United Nations Headquarters in New York.

A draft political declaration on pandemics, due to be adopted by the United Nations General Assembly later this month, offers “little hope” that the UN process will make a difference in global pandemic preparedness, global health experts said on Friday.

The document, made public on Thursday, is long on words but short on commitments. The only specific action the text commits to is to convene another high-level meeting on pandemics in 2026 – and even this is problematic.

“The three-year timeline is far, far too long,” one expert told Health Policy Watch. “A new pandemic threat could arise at any time.”

The draft declaration does not include any numbers or financing targets for global and domestic health spending to prevent and prepare for pandemics.

Earlier proposals for the UN to create an independent monitoring body to assess member state compliance with the pandemic treaty have been scrapped, and no enforcement or independent review mechanisms remain in the draft. 

The draft requests that countries commit to removing trade barriers and strengthening medical supply chains, “especially during pandemics and other health emergencies”, and to support “technology transfer hubs and intellectual property sharing mechanisms”.

“The document is mired in platitudes,” Nina Schwalbe, a public health expert and professor at the Columbia School of Public Health, wrote in the Financial Times on Friday. “The political declaration for this [UN] meeting suggests that pandemic amnesia has already set in,” 

General Assembly kicks the pandemic preparedness back to WHO

The lack of concrete commitments in the draft political declaration on pandemics may reflect a feeling within the United Nations General Assembly that the real action on pandemic preparedness lies in the hands of the World Health Organization (WHO).

The draft commits member states to providing “adequate and predictable funding” for the WHO, which struggled to keep up with the demands of the COVID-19 pandemic on its shoestring budget. It also stresses the importance of funding for the WHO Contingency Fund for Emergencies, which would allow the UN health body to respond quickly to future pandemics.

“The ball is kicked squarely back to WHO and the joint treaty and international health regulation negotiations to actually figure out how to make anything happen,” Suerie Moon, a global health expert and professor at the Graduate Institute in Geneva, told Health Policy Watch.

The draft is due to be adopted by the UN General Assembly on September 21. Global health officials are calling on member states to step up to the plate and make real commitments to pandemic preparedness.

“The UN General Assembly High-Level Meeting’s Political Declaration offers a one-time and historic opportunity to commit to lasting and transformative change to pandemic preparedness and response,” Ellen Johnson Sirleaf and Helen Clark, co-chairs of the Independent Panel for Pandemic Preparedness and former heads of state of Libera and New Zealand, respectively, wrote in an open letter to UN delegates last month. “We call on leaders and decision-makers to make this moment count.” 

In its current state, the draft declaration offers “little hope” of making a difference in the next pandemic, said Schwalbe. “History is on track to repeat itself – in the form of more pandemics which could have been avoided.”

The draft text addresses key issues, but no numbers to be found

United Nations Headquarters, New York

The vague language and lack of real commitments in the UN’s draft pandemic declaration are emblematic of the reasons for public frustration with the organization.

“The document contains almost no concrete commitments to anything transformative, is weak, and has low ambition,” another expert told Health Policy Watch. “If this is indeed the outcome, it represents a missed opportunity to make high-level commitments to better protect the world against pandemic threats.”

The draft calls for countries to spend a “sufficient” amount on domestic health spending and asks governments to “maximise efficiency” in distributing this indeterminate amount of funds. On global health spending, it calls for “solidarity” through “enhanced official development assistance and financial and technical support” for developing countries, especially in Africa and for Small Island Developing States.

The technology transfer and intellectual property rules in international public health emergencies are addressed in similarly general terms in the draft declaration. Despite the lack of new commitments by the General Assembly declaration, steps to improve technology transfer have been made since the pandemic. 

The WHO mRNA vaccine hub in Cape Town, South Africa, began operating at full capacity last year, following its announcement in 2021. The facility, which celebrated its official launch in April, aims to support mRNA technology transfer and provide equitable access to vaccines and other medicines in low- and middle-income countries.

Pharmaceutical giants, such as Moderna and Pfizer, have declined to provide the technical knowledge necessary to replicate the COVID-19 vaccines to the WHO mRNA hub. However, both Pfizer and Moderna have set up new vaccine production hubs of their own in Africa in partnership with local governments and the private sector. 

Despite its failure to commit to any specific actions, the draft text does hit most of the key points that must be addressed to prepare for the next pandemic.

“The draft is very short on concrete commitments, long on aspiration,” said Moon. “It does flag what are clearly the high political priorities of many countries in the pandemic treaty and IHR negotiations: Medicines access, publicly funded R&D, IP, local production, tech transfer, and pathogen access and benefit sharing, get a lot of air time, as does One Health and financing.”

“There’s some good language on some of these issues that could perhaps, eventually, make it into one of the binding agreements,” Moon added.

Calls for “solidarity” recall failures of COVID-19 response

Vials of Pfizer´s COVID-19 vaccine. COVID vaccines mostly reached in or around the regions they were produced, a WHO report finds.

Calls for solidarity proved to not be worth much at the height of the pandemic. In June 2020, the WHO and 30 low-income countries priced out of the vaccine supply race issued a “Solidarity Call to Action” that accompanied the launch of the UN health body’s COVID-19 Technology Access Pool (C-TAP) initiative.

The hope for C-TAP was that it would become a ‘one-stop shop’ where patent holders of COVID-19 vaccines, treatments and technologies could license their products for worldwide use. The initiative called on key pharmaceutical stakeholders to “advance the pooling of knowledge, intellectual property and data that will benefit all of humanity”.

Just two institutions – the Spanish National Research Council (CSIC) and the National Institutes of Health (NIH) – responded to the call, entering into licensing agreements for diagnostic tests.

Pfizer, BioNTech and Moderna rebuffed C-TAP when their vaccines hit the market, while rich governments with the ability to afford their vaccines elected to prioritize securing domestic supplies over global solidarity.

