IQAir air pollution map for PM 2.5 (2022). Only countries in blue meet the WHO guidelines.

Ninety percent of 131 countries exceeded the World Health Organization’s (WHO) air pollution guidelines for fine particulate matter (PM 2.5) in 2022, according to a new report that combines data from official monitoring stations and “citizens science” monitors around the world. .

The report was the fifth such World Air Quality Report to be released Tuesday by the Swiss firm managing the air quality monitoring site IQAir, which crowd sources real-time monitoring data from both citizen scientsts and more official sources. Altogether, that includes data from over 30,000 air quality monitoring sensors and stations across 7,323 locations in 131 countries. 

However, critics point out that the reporting combines data from low-cost monitoring sensors and stations with the more robust monitoring by governments and research institutions, which is typically reported on by WHO and research institutions. That, mix, some scientists and researchers, contend, can point to general trends, but it is not always reliable or consistent.

“The IQ database raises awareness and that is OK, but the transparency of the data is not a given. It is what it is,” one expert, who asked not to be named, told Health Policy Watch.

Low cost monitors becoming more reliable

On the other hand,  low-cost air quality monitors are becoming increasingly reliable, as well as popular – to cover critical gaps in coverage in low- and middle-income countries that cannot afford more expensive tools, supporters of the initiative maintain.

“In 2022, more than half of the world’s air quality data was generated by grassroots community efforts. When citizens get involved in air quality monitoring, we see a shift in awareness and the joint effort to improve air quality intensifies. We need governments to monitor air quality, but we cannot wait for them. Air quality monitoring by communities creates transparency and urgency. It leads to collaborative actions that improves air quality,” states Frank Hammes, Global CEO, IQAir.  The firm’s for-profit branch also markets air purifiers, filters and face masks.

PM 2.5 is made up of tiny particles in the air, including sulfates, nitrates, black carbon, and ammonium, which are considered among the most health-hazardous air pollutants.  PM 2.5 concentrations are also considered to be the best metric for estimating health impacts from air pollution. In line with this, updated WHO guidelines recommend that countries should ensure an annual average of five micrograms per cubic meter (μg/m3) or less to protect people’s health – a measure that even high income countries with strong air quality management systems often fail to meet.

Only six countries meet WHO guidelines

In fact, according to the data published by the company, only Australia, Estonia, Finland, Grenada, Iceland, and New Zealand met the WHO guideline in 2022.  

Countries with the most polluted air were Chad, (89.7 µg/m3, over 17 times higher than the WHO guideline), Iraq (80.1 µg/m3), Pakistan (70.9 µg/m3), Bahrain (66.6 µg/m3) and Bangladesh (65.8 µg/m3). However in the case of arid states in Africa, the Middle East and South Asia, dust storms can also be a huge factor in pollution levels, experts say.  

Pakistan’s Lahore was the most polluted metropolitan area in 2022, while eight of the world’s 10 worst polluted cities were in Central and South Asia.

The most polluted city in the US was Coffeyville, Kansas, while 10 of the 15 most polluted cities in the US were in California. Las Vegas was deemed the cleanest major city.

WHO has not published country-by-country averages for the past several years – so it is difficult to make comparisons between the IQAir’s “citizen science” findings and more official sources of data. 

Six million die annually from air pollution

Air pollution is the world’s largest environmental health threat, killing an estimated 6-7 million people each year, according to WHO and the Global Burden of Disease report 2019.

The total economic cost equates to over $8 trillion dollars, which is over 6% of the global annual GDP, according to the World Bank. Exposure to air pollution causes and aggravates several health conditions which include, but are not limited to, asthma, cancer, lung illnesses, heart disease, and premature mortality.

“Sustained exposure to PM2.5 concentrations above the annual average guideline level result in a chronic impact on individuals’ respiratory and circulatory systems leading to long-term complications such as heart disease and decreased lung function,” according to the report.

While the number of countries monitoring air has steadily increased over the past five years, there were “significant gaps in government-operated regulatory instrumentation in many parts of the world”, according to IQAir. 

“Low-cost air quality monitors sponsored and hosted by citizen scientists, researchers, community advocates, and local organizations have proven to be a valuable tool to reduce the massive inequalities in air monitoring networks across the world, until sustainable regulatory air quality monitoring networks can be established,” it added.

Only 19 African countries had the ability to monitor their air quality, and only 156 stations producing all the included data for the continent,

“In 2022, more than half of the world’s air quality data was generated by grassroots community efforts,” said IQAir CEO Frank Hammes. “We need governments to monitor air quality, but we cannot wait for them.”

 Aidan Farrow, Greenpeace International’s air quality scientist, said that “too many people around the world don’t know that they are breathing polluted air”. 

“Air pollution monitors provide hard data that can inspire communities to demand change and hold polluters to account, but when monitoring is patchy or unequal, vulnerable communities can be left with no data to act on. Everyone deserves to have their health protected from air pollution,” added Farrow, whose organisation collaborated with IQAir on the report.

Healthcare workers
Countries rich and poor suffered during the COVID pandemic due to healthcare worker shortages, but rich countries were able to import more workers.

Eight more countries in the global south have dangerously low numbers of healthcare workers in the wake of the COVID pandemic, a new WHO report has found. 

The World Health Organization’s 2023 report on “Health workforce support and safeguards” found that some 55 countries now rank below the global median in terms of their density of doctors, nurses and midwives per capita. 

That is in comparison to 47 countries in 2020 when the last report was produced, based on data collected just prior to the outbreak of the COVID pandemic. 

The WHO report series tracks countries where the number of professionally trained healthcare workers falls below the global median of 49 per 10,000 population. It also examines countries’ rankings in terms of a Universal Health Service coverage index. 

The negative health, economic and social impacts of COVID-19, coupled with the increased demand for healthcare workers in high-income countries experienced during the pandemic, likely helped trigger more outward migration of healthcare workers from countries that are already suffering from low health workforce densities, the report found. 

