Landlocked equatorial Burundi is one of the poorest countries in the world – yet it scored the highest out of 58 countries for its plans to integrate health measures into its climate mitigation plan, getting an almost perfect score of 17 out of 18.

Low- and middle-income countries were far more likely to include health goals in their climate commitments than more wealthy, industrialised nations that are responsible for the majority of global greenhouse gas emissions.

This is according to an analysis published on Tuesday by the Global Climate and Health Alliance (GCHA), a coalition of over 150 health and development organisations working to tackle climate change.

The alliance analysed the climate plans of 58 countries – which are called nationally determined contributions (NDCs) in terms of the Paris Agreement on climate change. All countries that are party to this agreement have to develop NDCs to cut emissions and adapt to climate impacts, submit these plans to the United Nations Framework Convention on Climate Change (UNFCCC) and update them every five years.

The countries included in the alliance’s NDC Healthy Scorecard were those that had submitted their plans between 1 October 2021 and 23 September 2022. 

Greater ambition

“Overall, the Healthy NDC Scorecard demonstrates a trend of low- and middle-income countries showing greater ambition for protecting their citizens’ health from the worst impacts of climate change, while identifying additional wins through health co-benefits of climate action,” said Jess Beagley, Policy Lead at the Global Climate and Health Alliance. 

Each NDC was assigned a health score, with a total maximum of 18 points available across six categories – health impacts of climate change, actions in the health sector itself, recognition of health co-benefits of climate action in other sectors, economic and financial considerations, and monitoring and implementation. 

For example, countries get points for how well different parts of government are integrated to address climate change, how the health sector is being adapted to address climate threats, whether there is a budget, if the health impacts of climate change are quantified in terms of their cost, and whether there are particular targets that are set out, that relate to health, that governments can e held accountable to.

Where available, data from Climate Action Tracker has been included to evaluate the country’s level of ambition with regard to its emissions reduction target, its key commitment to mitigating climate change and limiting global warming.

“The NDC of Burundi is really exemplary,” said Beagley.  “It really does do almost the maximum in terms of integrating health into the NDC.”

Burundi’s plan includes the need to address a likely increase in the spread of vector-borne disease and flooding. A spinoff of its “vulnerability analysis” includes plans to power 455 health centres with solar energy.

Health considerations are part of its plans related to agriculture, energy, transport and water. It has a budget, indicators and timelines. 

Some wealthy nations score zero

Some wealthy nations, including Australia, Japan and New Zealand scored zero, reflecting the lack of any reference to health and climate linkages in their NDC. 

Meanwhile, the NDC emissions targets of some G20 nations, including Indonesia and Saudi Arabia, as well as of COP28 host the United Arab Emirates and COP27 host Egypt, received the worst rating available on the scale used by Climate Action Tracker. 

“Their climate mitigation targets contained in their NDCs align with over 4°C of warming, far beyond the 1.5C target agreed under the Paris Agreement, and putting the world on track for catastrophic and irreversible climate change impacts,” according to the alliance.

Jeni Miller, executive director of the Global Climate and Health Alliance.

“Although COP28 is being marketed as the ‘Health COP’, the Healthy NDC Scorecard scores make it clear that virtually none of the countries most culpable for climate warming appear to be clearly focussed on protecting the health of their citizens, or people around the world, when making climate commitments”, said Dr Jeni Miller, executive director of the Global Climate and Health Alliance. 

“This is despite promising to protect people’s ‘right to health’ when adopting the 2015 Paris Agreement, as well as endorsing the ‘right to a healthy environment’ at COP27”.

Image Credits: UNHCR.

Artificial sweeteners don’t help to control weight and may cause long-term health issues, says WHO.

Artificial sweeteners should not be used to control body weight or reduce the risk of non-communicable diseases (NCDs), according to a World Health Organization (WHO) guideline issued on Monday. 

“Non-sugar sweeteners (NSS) are not essential dietary factors and have no nutritional value. People should reduce the sweetness of their diet altogether, starting early in life, to improve their health,” according to Francesco Branca, WHO Director for Nutrition and Food Safety. 

“Replacing free sugars with NSS does not help with weight control in the long term. People need to consider other ways to reduce free sugars intake, such as consuming food with naturally occurring sugars, like fruit, or unsweetened food and beverages,” he added. 

The recommendation applies to all people except those with pre-existing diabetes and includes all synthetic and naturally occurring or modified NSS that are not classified as sugars found in manufactured foods and beverages, or sold on their own to be added to foods and beverages by consumers. 

Common NSS include acesulfame K, aspartame, advantame, cyclamates, neotame, saccharin, sucralose, stevia and stevia derivatives.

Toothpaste, skin creams excluded

“The recommendation does not apply to personal care and hygiene products containing NSS, such as toothpaste, skin cream, and medications, or to low-calorie sugars and sugar alcohols (polyols), which are sugars or sugar derivatives containing calories and are therefore not considered NSS,” according to the WHO.

The recommendation is based on the findings of a systematic review of the available evidence which suggests that the use of NSS does not confer any long-term benefit in reducing body fat in adults or children – and long-term use could potentially increase the risk of type 2 diabetes, cardiovascular diseases, and mortality in adults.

The systematic review included 64 prospective cohort studies conducted in adults, 15 cohort studies in children, one cohort study in children and adults and 17 cohort studies in pregnant women.

Although a short-term benefit of NSS use on measures of body fatness was observed in controlled experimental settings, the WHO concluded that there was little evidence that long-term use of NSS is beneficial for body weight – and the possible long-term adverse effects in the form of increased risk of death and disease offset any potential short-term health benefit resulting from the relatively small reduction in body weight and BMI observed in randomized controlled trials. 

