Prepared by. Dr. James Orbinski Director, Dahdaleh Institute for Global Health Research,  Aria Ilyad Ahmad, Dahdaleh Institute for Global Health Research
Period. 14 – 20 May 2020
WHO’s World Health Assembly occurs entirely online

World Health Assembly takes place

“Impartial, independent, and comprehensive evaluation” For the first time in the WHO’s history, its annual World Health Assembly (WHA) was entirely virtual. With a focus almost entirely on the Coronavirus pandemic, the [... ]two minutes.

“Impartial, independent, and comprehensive evaluation”

For the first time in the WHO’s history, its annual World Health Assembly (WHA) was entirely virtual. With a focus almost entirely on the Coronavirus pandemic, the condensed two-day meeting was preceded by three weeks of intense negotiations. The most significant outcome this year was the adoption of a COVID-19 resolution that was proposed by the European Union and supported by 120 countries that contained three major elements (A73/CONF/1), including an “impartial, independent, and comprehensive evaluation (of the) international health response to COVID-19.” In the closing remarks, the WHO Director General affirmed that the review would take place “as soon as possible.”

Rising geopolitical tensions shape emergent Global Health institutions and practices

The WHA opened with a failed motion to grant Taiwan Observer status, underscoring growing tensions in part arising from accusations by the U.S. (and shared by other Western and Pacific Asian countries) that China was not transparent in the early days of the pandemic. In a letter, the U.S. President threatened to permanently eliminate the funding that was temporarily withdrawn from the WHO, suggesting the U.S. would pursue bilateral aid channels including US$500 million to 40 ‘at risk’ countries. The President of China addressed the Assembly directly pledging US$2 billion over the next two years to support COVID-19 response efforts in developing countries, and an ambition to establish China as a “global humanitarian response capital and hub.” Focusing on African countries in particular, President Xi referenced debt suspension initiatives, building “green corridors” to accelerate delivery of essential goods as well as partnering with 30 major hospitals in Africa to build a China Centres for Disease Control headquarters on the continent.

‘No monopolies on access’ to COVID treatments and vaccines in a pandemic

The negotiations on access to treatments and future vaccines were far more divisive. Led by Costa Rica, developing countries and civil society organizations expressed particular concern about ensuring equitable access, including to COVID-related knowledge, lessons learned, experience, and best practices. The WHO Secretariat will have until May 29 to develop a framework for a voluntary COIVD-19 Intellectual Property Pool for patents and clinical trial data, while the EU-led resolution also references WTO TRIPS flexibilities allowing countries to override patents to ensure access.

COVID is a ‘wake-up call to our global fragility’

In his address to the World Health Assembly, the UN Secretary General called for greater unity and solidarity along three dimensions: a coordinated and comprehensive health response guided by the WHO and focusing on developing countries; policies to address the social and economic dimensions of the COVID crisis; and a response and recovery plan based on equity, inclusion and sustainability centred on human rights. Given the unprecedented nature of the pandemic, some civil society organizations such as South Centre expressed disappointment in the lack of ambition of the COVID-19 resolution. Knowledge Ecology International (KEI) likewise referred to the “typical watered down, lawyered ambiguity” of the final draft that fails to limit legal monopolies that could affect access (they noted that other proposals like Canada’s would have called for “universal and non-exclusive and open-licensing” that referenced data sharing and more expansive mandate beyond existing mechanisms).
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Economic inequities threaten COVID-19 response

The growing pandemic funding gap The gap between donor commitments and the funding needed to respond to the pandemic continues to grow. As the UN Office for the Coordination of Humanitarian Affairs [... ]about four minutes.