“Health workers are the backbone of every health system, and yet 55 countries with some of the world’s most fragile health systems do not have enough and many are losing their health workers to international migration,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General, in a press release that accompanied the report. 

Rich countries still falling short on global code of practice for international recruitment of health professionals 

The outward migration of healthcare workers from low or middle income countries in search of better wages and working conditions is a longstanding issue, which has only become more serious as the global workforce becomes more mobile generally. 

For instance, the proportion of foreign-trained physicians increased from 32% in 2010 to 36% in 2020, in eight OECD countries already blessed with a high density of healthcare workers.

The voluntary Global Code of Practice for the International Recruitment of Health Personnel, adopted at the 2010 World Health Assembly, aims to curb aggressive recruitment of healthcare workers from the global south by rich countries – as well as supporting fair and transparent employment terms for those who do choose to migrate elsewhere.  

Healthcare Workers
Factors acting on healthcare workers demand and supply in the market.

Accompanying the code, WHO was mandated to track and periodically update member states on trends in health workforce numbers in countries deemed “vulnerable”, as well as examining how such worker migration is affecting progress toward the goal of Universal Health Coverage. 

Since 2010, member-states have reported every three years on data and trends regarding international migration of healthcare workers. 

The fourth round of review was launched in May 2021 against the background of the COVID-19 pandemic, which caused severe disruptions to healthcare services in many countries, as well as increasing rich countries’ reliance on international healthcare workers, the report stated. 

African countries are the hardest hit 

Among the countries that recently joined the list of those with vulnerable health workforces are Rwanda, Comoros, Zambia and Zimbabwe in the African region; Timor-Leste in the South-East Asia region; and Lao People’s Democratic Republic, Samoa and Tuvalu in the Western Pacific region of the WHO. 

Among all 55 countries with sub-par numbers of health care workers, 37 are WHO’s Africa region, eight in the Western Pacific region, six in the Eastern Mediterranean region, three in south-east Asia region and one country in the agency’s Americas region, the report found.  All of these countries have a healthcare workforce density of less than 49 workers per 10,000 people. 

These countries also rank at 55 or less on WHO’s Universal Health Coverage (UHC) service coverage index – which tracks access to key, lifesaving services on a scale of 0, to 100. Service coverage is calculated as the average of 14 “tracer indicators” for access to four broad groups of health services: reproductive, maternal, newborn and child health; infectious diseases;  noncommunicable diseases; and service capacity and access. 

Policy research has documented the linkages between the size of a country’s healthcare workforce and health outcomes. And the global data collected by WHO also shows a strong association between health workforce density, and UHC coverage rankings overall. 

Healthcare workers
Healthcare workforce density per 10,000 population. The countries in the blue rectangle are the ones added in the updated list, with healthcare worker density less than 55 per 10,000 population.

Approximately 15% of health care workers globally are working outside of their country of birth, WHO has found. But this varies widely by region – with the proportion of foreign-trained nurses reaching 70% to 80% in some affluent Gulf countries in WHO’s Eastern Mediterranean Region. About 10-12% of foreign trained doctors and nurses hail from countries deemed vulnerable by WHO due to their lack of sufficient numbers of indigenous healthcare workers.  

While the 2010 WHA resolution did not prohibit international recruitment of healthcare workers, it calls on the countries, particularly the high income countries, to ensure that their recruitment does not adversely affect the healthcare systems and delivery of healthcare services in the source countries. 

Call to countries to reduce adverse effects of international recruitment 

The WHO also recommends that healthcare workers migration agreements signed between two governments should explicitly ensure that benefits to the source country are “commensurate and proportionate” to the benefits accrued by the healthcare system of the destination country. 

It also recommends that such safeguards be applied to all low and middle income countries, regardless of their ranking on the list. 

Scarcity of healthcare workers in low and middle income countries, and their outward migration in search of better pay and conditions, has been a longtime global health policy issue. The COVID-19 pandemic only exacerbated an existing inequalities that hobble the development of robust health systems in many developing countries.

In 2020, the International Council of Nurses estimated that there is a global shortage of six million nurses and the effects of the pandemic will drive health worker migration from the low and middle income countries. A WHO report on the State of the World’s Nursing profession, published in that same year, estimated that one in eight nurses globally have migrated from elsewhere. 

Healthcare workers
Estimation of healthcare workers shortage across the world in 2013 and in 2030.

In 2020, when the list of vulnerable countries was first compiled, the UHC service coverage index benchmark was was 50 out of a score of 100. However, after COVID-19 caused widespread health, social and economic impacts, WHO increased the threshold to 55. 

“The increasing demand for health and care workers in high-income countries might be increasing vulnerabilities within countries already suffering from low health workforce densities,” observes the new WHO report. 

“WHO is working with these countries to support them to strengthen their health workforce, and we call on all countries to respect the provisions in the WHO health workforce support and safeguards list,” stated Tedros.

Image Credits: Photo by Carlos Magno on Unsplash, World Health Organization (WHO), World Health Organization (WHO).

Covid-19 pandemic
Thousands of small white flags stand sentinel outside the Washington D.C. Armory in October 2020, each representing an American who died from COVID-19.

Three years after the World Health Organization’s (WHO) declaration of the COVID-19 pandemic, the era of hourly headlines updating death and case counts has come to a merciful end. But the virus is still killing around 1,000 people worldwide every day, and it isn’t going anywhere. 

As of 7 March, WHO has confirmed over 750 million cases of COVID-19 and 6.8 million deaths – widely viewed as a considerable underestimate by experts. 

The world’s choice to move on from the pandemic is reflected in the increasingly sparse data on case, test and death counts that once underpinned the breathless news cycle at the height of COVID-19’s assault. 

Last week, Johns Hopkins University announced it was shutting down its global COVID-19 tracker due to the lack of data. The interactive map had been a trusted source for journalists, academics, researchers and policy makers since it launched shortly after the virus began its escape from China. 

