click here.

Dialogues is a new series from the Global Health Matters podcast that includes interviews with some of the world’s sharpest global health minds and brightest thinkers. The goal of each Dialogue is to go beyond the echo chambers that exist in global health and to have in-depth conversations with guests who have explored global health issues from their multi-disciplinary perspectives.

Image Credits: Global Health Matters podcast.

Dr. Zsuzsanna Jakab, Deputy Director-General of the World Health Organization, during the Annual high-level discussion on human rights mainstreaming. 43rd session of the Human Rights Council , Palais des Nations, Geneva, Switzerland, February 24, 2020.
WHO Deputy Director-General Zsuzsanna Jakab announced new measures to curb sexual misconduct in the agency’s Western Pacific office. The region is set to elect its next regional director next week.

In the wake of an abuse scandal that led to the removal of its regional director, WHO’s Western Pacific Regional Office on Friday announced a series of new measures to combat abusive behaviour and sexual exploitation among the region’s over 600 staff. 

Last March, in an unprecedented move, some countries in the 37-member region voted to sack Regional Director, Dr Takeshi Kasai, for the Western Pacific after several complaints from staff of abusive and racist behaviour. 

Speaking at the press briefing, Dr Zsuzsanna Jakab, who replaced him as acting regional director, said the organisation has prepared a country-specific agenda for the next regional director who will be elected on Tuesday, 17th October 2023. 

“We are focusing on the code of conduct and code of ethics which are global documents and need to be introduced and addressed in every part of the organisation,” said Jakab. “The WHO has a large number of zero-tolerance policies on abusive behaviour, sexual harassment, fraud and financial mismanagement just to mention a few.”

“We have systems and mechanisms in place on how staff members can report if they find or face any incident,” she added. 

The 37 member states set to vote by secret ballot for the new RD, countries span the Pacific region from China to Japan, New Zealand and Pacific island states, representing a combined population of 1.9 billion.  

In her comments at the briefing, Jakab addressed sexual harassment, toxic work culture and the behavioural and cultural changes that WHO is working to introduce. 

Dr Takeshi Kasai (left), began his term as WHO Regional Director for the Western Pacific in February 2019. He was removed in March 2022 following a prolonged investigation of allegations of abusive conduct towards his staff.

While Kasai did not face allegations of sexual misconduct, the WHO has also been shaken by a series of such harassment cases including at headquarters and in its Africa region. 

A total of nine WHO staff in headquarters have been fired over the past year for harassment including Temo Wqanivalu, accused of misconduct at last year’s World Health Summit in Berlin, and most recently, Maurizio Barbeschi, former head of WHO’s Health Security unit.  

In January, three WHO headquarters officials were cleared of allegations of a managerial cover-up of sexual exploitation cases involving dozens of Congolese women during the agency’s 2018-2020 Ebola response in the Democratic Republic of Congo (DRC). 

Legal cases against about a dozen WHO responders in the field are still being pursued by Congolese women in local courts, with WHO support. And WHO has invested millions in awareness-raising and prevention. 

But in July, a UN rapporteur criticized WHO for being far too slow in providing financial, psychological and legal assistance to victims of some 80 UN and WHO staff in the DRC. 

“This is a global issue. And actually, this was started by Dr Tedros after the events in one of the African countries. There is a very strong global policy in place and strong global leadership,” Jakab said, referring to the DRC scandal. 

Deadline of mid-November 

On a visit to the Congolese city of Goma in November 2022, Gaya Gamhewage, WHO’s lead official in prevention and response to sexual misconduct, committed to supporting survivors of sexual assault of the Ebola outbreak.

The WHO has set a deadline of mid-November to roll out a country-by-country action plan against sexual misconduct in WPRO’s 15 country offices. 

“I would like to assure you that this is a piece of work which is of high priority led by the Director General and regional directors. In our region particularly we reached out to all the country offices,” said Jakab. 

“Following some global and regional guidance, we worked with them to develop a country-by-country action plan which we are finalising now. We have received a number of action plans from the WRs [director of WHO country offices] and we’re hoping to do this by mid-November which is our global deadline.”

WHO also is strengthening mechanisms and building awareness about abuse prevention amongst staff members to help them address any complaints they may have. They can report to the WHO headquarters but also to the regional office.

In response to a question from Health Policy Watch, Jakab said, “We’ve invested quite a lot into strengthening our abilities and capacities at the regional office and country offices particularly on sexual misconduct and sexual exploitation.”

