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Garrett on Global Health - May 23, 2016

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May 23, 2016

Garrett on Global Health

Dear Friends and Colleagues,

We are at the start of a tough week for global health advocates, health security efforts, and humanitarian crises responders. The sixty-ninth World Health Assembly (WHA) opens today and lasts all week in Geneva; the World Humanitarian Summit also commences today in Istanbul. And the Group of Seven (G7) summit opens on May 26 on Japan’s Ise-Shima island, hosted by Prime Minister Shinzo Abe. In this update, I’ll offer a brief overview of the three events, and expectations for their outcomes. The overall take-home message: high hopes will be dashed, but skeptics may be mildly surprised. 


Sixty-Ninth World Health Assembly

The annual WHA gathering of delegates from 194 nations, along with representatives of dozens of UN agencies and other large multilateral organizations, is an exhausting event that typically finds backroom negotiations dragging on around-the-clock, while public proceedings continue at a snail’s pace with droning speeches that generally leave observers snoozing in the galleries. As a rule, the World Health Organization (WHO) Secretariat—the Geneva-based managerial circle around Director General Margaret Chan—drafts a series of resolutions in advance of the WHA, which are parsed and painstakingly rewritten in politically charged private meetings, eventually passed in some form by consensus. Issues that are unlikely to receive consensus support, such as raising the assessments levied on the 194 member nations to finance the WHO’s efforts, never formally reach the floor of the public assembly sessions. That critical issue—how much money the world provides to the WHO’s core budget—has not reached the floor for a vote for over thirty-nine years, meaning that when adjusted for inflation, the WHO basic operating budget has declined steadily for decades.

Though China’s Margaret Chan will continue to run the WHO until July 2017, the election process for her successor has begun, and the candidates will be working the hallways of the Geneva World Health Assembly. The election process will be unprecedented and highly controversial. Moreover, it follows an equally novel and disputatious selection process for secretary-general of the United Nations. The problems, and likely disappointments, associated with both elections, as well is what is at stake in their outcomes, are described in detail in my latest post.

Last year’s WHA was overwhelmingly concerned with Ebola, the agency’s failures in response to the West African epidemic, and reform of the WHO outbreak and health security capacity and governance.

This year, Ebola-related debate lingers, with few nations or global health observers satisfied with reforms made to date inside the WHO. But two new mosquito-carried infectious disease threats have moved to center stage—Zika and yellow fever. At least sixty countries have had Zika virus cases, most of them since October 2015. On February 1, Director General Chan declared a Public Health Emergency of International Concern (PHEIC) over Zika, citing its association with neurological disorders and congenital microcephaly as cause for PHEIC activation under the International Health Regulations. For weeks following the formal PHEIC declaration, scientists and public health officials scrambled to determine whether the virus, predominately transmitted by Aedes aegypti mosquitoes, was merely associated with skull malformations in fetuses and debilitating Guillain-Barré Syndrome paralysis in adults, or causative. As the numbers of Zika cases in the Americas soared, evidence mounted of sexual transmission, breast milk spread, and blood transfusion–linked cases.

The Zika virus’s role as the cause of a horrible constellation of symptoms and permanent damage to human brains and the entire central nervous system is now well established, as viral genetic and protein elements have been found in the brains of miscarried fetuses and babies born with microcephaly; laboratory infection of human brain stem cells results in cell death; the actual mechanism whereby Zika destroys brain function has been established; infection of experimental animals has produced brain damage and human-like disease symptoms; Zika has been shown to grow and reproduce on specific brain cell subtypes; a broader "shocking" range of neurological damage has been discovered in people of all ages that have survived Zika infections; the virus has been found in autopsies of the brains of malformed, miscarried human fetuses. By early April, as the weight of evidence mounted, the U.S. Centers for Disease Control and Prevention (CDC) formally named Zika as the cause of a broad range of neurological ailments and birth defects, and the WHO followed suit.

Though the worst outbreaks continue to be in the American hemisphere, Zika has now made its way around the world, across Asia and back, in genetically transformed status, to Africa’s Cape Verde. Europe is now on alert for arrival of Zika, and last week the World Federation of Neurology warned that Zika threatens the entire world. Given the Olympics will bring athletes and tourists from the entire world to Rio de Janeiro in a few weeks, and the Brazilian government is bankrupt and extremely unstable, there is serious concern that the event could thoroughly globalize Zika and its carrier mosquitoes.

In February, the WHO requested $26 million in emergency funds to support its Zika activities, but has, to date, received none of that money from donors. It has moved $3.8 million from a small outbreak contingencies fund that was created last year in response to slow mobilization of resources to combat Ebola. In part, this enormous funding gap is due to the U.S. congressional refusal to grant a White House request for $1.9 billion in special Zika funds, but other donors have also failed to demonstrate confidence in the WHO’s ability to combat outbreaks by providing financing.