Yet WHO has said it is not ready to declare an end to the pandemic, and some experts worry that the virus could mount a counter-attack. COVID-19’s continued circulation provides it with ample opportunities to mutate and become more transmissible by learning to sidestep immune responses. 

“Whatever the virus is doing today, it’s still working on finding another winning path,” Dr Eric Topol, head of Scripps Research Translational Institute told the Associated Press.

With public trust in global health institutions in free fall and deep global divisions permeating the COVID-19 landscape, Topol fears the world is not prepared for a more infectious variant to emerge.

“I wish we united against the enemy — the virus — instead of against each other,” he said.

‘Never Again’

Former United Nations (UN) Secretary General Ban-Ki Moon, Nobel laureate Joseph Stiglitz, and current Timor-Leste President and Nobel Peace Prize winner Jose-Manuel Ramos Horta joined nearly 200 global figures in signing an open letter calling on world leaders to “never again” allow pharmaceutical companies to choose profits over saving lives. 

The letter, published on the third anniversary of the WHO’s pandemic declaration on 11 March, pinned millions of preventable deaths on the “private monopolies” created by vaccine patents and the pharmaceutical industry’s “desire to make extraordinary profits” over “the needs of humanity”.

“Instead of rolling out vaccines, tests, and treatments based on need, pharmaceutical companies maximized their profits by selling doses first to the richest countries with the deepest pockets,” the letter said. “Billions of people in low and middle-income countries, including frontline workers and the clinically vulnerable, were sent to the back of the line.”

Equitable sharing of vaccines globally could have saved an estimated 1.3 million lives in the first year of vaccine availability – one every 24 seconds – according to an analysis published in Nature based on modeling by The Lancet. 

Helen Clark, former Prime Minister of New Zealand and co-chair of the Independent Panel for Pandemic Preparedness and Response established by WHO, said the vast public funding backing the science that contributed to the vaccines meant they should have be treated as global common goods. 

“Nationalism and profiteering around vaccines resulted in catastrophic moral and public health failure which denied equitable access to all,” she said. “We need to fix the glaring gaps in pandemic preparedness and response today, so that people in all countries can be protected when a pandemic threat emerges.”

IP-related suffering

Vaccines
A United States delivery of 655,200 COVID-19 vaccine doses through COVAX to Ethiopia on September 23, 2021.

The letter also noted that this is not the first time intellectual property claims by pharmaceutical companies over life saving medicines have caused unnecessary suffering.

“In the AIDS pandemic, pharmaceutical monopolies have resulted in an appalling number of unnecessary deaths – and it has been the same story with COVID-19,” said Winnie Byanyima, Executive Director of UNAIDS. “But governments still have not learned that lesson. Unless they break the monopolies that prevent people from accessing medical products, humanity will sleepwalk unprepared into the next pandemic.”

The pharmaceutical industry, meanwhile, points the finger at vaccine nationalism displayed by governments. Industry groups also highlight the scientific achievements of the COVID-19 vaccine race, which brought safe vaccines to market in record time and catalyzed hundreds of promising medical trials based on mRNA technology. 

“The pharmaceutical industry has been advocating for equitable vaccine distribution to vulnerable populations in low-income countries since 2021, and has worked as a key partner in COVAX,” Thomas Cueni, Director General of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) told Health Policy Watch in an email. 

“It must be recalled that after [the] initial fast roll-out of COVAX vaccines, which saw Ghana receive the first batch of vaccines less than three months after the first distribution in Europe, India – which was the principal source of licenced vaccine supply – shut its borders for almost seven months, and it took far too long for high income countries to step up and start dose sharing,” he said. 

The United States and European Union were also slow to share their vaccine supplies as they struggled to get their domestic outbreaks under control, resulting in millions of doses sitting in warehouses as poorer countries begged for them to be shared. 

In its 2022 annual report, the UN World Intellectual Property Organization (WIPO) estimated the social benefit of COVID-19 vaccines – a calculation of lives saved, health costs avoided, and value of saving economies from mitigation measures like lockdowns – at $70.5 trillion, 887 times pharmaceutical revenues of $130.5 billion. 

Vaccines have saved tens of millions of lives globally since the onset of the pandemic, according to the Lancet’s Infectious Diseases Journal. But unequal access in low-income countries has limited their impact, highlighting the need for global vaccine equity.

“Singling out intellectual property as the cause of lack of access also diverts attention from focusing on key hurdles such as weak health systems, supply chain challenges, vaccine nationalism, and gross misinformation, all of which significantly contributed to slow vaccine uptake,” Cueni said. “Governments must engage to create a social contract that enhances equity in future pandemic responses.” 

Negotiating a pandemic accord 

WHO Director-General Dr Tedros Adhanom Ghebreyesus has called on countries to not repeat the mistakes of COVID-19 in negotiating a new pandemic accord.

WHO member states are currently negotiating an accord to guide the global response to the future pandemics, including equitable access to medicines such as vaccines, but progress has been slow. 

The latest negotiations on the zero draft of the global pandemic accord were dominated by concerns over equity and financing, echoing the now familiar battle lines that have defined international climate adaptation and biodiversity negotiations. 

WHO Director-General Dr Tedros Adhanom Ghebreyesus, who has stated he hopes to preside over the initial approval of a WHO pandemic accord in 2024, when a final draft is due to be presented to the World Health Assembly, appealed to member states in his opening remarks to “not repeat the same mistakes” of the COVID-19 pandemic. 

He repeated that message on Monday in a ceremony at the University of Michigan, Ann Arbor, where he received a global public health award, saying that the importance of global cooperation is among the three lessons of the pandemic – along with the importance of health and science:

“Instead of a coherent and cohesive global response, the pandemic has been marked by a chaotic patchwork of responses. This is because of narrow nationalism,” Tedros said. “We can only face shared threats with a shared response, based on a shared commitment to solidarity and equity.”

Rooted in equity and human rights

Echoing that, Ban-Ki Moon said the pandemic accord must be “rooted in equity and human rights,” and place “the needs of humanity above the commercial interests of a handful of companies” in a comment accompanying the People’s Vaccine Alliance open letter.