‘Open House’

The acting Regional Director said she has personally taken steps to hear complaints and identified incidents that “still exist” since her appointment in March.

“I have an open house and any staff member from the office can come to see me if they have any problems with disrespectful or abusive issues in the office. It was very helpful to identify the incidents that still exist. The number is going down and that was good for me to see. Whenever we saw an incident like this we took action immediately,” she said. 

Jakab is set to remain in office until 1 February, while the new RD transitions into the role. 

In that capacity, she said she has already prepared a medium and long-term follow-up action plan for the new RD , who is to be elected next week. 

There are five candidates running for election. They include Dr Song Li, proposed by China, Dr Susan Mercado, proposed by the Philippines, Dr Jimmie Rodgers, proposed by Solomon Islands, Dr Saia Ma’u Piukala, proposed by Tonga and Dr Tran Thi Giang Huong, proposed by Viet Nam. 

Geopolitics at Heart of Elections for New Director of WHO Western Pacific Region  

 

Following the election, the winner will then be appointed by the WHO executive board in January – usually a formality – for a five-year term. 

Kasai was elected in 2019 and became the first-ever Regional Director of the WHO to be fired in the history of the 75-year-old organisation.

The election is held in the Regional Committee headquarters in Manilla, attended by health ministers of the member-states. 

The next Regional Director’s name will be announced on Tuesday after the vote. Each of the five candidates will have an hour-long interview, a presentation followed by questions and then voting. Each has already been asked about their approach to the controversies that have hit the WHO hard. 

No compensation for complainants against fired WHO regional boss

In a move to stimulate more awareness about the need for reforms,  WHO has invited a number of staff members to report on their experiences to the Regional Committee. 

Although the investigation against Kasai is “finished on our side,” Jakab responded to a Health Policy Watch question saying there is no compensation for the complainants.

“The compensation is to make sure that this will never happen again,” said Jakab. “But we do not have any policy in the WHO which provides compensation for any of these behavioural issues.”

As the harassment issues form a backdrop to the elections, it is just one of the many challenges facing a region which includes vast development divides and geopolitical rivalries between countries such as China, the Republic of Korea, Japan and Australia. While China remains one of the world’s largest carbon emitters, Pacific Island States face an existential crisis with climate change-triggered rising sea levels – another fault line the new regional director must navigate.

Image Credits: Flickr, WHO, WHO.

Moderator Lerato Mbele ,UN Climate and Finance Envoy Mark Carney, Moroccan Finance Minister Nadia Fettah Alaoui, World Bank president Ajay Banga and IMF Managing Director Kristalina Georgiva address a panel on climate solutions.

How to get more money to address the climate crisis and poverty has been the focus of the annual meetings of the World Bank and the International Monetary Fund (IMF), taking place in Marrakesh in Morocco this week.

Staggering under enormous debt burdens that increased exponentially during the pandemic, African countries appealed for a 10-year moratorium on interest payments and better debt relief measures at the continent’s recent climate summit in Nairobi.

“Africa is now paying more in debt service than the estimated $50 billion a year the Global Center on Adaptation says it needs to invest in climate resilience. These investments are not nice-to-haves — they are vital for building roads, bridges and dams that can withstand torrential rains and floods,” wrote the African Union’s Moussa Faki Mahamat, Kenya’s President William Ruto, and Africa Development Bank’s Akinwumi Adesina in a New York Times article on the eve of the Marrakesh meetings.

“But instead of receiving funds to address the climate crisis, Africa is borrowing at a cost up to eight times higher than the rich world to rebuild after climate catastrophes. This is why Africa urgently needs a pause in debt repayments so that it can prepare for a world of ever greater climate extremes,” they added.

Ajay Banga, appointed World Bank president in June, has acknowledged the need for cultural change at the Bank – a process that started before he assumed office – and used various public forums this week to elucidate his vision for this.

‘Intertwined challenges’ of climate, pandemics and food insecurity

A key concept is addressing “intertwined challenges”. 

“The effort to segregate challenges into poverty, separately from pandemics,  separately from food insecurity, separately from climate change, doesn’t work in practice,” Banga told a media briefing on Tuesday.

“We are seeking approval from our governors to redefine the vision of the bank to be that of eradicating poverty, but on a livable planet. And what we mean by a liveable planet is exactly the challenges of pandemics and climate change and food insecurity and fragility.”