In addition, limited evidence for the beneficial effects of NSS use on dental caries was observed in studies of children using stevia. But this was generally only observed in studies where NSS use was compared to sugars.

“This suggests that NSS do not have any inherent properties that impact the risk of dental caries; rather, the effect is a result of displacing free sugars,” the WHO noted.

But because the link between NSS and disease outcomes might be confounded by baseline characteristics of study participants and complicated patterns of NSS use, the recommendation is conditional, following WHO processes for developing guidelines. 

“This signals that policy decisions based on this recommendation may require substantive discussion in specific country contexts, linked for example to the extent of consumption in different age groups,” the WHO concluded.

Industry disappointment

However, the International Sweeteners Association contested the guideline, arguing that their products “continue to be a helpful tool to manage obesity, diabetes and dental diseases”.

The association added that it is  “disappointed that the WHO’s conclusions are largely based on low certainty evidence from observational studies, which are at high risk of reverse causality”. 

Image Credits: Towfiqu Barbhuiya/ Unsplash.

Self-Care: A Foundational Component of Health System Sustainability

Self-care practices hold the huge potential to improve people’s quality of life, helping to manage the burden of NCDs while simultaneously developing the sustainability of health systems.

On the occasion of the 76th World Health Organization (WHO) World Health Assembly (WHA), the United for Self-Care Coalition is hosting a side event to highlight why a WHO resolution on self-care is key to achieving Universal Health Coverage (UHC). This dialogue will bring together a diverse set of stakeholders to advance the call to codify self-care as a critical component of the healthcare continuum.

The event, which will be held on Wednesday 24 May in Geneva Press Club is titled “ Self-Care: A Foundational Component of Health System Sustainability,” and will bring together policymakers, healthcare providers, academics, and patient advocates to discuss strategies for advancing health equity by integrating self-care into national health systems.

“The time to act is now. We believe that self-care is a critical component for the advancement of UHC, and we are committed to working with policymakers, healthcare providers, patients, and academia, to promote its integration into health systems,” said Judy Stenmark, Director General of the Global Self-Care Federation. “This event is also an opportunity for us, as a Coalition, to advocate for the adoption of a World Health Assembly Resolution on Self-Care, promote evidence-based interventions, and support policies and strategies that encourage the integration of self-care as a core component of people-centered care – we invite everyone to join us on this journey.”

Self-care is an indispensable solution for realising Universal Health Coverage by 2030 and should be integrated into future health and economic policy, with a focus on affordability and access. This whole-society approach is backed by research proving that person-centric healthcare is both a politically and economically viable way of managing the global spread of NCDs, especially in low and middle-income countries (LMICs).

Panel to focus on ‘crucial role’ of self-care

The panel will discuss the crucial role of self-care including today’s most significant challenges to health system sustainability, ways self-care can help advance the achievement of UHC and how a patient-centered approach can be beneficial to managing NCDs.

Panelists include Dr Slim Slama, Head of the Management-Screening, Diagnosis and Treatment Unit (MND), in the Non-Communicable Diseases Department at World Health Organization, Manoj Raghunandanan, Chair of the Global Self-Care Federation, Dr Mariet Eksteen, Professional Development Officer at the Pharmaceutical Society of South Africa (PSSA) and the Global Lead for Advancing Integrated Services in the FIP Hub, Dr Manjulaa Narasimhan from the World Health Organization, and Self-Care Trailblazer Group, Kawaldip Sehmi, CEO of the International Alliance of Patients’ Organizations and Austen El-Osta, Director of the Self-Care Academic Research Unit (SCARU) & Primary Care Research Manager at Imperial College London School of Public Health.

The session, moderated by broadcast journalist Shiulie Ghosh, will also be live-streamed.

United for Self-Care Coalition is a coalition of like-minded organisations unified by one common goal – to achieve Universal Health Coverage (UHC) by codifying self-care as a critical component of the healthcare continuum, particularly in the context of managing the burden of NCDs.

To join this in-person event, register here. To learn more about the coalition, click here.

This article is part of a supported series in collaboration with the United for Self-Care Coalition ahead of the 76th World Health Assembly.

Taiwan is set to be excluded from the World Health Assembly for a seventh straight year.

Despite a forceful message from the US calling for its inclusion, Taiwan appears set to be shut out once more from the World Health Assembly (WHA) as Chinese diplomats continue to block chances of a personal invitation by WHO Director General Dr Tedros Adhanom Ghebreyesus that would allow Taipei to attend as an observer. 

In a quick rebuttal of the US appeal, a spokesperson for the Chinese Foreign Ministry said the rejection of the “one-China” principle by the Taipei – which both the US and United Nations follow – meant “the political foundation for the Taiwan region to participate in WHA no longer exists.”

“The US statement is misguided and misleading,” Wang Webin said at a press conference in Beijing on Wednesday. “We once again urge the United States to adhere to the one-China principle, observe international law, and act on the US leader’s assurances that the country will not support ‘Taiwan independence’.”

The debate over Taiwan’s participation in the upcoming WHA has been a perennial issue since 2017, when the election of Tsai Ing-Wen’s pro-independence party prompted WHO’s director-general to stop extending the traditional invitation to the island nation to attend the WHO’s top decision-making forum in response to pressure from China.  

The debate over Taiwan’s participation has taken on added significance following a year of growing tensions in the Western Pacific region as China flexes its military might in war games and the United States increases its military support for Taiwan. 

In April, the US approved a $120 million sale of arms to Taiwan, the largest military sale to the island in over a decade. The sale coincided with a joint military exercise with Japan in the East China Sea in a show of force just beyond Chinese waters, adding weight to Joe Biden’s statement that US forces would defend Taiwan in the event of a Chinese attack. 