Earlier this week, Taiwanese vaccine manufacturer Medigen Biologics Corp. became the first private pharmaceutical company to share its vaccine technology with C-TAP.

Waiting on WHO?

Tedros addressing the opening of the 73rd WHO Africa regional meeting on Monday.

The Pandemic Accord process, launched by WHO in 2021, is scheduled to conclude in May 2024 at the World Health Assembly, the top decision-making forum of the UN health body.

Negotiations at the WHO, however, have also proven difficult. WHO Director-General Dr Tedros Adhanom Ghebreyesus warned on Monday that the slow pace of negotiations has put the pandemic accord at risk of missing the May 2024 deadline.  

“This is a unique opportunity that we must not miss to put in place a comprehensive accord that addresses all of the lessons learnt during the pandemic with a particular emphasis on equity,” Tedros said at the WHO Africa regional meeting. “As the COVID-19 pandemic laid bare, there are serious gaps in compliance and implementation which must be addressed.” 

Tedros has chafed at the power of pharmaceutical companies over the final outcome of negotiations. At a heated press briefing in July, Tedros called out “groups with vested interests” for spreading “lies” about the pandemic treaty that are “endangering the health and safety of future generations”. 

Despite the expansion of vaccine manufacturing worldwide – which now totals over 90 manufacturers – fewer than ten companies control the vast majority of global vaccine supplies, the WHO found in its vaccine market report released in May. 

“The new global architecture cannot be designed, built or managed by those with the most power, money and influence,” Tedros said on Monday. 

Whether the companies and governments with the power, money and influence to make that determination will choose to play ball remains an open question. 

Image Credits: UN, United States Mission Geneva, UN Photo/Manuel Elias, Photo by Mat Napo on Unsplash.

Methane, a colorless gas, is released from a rig during oil and gas extraction – other key human-made sources include agriculture, livestock production and poor waste management.

International climate targets cannot be met without rapid and drastic cuts to global methane emissions, according to a series of reports published on Wednesday by the Global Climate and Health Alliance (GCHA).

The reports found that reducing methane emissions by 45% by 2030 would avert nearly 0.3C degrees of global warming by 2045, a margin that could prove critical to global ambitions to keep temperature rise at or below 1.5C degrees.

Methane is a powerful greenhouse gas that is 80 times more effective at trapping heat than carbon dioxide over a 20-year period. It is emitted by livestock production, rice cultivation and from uncontrolled waste dumping, as well as gas flaring and leaks from fossil fuel extraction, as well as from natural sources like peat bogs. Overall, methane emissions are estimated to have caused more than 30% of global warming to date.

But since it´s lifespan in the atmosphere is limited, reducing methane emissions would deliver quick gains for climate as well as health – where methane is a key contributor to ground level ozone levels. The adverse health outcomes of ground-level ozone include cardiovascular diseases, asthma, and respiratory illnesses which result in roughly one million premature deaths every year.

“Every pathway to limiting climate warming to close to 1.5C demands rapid, substantial cuts to methane,” said Dr Jeni Miller, Executive Director of the GCHA, which is a network of health professional and health civil society organizations addressing climate change. The pathway to limit global warming to 1.5C  set out by scientists from the Intergovernmental Panel on Climate Change (IPCC) also includes substantial cuts to methane emissions as a key component of its roadmap. 

Low hanging fruit ?

Livestock production is another key source of human-produced methane emissions.

Reducing methane emissions has long been seen as ¨low-hanging fruit¨ in climate policy circles – although political action has lagged behind its mitigation potential. While carbon dioxide remains in the atmosphere for centuries after it is emitted, methane has an atmospheric lifespan of just 12 years. This makes methane an ideal target to achieve rapid reduction of the impact of the greenhouse gas effect on global temperatures.

“Methane mitigation offers a quick win, while tackling CO2 is the long game – at this stage in the climate crisis, we need both,” said Miller. “Fortunately, both offer opportunities that could improve people’s health.”

Global momentum building – but COP28 host UAE fails to report methane emissions

Methane emissions are set to be a key topic of discussion at the UN climate summit, COP28, set to take place in the United Arab Emirates in December later this year.

Around 150 countries have signed the Global Methane Pledge since its launch at COP26 in Glasgow in 2021. The pledge commits countries to reduce methane emissions by 30% by 2030.  See related story:

Africa’s Methane Gamble – Can A Climate-Warming Gas Become An Asset to Health?

The UAE has said that it will work with NGOs and governments on a plan to slash methane emissions ahead of the arrival of delegates in Dubai. However, the host nation has also been charged with failing to report its own methane emissions for around a decade.

The fossil fuel, agricultural and waste management sectors are the major sources of human-produced methane emissions, according to GCHA.

“We’re constantly learning more about the extent and impact of methane sources,” said Miller. “Methane leaks from fossil fuel production and use are far greater than previously thought, and leaks are occurring at every stage in the fossil fuel life cycle.”

The extent of the UAE’s commitment to reducing methane emissions and acting as a shepherd of international climate goals remains questionable, given that the president of COP28, Sultan al Jaber, is also the CEO of the UAE’s state oil giant.

Agriculture, energy, and waste management systems must change

Birds scavenge for food scraps at a landfill in Connecticut. Landfills and sewage pools are another major source of methane emissions; the gas is released as disposed organic materials – including paper, food scraps, and human waste, biodegrade.

The technology to slash methane emissions already exists, but it will take individual and system changes to make it happen, said GCHA.

One important way to slash methane emissions would be to plug leaks during fossil fuel extraction to prevent methane gas escape,  employing the latest technologyies. Shifting away from fossil fuels to renewable energy at a faster rate would also make an impact, but the reports concede that eliminating fossil fuels from the global energy system is not likely in the immediate future.

“Cutting methane emissions from fossil fuel production, distribution, and end use through readily available, cost-effective solutions is a powerful lever for reducing near-term warming and avoiding dangerous warming tipping points, while also yielding benefits for people’s health,” the reports say.