World Bank President Ajay Banda

“Climate change tends to mean different things, depending on where you’re coming from,” Banga told a public forum.

The narrow definition addresses how to avoid “carbon-intensive growth, as in the emissions from energy generation, transportation and construction materials”, he added.

But the Global South’s definition is “loss of biodiversity, forestry cover going, less rainfall, challenges with the soil degradation”, exacerbated by weather crises such as hurricanes – which “takes away double digits of your GDP” if you’re a  Caribbean island.

“Africa is a continent where 600 million people don’t have access to electricity so if you don’t get them the basics, it’s no point discussing the alternatives,” said Banga.

“There is the issue beyond energy – of heavy transportation, construction materials, methane emissions. And finally, even if you get all that right in the world over the next 25-30 years, if you don’t get carbon capture right, we’re still dead in 2050.”

How to tackle climate?

The World Bank is putting 50% of its climate money into mitigation, which Banga defined as “the avoidance of future heavy emissions-growth patterns”, and 50% into adaptation, covering the concerns of the Global South.

IMF Managing Director Kristalina Georgiva said that mitigation was somewhat more straight forward than adaptation: “What we could see is technologies being brought in cost terms to a level that they are commercially viable. Take, for example, solar. When we look around, how today, solar energy is becoming massively available.

“Adaptation is more complicated because it is so multifaceted. You need the infrastructure to be climate resilient. You need agriculture to be climate resilient. You need to address so many aspects of it at the same time.”

However, Georgiva said that it was possible to do this, as Bangladesh, which “used to lose thousands and thousands of people in floods”, had done.

“They have built schools to be also places for retreat for people, for animals. They built a system that alerts people. Go there, save yourself and your livelihood. They switched from chicken to ducks because ducks can swim.”

IMF Managing Director Kristalina Georgiva

Where will the money come from?

The Bank put around $40 billion into climate last year, but the need is far greater. So where will more money come from?

Banga believes there are three key sources. The first one is subsidies. 

“The world spends $1.25 trillion on subsidising fuel, agriculture and fisheries,” said Banga, adding that while some of these were “critical for the social contract between the government and its citizens”, the number is too high. 

“Europe used to spend close to $60 billion a year on fertiliser subsidies. They’ve now spending the same money with their farmers, but to incentivise them to use less fertiliser. That to me is a clever way of taking a subsidy which was environmentally challenging and converting it to a subsidy that is environmentally useful. And so I just believe that this topic of subsidies needs discussion. It gets lost very easily because of the politics involved.”

The second is voluntary carbon markets, which allow companies, governments, and other groups to address greenhouse gas emissions by buying and selling carbon emission credits.

“The World Bank is a few months away from being able to convert real forestry change into credits on a voluntary carbon market,” said Banga, who described this measure as “the ultimate way of getting money to move in the right direction”.

If the Bank issued certification for carbon credits, this would eliminate “greenwashing” and unlock “green credit”.

The third pillar is private sector involvement, particularly in larger middle-income countries that need to curb their greenhouse gas emissions.

“There are enough private sector investors with projects who would like to be able to invest in those countries,” he added, but the political and foreign exchange risks need to be managed.

Political risk relates to when governments change and this brings about policy changes.

“Foreign exchange risk is more difficult to fix than political risk – we actually have ways including getting the right regulatory policy laid out by my smart ministers and regulators in advance. Ask me about forex risk after a year because right now, I have no clue how to solve that!” said Banga.

Protestors calling for debt cancellation outside the Marrakesh meetings.

What about special drawing rights?

What African leaders really want is for the IMF to channel $100 billion a year in special drawing rights (SDR) to climate and development efforts. SDRs are an international reserve asset issued by the IMF to help supplement a country’s reserves. They are not a loan so don’t add to debt and can be exchanged for hard currency or donated amongst IMF member countries.  

Mia Mottley, the Prime Minister of Barbados, called for an annual $500 billion allocation of SDRs to finance a transition to climate mitigation and climate adaptation policies at the Conference of the Parties on Climate Change (COP26) in November 2021.

A few months earlier, in August that year, the IMF had allocated a historic $650 billion worth of SDR to its 190 member countries to help address the impact of the pandemic. 

High-income countries can channel some of their SDR allocations to low- and middle-income countries, but at present, this reallocation “incorporates conventional IMF lending mechanisms involving new debt and conditionality”, according to the Center for Economic and Policy Research (CEPR). 