Last year’s assembly saw more WHO member states than ever – including Germany’s new coalition party – appealing to re-install Taiwan as a WHA observer. But in the absence of a special invitation from the director-general to circumvent the WHO member states, the mounting pressure amounted to nothing. 

US: Taiwan is a “reliable partner and vibrant democracy”  

In keeping with what has become an annual routine, the United States and other key allies of Taipei have ramped up diplomatic efforts to pressure WHO into granting Taiwan accession to the WHA, just ahead of the start of the assembly on Sunday 21 May. 

This year’s debate was kicked off by a particularly forceful statement issued by US Secretary of State Anthony Blinken, who called Taiwan’s exclusion from WHA “unjustified” and harmful to “global public health” and “security”.

“Taiwan’s distinct capabilities and approaches – including its significant public health expertise, democratic governance, and advanced technology – bring considerable value that would inform the WHA’s deliberations,” Blinken said. “Inviting Taiwan as an observer would exemplify the WHO’s commitment to an inclusive, “health for all” approach to international health cooperation.” 

Blinken also highlighted Taiwan’s significant contributions to global health, including its track record of scientific research on COVID-19, and the aid it has provided to low-income countries with which it has relations.

“Taiwan is a reliable partner, a vibrant democracy, and a force for good in the world,” he said.

China began blocking Taiwan’s participation in 2017

China, which considers Taiwan to be one of its provinces, began blocking Taipei’s participation in WHO after the election of Tsai Ing-Wen in 2016, whose Democratic Progressive Party views Taiwan as an independent state.

Taiwan participated in WHO as an observer state from 2009 to 2016 under the name “Chinese Taipei”, a designation viewed as unacceptable by the current government.

Taiwan is not recognized as an independent state by the United Nations, and the WHO is far from the only international organization from which it is excluded. Chinese efforts have successfully blocked Taipei’s accession to other major organisations such as the International Civil Aviation Organization and Interpol, which facilitates worldwide cooperation between police forces. 

Meetings dedicated to “expanding Taiwan’s participation in the United Nations system and other international forums” took place in between US and Taiwanese officials Washington DC in April, with discussions focusing on “near-term opportunities to support Taiwan’s expanded participation in the coming WHA” and “meaningful participation in non-UN international, regional and multilateral organizations”, the US State Department said.

Taiwan is a member of organizations like the World Trade Organization, Asian Development Bank and the Asia-Pacific Economic Cooperation since they do not require members to be states. 

“The one-China principle has the overwhelming support of the international community and represents the global trend,” Webin said. “This is not to be denied.” 

Drama around WHO’s relationship with Taiwan is not new

The 76th WHA marks the seventh year of headaches for WHO leadership, who have long struggled to navigate the minefield around the Taiwanese question. 

In an explosive 2020 interview by Hong Kong broadcaster RTHK news, top WHO official Bruce Aylward hung-up live on air after being pressed on the issue of Taiwan’s inclusion in the organization. 

The viral interview prompted heavy criticism and accusations of bias from Taiwan. Joseph Wu, Taiwan’s foreign minister, reposted the interview with Aylward in a tweet, saying: “Wow, can’t even utter ‘Taiwan’ in the WHO?”

Wu, who has been Tsai Ing-Wen’s foreign minister since 2018, has repeatedly criticized the WHO for its “continued indifference” to the health of Taiwan’s 23.5 million people, and has called on the organization to “reject China’s political interference.”

Accusations of bias in favor of China have also swirled around the WHO’s investigation into the origins of the SARS-CoV2 virus.  Many independent critics found WHO’s initial mission to Wuhan in early 2021 and its subsequent report on the possible causes of the virus emergence to be too “soft” on China. 

Critics noted that the initial report failed to both demand transparency from government officials regarding data on human infection from the early days of the virus’ spread in Wuhan, or adequately investigate shortcomings in food safety practices as well as biosecurity lapses in a local virus research lab. 

WHO eventually sharpened its tone vis-à-vis Beijing, bolstered by the support of new US President Joe Biden who re-engaged with WHO after a chaotic year in which Donald Trump had suspended membership to the global health body.  

But Beijing never agreed to a second mission and thus in-situ research on the origins of the virus gave way to remote analyses of available shards of data. 

Taiwanese delegation will be present on the sidelines 

Despite Taiwan’s likely exclusion from official WHA proceedings, Taiwanese experts and civil society groups may be allowed to participate in expert working groups as well as other side-events. 

The Taiwan Digital Diplomacy Association (TDDA), announced that at least 10 civil society organizations will make the trip to Geneva to participate on the margins of the WHA. 

The civil society participants say that they are organizing a parallel event to the World Health Assembly in Geneva to promote the stronger role Taiwan can have in public health diplomacy and the lessons learned from the SARS-CoV2 pandemic. 

Taiwanese civil society leaders also say that they are planning a walking demonstration through Geneva to advance Taiwan’s inclusion in the WHO as well as launching a global petition supporting Taiwan’s participation in the WHA.  

Image Credits: © Keystone: Ritchie B. Tongo .

South African President Cyril Ramaphosa visits Aspen Pharmacare’s manufacturing facility in Gqeberha.

Regional vaccine production features in the draft pandemic accord, but there is still a long road before this becomes a reality

Aspen Pharmacare invested millions of dollars in scaling up its South African production plant to make COVID-19 vaccines – yet it never sold a single vial.

Meanwhile, in a “demoralising blow”, Bangladesh’s government rejected a vaccine developed by Professor Peter Hotez that was being made by a local company because it wasn’t an mRNA vaccine.