Source: Climate and Clean Air Coalition.

Other ways to reduce methane emissions include rapidly moving towards regenerative agriculture, improving access to nutritious, plant-rich whole foods diets, and making existing livestock healthier. Improved waste management by composting or, better yet, developing industrial-scale biogas digesters to handle  food, farm, and human waste will also deliver big benefits, harnessing methane for fuel, which can then be used for energy production, in what is an almost climate-neutral process.

Biogas plant, South Africa. Pilots abound but largescale harnessing of methane has yet to take place.

“Methane’s effects on the environment are extensive and well understood,” said Amanda Quintana, the project director for Abt Associates who was involved with the reports. “What we need now is to mobilize the health community and help people understand that, because methane has both indirect and direct impacts on human health, there are direct health benefits to reducing methane emissions, both in the short- and long-term.”

Quintana added that the evidence in the reports is not new but puts the focus on the extreme health impacts of methane. “The report highlights these health impacts and linkages to make it easier for people to understand the important role the health community can play in methane mitigation.”

Stefan Anderson contributed reporting for this story. 

Image Credits: Clean Air Task Force , Evan Schneider, United Nations multimedia , SuSanA Secretariat/Flickr.

Vaccine access groups praised the agreement as a long-overdue victory for vaccine equality in low-income countries but called out major pharmaceutical companies for putting profit over people.

Three years after the launch of its COVID-19 Technology Access Pool (C-TAP) initiative, the World Health Organization (WHO) has secured its first COVID-19 vaccine license from a private pharmaceutical company, the UN health body announced on Tuesday.

The agreement with Medigen Vaccine Biologics Corp., a private vaccine manufacturer based in Taiwan, is a welcome but underwhelming landmark for C-TAP, whose initial launch was accompanied by ambitions of ensuring equitable access to COVID-19 vaccines, treatments and technologies around the world.

“This is not just about COVID-19, it is about setting a precedent for future global health challenges,” said Charles Chen, Medigen’s CEO. “We hope to inspire other organizations to follow suit.”

The agreement with the Taiwanese manufacturer is one of three new licences acquired this week by the WHO through the Medicines Patent Pool. The other two agreements are with the Spanish National Research Council (CSIC) and the University of Chile. CSIC is sharing a licence for a COVID-19 vaccine prototype, and the University of Chile is sharing its technology for a test used to measure COVID-19 antibody levels.

CSIC became the first entity to share technology with C-TAP in November 2021, when it signed a worldwide license for its COVID-19 antibody diagnostic test.

“COVID-19 is here to stay, and the world will continue to need tools to prevent it, test for it and treat it,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “WHO and our partners are committed to making those tools accessible to everyone, everywhere.”

C-TAP ambitions not shared by pharma 

C-TAP launched at the height of the pandemic in June 2020 to promote technology sharing based on “equity, strong science, open collaboration and solidarity”. The call to action was supported by 30 WHO member states, all of which were low-income countries without access to vaccines.

However, without the backing of major pharmaceutical companies and powerful governments, C-tap only secured two licencing agreements during the peak years of the pandemic – neither of which were vaccines. With the agreements announced this week, a total of just five licences – including two provided by CSIC – have been shared on C-TAP.

“It is shameful that, despite receiving unprecedented public funding and advance purchases, not even one of the major pharmaceutical companies has shared vaccine technology with C-TAP,” said Julia Kosgei, policy co-lead for campaign group the People’s Vaccine Alliance.

The WHO and its Director-General, Tedros Adhanom Ghebreyesus, have repeatedly called out the outsize power of pharmaceutical giants over the global vaccine market. This issue is once again in the spotlight as ongoing negotiations over the international Pandemic Treaty highlight the world’s dependence on a small number of companies to ensure equitable vaccine distribution for future pandemics.

In May, the WHO’s vaccine market report found that global vaccine supply is concentrated in fewer than a dozen manufacturers, leading WHO officials to call out the vaccine market for being controlled by “oligopolies”. Without “predefined and binding rules for vaccine distribution in times of scarcity” to prevent vaccine distribution from being guided by profits, the story of inequality borne out during the COVID-19 pandemic is destined to repeat itself, Tedros wrote in the foreword to the report.

Pfizer, BioNTech and Moderna refused to join C-TAP once their vaccines hit the market, citing research and development costs and the high risks associated with vaccine development.

In its press release accompanying the new license agreements this week, the WHO credited C-TAP with “raising awareness” for the need for wider sharing of patents for critical medicines – a tacit admission it has fallen well short of its ambitions to spur solidarity in the boardrooms of pharma giants.

Image Credits: Photo by Mat Napo on Unsplash.

A technician weighs cannabis buds.

Cannabis should be avoided during adolescence and early adulthood; in pregnancy, by people prone to mental health disorders and while driving, according to experts in a study published in The BMJ on Thursday.

Cannabis contains over 100 cannabinoids, of which tetrahydrocannabinol (THC) and cannabidiol (CBD) are the most clinically relevant. THC can induce a psychoactive “high” and can foster dependence, as well as other adverse psychiatric health effects.  Conversely, CBD has certain anti-psychotic and anti-anxiety properties and one purified form, Epidiolex®, has even been approved by the FDA as a medication for certain forms of epilepsy.

The BMJ study confirmed that CBD is indeed effective in helping people with epilepsy, while some cannabis-based products containing THC can help ease multiple sclerosis, chronic pain and inflammatory bowel disease in affected adults.

The researchers based their findings on 101 meta-analyses on cannabis and health conducted over 20 years (2002-2022), grading evidence as high, moderate, low, or critically low certainty in randomised trials – and as convincing, highly suggestive, suggestive, weak, or not significant in observational studies.

“An increasing number of studies have examined the effects of cannabinoids on health and other outcomes, but most findings are observational and prone to bias, making it difficult to draw firm conclusions,” according to the BMJ in a media release.