In addition, some high-income countries “face domestic legal or legislative hurdles that may prevent them from engaging in bilateral SDR transfers”, adds the CEPR, arguing that “the most accessible, costless, and rapid way to get desperately needed aid to developing countries is through a new allocation of SDRs”.

Thursday marked a Global Day of Action for debt, climate and economic justice observed by various civil society organisations engaged with the topic, some of which demonstrated outside the World Bank-IMF meetings.

Shortly before the start of the meetings, an alliance of civil society groups wrote an open letter to the World Bank and IMF urging them to triple multilateral development bank (MDB) finance in order to achieve global climate goals including “a phase-out of all support to fossil fuel projects by 2024”. 

They also urged the delivery of  $100 billion in SDR, guidelines on pandemic investments to leverage the Resilience and Sustainability Trust (RST), and called on Ministers at Marrakesh to “recognise loss and damage as a critical part of the climate finance architecture and the need for additional sources of financing, including international taxes or levies”. 

While Banga has proved to be approachable and open to dialogue during this week, it remains to be seen whether any of these demands will be met by the close of the meetings on Sunday.

Burned out ruins of Kibbutz Beeri near the Gaza Strip in southern Israel following the incursion by Hamas militants into the village on Saturday.

The World Health Organization has called for the end of hostilities between Hamas and Israel, and the opening of a humanitarian corridor from Egypt to Gaza Strip for vital medical supplies – along with the release of over 100 Israeli and foreign hostages seized when thousands of Hamas militants first crossed the border on Saturday, killing an estimated 1200 Israelis, foreign workers and students.

The dead included infants and children, older people and women shot or bludgeoned to death, or burned alive in their homes and even in their beds. The rampage occurred after the militants broke through an Israeli border fence early in the morning and moved systematically through about a dozen kibbutzim (collective villages) and small towns scattered only a few miles from the Gazan enclave – on a morning when Israeli families had gathered to celebrate the Jewish holiday of Simchat Torah.

The grisly operation has been roundly denounced by US President Joe Biden, the European Union and other world leaders as a massacre.

The Hamas militants, who surprised Israel’s powerful military, also took about 130 as hostages. The captives included young mothers with infants and young children, seen in Hamas social media posts cowering in the back of vehicles as they were hauled back to the Gazan enclave. The hostages, which also include foreign nationals from the US, Canada, Thailand, Nepal, and other nations, are to be used as apparent bargaining chips for the release of Palestinian prisoners in Israeli jails.

Since the Hamas operation on Saturday, Israel has responded with massive bombing of the Hamas-controlled Gaza Strip – as well as cutting off access to vital water, electricity and fuel supplies.  About 900 residents of Gaza have so far died in the Israeli bombings, which have ruined many neighborhoods, many of them only recently rebuilt from a devastating clash with Israel in 2014. Tayyip Erdoğan, president of Türkiye, has denounced the Israeli attacks on Gaza as a “massacre”, as well.

Ruins of a Gaza apartment building bombed by Israel in reprisals for Saturday’s attacks.

However with Hamas continuing massive missile strikes on southern and central Israel, there is almost no chance that Israel would lift its blockade soon, or that either side would respond to the appeals for calm.

On Wednesday, there were also fresh worries of a widening war front, with the Iranian-backed Hezbollah, a Hamas ally, launching guided missiles into Israel for the third day this week.  However, a report Wednesday evening of a drone incursion from the north, which sent millions of Israelis in northern Israel into shelters, was later determined to be a false alarm.

WHO has offered assistance 

Bodies gathered for burial in one of the Israeli kibbutzim entered by Hamas militants on Saturday.

“WHO has offered assistance to health officials in both Israel and the occupied Palestinian territory,” said the WHO statement, stressing that Gaza’s hospitals and health care facilities face paralysis even as thousands of injured are seeking treatment.

Late Wednesday afternoon Gaza’s central power plant ceased to function due to lack of fuel.

“In the Gaza Strip, hospitals are running on backup generators with fuel likely to run out in the coming days. They have exhausted the supplies WHO pre-positioned before the escalation. The life-saving health response is now dependent on getting new supplies and fuel to health care facilities as fast as possible,” WHO said.

“WHO is urgently working to procure medical supplies locally to meet demand, and preparing supplies from its Global Medical Logistics Hub in Dubai, UAE.