While the pandemic accord currently being negotiated is almost certain to support regional vaccine production, setting this up is complex and the COVID-era failures offer a number of sobering and cautionary lessons.

“Unless there is security around domestic or regional procurement, you’re going to be very guarded about getting into this business ever again,” Aspen’s Stavros Nicolaou, head of Strategic Trade, told a recent webinar hosted by Brown University’s Professor Wilmot James.

While Nicolaou’s comment sounds mild, the body blow that his company took would have bankrupted a smaller company.

Three key factors combined to undermine Aspen’s vaccines. First, despite the hype about the need for African-produced vaccines, African governments failed to buy the locally-made vaccines. 

Then Aspen became caught in a political stand-off between Africa and Europe about the fate of African-produced vaccines which delayed production by months. 

When that was eventually resolved, the world had fallen for mRNA vaccines and no longer wanted the viral vector vaccine that Aspen had been licensed to produce by Johnson & Johnson.

Professor Peter Hotez

Hotez, who directs the Texas Children’s Hospital Center For Vaccine Development, assisted to develop a viral vector vaccine concept. The Center then affected a technology transfer to Indian and Indonesian manufacturers that went on to make over 100 million doses, he told the seminar. But Bangladesh had passed over the vaccine, being made locally by a company called Incepta, in favour of the mRNA vaccines.

Scaling up to make vaccines

With the waning of COVID-19, maintaining countries’ and companies’ interest in building regional vaccine manufacturing ability is a challenge – and Aspen’s difficulties should be well noted.

Aside from being Africa’s biggest pharmaceutical company, Aspen is also the leading manufacturer and supplier of general anaesthetics in the world outside of the US.

Aspen’s main production facility, comprising six different manufacturing units, is in Gqeberha, an economically depressed city in one of the poorest regions in South Africa.

Shortly before the pandemic, Aspen had invested around $400 million to expand its sterile capacities and volumes as it planned to relocate the production of some of its general anaesthetics and muscle blockers to Gqeberha.

But when the company saw what was happening with COVID-19, it decided to switch to vaccine production. What followed, said Nicolaou, was “frenzied activity to try and acquire additional capacity” to enable its facility to make vaccines.

In November 2020, Aspen announced that it had reached an agreement to “perform formulation, filling and secondary packaging” for Johnson & Johnson’s COVID-19 vaccine. 

The vaccine only needed one dose, it didn’t need ultra-cold storage and thus seemed to be the most “African-friendly vaccine”, said Nicolaou.

The announcement was a source of national and continental pride, particularly as South Africa’s President Cyril Ramaphosa was chair of the African Union and spearheading the quest to get vaccines for the continent.

But in August 2021, the New York Times exposed that millions of the J&J doses being produced in South Africa were being exported to Europe – at a time when only 7% of South Africans had been vaccinated. 

A political storm erupted. Ramaphosa intervened, appealing to the Europe Commission head Ursula von der Leyen to intervene. By September, European countries had agreed to return the J&J vaccines produced by Aspen for distribution in Africa.

“There was a standoff between Europe and the African Union in terms of where these vaccines would finally land,” explained Nicolaou. “And it took quite significant negotiating and eventually, an agreement was settled between the EU and Africa for some of these vaccines, initially 60% and eventually 90%, to be retained on the African continent.”

Aspen’s Stavros Nicolau

By March 2022, J&J had licensed Aspen to produce and supply the vaccines under their own brand name, Aspenovax. 

Strive Masiyiwa, AU Special Envoy on COVID-19 and Head of the African Vaccine Acquisition Trust (AVAT), described the agreement as “the single biggest win for the African continent in the fight against COVID and future pandemics. It is a timely milestone and an important step in making sure that the gross vaccine inequality we witnessed in the early part of the pandemic is not repeated.”

Aspen had expected to make 400 million vaccines. But the orders never came. Not a single one. By the time the agreement had been secured, Pfizer and Moderna had upped their production, and most African countries had opted for their mRNA vaccines which were being distributed by COVAX.

“That was in November 2021 and demand had dropped off, and not a single Aspen COVID vaccine was produced thereafter. We called our product Aspenovax, and to date, we haven’t sold a single vial of Aspenovax. And that is the problem,” concluded Nicolaou plainly.

After a few months of waiting with no orders materialising, Aspen was forced to close its production line.

Stable and predictable demand

“The first and most important element is we require a stable and predictable demand,” said Nicolaou, adding that there needed to be a proper procurement process through the African Union.

Other important factors are an integrated regulatory system, the transfer of technology and knowledge to local African producers and public-private partnerships.

For Hotez, his Texas Children’s Hospital Center For Vaccine Development disproved the belief that only big pharma companies “have the chops” to make vaccines.

Nonetheless, Hotez says that “too often, those who are in the pharmaceutical space don’t differentiate between the challenges of producing vaccines at scale, compared to small molecule drugs or diagnostics or medical devices”.

“The vaccine space is quite different, mostly because, when you’re talking about far more complicated biologics, the upfront investment is larger. The time horizons are longer and the risk is high as well. So it takes a very special type of biotech or pharma investor to invest in vaccines,” says Hotez.

“People focus a lot on the patents and in my view, that’s in some ways, the least of it. It’s more the capacity building that can take years and years.”

Lora du Moulin, Global Health and Security Lead at the World Economic Forum.

Meanwhile, Lora du Moulin, Global Health and Security Lead at the World Economic Forum (WEF), told the webinar that the WEF was trying to bring together the public and the private sectors through the Regionalized Vaccine Manufacturing Collaborative.

“What we’ve been doing is thinking through what does this ecosystem approach look like? What are the necessary components to ensure vaccine manufacturing is sustained during both peacetime and then able to surge,” said du Moulin. 