The growing pandemic funding gap

The gap between donor commitments and the funding needed to respond to the pandemic continues to grow. As the UN Office for the Coordination of Humanitarian Affairs tripled its appeal last week to US$6.7 billion, they admit to only receiving US$1 billion towards its initial request for US$2 billion. That includes a mere $65 million contribution from the U.S. that a senator described as “unconscionable,” while the Washington Post reports the US$3 trillion COVID-19 bill introduced by Democrats this past week contains no funding for international assistance. Germany and France likewise agreed to support a 500 billion Euro aid package to support E.U. countries with recovery from the pandemic. NGOs such as the International Rescue Committee argue that much of the aid is stuck within multilateral channels, as humanitarian funding to front-line NGOs accounts for only 2% of commitments under the UN Global Humanitarian Response Plan.

The global economy is shrinking, and 130 million people may be pushed into extreme poverty

Global economic output is expected to drop by 3.5% in 2020, and by US$8.5 trillion over the next two years as a result of the pandemic. The UN World Economic Situation and Prospects report warns that an additional 34 million people could fall below the extreme poverty line by the end of this year. The UN Department of Economic and Social Affairs did “not anticipate (the global economy) would dive as quickly as it did” amidst the sharpest economic contraction since the Great Depression. The report projects that by 2030, an estimated 130 million will be pushed into extreme poverty. Africa is expected to absorb 56% of the rise in poverty, in part due to limited economic and social protection measures as well as debt burdens. In the World Economic Forum’s weforum.org, the Dean of the Wharton Business School projects that COVID-19 would also reverse trends in globalization and urbanization. The resulting compression of the global economy, he predicts, will be further impacted by reduction in international cooperation and increased likelihood of international conflict.

250 million Africans could be infected, with up to 190,000 dead by years’ end

Modelling by the WHO predicts that nearly a quarter of a billion people across 47 African countries will be infected with the Coronavirus, with as many as 190,000 projected mortalities by year’s end, according to a study to be published in BMJ Global Health. While African countries may experience fewer severe cases and deaths per capita due to younger populations and lower obesity rates, health system capacity gaps and disruptions in maternal and child health could result in additional deaths.=

ODI calls for increased solidarity to support developing countries

The Overseas Development Institute estimates that the economic impacts of the pandemic to sub-Saharan Africa remain uncertain but will likely exceed $100 billion. While many countries have imposed stringent measures to contain the spread of the virus, there are immediate and long-term concerns about the lag in economic and social protection measures as governments face major liquidity and fiscal constraints. Since much of the global economic dislocation stems from decisions to protect citizens in wealthier countries, the ODI calls for increased international solidarity to support developing countries. That can include special drawing rights to address capital outflows, moratoria on debt service repayments, development finance to provide liquidity to protect employment, as well as non-concessional lending and economic resource packages as aid.

Rising Inequity Gap

The IMF warns that COVID-19 could widen the inequality gap between rich and poor across and within countries, urging policymakers to put in place risk-sharing and social assistance mechanisms to protect the most vulnerable from economic impacts. Using past pandemics as a guide, the analysis shows net increases in Gini coefficient (a measure of inequity within a country) after five years as well as long-term impacts due to job loss and other shocks to income (e.g. lower remittances). To minimize long-term damage (or “scarring”) to the livelihoods of vulnerable communities – and improve resilience to future shocks (including the effects of climate change), the IMF urges countries to consider a range of measures including:
  1. Access to sick leave, unemployment benefits, and health benefits;
  2. A “New Deal,” particularly in countries where the employment sector is largely informal and where social protection systems are limited; and
  3. Expanding social assistance systems, introducing new transfers, boosting public work programs, and progressive tax measures.

“Nothing lays bare inequality and discrimination like a disaster”

In a forceful address on the human rights dimensions of the COVID-19 pandemic, the UN Special Representative for Disaster Risk Reduction highlighted the disproportionate impact on marginalized and vulnerable populations, amplifying social inequities, forced displacement as well as gender- based violence. The central message was that the international community “must do more.” This includes treating persons at risk as people with human rights and not just as beneficiaries of humanitarian actions, who are consulted in decision-making relevant to their lives, and to foster greater resilience by focusing on the drivers of disaster risk, including poverty, lack of international solidarity and pandemic preparedness, and increasing frequency and magnitude of extreme weather events.