“To address this, an international team of researchers set out to assess the credibility and certainty of over 500 associations reported between cannabis and health in 50 meta-analyses of observational studies and 51 meta-analyses of randomised controlled trials, pooling data from hundreds of individual studies.”

Increased risk of psychosis

There was an increased risk of psychosis associated with THC-containing cannabis in the general population, particularly in adolescents, and with psychosis relapse in people with a psychotic disorder.  

The researchers also found an association between cannabis and depression and mania, as well as detrimental effects on memory, and verbal and visual recall.

Observational evidence suggested a link between cannabis use and motor vehicle accidents, while pregnant women who used cannabis use had an increased risk of having a small, low birth weight baby.

Cannabis-based medicines were, however,  beneficial for pain and muscle stiffness (spasticity) in multiple sclerosis but increased the risk of dizziness, dry mouth, nausea and drowsiness. 

For chronic pain, cannabis-based medicines reduced pain by 30%, but increased psychological distress. 

For cancer, some cannabinoids reduced sleep disruptions but resulted in increased gastrointestinal events.

Cannabidiol (CBD) was, on the other hand, beneficial in reducing seizures in certain types of epilepsy, particularly in children – but came with an increased risk of diarrhoea.

Weak evidence

This umbrella review is the first to pool observational and interventional studies on the effects of cannabinoids on humans, but the researchers note that most outcomes associated with cannabinoid use are supported by weak evidence, have low to very low certainty, or are not significant.

They also point to other limitations in the study, particularly the wide variations in the make up of cannabis products, such as the proportion of psychoactive THC. Additionally, not all individuals will experience the same effects of cannabis on their mental health and cognition.  And randomised trials might not be representative of the real-world population. 

Nevertheless, the researchers conclude that law and public health policymakers and researchers “should consider this evidence synthesis when making policy decisions on cannabinoids use regulation, and when planning a future epidemiological or experimental research agenda.” 

Millions are addicted

According to the Global Burden of Disease 2019 study, around 24 million people worldwide are addicted to cannabis, particularly men and people in high-income countries. 

In Europe, over the past decade, self-reported use of cannabis within the past month has increased by almost 25% in people aged 15-34 years, and more than 80% in people aged 55-64 years.

The potency of cannabis has also increased in Europe, with the THC content associated with the ¨high¨ and subsequent adverse psychiatric increasing from 6.9% to 10.6% between 2010 and 2019.

Image Credits: Unslash.

A researcher working on an mRNA vaccine at Afrigen, South Africa’s mRNA hub.

The best way to pandemic-proof the world is through ‘last-mile innovation’ based on strong regional and subregional research and development (R&D) hubs that can tackle disease outbreaks before they become pandemics.

These hubs should be led by local scientists and have the capacity to adapt established technologies without intellectual property restrictions to produce vaccines, treatments and diagnostics to address threatening pathogens.

This is the argument put forward by a group of health experts in a paper published this week in The Lancet amid three separate global negotiations aimed at improving the world’s response to future pandemics.

They assert that there has been too much focus on building new vaccine manufacturing facilities in developing regions and argue that the Pandemic Fund and development banks could finance “R&D for the common good rather than just vaccine manufacture and distribution through a market approach”. 

“As we have seen again during COVID-19, a system that largely relies on market dynamics to drive the research, manufacture and marketing, results in highly inequitable access and preventable deaths, particularly in developing countries,” said co-author Dr Soumya Swaminathan, former Chief Scientist, World Health Organization (WHO).

“Our proposal, which centres on equity from the start, would give researchers from developing countries greater ability to quickly and collectively contribute to solutions to infectious outbreaks in their regions. When each region has that ability, all of the world is better protected from pandemic threats, which are only going to increase due to climate change.”  

Speed is essential

“Time and again, developing countries are left waiting for tools like vaccines developed by others, while wealthier countries produce and access them first,” said Helen Clark, one of the authors and former co-chair of The Independent Panel for Pandemic Preparedness and Response. 

“The deadly lessons from COVID-19 demand transformative change, starting with action to ensure that all regions have the technology and capacities required to develop products that stop outbreaks before they spread worldwide. That’s not only equitable, it’s strategic.”

Dr Els Torreele, the lead author, explained that “in outbreak control, speed and versatility are of the essence, so having the ability to rapidly adapt the most suitable existing technology to local needs is critical”.

“The opportunity for ‘last-mile innovation’ will let researchers develop and produce products people can use, where they live, for the outbreaks in their regions,” added Torreele.

Dr Amadou Sall, Director of the Institut Pasteur de Dakar in Senegal, added that “given available technologies and in the wake of a pandemic that has led to some 24 million excess deaths, there should be no question that we need a new model – one that fully empowers all regions to be self-reliant”.

“Many of these technologies have been available for decades now, and others have been developed with public funds. It’s time to make them available in Africa and on other continents,” said Sall, who is also a co-author.  

Sharing mRNA technology

Professor Petro Terblanche, who heads the WHO’s mRNA technology development and transfer programme in South Africa, explains that if, for example, mRNA technology is made accessible, “researchers can innovate and develop vaccines that address local or regional health needs and are suited to optimal delivery into local and regional health care systems”.

The authors also make a strong case for a common goods approach to R&D, in which the ownership and control over technologies that are critical for public health are governed collectively and in the public interest.  

They cite the CERN research facility in Europe, which is jointly funded by 23 countries, as an example of a sub-regional R&D hub. 

“The public sector is already investing billions in research, which is then often sold or handed out to the private sector who decide whether or not to develop products based on profit potential,” said Dr Joanne Liu, a Canadian paediatrician, former International President of Medecins sans Frontieres (MSF) and member of The Independent Panel.

“We’re saying, tools to protect lives and stop outbreaks from crossing borders must be common goods – and must and can be funded with that mindset.” 

Timely intervention

The authors’ call comes as the Intergovernmental Negotiating Body (INB) working on a pandemic accord is set to meet in Geneva next week to continue negotiations. Issues of equitable access to pandemic countermeasures are being negotiated in specific articles on research and development and on technology sharing and co-development, and are considered some one of the most difficult areas to solve. 