“We have identified seven pillars which include business models, market shaping, public-private financing, manufacturing, innovation, tech transfer, workforce supply chain and last but not least, regulatory harmonisation.”

In preparation for the next pandemic, says Hotez: “We need to broaden the ecosystem, broaden the tent and not demonise the pharma companies either. They do a lot of good. They provide a lot of innovation and a lot of important vaccines for the GAVI Alliance.

“Remember, COVID-19 is the third major coronavirus epidemic pandemic of the century. We had SARS in 2002, MERS in 2012, and now COVID-19. So the fourth one’s coming. It’s going to happen before the end of this decade and we still haven’t prepared for that.”

mpox

The World Health Organization (WHO) has ended the global health emergency for mpox, marking the end of a 10-month juggling act by the UN health agency as it scrambled to deal with concurrent global pandemics. 

The announcement arrives just days after WHO declared the end of the global health emergency for COVID-19 last Friday, three years and 6.9 million lives after the virus was elevated to a global pandemic in January 2020. 

At a press briefing at WHO’s Geneva headquarters on Thursday, Director-General Dr Tedros Adhanom Ghebreyesus said that despite the change in designation, both viruses still pose “significant health challenges”. 

“While the emergencies of mpox and COVID-19 are both over, the threat of resurgent waves remains for both,” Tedros said. “Both viruses continue to circulate, and both continue to kill. This does not mean the work is over.”

What now?

Tedros’ announcement follows a recommendation by WHO’s emergency committee on mpox hashed out at a prolonged closed-door meeting on Wednesday. The committee assessed that the virus no longer represented a public health emergency of international concern, and recommended an end to the emergency. 

Leaders of the emergency committee stressed that the end of the emergency is not the end of the fight against the virus – but the beginning of a policy shift. 

“Lifting the public health emergency of international concern in no way means that mpox is no longer an infectious disease threat,” said Dr Nicola Low, vice-chair of the mpox committee that issued the recommendation. “[It] means moving towards a strategy that is going to manage the long-term health risks posed by mpox rather than the emergency measures that are inherent in public health emergencies.”

The committee’s recommendations include integrating mpox into national pandemic prevention, preparedness and surveillance programmes, as well as sexual health services already in place for diseases like HIV. 

“It is critically important that we continue the efforts that have been initiated already,” said Dr Rosamund Lewis, technical lead for mpox at WHO’s health emergencies programme. “As long as the virus is given an opportunity to continue to transmit from person to person, it also has the opportunity to evolve.”

Affected communities are key to sustained success

Men queuing for the monkeypox vaccine in the early months of the global outbreak.

Central to the WHO mpox committee’s policy recommendations is an emphasis on continued engagement with affected communities like men who have sex with men. 

Outside of the endemic African countries, men who have sex with men account for nearly all mpox cases, including 99% in the United States. Meanwhile, around half of all mpox infections have been in people living with HIV. 

Immunocompromised patients with HIV are not only at higher risk of severe disease from mpox, but also present an ideal environment for the virus to mutate and evolve to become more transmissible. 

Including mpox as standard in monitoring, detection and prevention programmes for sexually transmitted diseases will allow men who are already connected to sexual health services to be checked for mpox at the same time as other STIs – streamlining surveillance and treatment for both patients and health authorities, experts said. 

“Typically, around half of the cases have been among people who are living with HIV. Gay and bisexual men who have sex with men are the most affected population group here,” said Andy Seale, senior advisor at WHO on global HIV, hepatitis and sexually transmitted infections programmes. “Outbreaks like this start and end in communities and it is these communities that will help us be on top of the surveillance, the intelligence and the dynamics as the outbreak continues to evolve.” 

WHO experts also credited community organisations for their key role in helping to contain the outbreak of the virus through education, awareness, treatment and vaccination campaigns. 

“We now see steady progress in controlling the outbreak based on the lessons of HIV and working closely with the most affected communities,” Tedros said. “The work of community organisations together with public health authorities has been critical.” 

Endemic African countries are another story

mpox
Patient participating in a clinical trial of Tpoxx, an antiviral treatment for the mpox virus, in the Democratic Republic of Congo.

Lost in the shuffle of the celebrations over the end of the mpox emergency is the reality that countries where the disease is endemic – such as the Democratic Republic of Congo and Nigeria – still have a steep hill to climb. 

While a vaccine intended for smallpox made by Danish company Bavarian Nordic was quickly deployed under emergency authorizations in the United States and Europe at the start of the mpox emergency, the manufacturer’s monopoly over the vaccine patent and limited stock prior to the global outbreak made access difficult, even for rich countries. 

“[We] recognize that there has been less than expected or less than desired commitments to vaccine equity and distribution, particularly to Africa,” Lowe said. “But it’s also recognized that we still have insufficient evidence about vaccine effectiveness from randomized control trials.”

Currently, WHO recommends the use of Bavarian Nordic’s vaccine primarily for post-exposure prophylaxis, and only for use in prevention under specific circumstances. Randomised control trials to improve data on the efficacy of the vaccine are being planned in endemic countries, Lowe said. 

Another obstacle to eradicating mpox is the mystery around how the strain of the virus that spread globally evolved to sustain prolonged human-to-human transmission. Until that question can be solved, the road to ridding the world of the virus remains a long one.

“How it went from a possible zoonotic source to the human population with amplification of transmission is something we don’t yet have information on,” Lewis said. “We need to continue to support countries and regions where this research on the origins of the virus that will be instrumental to our understanding going forward is ongoing.

“Countries in Africa were dealing with mpox long before this outbreak began, and will continue to deal with it for some time to come,” Lewis said. 