‘Donor states can and must do more’

According to a Devex survey of development professionals, two thirds say donors are not doing enough to respond to the Coronavirus. The UN estimates that US$500 billion will be needed to address the pandemic in developing countries, as Oxfam urged 30 donors of the OECD Development Assistance Committee to contribute $300 billion. In addition to more funding, development experts point to three other steps donors should take:
  1. Simplified funding mechanisms for a faster response;
  2. Clarity and transparency on decisions; and
  3. Looking beyond the immediate needs, including longer-term impacts of COVID-19 and what preparation is needed now to respond to those.
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Research Updates

Social Distancing Works An article in Health Affairs examines the role of social distancing measures in reducing the growth rate of the pandemic in the U.S. The authors conclude that jurisdictions with [... ]less than two minutes.

Social Distancing Works

An article in Health Affairs examines the role of social distancing measures in reducing the growth rate of the pandemic in the U.S. The authors conclude that jurisdictions with no physical distancing policies had 35 times more cases of COVID-19, and that the rate of new infections dropped the longer a physical distancing policy was in place.

COVID-19 can cause severe illness in children

A cross-sectional study in JAMA Pediatrics confirms earlier reports that COVID-19 can cause severe illness in children (CFR of 4.2), but considerably less than in adults. Similar to adult COVID-19 patients, severe cases in children are strongly associated with pre-existing comorbidities (including developmental delays, genetic anomalies, and immune suppression). A separate retrospective review in the Journal of Pediatrics, authors examined associations between underlying epidemiologic and clinical conditions with rates of hospitalization, finding positive correlations with neurological disorders (19%), cardiac conditions (9%), hematologic conditions (9%) and oncologic conditions (5%).

COVID-19 may  increase frequency of Children’s Kawasaki Syndrome

Emergent reports from around the world suggest an association between a Kawaski-like syndrome and COVID infection in children. An observational cohort study in the Lancet hypothesizes that COVID-19 may be responsible for the 30-fold increase in the incidence of hyper-inflammatory syndrome Kawasaki-like disease among older children in Italy.

RCTs pending on the benefits and safety of convalescent plasma for people with COVID-19

A Cochrane Rapid Review shows that only 32 patients in seven case-series studies have been studied systematically, and there is at this time limited evidence on the benefits and safety of convalescent plasma for people with COVID-19. The review noted that 47 studies are currently underway, and 22 of these are Randomized Control Trials. Cochrane will update this clinical review on a monthly basis as trial results emerge. It notes that its review and conclusions are likely be different from its current assessment of “limited evidence.”

80% of secondary transmissions may have been caused by a small fraction of infectious individuals

A pre-print publication on Wellcome Open Research examines outbreak size outside China, and highlights the high variability across countries in the overdispersion of COVID-19 transmission.  Findings suggest that 80% of secondary transmissions may have been caused by a small fraction of infectious individuals, and that the effective reproduction number could be drastically reduced by preventing relatively rare superspreading events.

Voluntary collective isolation and contact-tracing for vulnerable Indigenous Communities

The Lancet published a paper this week on a case study and potential protocols for indigenous populations in the Bolivian Amazon. The interdisciplinary study proposes a multiphase COVID-19 prevention and containment plan focused on voluntary collective isolation and contact-tracing that could be exported and adapted to local circumstances elsewhere to prevent widespread mortality in indigenous communities.
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Compounding crises undermine ethical, equitable COVID-19 response

Compounding Crises of COVID-19 and Super Cyclone in India and Bangladesh The strongest cyclone ever recorded in the Bay of Bangal (with maximum sustained winds up to 265km/h) is expected to hit [... ]five minutes.