“The great tragedy of the COVID-19 pandemic has been the failure of multilateralism and the absence of solidarity between the Global North and the Global South,” Ban-Ki Moon said in his statement accompanying the open letter. “We need a return to genuine cooperation between nations in our preparation and response to global threats.”

But negotiations are still in their early stages, and it is too early to judge whether they will be successful. 

The US, Japan and India have expressed opposition to the current accord draft’s stipulation that 5% of GDP be designated for pandemic preparedness, with India calling the provision “overly prescriptive”.  

Western Pacific countries, inscluding small island states that are already facing the earliest consequences of climate change, meanwhile, have requested that “specific recommendations in recognition of the impacts of climate change” be considered. 

A confluence of crises  

Former United Nations Secretary General Ban-Ki Moon called the global response to COVID-19 a “failure of multilateralism and an absence of solidarity.”

It is hard to keep count of the generational crises that have hit the world since WHO declared the COVID-19 pandemic. 

Estimates of lives lost in Russia’s invasion of Ukraine number well over 200,000, with hundreds of thousands more injured, and millions displaced. The largest earthquake since Fukushima shook Turkey and Syria, claiming 50,000 lives and counting. 

The visceral images of the devastation wrought by these catastrophes empower their death counts with shock value, but also put into perspective the numbness with which the 1,000 daily global deaths from COVID-19 are met three years into the pandemic. 

This confluence of crises over the past three years has created a perfect storm where the eye of the hurricane looms over the livelihoods of the world’s most vulnerable.

The virus as a test run for other challenges…

In a 2022 analysis by Nature, researchers found that up to 667 million people were living in extreme poverty – nearly 100 million more than before the pandemic and Russia’s invasion of Ukraine. 

The virus showed that a threat anywhere could be a threat everywhere – a trait shared with the overlapping crises of climate change, conflict, economic inequality, migration and global health.  And if the pandemic was the test run, it has shown the world is not up to the challenge of meeting any of these challenges.  

Climate change declared its arrival as a regular part of the day-to-day lives of billions around the world as floods submerged over a third of Pakistan last August, and drought-related hunger gripped the Horn of Africa this year with increasing severity.  Meanwhile, the world’s efforts to curb global warming to 1.5 degrees continue to fall far short. 

Russia’s invasion of Ukraine sent shockwaves through the world’s fertilizer and energy markets, further exacerbating a global food crisis that had already reached historic heights. 

Over 345 million people will face food insecurity in 2023 – over double pre-pandemic levels, with 200 million more people struggling to feed themselves and their families than in 2020, the World Food Programme said. Another 900,000 worldwide are facing famine, 10 times more than five years ago. 

Meanwhile, the past decade has seen the top 1% capture around half of all new wealth created since 2020, worth $42 trillion, according to a January 2023 report by Oxfam published on the opening day of the World Economic Forum in Davos, Switzerland. 

“While ordinary people are making daily sacrifices on essentials like food, the super-rich have outdone even their wildest dreams,” Gabriela Bucher, Executive Director of Oxfam International said. “Forty years of tax cuts for the super-rich have shown that a rising tide doesn’t lift all ships – just the superyachts.”

The legacy of the pandemic is not yet fully written. But as it stands, it is a story of inequality. 

Image Credits: Ron Cogswell, US State Department, World Bank.

Omicron
A COVID-19 sanitation worker in Dalian, a port city in China’s Liaoning Province

The US and Australia lifted COVID-19 travel restrictions on Chinese travellers last Friday and Saturday respectively, effectively acknowledging that the world’s biggest pandemic outbreak is over.

Until the weekend, Chinese citizens had to present a negative COVID-19 test or proof of recovery to enter either country.

In late January, the Chinese government reported that 80% of the country had been infected by the virus – but insisted that its death toll was very low. However, this was mainly because it had a very narrow definition of deaths, only recognising those who have died of a respiratory illness and have had a scan to confirm lung damage caused by the virus. 

Trying to get a full picture of the pandemic’s trajectory in China has been difficult as, once it had abandoned its strict zero-COVID policy, China’s National Health Commission also stopped issuing detailed public reports, publishing the last report on 24 December 2022.

The most recent COVID-19 report by the China Center for Disease Control and Prevention (China CDC) shows that the country’s pandemic outbreak peaked on 23 December with 6.94 million positive COVID-19 tests being recorded on 23 December. 

That same day, China CDC reported that over 2,8 million people visited “fever clinics”. In contrast, only 481,000 people visited these clinics on 9 March, 2023, representing a decrease of 83.2% from the peak 

Meanwhile, hospitalisations peaked at 1.625 million on 5 January this year but plummeted by 99% to  8,629 on 9 March.

However, according to China CDC, hospital deaths peaked at 4,273 on 4 January but by 9 March, there were no COVID-related deaths.

Official Chinese figures reported to the World Health Organization (WHO) show that over 99 million Chinese were infected with COVID-19, but there have been only 120,227 deaths by 7 March.

However, independent health analytics company Airfinity modelled that daily deaths would reach 32,200 by 17 January with cumulative deaths from 1 December 2022 to 17 January to be 608,000 – almost three times the total fatalities reported by China to date.

“Deaths are forecast to peak at 36,000 a day on 26 January during the lunar new year festival. This is up from our previous estimate of deaths peaking at 25,000 a day,” said Airfinity. 

The full extent of COVID-19’s impact is unlikely to surface after Chinese authorities announced an internet crackdown on people spreading “false information” and “gloomy sentiments” about COVID-19 for a month around the lunar new year festivities in late January, according to The Guardian.

By 9 March, over 90% of the Chinese population – 1.28 billion people – had received the recommended two vaccines, while over 827 million people had received their first booster dose.