Nurses working in Neonatal intensive care unit, Yekatit Hospital Medical College, Ethiopia.

Zero gains have been made in any region of the world in reducing premature births in the past decade, a major UN report found. In a perfect storm of flatlining progress in maternal and newborn health, preterm birth has become to the leading cause of child mortality worldwide, responsible for the deaths of over one in five children who die before their fifth birthday. 

The report, which includes the first updated estimates from the UN on preterm births since 2012, estimates 13.4 million babies were born prematurely in 2020, with nearly one million dying from complications related to their premature birth. Since 2010, a total of 152 million babies – one in 10 worldwide – were born too soon.

The consequences of preterm birth, where a baby is born in the first 37 weeks of pregnancy, can be lifelong, leaving millions of children facing serious physical and developmental disabilities and health complications that will shape their lives and that of their families.

“Every two seconds, a baby is born too soon,” the report by the World Health Organization (WHO), UNICEF, and the Partnership for Maternal, Newborn and Child Health (PMNCH) said. “Every 40 seconds, one of those babies dies.” 

Efforts to expand investments in the health of pregnant women, mothers and newborns remain chronically underfunded, the report found, adding that climate change, the cost of living crisis, conflicts and COVID-19 have added to the risks for women and babies around the world.

“Every woman must be able to access quality health services before and during pregnancy to identify and manage risks,” said Dr Anshu Banerjee, WHO’s Director of Maternal, Newborn, Child and Adolescent Health. “Ensuring quality care for these tiniest, most vulnerable babies and their families is absolutely imperative for improving child health and survival.”

“Where babies are born determines if they survive” 

Preterm birth by gestational age and region in 2020. Source: UNICEF, WHO.

Most preterm deaths and disabilities are preventable, but inequalities in access to quality and timely care can create staggering differences in a preterm baby’s odds of survival. In analysing the new data set out in the report, its authors are blunt: “Where babies are born determines if they survive.”

Fewer than one in 10 babies born before the 28-week mark survive in low-income countries, compared to nine out of 10 in high-income countries. Sub-Saharan Africa and South Asia have the highest premature birth rates and highest mortality risk. Together, they account for over 65% of preterm births globally. Overall, almost half of all preterm babies born in 2020 were from just five countries: China, India, Nigeria, Ethiopia and Pakistan.

“The single biggest gap that we see around the world is the chance of survival for a preterm baby,” Joy Lawn, a professor at the London School of Hygiene and Tropical Medicine and co-author of the report told BBC Africa. “So this is the loudest cry in this report, that these babies should have an equal chance.” 

Sister Munaye Esmael holds her four-day-old son Umar Abdul Shafri at the UNICEF-supported Neonatal Intensive Care Unit in Ethiopia.

A broader crisis in maternal health

But premature births are just one part of the larger story of maternal health inequalities. 

In 2020, nearly 95% of maternal deaths occurred in low- and lower-middle-income countries. Over 200,000 of those deaths – 70% – took place in sub-Saharan Africa, where girls who reach the age of 15 face a one in 40 chance of dying from pregnancy-related causes. 

Meanwhile, an estimated 2.3 million newborns died within their first 28 days of life in 2022. Of the 6400 infants dying every day, 98% were in low- and middle-income countries, and 78% were in sub-Saharan Africa and Asia.

“Pregnant women and newborns continue to die at unacceptably high rates worldwide, and the Covid-19 pandemic has created further setbacks to providing them with the healthcare they need,” Banerjee said. “More and smarter investments in primary healthcare are needed now so that every woman and baby – no matter where they live – has the best chance of health and survival.” 

More staff, more equipment, more support

As premature births claim the top spot on the ladder of causes of child mortality, less than a third of countries report having enough care units to treat vulnerable newborns, a new UN report launched at a major maternal and newborn health conference in Cape Town, South Africa, this week found. 

Around two-thirds of emergency childbirth facilities in sub-Saharan Africa are not fully functional due to a lack of vital resources like water, electricity, medicines, equipment, or staff for round-the-clock care, the report added. 

Miriam Asembo, a nurse and mother of two premature babies, shared her experience of what it is like to be on both sides of an underfunded maternal care system in her home country of Kenya. 

“There is a lack of incubators per number of premature babies born, we find babies sharing incubators in public hospitals, which is ridiculous,” she said, adding that sharing incubators can increase infant mortality due to infection risks. “It boils down to access to oxygen cylinders and medical air, which is something that we should not be talking about in 2023.” 

There is also a chronic lack of trained midwives, nurses and hospital staff. In 2022, nearly a third of women did not receive even half of the WHO’s recommended antenatal checkups during the pregnancy or have access to any postnatal care.

“We need to address the human resource shortages and training of personnel in these low-income countries, right from the traditional midwives to the nurses to the doctors,” Asembo said.

“The saddest bit is as much as [people] give birth to babies prematurely, nobody follows up with you to find out what you are doing to keep the child alive,” she said of her experience after the birth of her two children, Sifa and Teko.

Lost years, lost potential 

Estimated national preterm birth rates and numbers in 2020. Source: UNICEF, WHO.

Poor neonatal conditions have been the leading cause of lost disability-adjusted life years (DALYs) since 1990. This high burden of DALYs – each representing the loss of one full year of health compared to life expectancy –  is due to how early babies who lose their lives to preterm-related complications die, effectively leaving their entire lives, and economic potential, ahead of them. 

“Investment in the right care during this sensitive period can unlock more human capital than at any other time in the life-course, bolstering the case for investing now to gain significant human and economic returns,” the report said. 

Lawn, who has worked in neonatal care across Africa for her entire career, echoed the report’s findings, highlighting the role Africa’s youthful demographics are already playing in the continent’s growth, and can play in its future. 