Compounding Crises of COVID-19 and Super Cyclone in India and Bangladesh

The strongest cyclone ever recorded in the Bay of Bangal (with maximum sustained winds up to 265km/h) is expected to hit India and Bangladesh on Wednesday. Millions of people are being forced to evacuate north-east India, while only 12,000 shelters have been prepared in Bangladesh to house the nearly five million people in the expected path of Cyclone Amphan. The impact is likely to be hardest on those living in low-lying flood prone coastal areas, as the Needs Assessment Working Group of Bangladesh estimates that up to 14.2 million people in coastal districts are likely to be affected, displacing 1.4 million people and damaging up to 600,000 houses. Vulnerable communities affected by COVID-19 outbreaks and lockdown will also likely be impacted, including the approximately 1.2 million Rohingya refugees that live in over-crowded camps in Cox’s Bazar in Bangladesh. In collaboration with humanitarian partners, including UNICEF and UNHCR, the IOM is constructing a COVID-19 treatment centre in Cox’s Bazar along with cyclone preparedness effort (alerting the community, reinforcing critical infrastructure and prepositioning emergency items before the cyclone makes landfall).

COVID needs in Humanitarian Emergency Settings

The UN High Commissioner for Refugees made an appeal for US$745 million for preparedness and response to outbreaks of COVID-19 among the more than 71 million refugees and forcibly displaced people that remain acutely vulnerable. While no major outbreaks have been reported in large refugee and IDP settlements, UNHCR is rapidly scaling up efforts in 134 refugee-hosting countries that are reporting local transmission. There is also widespread evidence of deep economic impacts on refugees, as 70% of refugees surveyed admitted to skipping meals, and this is most acute among refugee women. Médecins Sans Frontières has outlined five key priorities for the international community in order to protect migrants and vulnerable populations in humanitarian response locations. These include:
  1. Ensuring COVID-19 is not used as an excuse to enforce restrictive migration control policies and evade international obligations towards refugees, asylum seekers and migrants;
  2. Governments must not use COVID-19 emergency measures to target refugees, asylum seekers and migrants, and measures should be proportionate and limited in duration, respect human dignity, and based on scientific evidence and not applied arbitrarily;
  3. Lockdowns and mass quarantining cannot be cut-and-pasted or discriminatorily applied;
  4. Direct humanitarian evacuation corridors for displaced people at risk (including people above 60 years and those with respiratory conditions, diabetes, or other health complications); and
  5. Safeguarding access to healthcare for all (ensuring border closures do not prevent the mobility of people, essential supplies and aid workers, particularly in humanitarian response locations).

EU is Creating Humanitarian Air Bridges to enable the COVID-19 Response

The European Commission has allocated 10 million Euro to support a humanitarian air bridge amid travel shutdowns. In the absence of commercial air travel, the air bridge will allow humanitarian staff and supplies to be delivered across 30 routes deemed important for the COVID-19 response, with the first flight launched last week from France to the Central African Republic with 60 humanitarian workers and 13 metric tons of humanitarian cargo.

Build Back Better After COVID-19

The International Recovery Platform developed a toolkit of existing guidelines and tools to support countries and communities when they are ready to recover from the COVID-19 pandemic crisis. It supports recovering communities to "build back better" towards more resilient health systems, economies, and more just societies. The Compendium of Tools and Guidelines are organized according to four categories: Health Sector Recovery; Private Sector and Livelihood Recovery; Inclusive Recovery; and Disaster Recovery Governance. The IRP is a joint initiative of UN, international finance institutions, national and local governments, and NGOs engaged in disaster recovery and sustainable development. A paper commissioned by the Swedish International Development Cooperation Agency provides analysis and guidance on to inform the design, implementation and adaptation of conflict sensitive humanitarian and development responses to COVID-19.

Lancet Papers Decry the lack of Ethical global leadership on health inequities around COVID-19

A paper in the Lancet calls for greater ethical global leadership on health inequities during the COVID-19 pandemic. The authors reference widespread reports of the disproportionate impact of the pandemic on vulnerable communities around the world, while pointing to “unconscionable stockpiling by wealthy countries” and even attempts to extract profits from the crisis through economic speculation. Another paper in the same issue highlights how social inequalities in health profoundly, and unevenly, impacting COVID-19 morbidity and mortality. Among the social determinants of health, the authors identify emerging findings on the correlation of the pandemic with poverty (including homelessness), physical environment, and race or ethnicity. The paper also notes how physical distancing measures are significantly more difficult for vulnerable and marginalized populations, while school closures have increased food insecurity for children living in poverty, exacerbating physical and mental health. The authors urge policymakers to emphasize the mitigation of social determinants, including improving housing and reducing overcrowding as well as improving access to health services and income support. The paper also calls on social determinants of health to be an essential part of pandemic research priorities, public health goals, and policy implementation.