Last Friday, the Chinese parliament, the National People’s Congress, re-elected Xi Jinping as the country’s president for a third term, something that was already assured by the Communist Party congress last October,

However, Ma Xiaowei, the head of the National Health Commission scraped back into the position with the lowest number of votes, facing 21 objections and eight abstentions. Ma is blamed for the country’s zero-COVID policy that locked down millions of people for months at a time, and forced others into quarantine camps.

Image Credits: Jida Li/Unsplash.

Before the Framework Convention on Tobacco Control was adopted in 2003, the World Health Organization had worked for many years to prevent damage caused by tobacco consumption with the goal of passing an international agreement on tobacco regulation. The agreement, however, was not moving forward.

“The real breakthrough came as scientific evidence emerged showing the negative consequences of passive smoking and its impact on children,” Ilona Kickbusch, the founding director of the Global Health Centre at the Graduate Institute in Geneva, tells host Garry Aslanyan in the new episode of the “Global Health Matters” podcast. “These data and this evidence really made a significant difference in getting the negotiations started.”

Thanks to this development, the convention was eventually adopted, becoming the first international treaty negotiated under the auspices of WHO. Today, the agreement includes 182 parties, covering over 90% of the world population.

According to Kickbusch, the convention embodies an important example of how science and diplomacy can complement each other in achieving a goal or in driving a change. The expert discusses the role of science diplomacy in global health with Aslanyan and Aída Mencía Ripley, the Vice-Chancellor for Research and Innovation at Universidad Iberoamericana in the Dominican Republic.

Ripley shares how in the Dominican Republic science diplomacy was key to overcoming the challenges of the coronavirus pandemic.

“We were able to use science diplomacy to build some bridges and provide some of the early data on COVID sequencing for our country,” she recalls. “We were actually one of the first countries in the region that was able to do this, thanks to some of these international collaborations.”

Kickbusch also notes that the pandemic clearly showed how many global health issues are also subject to ideology, making hard evidence crucial.

“Being able to come together and create a global consensus also means we have to overcome ideology and we need to have really, really good data,” she says. “We can see that over the years, particularly in issues related to sexual health in the widest sense of the word, many of the international agreements, such as those guaranteeing access to medicines for stigmatized groups, were only possible because we had the hard science.”

Another important element for building consensus is promoting trust in governments and institutions, the two experts say.

“We are in a situation where trust in science and in policy-making is not as strong as it was ten or twenty years ago,” Kickbusch says. “We really need to work on that trust. We need to work on health literacy. We need to work on science literacy, both of the general population and of policy-makers and diplomats.”

Ripley highlights that in order to tackle health issues at the global level, it is essential to consider not only the hard science but also each society’s context.

“Global health is completely over-medicalized at this point,” she points out. “I think that some of the nuances that social and behavioral sciences bring to the table are crucial because we need to be able to understand people’s socioeconomic and political contexts in order to make sure that we meet people halfway, especially when we ask them to make major changes to their way of life, such as we did during the pandemic.”

Listen to previous episodes of Global Health Matters on Health Policy Watch.

Image Credits: TDR.

COVID origins
Redfield testified to the US Congress subcommittee on COVID-19 that he had been “sidelined” in the investigation into the origins of the virus by former NIH Director Anthony Fauci for promoting the lab leak theory. Fauci has called the claims “completely untrue”.

This week’s testimony by former CDC director Dr Robert Redfield to US Congress has reignited widespread speculation in the United States that the SARS-CoV-2 virus first emerged in a Wuhan research laboratory rather than in animals. The scientific debate about the origins of the virus took off this week just before the three-year anniversary of the World Health Organization’s declaration of the pandemic on 11 March 2020.

Redfield’s testimony on Wednesday, in which he stated it was “not scientifically plausible” that the virus had natural origins, comes on the heels of several weeks of US media reports that revealed support for the laboratory leak theory in several US government agencies. 

To sceptics, the information shared by Redfield and others remains “anecdotal”. Three years and 7 million deaths from the start of COVID-19’s global assault, researchers stress that the world is a long way from having definitive answers to how the SARS-CoV-2 virus made the jump to humans. 

The three keys to Redfield’s testimony 

The Wuhan Institute of virology is located 8 miles from the market where scientists believe SARS-CoV-2 first made the jump to humans.

In his testimony, Redfield, director of the CDC under former president Donald Trump at the onset of the pandemic, told Congress about three events that occurred shortly before the pandemic began which led him to believe the virus emerged from laboratory biosecurity failures.  

Those included a shift from Chinese civilian to military control of the lab and renovations to the facility’s ventilation system, as well as the deletion of the Wuhan Institute of Virology’s research database on coronavirus genome sequences that it was researching.

“The declassified information now shows in September 2019, three things happened in that lab,” Redfield told the Congressional subcommittee. Convened by the Republican House majority, the bipartisan group is once again investigating the origins of SARS-CoV-2. “Clearly there is strong evidence that a significant event happened in that laboratory in September.”  

“One is they deleted the sequences,” he said in reference to an online database of genome sequences of bat-related coronaviruses, which was taken offline  in September 2019 and has not resurfaced since. “That is highly irregular. Researchers don’t usually like to do that.”

“The second thing they did is they changed command and control of the lab from civilian control to military control. Highly unusual,” Redfield said, without elaborating his sources.

Media reports have shown that WIV likely operated as a “dual-use” facility with civilian and military functions and hosted military scientists.

One military scientist hosted by WIV was Zhou Yusen, director of the State Key Laboratory of Pathogen and Biosecurity at the Academy of Military Medical Sciences Institute of Microbiology and Epidemiology in Beijing, a joint investigation by ProPublica and Vanity Fair found.  He began researching coronaviruses as early as 2012, and was one of the first scientists to apply for a vaccine patent. 

“The third thing they did I think is really telling,” Redfield said. “They let a contractor redo the ventilation system in that laboratory.”  

Prior Congressional investigations tend to support Refield’s claim on the ventilation issues that plagued the Institute. In August 2021, the House Select Committee on COVID-19 released a memo detailing the malfunctioning of multiple air ventilation systems inside WIV in the months leading up to the pandemic.