The G20 Health Ministers also recognised the need for “sustainable global and regional research and development networks to facilitate better access to VTDs (vaccines, treatments and diagnostics) globally, especially in developing countries” at its meeting last week.

Meanwhile, the United Nations High-Level Meeting on pandemics is set for 20 September in New York, and will adopt a political declaration mapping out how to address future pandemics.

Image Credits: Rodger Bosch for MPP/WHO, Kerry Cullinan.

WHO Director-General Dr Tedros Adhanom Ghebreyesus arriving at the 73rd meeting of the WHO Africa region.

After a two-week hiatus in negotiations, United Nations (UN) member states this week received a third draft of the Political Declaration being developed for the High-Level Meeting on Pandemic Prevention, Preparedness and Response on 20 September.

The declaration was supposed to have been finalised by early August and put under silence procedure but member states failed to agree on a number of clauses and negotiations were interrupted by the northern hemisphere summer holidays.

Last week, bilateral meetings resumed and sources told Health Policy Watch that member states finally received an amended draft this week.

Slow pandemic accord talks

Meanwhile, World Health Organization (WHO) Director-General Dr Tedros Adhanom Ghebreyesus expressed concern this week about the slow pace of negotiations on the pandemic accord, warning that it may not be completed by the May 2024 deadline.

“I’m concerned that negotiations are moving slowly and that the accord may not be agreed in time for next year’s World Health Assembly (WHA). I urge all member states to work with a sense of urgency with a particular focus on resolving the most difficult and contentious issues,” Tedros told WHO Africa’s regional meeting at its opening on Monday.

“This is a unique opportunity that we must not miss to put in place a comprehensive accord that addresses all of the lessons learnt during the pandemic with a particular emphasis on equity. This region has more to gain from a strong accord than any other so I urge you to continue engaging actively in the negotiations to make sure the needs and expectations of Africa are heard,” added Tedros.

The Intergovernmental Negotiating Body (INB) in charge of developing the accord to present to the WHA is set to meet again on 4-6 September.

Tedros also referred to the negotiations to amend the International Health Regulations (IHR) currently underway, describing the IHR as the “cornerstone of detecting and responding to disease spread internationally”.

“But as the COVID-19 pandemic laid bare, there are serious gaps in compliance and implementation which must be addressed. We need an IHR that’s fit for purpose,” said Tedros.

“The proposed amendments now being discussed by member states address many crucial areas including compliance, cooperation, and more efficient communication. We must learn the lesson of COVID-19, which is that global threats require a global response that is based on coherence and mechanisms for cooperation, rooted in solidarity and equity.”

The Working Group on IHR meets again on 2-6 October for the fifth time and is expected to debate the definition of a pandemic, amongst other issues.

“Crucially, the new global architecture cannot be designed, built or managed by those with the most power, money and influence. It must be designed, built and managed by all member states and partners in a truly inclusive process,” Tedros urged.

Dr Tedros addressing the opening of the 73rd WHO Africa regional meeting

Botswana’s approach to health is an example to the African continent, with strong leadership, investment in research and development and universal health services available for a nominal charge, said Dr Jean Kaseya, head of the Africa Centres for Disease Control and Prevention (Africa CDC).

Kaseya was speaking on Monday at the opening of the World Health Organization (WHO) Africa regional committee meeting being held in Botswana’s capital, Gaborone.

“Botswana was the first African country to achieve 70% coverage of COVID-19 vaccines because of the strong leadership of the president and the allocation of adequate resources to procure vaccines,” said Kaseya.

“Its investment of 1-2% of its GDP to research and development is why Botswana is one of the leaders in the development of vaccines for animals. Knowing that the next pandemic will be a zoonotic one, it means that Botswana will play a key role in addressing this issue in Africa,” he added.

Africa CDC head Dr Jean Kaseya

Kaseya added that he was surprised to learn that Botswana’s citizens were able to “access to all the healthcare that they need” by only paying a 15-cent contribution for every dollar charged.

Kaseya said that Africa needed to prepare for the next pandemic by pushing local manufacturing of vaccines and medicines and ensuring there was “enough funding for pandemic prevention, preparedness and response”.

The African region had failed to submit a regional application to the Pandemic Fund, unlike the Caribbean, Asia and Latin America and needed to ensure it made an application during the next call for proposals to fund a joint emergency action plan, he added.

The WHO Africa region excludes some of the countries in the far north of the continent that associate more closely with Arab states and are part of the Eastern Mediterranean Region (EMRO).

HIV laboratory declared WHO centre of excellence

Meanwhile, WHO Director-General Dr Tedros Adhanom Ghebreyusus told the meeting that Botswana’s National HIV Reference Laboratory has been designated as a WHO Collaborating Centre of Excellence “in recognition of the laboratory’s excellence in the field of HIV diagnosis and the potential of deeper collaboration with WHO in advancing the health and well-being of people living with HIV”.

“In 2021, WHO certified Botswana for reaching the silver tier on the path to eliminating mother-to-child transmission of HIV. And in 2022, Botswana reached the 95-95-95 targets for testing, treatment and viral suppression of HIV, one of only five countries to do so,” said Tedros, referring to the targets of 95% for testing all people, putting 95% of those with HIV on treatment, and achieving viral suppression in 95% of people living with HIV.

“Botswana is a model to show anything is possible, added Tedros. Peace is possible. Stability is possible. Democracy is possible. Growth is possible, even to an upper middle-income country or even even higher. Africa can grow. Africa can be stable, Africa can be peaceful. Africa can be a democratic continent,” added Tedros.

Botswana has a small population of 2.6 million people and has made its wealth from minerals.

Urgency of universal health coverage

Matshidiso Moeti

WHO Africa Regional Director Dr Matshidiso Moeti, who hails from Botswana, also expressed pride in her country’s health milestones. 