Negotiations on hostages and humanitarian relief

There are widespread reports of negotiations involving Egypt, Qatar, the United States and Israel in an effort to contain the conflict, and open up a channel for hostage exchanges and humanitarian aid.

“On 9 October, WHO Director-General Dr Tedros Adhanom Ghebreyesus met with the Egyptian President Abdel Fattah El-Sisi, who agreed to a WHO request to facilitate the delivery of health and other humanitarian supplies from WHO to Gaza via the Rafah crossing. Such humanitarian corridors must be protected,” asserted WHO in its statement.

“WHO is urgently working to procure medical supplies locally to meet demand, and preparing supplies from its Global Medical Logistics Hub in Dubai, UAE.

Within Israel, however, there is widespread support for the fuel and power blockade amongst the widening circle of Israelis caught up in the hostilities.

“If you see who has backup fuel and generators in their homes, it is the Hamas militants,” said one media channel, saying that humanitarian aid would merely be syphoned off by Hamas to prolong the hostilities.

The WHO statement also made reference to the hostages held in Gaza, which Hamas has said number 130 – calling for their safe release.

“WHO is also gravely concerned about the health and well-being of hostages, including elderly civilians, seized from Israel by Hamas in attacks on 7 October. The hostages’ health and medical needs must be addressed immediately, and we call for their safe release,” said WHO.

Hamas has controlled the Gaza Strip since 2007, when it expelled the PLO’s Fatah, breaking up a unity government formed after Hamas won elections.  Israel withdrew its forces and dismantled its settlements in the tiny enclave in 2005. But since the takeover by Hamas, Israel has maintained a blockade on the tiny enclave, which is only 365 square kilometres, and with more than two million residents, one of the most densely populated places on earth.

Image Credits: @Israel, WHO , M. Schwartz @YWN.

The health impacts of the devastation caused by the floods in Pakistan in June 2022 are still unfolding.

The devastating floods that submerged one-third of Pakistan in 2022 have severely disrupted the country’s vaccination programme, leaving millions of children at risk of preventable diseases.

The floods severely damaged health infrastructure, causing overall immunization coverage in the country to drop to 64% in 2022, from a national average of 74% in 2020, according to a new national survey conducted by the World Bank and Aga Khan University seen by Health Policy Watch. 

The survey found that Baluchistan, Pakistan’s largest and least populated province of over 12 million people, has the lowest immunization coverage rate for fully immunized children (FIC), at 37.9%. 

Khyber Pakhtunkhwa (KP) province follows with 60.5%, Sindh with 68%, and Punjab, the only province to achieve the national immunization target, with 88.5%. 

Pakistan’s vaccination rate was already one of the lowest in the world before the floods hit, with around 431,000 children not fully vaccinated in 2022, according to the World Health Organization. 

Immunization rates by district, according to the 2022 World Bank and Agha Khan University survey. 

The floods devastated immunization infrastructure across Pakistan and displaced 33 million people, including 16.5 million children, according to UNICEF.

Iftikhar Nizami, a senior advisor at Help Foundation, an NGO working in flood-hit regions, told Health Policy Watch the devastated areas of Baluchistan, Sindh, and Punjab were already poverty-stricken before the floods caused immense damage.

“Health infrastructure was scarce in these areas, and the floods washed away what little there was,” Nizami said. “Even a year later, water is still standing in many areas, and people are displaced. Reaching them to provide basic immunization services is a very difficult task.”

Health ministries at the federal and provincial levels told Health Policy Watch that the floods have made it more difficult for Pakistan to reach the targets set out by its Expanded Program of Immunization (EPI) – Pakistan’s national immunization strategy –  but they are hopeful that they can narrow the gap once health infrastructure is rebuilt. 

“Flood-hit areas face major structural problems, and the residents’ bad days are not over yet,” Nizami said.

Immunization facilities in flood-hit Sindh are still struggling

Trees cocooned in spiders webs after flooding in Sindh, Pakistan.

Health authorities in Sindh, the province hardest hit by the 2022 floods in which 4.4 million acres of agricultural land and 799 lives were lost, are still struggling to cope with the aftermath. 

“Immunization facilities in flood-hit districts are still inundated,” said Dr Muhammad Naeem, Director of Communicable Disease Control at the Health Department of Sinhd. “We are trying to reach out to people with mobile teams.” 

Naeem said there are currently 30,000 children in the province who have not received any vaccines, and that challenges with the availability of vaccinators and their transportation remain in flood-hit districts.