Other media reports from 2021 suggested that the renovations on the defective ventilation systems were launched shortly before the pandemic exploded.

Department of Energy report  

Founded in 1952, the Lawrence Livermore National Laboratory in California operated by the US Department of Energy conducts high-level military research on bioweapons.

Redfield’s testimony follows the leak of a recent US Department of Energy report to the Wall Street Journal. The new DOE report assessed that COVID-19 “most likely” came from a lab leak. The agency described its assessment as “low-confidence”. 

The DOE assessment is significant due to the agency’s scientific expertise. It runs a total of 17 biolabs across the country, including Lawrence Livermore National Laboratory, which conducts high-level military research into biological weapons including viruses. US officials have declined to provide details on the intelligence that led to the DOE’s updated position. 

That report a Fox News appearance by FBI director Chrisopher Wray in which he said the bureau has “for quite some time” assessed that the origins of the pandemic are “most likely a potential lab incident in Wuhan.”

Despite differing analyses, Redfield, the classified Department of Energy report, and FBI all concluded that the lab leak was accidental and not the result of a Chinese biological-weapons programme.

A US intelligence community review ordered by President Biden in May 2021 produced two more points of consensus across all US agencies: that the virus first appeared in Wuhan no later than November 2019, and that it emerged without the foreknowledge of the Chinese government. 

“Show me the evidence”

FBI Director Christopher Wray publicly revealed the bureau’s belief in the lab leak hypothesis, but no evidence underpinning the assessment has been made public.

Despite the noise and political theatre of the Congressional hearings, the Department of Energy report remains classified, and the FBI has declined to comment further on the evidence underpinning the bureau’s “moderate confidence” in the lab leak theory. 

Other US agencies, privy to the classified assessments of the DOE and FBI, have not changed their position despite the new evidence. 

The World Health Organization has said that while zoonotic spillover remains the likeliest point of origin, the lab leak theory cannot be ruled out. WHO has said its investigation will continue until a definitive origin is identified. 

For many scientists, the classified nature of the US government reports make them impossible to assess. They have called for more transparency around the recent documentation. 

“I’m a scientist. I need to see the evidence rather than take the FBI director’s word for it,” University of Saskatchewan virologist Angela Rasmussen told the Associated Press. “The vast majority of the evidence continues to support natural origin.”

In contrast to the evidence supporting the lab leak theory, the reasoning behind the animal origin is publicly available. In an influential set of peer-reviewed papers published in July, researchers concluded that SARS-CoV-2 “occurred through the live wildlife trade in China” via the Wuhan market. 

Stephen Goldstein, a virologist at the University of Utah and one of the paper’s co-authors, remains open-minded about the lab leak theory. But like Rasmussen, says it is impossible to assess without access to the evidence. 

“It’s very difficult to say anything until we see what information drove this [DOE] updated analysis,” Goldstein told Vanity Fair. “If the data exists and is declassified and I can update my own analysis, wonderful.”

SARS-CoV2 lacks molecular structure of an engineered virus

The molecular structure of SARS-CoV-2 makes it highly unlikely the virus was engineered.

Redfield’s view that the virus could not have had natural origins is widely disputed by scientists. The SARS-CoV-2 virus has no known backbone, a critical molecular structure on which all engineered viruses are built, making it a bad candidate for bioengineering. 

“Virologists cannot create or design viruses out of thin air,” Robert Garry, professor of microbiology and immunology at Tulane University told the New Republic. “There would need to be at least something close to it in nature.”

The polarized nature of discussion around the origins of SARS-CoV-2 also overshadow a potential middle-ground: the virus was found in nature was brought to the Institute for study. But without the cooperation of Chinese authorities, no evidence that the virus was being studied at the lab has emerged.

Until the full-scope of the work that took place at the Wuhan Institute is made public, the origins of the virus that has killed over seven million people are likely to remain a mystery.

Image Credits: NIH, Creative Commons, LLN, FBI.

sodium
Nearly three-quarters of countries have yet to set policies to regulate sodium content in processed foods.

Eating too much salt kills nearly two million people every year, and without the rapid introduction of global policies to limit sodium content in processed foods, another seven million preventable deaths will occur by 2030, the World Health Organization (WHO) said in a new report.

Unhealthy diets are a major global health challenge, and sodium’s link to high blood pressure and cardiovascular diseases makes it one of the major contributors to nutrition-related deaths.

The average sodium intake globally is more than double the recommended 5-gram, or one teaspoon, daily limit, according to the report.

“That leaves people at risk for heart attack and stroke,” said Dr Tom Frieden, Director of Resolve to Save Lives, a non-profit organization that works to prevent deaths from cardiovascular diseases. “The world needs action, and now, or many more people will experience disabling or deadly, but preventable heart attacks and strokes.”

 

All 194 WHO member states have committed to the goal of reducing national sodium intake by 30% by 2025, and the science is clear: sodium is an essential nutrient but increases the risk of heart disease, stroke, and premature death when overconsumed.

At a press conference accompanying the launch of the report, WHO Director-General Dr Tedros Adhanom Ghebreyesus was blunt about the chances of reaching the 2025 target: “The world is off-track,” he said.

Only nine countries have fully implemented best-practice policies, leaving more than two-thirds of the world unprotected by policies limiting sodium content in food products. The lack of progress by governments in passing basic policies to regulate sodium levels has frustrated WHO officials.

“We cannot fail this completely achievable and affordable public health goal,” said Dr Francesco Branca, Director of Nutrition for Health Development at WHO. “Reducing sodium intake is one of the most cost-effective ways to improve health. It can avert millions of deaths every year at very low total programme costs.”

Governments must push industry

sodium
Higher-income regions achieved marginally higher policy implementation to regulate sodium than their lower-income counterparts.

The report sets out a series of so-called “best buy” policies, which it describes as easy to implement and highly cost-effective measures to reduce sodium intake. These recommendations, however, are not new. These were first endorsed by member states in 2017, yet many have yet to implement any of them.