“It is one of the countries where direct payments for healthcare is almost non-existent,” said Moeti. “With a minimal nominal contribution, people have access to everything that is available in the country and transferred outside of it [for other treatment]. It is an example of how to make sure that payments are not a burden to the customer. I’m very proud of this.

“We could take many examples and I’ll just cite a couple. For example, the mother-to-child transmission of HIV has been reduced to less than 5%, and Botswana has been the first high-burden country in the world to achieve this milestone.

“HIV transmission rates have fallen from 40% of the sexually active age group in 1999 to below 1% this year. What an achievement for a nation that once had the highest HIV prevalence rate in the world.”

In contrast to Botswana, Moeti pointed out that “public spending on health is low in the majority of our countries, and Africa is home to two of the three poorest people who pay directly out of pocket for their health care.” 

Meanwhile, Tedros said that every WHO member state needed to “radically reorient health systems towards primary health care as the foundation of universal health coverage”.

“Nowhere is more important than here in our continent. Across the region, hundreds of millions of people lack access to essential services or are pushed into poverty by catastrophe out-of-pocket spending. Closing these gaps must be top of the to-do list for every member state,” urged Tedros.

Climate change threat

Moeti and Tedros both urged African member states to take measures to mitigate the effects of climate change on their citizens’ health.

“We have seen Europe burn literally over the past few months. Here in our region, prolonged drought in the Sahel, and also in the greater Horn of Africa and cyclones in southern Africa have increased morbidity, mortality and human suffering,” said Moeti.

“These phenomena are taking a heavy toll on health services. We are working with partners to support our member states in their efforts to provide essential health and nutrition services to affected countries and communities.”

She said that an African regional initiative to combat the health consequences of climate change on the continent had been launched in May on the sidelines of the World Health Summit, while the Climate-Health Africa Network for Collaboration and Engagement (CHANCE) had been formed in 2021 to assist countries in southern and east Africa to address climate change.

Meanwhile, Tedros encouraged all African member states to participate actively at COP28 in the United Arab Emirates, which will feature a day dedicated to health for the first time.

“Health systems are increasingly dealing with the consequences of climate change in terms of communicable and non-communicable diseases, and the impacts of more frequent and more severe extreme weather events,” said Tedros.

WHO's New Leadership Team
The World Health Organisation is losing track of the evolution of COVID-19 as governments lose interest in reporting data about the virus.

Fewer than 20 countries worldwide still report COVID-19 hospitalization and ICU data to the World Health Organization (WHO), leaving the UN health body blind to the impact and evolution of the virus in most of the world, agency leaders said Friday.

The decline in data reporting is a major setback for the WHO’s efforts to track the pandemic. Without reliable data, the WHO cannot accurately assess the burden of disease, identify new variants, or target its resources where they are most needed.

“We don’t have good visibility of the impact of COVID-19 around the world,” said Dr. Maria Van Kerkhove, who leads the WHO’s COVID-19 task force. “It is really important that surveillance continues, and this is on the shoulders of governments right now.”

Out of the 243 countries and territories party to the WHO, the UN health body has data on cases for just 103 of those. Only 19 countries and territories continue to report hospitalization data, while just 17 report data on cases that end in the ICU. The number of countries reporting COVID-19 deaths has fallen to 54.

“While we are certainly not in the same situation that we were in a year ago or two years ago, SARS-Cov-2 circulates in all countries right now,” said Van Kerkhove. “It is still causing a large number of infections, hospitalizations, admissions to the ICU and deaths.”

The current set of dominant COVID-19 variants can still cause the “full spectrum” of disease, from asymptomatic infections to severe disease and death, Kerkhove said.

The continued circulation of the virus also puts individuals at risk of joining the millions of people around the world suffering from the effects of long COVID. Research into the prevalence of long COVID worldwide estimates the number of people affected as high as 65 million — likely a vast underestimate.

“COVID remains a global health threat, and data available to WHO continues to decline,” WHO Director-General Dr Tedros Adhanom Ghebreyesus said at a media briefing on Friday. “We continue to call on all countries to strengthen surveillance, sequencing and reporting so we can assess the risk of new variants.”

Image Credits: Guilhem Vellut.

A health worker provides treatment to a malnourished child in Yemen.

For most people, electing the regional director – or chief health officer – for the Eastern Mediterranean Region (EMRO) of the World Health Organization (WHO) will not set the pulse racing.  Is this just another shuffling of chairs around the world’s bureaucratic table? Even among global health nerds, it will trigger just a faint tremor.

Yet the role matters to 22 countries spanning the Arab World from Morocco to the Gulf and extending across West Asia to Pakistan. They come together as the Regional Committee for the Eastern Mediterranean to select a new regional director on 10 October to helm the health aspirations of over 700 million hopeful people.

EMRO is one of six regional offices, the directors of which have almost complete authority for executing WHO’s health policies and programmes under its decentralised constitution.  

EMRO’s regional director election comes at a time of health’s increased geopolitical importance due to unpleasant global competition around the COVID-19 pandemic.  Today’s heavily securitised world has also realised that the might of nations is measured not just by guns. Healthy people make content, creative citizens and, ultimately, stronger nations.

EMRO’s life-and-death lottery

WHO EMRO is made up of 22 countries that differ vastly in income and health expenditure.

How is EMRO doing? Its people live 71.4 years, a little under the global average of 73 years. But this hides grave inequalities from Qatar’s 80 years to Somalia’s 55.4 years. Five other nations don’t make it past 66 years.  It is similar with maternal mortality: 620 Afghan women lose their lives for every 100,000 live births, compared to 223 globally. Kuwait does best with seven mothers’ deaths while seven countries are way off the SDG target of 70 maternal deaths per 100,000 live births by 2030.