Preventing a COVID-19 Related Global Food Crisis

  • The Food and Agriculture Organization made an appeal for US$350 million to scale up efforts to address hunger and livelihood-boosting efforts in contexts vulnerable to food crisis. As part of the broader UN Global Humanitarian COVID-19 Plan, the appeal will include supporting farmers’ access to fields, seeds and other inputs to plant or buy feed for their animals in order to avoid the cascading impacts of missing planting seasons such as drops in output. The FAO also advocates proactive efforts for stronger emergency livelihoods interventions to avoid famines.
  • The WEF also reports how the pandemic has amplified the risk of worldwide food-price spikes, urging greater coordination across governments to avert disruptions to food supply chains, including through food protectionism. While lockdowns have led to a collapse in demand for discretionary goods and services, the opposite is true of food as panic buying and food hoarding has proliferated. On the supply side, global grain stockpiles could be quickly depleted as the virus disrupts production and distribution, compounded by the worst locust outbreak in 70 years that have left countries in East Africa acutely vulnerable. In Kenya, for example, the price of staple foods has risen by 60% since last year.
  • ICRISAT published a new report that outlines four key strategies to protect the lives and livelihoods of farming communities in Eastern and Southern Africa. These include:
    1. Diversification of farming systems for improved resilience and profitability (including technologies suitable for sustainable intensification);
    2. Enhancing access to seed at scale of grain legumes and dryland cereals (through community seed banks that also supports grain aggregation);
    3. Building capacity of partners to promote technologies in a participatory manner (including governments, community organizations, local leaders and women); and
    4. Gender integration and empowerment to engage actively in agribusinesses (including livelihood-strengthening activities like climate-smart agriculture)

CommunityFirst COVID-19 Roadmap

This week, SeeChange Initiative and Ilisaqsivik Society, in partnership with the Association of Médicos Sin Fronteras in Latin America, and the Dahdaleh Institute, launched the CommunityFirst COVID-19 Roadmap, a planning tool to empower communities in developing local strategies to organize, prepare and respond to COVID-19. The Roadmap is available in English, Spanish and Inuktitut, and also includes an Emergency Readiness Checklist. Last month, the Executive Director of SeeChange and a Steering Committee member of the CommunityFirst Roadmap published an article in the Lancet on local efforts among Inuit communities to address COVID-19 and TB. The role of community-based responses to the pandemic was also highlighted in STAT.

Webinar Resources

  1. COVID-19 in Humanitarian Setting: Magnifying Gender Inequalities? (JHU)
    • Wednesday, May 20, 2020 (8-9am EST)
  2. Digital Solutions to Covid-19 and Urban Challenges in Sub-Saharan Africa (CSIS)
    • Thursday, May 21, 2020 (9-10am EST)
  3. Humanitarian Operations During Covid-19: A Conversation with UNHCR (CSIS)
    • Monday, June 8, 2020 (9:30-10:15am EST)
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WHO to create a COVID-19 Intellectual Property Pool

WHO to create a COVID-19 Intellectual Property Pool The WHO embraced a proposal by Costa Rica to develop a voluntary mechanism that would pool patents and regulatory testing data to develop drugs, [... ]three and a half minutes.