“Best buy” policies include steps like reformulating foods to contain less salt, establishing public procurement policies to regulate sodium levels in foods purchased by institutions such as hospitals, schools and workplaces, and clear package labelling to help consumers avoid sodium-rich foods.

But these are no replacement for governments setting maximum limits for sodium in processed foods, WHO said. “Best buy” practices, while helpful, do not prohibit manufacturers from producing high-sodium foods and continue to place a significant burden of responsibility on consumers.

“Government-led mandatory maximum limits for sodium in processed foods promote industry-wide reformulation [by creating] a marketplace that restricts the less healthy food options regardless,” Branca said. “This type of policy requires no consumer action and places the burden of avoiding manufacturing less healthy products on the food industry.”

Top down limits on sodium content also safeguard against industry prioritizing short-term commercial interests while leveling the playing field for food manufacturers, preventing competition from developing based on sodium content.

“We know that unfortunately, self-regulation by the food manufacturing industry has repeatedly proven to be ineffective,” Frieden said. “The mandatory approach safeguards against commercial interests which may delay, weaken, distort or impede the development of healthy food and nutrition policies and programmes.”

By October 2022, just 5% of member states had implemented the recommended two mandatory sodium reduction policies. Another 22% had implemented their first mandatory policy. The remaining 73% have no hard restrictions on sodium content.

“We all have a role to play. WHO, governments, the private sector and consumers,” Tedros said. “Together we can make sure that food is a source of health, not a cause of death.”

Panellists Janet Mbugua, Dr Alaa Murabit,  Adriana Rubio, Goodness Ogeyi Odey and Mary-Ann Etiebet.

Millions of African girls are married before they turn 18, while others suffer female genital mutilation (FGM) and a multitude of preventable conditions, the closing plenary of the Africa Health Agenda International Conference (AHAIC) heard on Wednesday.

The plenary promised “bold and honest conversations” about the “backsliding on sexual and reproductive health and rights (SRHR)” on the continent, including scrutinising “social, economic, and cultural barriers driving the suppression of health rights”.

However, many of the panellists tiptoed around the prevailing religious and cultural conservatism despite an early appeal from the MC, Janet Mbugua, to address “the elephant in the room” – how to prevent the backsliding and ensure women and girls have “agency and power”.

Janet Mbugua

Mbugua runs the Inua Dada Foundation, a girls’ empowerment organisation, and spoke about a 16-year-old girl her foundation had assisted who “had never heard about sex or consent, but somehow ended up engaging in unsafe sex and becoming a teen mom”. 

“While there’s been so much progress, there’s equally been so much pushback. In fact, the more agency we have, the more it seems that our voices are silenced. We need to start having really tough conversations, really honest ones, and we need to push back against the pushback,” said Mbugua.

“Ultimately, if we don’t do that, we’re going to find ourselves here every so often asking ourselves: ‘Why are the rates of pregnancy on the rise? Why are we having adolescent girls compromised? Why the numbers are of HIV and AIDS on the rise?” said Mbugua.

Goodness Ogeyi Odey

Goodness Ogeyi Odey, Associate Editor at Wiley Journal, said that many young people did not understand consent, which was why “comprehensive sexuality education” was so important.

In Cross River State in Nigeria, where Odey comes from, many men assumed they could touch women in the market without consent, she said.

“That’s appalling. So we need to understand that, with sexual reproductive health and rights, consent is critical and young people have to understand and respect each other,” said Odey. 

“Many married couples say you can’t rape your wife because they don’t understand choice. They don’t understand consent. They don’t understand respect. They don’t understand bodily autonomy,” she said.

Odey added that many African countries had restrictive abortion laws yet they did not enable women and girls to get access to contraception or choices.

‘Bodily autonomy’

Natalia Kanem, UNFPA Executive Director

UNFPA Executive Director Natalia Kanem assured the plenary that her agency was “protecting sexual and reproductive health and rights in both development and humanitarian settings”. 

“We are helping young people to exercise their right to bodily autonomy, their body rights. We are helping young people to gain access to comprehensive sexuality education, so important to counter ignorance,” she added.

However, the obstacles are huge.

“Across Africa right now, 125 million women and girls alive today were married before their 18th birthday. Harmful practices like child marriage and certainly female genital mutilation violate the rights of the girl child,” she warned.

UNFPA is “countering harmful cultural norms and supporting the good norms, those that helped to end gender-based violence norms that call out harmful practices. This has to include promoting positive masculinities”, said Kanem.

Access to contraception

Mary-Ann Etiebet, head of MSD for Mothers

Mary-Ann Etiebet, head of MSD for Mothers, said that if women and girls had access to family planning, this could reduce the global maternal health burden by at least 30%.

“We need to ensure that every girl and woman has a fair and equal just chance to live life to their fullest capability and realise all of the opportunities in front of them,” said Etiebet, adding that this would never happen unless there was gender equity.

Dr Alaa Murabit, Director of Health at the Bill and Melinda Gates Foundation, agreed that access to contraception was the single most important SRHR intervention, and appealed for more money to be invested in SRH. 

“Women’s ability to control when and if they want to have children sets them on a completely different trajectory,” said Murabit.

Dr Alaa Murabit, Director of Health at the Bill and Melinda Gates Foundation

“We can’t talk about women’s health from menstruation to contraception to pregnancy to the entire lifecycle of a women’s health, without having tools that actually meet women where they are in communities where they are,” said Murabit.

“We’re talking about incredibly exciting things we have that can transform realities for women. We’re talking about contraception that women can take once every six months to ensure they have protection across the board. We’re talking about portable ultrasound that ensure that women who are pregnant have immediate reassurance and security,” she added.

“We’re talking about things we already have,” she said, remarking that not enough energy was being invested in these products _ or in urging policymakers to pass policies that ensure they can reach primary health care services.

“Let’s really rally around what we do have, let’s look at the resources we do have and talk about how we’re spending them and how we can spend them better.”