The primary healthcare infrastructure destroyed in the flood is being rehabilitated under a World Bank project, and the province is also working with public-private partners to reach displaced people, Naeem said. 

“If there were no floods in 2022, we would have achieved the target of 80% FIC in the province,” said Naeem.

Pakistan’s immunization indicators fall short of goals

Percentage of fully immunized children by province. Only Punjab was able to meet its immunization
target.

Despite significant efforts by the Pakistani government and its partners, the country’s immunization indicators have yet to reach the expected benchmarks, according to the WHO. The key goals of polio and measles eradication, and measles control, have not been achieved.

A survey conducted by the World Bank and Agha Khan University after the floods found that Baluchistan has the highest rate of zero-dose children at 39%, followed by Khyber Pakhtunkhwa at 10.1%, Sindh at 7%, and Punjab at 0.9%. 

The measles rate per million population in these provinces is 17.72%, 28.22%, 12.71%, and 5.68% respectively.

The Director General (DG) of the Ministry of National Health Services Coordination and Regulations (NHSR&C), Dr Baseer Khan Achakzai, told Health Policy Watch that immunization coverage in the southern parts of Punjab, Sindh, and Baluchistan provinces was already low because of human resource shortages and areas being hard to reach.

“The 2022 floods completely wiped out more than 1,600 static sites used for immunization, which brought coverage down to 64%,” said Achakzai.

Achakzai added that when the homes of millions were flooded, the immunization records of the displaced were often lost. Authorities and international partners spent eight months reaching the scattered population for immunization.

Pakistan’s national strategy aims to achieve universal immunization coverage

Timeline of vaccine introductions to Pakistan’s national health system, according to Aga Khan University.

Immunizing children with vaccines may avert up to 17% of childhood mortality in Pakistan, according to the WHO. 

Pakistan’s newly drafted National Immunization Policy 2022 of its Expanded Program of Immunization (EPI) envisions “to achieve the universal immunization coverage leaving no one behind to die from a vaccine-preventable disease”. 

The goal of the EPI is to reduce infant, child, and mother mortality and morbidity linked with vaccine-preventable diseases, as per EPI’s schedule, and to limit other infectious diseases (epidemics and pandemics) through emergency vaccination drives. The policy aligns with international commitments and national directions, including SDG 3 and the National Health Vision (2016-2025). 

Dr Mukhtar Ahmed Awan, director of EPI Punjab province, told Health Policy Watch that the immunization coverage in the province’s southern parts had been hit hard by the floods, but that the region has still performed well compared with the rest of the provinces.

“Punjab’s coverage is above 88%, which is the highest, and this is because of multiple interventions adopted by the program to immunize 3.39 million children aged 0 to 23 months annually,” Awan said.

Awan said the provincial program has focused on vaccinating mothers and children in labor rooms of government hospitals, rolling out mass vaccination campaigns, hiring staff for vacant positions, and using technology to get real-time data during immunization.

Awan added that each vaccinator visits each outreach site eight times in 18 months, resulting in the vaccination of approximately 1.8 million children a month.

“We are confident that we can achieve 95% coverage in the next five years,” said Awan.

Rebuilding 1,700 vaccination sites destroyed in floods

Pakistani Prime Minister Shehbaz Sharif described the devastation of the 2022 floods as  “greater than that caused by the 2010 floods in Pakistan, which the UN then described as the worst natural disaster it had ever responded to.”

The National Immunization Policy 2022 draft envisions achieving more than 90% coverage with the third dose of Pentavalent vaccine among children under 1 year of age at the national level and at least 80% coverage in every district through routine immunization by 2025 and sustaining it.

Achakzai, the Director General of the Ministry of National Health Services Coordination and Regulations (NHSR&C), said the government is working on three strategies to close the immunization gap created by the 2022 floods.

First, the government is rebuilding around 1,700 static vaccination sites that were washed away in the floods with the help of international partners. Second, it is recruiting more than 3,000 vaccinators to bridge the human resource gap. Third, it is installing solar panels in health facilities where electricity provision has been discontinued, as vaccines need to be kept at a certain temperature.

“With these measures, the government is trying to improve the current immunization coverage status by 10 to 15 per cent in the provinces of Baluchistan, Khyber Pakhtunkhwa, and Sindh by February and March next year,” said Achakzai.

Image Credits: UK DFID, OXFAM, UNDP.