“We continue to accept that more than one million newborns die every year in Africa, more than on any other continent,” she said. “This is really critical for Africa … Those newborns, they don’t have a voice. Often the women who it happened to don’t have a voice. And politicians are not rising up and saying that this is not just charity, it is investing in the future of your country.

“You want your newborns not just to survive, but to thrive,” Joy concluded. “The investment may not be small, but the return is huge for the next generation.”

Image Credits: UNICEF.

HIV activists want the US government to appeal Tuesday’s court ruling that pharmaceutical company Gilead did not infringe on patents held by the Centers for Disease Control and Prevention (CDC) related to two anti-retroviral (ARV) drugs.

The US government had claimed $1 billion in patent violations in relation to the use of Gilead’s Truvada and Descovy for HIV prevention – called pre-exposure prophylaxis (PrEP).

The case is the conclusion of a lawsuit filed by the Trump administration in 2019, in which the federal government argued that Gilead had violated its collaboration with the CDC and patents the CDC had secured while the two bodies were working together.

Gilead had provided the CDC with its drugs for a trial to see whether they could be used to prevent, not just treat, HIV. The CDC had paid for the trials on macaque monkeys and acquired patents related to this research.

The CDC had then offered Gilead licenses on the patents in exchange for royalties on two drugs if they were marketed for PrEP.

However, Gilead refused and went on to market its drugs for PrEP, initially charging patients around $20,000 for a year’s supply of Truvada.

In addition, Gilead had counter-sued the federal government in 2020 for violating the terms of their PrEP collaboration, arguing that the CDC had sought the patents without notifying the company of its intention, as required by their agreement, and that these patents – on Gilead’s drugs – were thus invalid.

Gilead won that case last year, which undermined the federal government’s case.

However, the advocacy organization PrEP4All, said that, “if the jury’s verdict stands, it will not only perpetuate harm to the American people but also threaten to set a dangerous precedent, encouraging other drug companies to privatize and profit from publicly developed technology with impunity”.

“Taxpayers paid for CDC and NIH’s invention and development of HIV PrEP. CDC scientists patented their work. The government attempted, for years, to negotiate with Gilead a reasonable license to these patents.”

However, Gilead said in a statement that the court decision “confirms our longstanding belief that we have always had the rights to make Truvada and Descovy for PrEP available to all who need it”.

The UN multi-stakeholder meeting on pandemic prevention, preparedness and response.

The global response to COVID-19 failed people in developing countries, women and health workers and must never be repeated, non-state actors told a meeting hosted by the United Nations (UN) in New York on Tuesday.

The UN convened the four-hour multi-stakeholder meeting on pandemic prevention, preparedness and response (PPPR) in preparation for a High-Level Meeting (HLM) on the issue in September, which will adopt a political declaration.

Dr Joanne Liu, representing the Independent Panel for PPR, told the meeting that Ebola would not have been defeated without high-level political leadership, and the same was necessary to address future pandemics.

“We need the highest level of political attention on pandemic threats because they are overwhelming, complex and have a multi-sectoral impact,” said Liu. “A leader-led Global Health Threat Council is essential to sustain global pandemic readiness.”

Lui added that “it is certain that new pandemic threats will emerge, but full-blown pandemics are a political choice.

“This September, the UN General Assembly has the historical opportunity to choose to make COVID-19 the last pandemic of such devastation.”

Health threats council?

In a recorded message, World Health Organization (WHO) Director-General Dr Tedros Adhanom Ghebreyesus supported “the proposal for a health threats council as a forum for high-level political leadership”. 

However, he warned that such a council had to be “grounded in WHO constitutional mandate and complement and strengthen existing governance structures, including the World Health Assembly and the Standing Committee on Health Emergency Prevention, Preparedness and Response, which the WHO’s executive board established last year”. 

Otherwise “we face the risk of establishing multiple disconnected initiatives that drive further fragmentation”, he added.

But Nina Schwalbe, representing the UN University’s International Institute of Global Health, advocated for a high-level council to hold member states accountable for their commitments to PPR that was independent of the WHO.

“As has been evidenced by other sectors, including human rights, chemical weapons, climate and atomic energy, signing a treaty is not enough,” she noted. 

“Compliance requires independent monitoring. Reporting to the highest level of government, a high-level political council made up of heads of state and their representatives can drive cross-national, multisectoral accountability and monitor member states compliance with the pandemic accord,” she added.

Meanwhile, the Pandemic Action Network called for “a robust set of monitoring and accountability mechanisms in the high-level declaration, starting with a progress review within 12 months of the summit”. 

Nurses from the primary care team at the Gonçal Calvo Health Centre in Spain test for COVID-19.

Addressing inequity

“The primary manifestation of inequality was the inequitable distribution of vaccines,” said Dr Carlos Correa of the South Centre. “The COVAX mechanism failed to achieve equitable distribution of vaccines not only due to financial reasons but because the governance of the system was not multilateral in nature.”

Amnesty International noted that 28% of COVID-19 deaths were in Latin America and the Caribbean, yet it is home to only 8.4% of the world’s population.

“Our societies suffer a rampant inequality that excludes entire populations from health systems, especially women and indigenous peoples,” it noted.

The Medicines Patent Pool (MPP) said it was possible to include equitable access conditions in funding agreements to help “address questions of affordable access long before the product comes to market”. 

“This is especially important in the context of PPPR. Public, multilateral and charitable financing of r&d can be conditioned on funded entities taking sufficient measures by voluntary licencing or otherwise, to ensure that every medical technology is available and affordable to all,” said the MPP.