Why does the region’s heath lag so far behind?  The main cause is that this is the world’s most conflict-torn corner, with two-thirds of its people directly and indirectly affected. Furthermore,  healthcare is brutally instrumentalised with facilities and workers attacked in Yemen, Syria, Iraq, Afghanistan and Pakistan.  Food has been denied in several conflicts with Sudan and Somalia generating starvation headlines and stratospheric malnutrition rates. 

Furthermore, glaring socio-economic gaps hallmark the region. Some of the world’s richest countries – Qatar, the United Arab Emirates (UAE), Saudi Arabia, Bahrain, Kuwait and Oman – are in the same administrative group as Pakistan, Palestine and Egypt, which barely get into the middle-income category, while others like Afghanistan and Yemen remain mired in abysmal poverty.   

This life-and-death lottery is detailed in WHO’s own health observatory, EMRO expends $669 per capita on health – half of the average global spending.  That is skewed further by profligate nations spending $1500-2500, masking other countries that spend less than $150 per person. 

Thousands of Somalis escaping drought and conflict are living in sprawling settlements on the outskirts of towns, like this one in Baidoa in south-central Somalia.

The new regional director needs courage

In such a diverse and divided region, the new regional director will have their work cut out. For starters, they must go courageously where others fear to tread and defend humanity by speaking out without fear or favour. But they must also be astute in walking the fine line between promoting health as a bridge for peace and over-politicising health’s humanitarian mission.

It is our human tendency to get de-sensitised to long-standing suffering and inequalities. Therefore, the incoming regional director will have to be super-human. They must feel stronger outrage about unfairness and injustice, possess greater compassion for misery, burn more intensely with urgency,  be smarter at delving into root causes and shine a brighter light on the path ahead.

Of course, these virtues are nowhere to be found in the sober language of the regional director’s job description. But they should be core considerations for EMRO member states. Can they rise above their usual politicking to unite for the collective good, knowing that the massive health risks they face know no boundaries?

They have six impressive candidates with a range of qualifications and experiences to choose from. Iraq has nominated pharmacologist Najim Abbas Jabir Al-Awwadi and Morocco has proposed former health minister Anass Doukkali. Pakistan has suggested health systems expert Abdul Ghaffar and Iran has put forward health policy professor Ali Akbari Sari. Sudan has nominated its goodwill health ambassador Ahmed Farah Shadoul and Saudi Arabia has proposed the sole woman, clinical and public health specialist Hanan Hassan Balkhy.  If elected, she would be EMRO’s first-ever female regional director, other WHO regions having passed that milestone earlier.

 Consolidation or change?

Whoever is elected, it is not too early to consider their desired legacy from a potential  5-10 years in office. Will they be a transformer or consolidator of business-as-usual?

The business-as-usual approach will see the incumbent – however technically proficient and managerially efficient  – see illusionary progress while presiding over strategic decline. To elaborate: even if the WHO/EMRO leadership does little, health indicators will continue to improve in most countries. Because, thanks to external stimuli, especially the private sector, they will get richer, stabilise some conflicts, improve governance here and there, expand key health capacities, and roll out new technologies wherever they prove useful. 

But such gains are threatened by bigger vulnerabilities. Climate change is heating the Mediterranean and the Middle East at twice the global average with devastating environmental and health impacts. Five of the 10 biggest disasters over the past two years were spawned here, including massive floods, droughts and earthquakes. 

In August 2022, massive floods in Pakistan displaced some 33 million people.

Some 127 million people – 37% of the world’s humanitarian caseload – come from this one region due to a combination of disasters, conflicts, and displacement. WHO’s middling performance on humanitarian assistance in this region needs urgent augmentation.

Concurrently, as the region ages, the burden from non-communicable diseases (particularly diabetes, cardiovascular and lung conditions and cancers) increases. Already 70-80% of deaths occur from NCDs. Other conditions such as substance abuse are surging.

Thus,  business-as-usual in EMRO implies regression. We already see this with continuing neglected tropical diseases such as leishmaniasis, and the emergence of new pandemic-potential agents such as MERS, or the re-emergence of old conditions such as tuberculosis and polio.  

Health systems are struggling in the Middle East and West Asia where health professionals are scarce in poor countries and, although sufficient in the rich ones, skewed towards specialised hospitals. Universal health coverage (UHC), the aspiration that all should receive quality healthcare without personal financial hardship, is still a dream when nearly half the population don’t access 16 essential services.

Healthcare demand will always outstrip provision and traditional health system mantras can never catch up. Will WHO EMRO’s new leader be capable of thinking outside the box? It means breaking old moulds and casting new ones – causing discomfort within WHO and member states. Will they have the guts for that?

Look inwards first for resources

Even if the incoming regional director goes down the egg-breaking, omelette-making track to transform healthcare, they can’t do it on their own. They must build partnerships and garner significant additional resources.

This must start internally inside WHO where its over-staffed headquarters operates out of Geneva, the world’s third most expensive city. Fortunately, WHO Director General Dr Tedros is committed to decentralisation, and although he faces resistance to pushing that through, the incoming regional director should hold him to that pledge. Meanwhile, they must do their utmost to radically reshape EMRO’s regional and country offices to make them investment-worthy.

The new regional director should resist holding out the begging bowl to traditional OECD (mostly Western) donors. The pennies received are not worth the self-respect expended. Multilateral development banks should be pushed to do more. But the real resourcing transformation must be within the region. After all, generosity towards the needy and suffering is an integral part of the region’s dominant religion and culture.

Gulf states are already giving more: $ 9.2 billion in official development assistance in 2022 led by Saudi Arabia ($6.2 billion) and UAE  ($1.4 billion). But such aid tends to be volatile and skewed towards emergency relief and the health sector’s share is small. The regional director must be politically skilled at changing that and establishing long-term health investment – and not donor-recipient – relationships.

Is all this too much to ask from the new WHO EMRO regional director?  No – because it is do-able. Anything less is a betrayal of trust and a missed opportunity to better the lives of people who deserve better.