WHO to create a COVID-19 Intellectual Property Pool

The WHO embraced a proposal by Costa Rica to develop a voluntary mechanism that would pool patents and regulatory testing data to develop drugs, vaccines and diagnostics for COVID-19. Modelled after the Medicines Patent Pool by UNITAID for HIV/AIDS medical products, the COVID IP Pool would serve as a repository that target governments, industry, universities and non-profit organizations in order to ensure equitable access to resulting medical products, something that the Access to COVID-19 Tools (ACT) Accelerator announced last month does not sufficiently address. The WHO has until May 29 to finalize the framework for the voluntary pool. The US has expressed reservations, while it has been accused of “pandemic chauvinism” because it refused to attend the launch of the WHO ACT Accelerator and is alleged to have offered to buy a German vaccine developer, while the CEO of Sanofi said that the U.S. may get priority access to COVID-19 vaccine, even though the company is headquartered in France.

Covid-19 has exposed the limits of the pharmaceutical market model

As the global search for Coronavirus treatments and vaccines intensify, two articles this week highlight the limitations of the existing drug development models. Health Policy Watch featured an interview with the Director General of a trade association representing the leading pharmaceutical companies. Among the “old-new tensions between profit and public needs” that were discussed was the “concern” by the pharmaceutical industry that the newly adopted World Health Assembly resolution referenced WTO flexibilities that allow countries to override patents to ensure access to vaccines, therapeutics and diagnostics. The STAT article, meanwhile, points to failures of the existing market model that do not sufficiently incentivize investment into new treatments and vaccines for neglected diseases and pandemic preparedness despite warnings. Building on an extensive body of research, the author advocates for a new economic model of drug development that does not rely on market mechanisms. That would include more open and transparent research and development practices that address the “rapid global expansion of intellectual property” as well as more expansive government initiatives to address collective challenges (particularly given the significant role of government-funded research).

The 15 drugs being tested to treat COVID-19 and how they work

Even under the most optimistic projections, developing new treatments and vaccines for COVID-19 will require far greater time and resources than would be required for repurposed existing therapeutic compounds. An article in Nature this week provides an overview of the 15 leading candidates of existing drugs that are being studied as treatments for COVID-19. These can be divided into two categories: those that target the viral replication cycle, and those that aim to control the symptoms of the disease. They include:
  • Chloroquine/hydroxychloroquine (primarily used to treat malaria)
  • Lpinavir and ritonavir (HIV/AIDS)
  • Nafamostat and camostat (pancreatitis)
  • Famotidine (heartburn)
  • Umifenovir (influenza virus A and B)
  • Nitazoxanide (anti-infective)
  • Ivermectin (anti-parasitic)
  • Corticosteroids (cytokine storm, acute respiratory distress syndrome)
  • Tocilizumab and sarilumab (cytokine storm, ARDS)
  • Bevacizumab (oncology)
  • Fluvoxamine (antidepressant)

Contact tracing apps: balancing privacy and public health

Traditional public health contact tracing systems require significant time and resources, as one projection by Johns Hopkins University estimates a workforce of 100,000-300,000 would be needed to contain COVID-19 in the U.S. alone at a cost of $12 billion. As a result, health systems are increasingly turning to mobile contact tracing apps that are pitched as a way to reduce these costs by automating the process of logging people’s contacts should they became infected in the future.  Despite their promise, there are outstanding challenges, including marginalizing vulnerable populations that may not have smartphones. There are also privacy concerns that has led civil liberties advocates to raise warnings about potential abuses, including by authoritarian countries during and after the pandemic. The CSIS also urges policy makers that digital tools such as contact tracing apps are not “silver bullet” substitutes for investment in fundamental pandemic response capabilities. That message was echoed by health authorities in Iceland, where Rakning-19 yielded very little benefit compared to traditional public health systems, despite its high uptake of 40% of the population.

Machine learning applications

In Nature Machine Intelligence, authors report on machine learning tools applying pattern classification to identify three biomarkers associated with COVID-19 mortalities. Another paper in Nature examine real-time tracking of self-reported symptoms to predict potential cases of COVID-19. The smartphone app allowed the authors to develop a model that was 80% accurate and showed that loss of smell and taste were additional symptoms indicative of COVID-19. While this study used simple statistical regression analysis, another paper in pre-print used machine learning algorithms on a smaller Brazilian dataset that achieved better performance of 92% specificity and 95% sensitivity.
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