Meanwhile, the People’s Vaccine Alliance wants any political declaration to “enable local production to ensure a sustained supply of countermeasures”. 

“That means a commitment to sharing technology, removing intellectual property barriers, investing in r&d in the south, and investing in actual manufacturing,” said the alliance’s Mohga Kamal-Yanni.

Protecting healthworkers 

“The pandemic exacted a huge toll on the physical and mental health of health workers around the world, infecting millions and causing the deaths of more than 180,000,” said Pamela Cyriano from the International Council of Nurses.

“Excessive” burnout and the ageing of the workforce are exacerbating the already existing shortage of six million nurses, half of which are in our African nations. 

“Healthcare workers stepped up for COVID and put their lives on the line. But we have to ask, will they be there the next time,” she said, calling for the investment in fair and decent pay and in the training new nurses,” sakis Cyriano.

David Bryden, director of the Frontline Healthworkers Coalition, also pointed out that “migration of health workers, in particular nurses, from low and middle-income countries to high-income countries has increased dramatically in recent years, putting pandemic response capacity at risk in their countries of origin”.

More parliamentary involvement

Ricardo Baptista Leite, president of UNITE Parliamentarians’ Network for Global Health

Ricardo Baptista Leite, president of UNITE Parliamentarians’ Network for Global Health, urged more involvement of Members of Parliament in negotiations on a pandemic accord, currently coordinated by the WHO.

“I was in a meeting of 300 MPs recently and asked who had heard of the pandemic accord and no one put up their hand,” said Leite, pointing out that MPs pass the budgets of countries and are thus essential in securing finances for pandemic preparedness.

Leite also urged more action against the deluge of misinformation that is undermining public trust in medicines and vaccines.

Angela Kane, Senior Advisor to the Nuclear Threat Initiative.

Angela Kane, former UN Undersecretary General and Senior Advisor to the Nuclear Threat Initiative, said that there were “significant gaps” in international mechanisms to help figure out the source of biological events.

The WHO “is well positioned to assess outbreaks of natural origin, so-called spillover from animals to humans”, said Kane, adding that it is “still deciding how far it will go to assess an outbreak origin once signs begin to emerge that it may have resulted from a lab accident or deliberate bioweapons attack”. 

“This is an important decision because WHO needs to maintain the trust and openness of its member states to carry out its public health mission and engaging in security-related issues could make that difficult,” said Kane.

On the other end of the spectrum the UN Secretary-General has the authority to investigate allegations of deliberate bioweapons use –  but only when there were brought to it by member states and this had never happened.

“There is no mechanism in the UN system to assess events of unknown origin that fall between the scope of these two mandates,” said Kane. “Are we doing enough to rapidly identify cases where there’s ambiguity about a source of an outbreak?

“The challenges of discerning COVID-19 origins have highlighted the need to fill this gap for determining the origins of a disease outbreak in a form that is scientifically based.”

The multi-stakeholder meeting was one of a trio – the others dealing with tuberculosis and universal health coverage – held this week in preparation for the UN HLMs on these three issues over three consecutive days from 20-22 September.

Image Credits: Consorcio Sanitario del Maresme, Spain.

TB activists attend a community assembly in New York’s Battery Park to call for more investment in TB vaccines and treatments.

The United Nations (UN) is hosting three multi-stakeholder meetings in New York on Monday and Tuesday on tuberculosis, pandemic prevention, preparedness and response (PPPR) and universal health coverage (UHC).

They are aimed at getting the views of non-state actors in preparation for UN High-Level meetings in September, starting with pandemic preparedness on 20 September, followed by UHC, then TB on consecutive days.

On Sunday, a community assembly was held in New York’s Battery Park to call for more investment in TB, the second-biggest infectious disease killer after COVID-19. It included the public reading of the TB vaccine R&D investment open letter signed by almost 1200 individuals and organisations around the world.

“We have seen before that investing in averting TB deaths can bring significant economic benefits! Every dollar invested in this effort returns an average of $43 dollars, making it a smart and impactful investment for communities and economies alike,” said Kate O’Brien from We are TB USA.

“We need new TB vaccines to end TB, mitigate the impact of COVID-19 on the global TB response, and control the spread of drug-resistant TB, a key driver of antimicrobial resistance. Yet, the only available TB vaccine is the century-old Bacillus Calmette-Guérin (BCG) which is largely ineffective in adolescents and adults,” said Keyuri Bhanushali, a TB survivor and activist from Mumbai, India.

“Let’s invest in TB vaccine R&D to finally put an end to this devastating pandemic.”

Lack of consultation over pandemic and UHC meetings

However, some civil society participants told Health Policy Watch that there had been little consultation about participation, particularly in relation to the pandemic and UHC meetings, including over speakers on the panels and the procedures to be followed.

Many organisations had invested in bringing affected people from other parts of the world to the UN meetings yet they were unsure of whether they would be able to speak from the floor. In addition, they questioned why organisations’ statements would be loaded onto the website of the World Health Organization (WHO), not that of the UN.

In response, Paulina Kubiak, spokesperson for the President of the General Assembly (PGA), told Health Policy Watch that there had been “an open registration process on the UN Indico website for stakeholders to participate in the multi-stakeholder hearings”, with registration open from 2 March to 7 April. 

“The panellists were selected in accordance with the relevant resolutions of the General Assembly which require the PGA to organize the multi-stakeholder hearings with the support of the WHO and other relevant partners (Stop TB Partnership in the case of TB and UHC2030 in case of UHC),” said Kubiak.

“Written statements can be submitted by participants until May 15 and will be available on the WHO website in due course (pending the volume of submissions).”

The meetings are being broadcast live on the UN webTV:

Image Credits: UN Photo/Manuel Elias.