Mukesh Kapila is a physician and public health specialist who has worked in 120 countries, including as a former United Nations (UN) Resident and Humanitarian Coordinator in Sudan and a UN Special Adviser in Afghanistan.

 

Image Credits: WHO Yemen, Mercy Corp/ TNH, Rahul Rajput.

Amidst the vibrant rhythms of Africa, a less audible rhythm beats – an alarming rise in cardiovascular diseases (CVDs) and non-communicable diseases (NCDs). Between 50% and 88% of deaths in at least seven African countries are due to NCDs, according to the 2022 World Health Organization (WHO) Noncommunicable Disease Progress Monitor. Yet, the realm of research has yet to fully recognize the magnitude of this symphony. 

The cacophony of these diseases is not confined to developed nations; Africa bears witness to their increasing impact, largely unseen by the global research community. Against this backdrop, we stand resolute in our commitment to shifting the focus to the African narrative in cardiovascular medicine.

Closing research disparities: Unravelling the findings 

We are two young cardiologists, both graduates of Egypt’s esteemed medical schools. One of us went on to pursue his career in the United States, where he is now a rising researcher at the Department of Internal Medicine at Yale School of Medicine in New Haven, Connecticut. The other, determined to make a difference in his country, dedicated himself to the demanding work of a physician-scientist in Egypt.

Our paths converged when we decided to address the striking lack of randomized clinical trials (RCTs) in Africa. This scarcity robs the continent of vital disease-specific and population-specific data, which stalls progress in clinical outcomes. This deficiency has global implications, as it dampens cardiology research on a global scale by preventing researchers from tapping into a vast, diverse, and treatment-naive population.

Our journey led us to a comprehensive evaluation of African-led clinical trials in cardiovascular medicine over the past three decades. We recently published our findings in a research letter in the journal Circulation: Cardiovascular Quality and Outcomes.

About 80% of RCTs came from 3 countries (Egypt, Nigeria, and South Africa). Yet, 37 African countries didn’t produce a single RCT.

Our analysis revealed a stark reality: only approximately 2% of published and registered clinical trials in cardiovascular medicine originated from Africa. However, within this fraction, we found a tale of perseverance and determination.

We examined a total of 179 trials from African countries from 1990 to 2019. Egypt, South Africa and Nigeria were the most notable contributors, with Egypt leading the way. The number of African-led trials surged over the past decade, with 2010 to 2019 witnessing a remarkable increase.

The primary outcomes assessed in the trials included biochemical and cardio-metabolic markers, hemodynamic outcomes, clinical events, and patient-related outcomes. African trials often had small sample sizes, few participating centers and short follow-up periods.

The impact of published trials from different countries was measured using the H-index, a metric that gauges the impact of scientific research by tracking how many times a published paper is cited by other researchers. South African publications had the highest impact score, followed by Egypt and Nigeria. A significant number of trials were not published as open access, and risk of bias assessment showed that a significant number of studies had unclear or high risks of bias.

It is estimated that only 2000 cardiologists practice in Africa (≈1 cardiologist for 600,000 individuals)

Collaborations transcended borders, as African centres actively participated in 45 multinational trials, contributing valuable insights to global research endeavors. On the issue of funding, the researchers noted that 91 trials did not disclose their funding sources, while 20 disclosed no external funding. Of the remaining 68 trials, 35.7% had funding from private sources, 28.6% from academic sources, 28.6% from governmental sources, and 7.1% from non-governmental sources.

Our research letter underscores several critical points. First, there is a need for increased investment in training cardiovascular researchers, beyond just cardiologists, to strengthen the research workforce in Africa. Second, it is important to allocate more resources for research and development in African countries, in line with the local disease burden and international recommendations.

Third, initiatives like the Clinical Trials Community platform and the Pan-African Clinical Trials Registry have the potential to improve research infrastructure and collaboration. Lastly, there is a need for multifaceted interventions to address barriers to clinical research in Africa, including regulatory frameworks, electronic medical records adoption, and institutional partnerships.

Forging a new path: Towards inclusivity and impact

Of the 179 trials included, 54 (30.2%) were performed in collaboration with another African (n=42) or non-African center (n=33), most commonly in Europe and the USA.

Together, we can overcome the disparities impeding Africa’s research progress. Our findings have revealed challenges that, once addressed, could amplify the continent’s contributions. Trials across the continent often have limited sample sizes, are conducted at a small number of participating centres, and have short follow-up periods. The intricate dance of collaboration also extended beyond African borders, with European and North American centers partnering to enhance the scope and impact of research.

To unleash the true potential of African-led clinical trials, key changes are needed. Increased investment in training for cardiovascular researchers, beyond just cardiologists, would enrich the research landscape. Clinical research is a cornerstone of sustainable progress, and local governments must invest more in it.

A symphony of change 

As the curtain falls on our story, the call for change echoes. To harmonise Africa’s cardiovascular research and amplify its impact on the world, we need multifaceted interventions. Expanding clinical research sites, standardising regulatory frameworks, and widely adopting electronic medical records will strengthen Africa’s research infrastructure.

Open-access publishing and robust institutional partnerships are our allies in the journey towards progress. The song of African science, once muted, now crescendos as we work to break down barriers and illuminate a path toward equitable cardiovascular knowledge. In this rhythm of change, we are architects of transformation, orchestrating a symphony of research that resonates far beyond the boundaries of continents and borders.

Dr Ahmed Bendary is Associate Professor in the Cardiology Department at Benha University, a member of the Egyptian Society of Cardiology and a Fellow of the European Society of Cardiology (FESC). He also serves on the Board of the Egyptian Association of Vascular Biology and Atherosclerosis (EAVA), is part of the abstract reviewing committee for the European Society of Cardiology (ESC) Congress and serves as associate editor for The Egyptian Heart Journal (TEHJ).

Dr Abdelrahman Abushouk is an Internal Medicine Resident at Yale-New Haven Hospital. He earned his medical degree from Ain Shams University.

Image Credits: CC.