Adriana Rubio, General Manager of Roche Diagnostics, added that there were many innovations such as HPV tests, and other “homecare point-of-care testing” options and digital care to improve women’s lives.

“How do we remove regulatory barriers and make public policy embracing the value that innovation is bringing to allow us to realise the dream of universal healthcare?” Rubio asked.

Women health
Community-level intervention is necessary to achieve women’s public health goals.

It takes community-level interventions to improve public health outcomes, especially when it comes to access to sexual and reproductive healthcare services by women and girls who are refugees and migrants, experts from the US-based Mayo Clinic said. 

“We know that the barriers for women are multifactorial and one solution is not going to fix our problem or increase cancer screening…We need to have these addressed by a multifactorial approach,” Brittany Strelow, a physician assistant at the Mayo Clinic said. 

Speaking at a webinar hosted by the World Health Organization (WHO) on Wednesday, Strelow shared her experiences with a community-centric project working with immigrant women in Rochester, Minnesota.   

Migrants and refugees face several challenges in the host countries, not only due to their civil status. Socio-cultural aspects like language and culture often stand in their way of accessing quality and timely healthcare. 

Strelow said that migrant women place a low priority on getting screened for cervical cancer and breast cancer because they struggle with other more important and basic things like finding affordable housing, food and nutrition.  

Language can be another major barrier for migrant women and girls to access sexual and reproductive healthcare. For example, in the US, one in ten residents are born abroad and around 7% of the residents do not speak English at all, Strelow pointed out. 

“Although we speak mostly in English in the United States, this can be applied on an international spectrum where an immigrant might be coming to another country that does not speak their native language.”

Danielle O’Laughlin, another physician assistant at the Mayo Clinic, added that women in their studies also struggled to access healthcare services due to religious and cultural barriers. In several cultures, women are not allowed to expose themselves even for medical examination or treatment to a doctor of the opposite gender. 

The WHO recently released a report outlining similar findings in a case study on the “Sexual Reproductive Health Rights and HIV Knows No Borders” project run by the International Organization for Migration (IOM), Save the Children and other governmental and non-governmental partners. 

The project, aimed at improving the access to HIV prevention methods and sexual and reproductive health of migrant women, girls and sex workers, worked with a variety of community-led approaches to achieving its goals. Initiatives like widespread sensitization on HIV transmission and screening, sexual and gender-based violence and setting up dialogue platforms with community, traditional and religious leaders helped the project see success. 

“In 2021 the project reached over 100 000 young vulnerable people, migrants and sex workers with health education on sexuality, HIV/AIDS, sexually transmitted infections, pregnancy and contraception through door-to-door visits and community events such as mobile clinics, outreach campaigns and community dialogues,” the report said. 

Over 14,000 young vulnerable people, migrants and sex workers were redirected to appropriate healthcare-based and non-healthcare-based interventions by this project. While healthcare interventions include HIV testing and distributing antiretroviral drugs, non-healthcare-based interventions include helping them access police, social welfare and counselling services. 

Image Credits: Photo by Rendy Novantino on Unsplash.

Jacqueline Acquah, Johnson & Johnson associate director responsible for vaccines regulatory affairs in emerging markets in Europe, Middle East and Africa.

The African Union (AU) is making good progress in operationalising the African Medicines Agency (AMA), having recently formed its Bureau and currently shaping its governing board.

This is according to Chimwemwe Chamdimba, Head of Health at the AU Development Agency (AUDA-NEPAD), who addressed a session of the Africa Health Agenda International Conference (AHAIC) in Rwanda on Wednesday.

AMA is being set up as a specialised health agency of the AU to ensure the regulatory harmonisation of medicines across Africa.

“We are hopeful that, in the next quarter, we should have the governing board of the AMA formalised by the congress of state parties,” Chamdimba told the session on the regulatory harmonisation, which was organised by the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA).

Tackling fragmentation

“As the African Union, from the very beginning our thoughts have been to move from the fragmented 55 member states’ regulatory authorities, where manufacturers have to submit their [product] dossiers to each regulator, to the five regional economic communities (RECs),” said Chamdimba.

Chimwemwe Chamdimba, Head of Health at the AU Development Agency (AUDA-NEPAD)

She says that the RECs started harmonisation efforts as early as 2009, and the aim is to develop a common product application template that can be used by all the countries in the region.

By working together in the regions, national regulators had been able to do joint assessments and inspections, and this has started to “create trust between the regulator authorities within the RECs”, she added.

The AU is currently developing a continental regulatory reliance framework that will be piloted in the East Africa region.

In addition, the AU was working with partners such as Amref to train national regulators.

AUDA Nepad has also been mandated by the AU to lead private sector engagement in health and “we want as much as we can to have a more systematic way of engaging the private sector”, she added. 

“We all need to hold hands. The proof of the pudding is in the eating and we can only get feedback from the industry if they are willing to try the processes that we are putting in place on the continent.”

Timely access to medicines

Johnson & Johnson’s Jacqueline Acquah, the IFPMA’s co-chair of the Africa regulatory network, said that AMA was essential to ensure that patients had timely access to medicines.

“As a result of the globalisation of markets, we have a lot of products that move in within international commerce, and supply chains have become very, very complex,” said Acquah.

“The public has become more aware, and there’s a high expectation of our health systems. Unfortunately, the world over there’s a limited resource when it comes to global regulatory affairs. Regulatory resources are very, very limited so it’s important that national regulatory agencies collaborate more.”

As a result, said Acquah, regulators needed to develop a reliance on one another to avoid duplication of work and resources. 

“Regulatory reliance is when a regulator in one jurisdiction gives significant weight to the work that has been done by another regulator in another jurisdiction or an agency such as the World Health Organization (WHO) when making its own decisions,” she said.

“The regulatory agency is, however, still sovereign in the decision-making process, and also accountable for the decisions that they make.”

Egypt Drug Administration’s Dr Asmaa Fouad described regulatory reliance as “one of the magic tools that help regulators and industry and patient at the same time, so we achieve a triple win situation”.