The same Aedes mosquitoes that transmit Zika also carry chikungunya, dengue, and yellow fever—all dangerous diseases that are surging in prevalence. The chikungunya and dengue epidemics preceded the observed arrival of Zika in Latin America, and exacerbated difficulty in recognizing and diagnosing the new disease. Yellow fever’s surge in Africa has not yet been associated with the other diseases.

Last week, scientific advisors to the WHO declined to declare a formal PHEIC regarding the African yellow fever epidemic because highly effective vaccines against the virus can, theoretically, bring the situation under control. But the advisory committee "strongly emphasized the serious national and international risks posed by urban yellow fever outbreaks." The WHO group concluded "the current yellow fever situation is serious and of great concern and requires intensified control measures, but does not constitute a PHEIC at this time," though thousands of individuals have, since January 2016, contracted the disease in Angola, and secondarily in Uganda, Democratic Republic of the Congo, Kenya, and China, with a 12 percent mortality rate. Shortages in vaccine supplies threaten control efforts.

Based on documents released by the Secretariat over the week of May 5, the WHA will review proposals that:

  • Approve development of a Health Emergencies Program that deals with both outbreaks and humanitarian events with health consequences, and is overseen by an Emergencies Oversight and Advisory Committee (of eight members, appointed by the WHO director general), all requiring a budget increase of $160 million for 2016–2017;
  • Acknowledge that the WHO has responded to record numbers of catastrophes and outbreaks over the last two years with no additional resources or support—these acknowledgement carries no price tag or action request;
  • Approve a special WHO committee document detailing the many critiques and reform recommendations issued by multiple independent panels in reaction to failures in the Ebola epidemic—twenty-six recommendations were proffered by the committee, and its report is submitted without comment to the WHA for approval;
  • Acute shortages of vaccines and medicines have arisen all over the world over the last year, presenting genuine crises in treatment for a range of diseases from diabetes and yellow fever to tuberculosis and heart disease. There are many reasons for these dire drug and vaccine shortages, but long-debated disputes in the WHA feature demands for technology and patent transfers to BRICS (Brazil, Russia, India, China, and South Africa) and poor countries, support for generic manufacturing, and opposition to dramatic price increases that have resulted from financial industry takeovers of patents and drug-making businesses;
  • With antibiotic resistance mounting across a broad range of bacterial diseases, accept an action plan for controlling use of medicines and promoting development of new compounds;
  • Adopt resolutions calling for total transparency during outbreaks, open sharing of viral samples and data, and promotion of rapid development of diagnostics and vaccines.

Barring unprecedented shake-ups, expectations for this week’s World Health Assembly should be low. Institutions rarely do a great job with self-reform—the possibility of meaningful change is even dimmer when all the nations of the world hold equal votes, but just three donors (the U.S. and UK governments and the Bill & Melinda Gates Foundation) provide nearly 80 percent of the entity’s financial support. Worse, the number one donor—the U.S. government—is facing a distracting national election in which one of the candidates (Donald Trump) holds that all forms of foreign aid should be linked to larger political alliances, giving "to our friends." And the number three donor (the United Kingdom) is soon to vote whether it should "Brexit," or exit the European Union, offering the strong possibility that London will be compelled to radically shift every aspect of its foreign policy, including aid.

The Ise-Shima G7 Summit

The prospect of a "yes" vote on Brexit looms so largely over the upcoming summit of the G7 nations that the finance ministers of Canada, France, Germany, Italy, Japan, the United Kingdom, and the United States stated in their May 21 gathering in Sendai, Japan, that the United Kingdom must stay in the European Union.

"The G7 did not talk about a Plan B to respond to what would happen if Britain left the European Union," French Finance Minister Michel Sapin told reporters. "We talked about ways to help Britain stay in the EU."

"We have no Plan B for Brexit," European Union Commissioner Pierre Moscovici added on Friday. "Our only plan is for Britain to remain in a united Europe."

And President Barack Obama warned that a "yes" on Brexit would place the United Kingdom "at the back of the queue" of trade deals with the United States. 

The Brexit referendum national vote taking place on June 23 is widely forecast to have devastating consequences for both the British and European economies,  but is looked on favorably by many in the United Kingdom who feel left out by economic growth that has shifted the nation’s wealth to a small minority of the ultrarich, largely at the expense of the middle class—they blame European Union rules for stifling broader economic growth in their homeland. 

According to the Economist, the Brexit race is so close right now that it cannot be called, and uncertainty is having ripple effects across economies all over the world, and in the halls of the G7. 

As is the case across much of Europe, the influx of refugees fleeing wars and the self-proclaimed Islamic State threats across the Middle East and North Africa have spawned strong anti-immigration sentiments, increasing nationalism and calls for isolationism.

International efforts that are highly dependent upon wealthy world donations, as is the case for nearly every global health program, should share the G7’s concern about Brexit as UK withdrawal from the European Union will have immediate consequences not only for the entire European region’s economies, but might also push the European Union into a spiral toward dissolution. The consequences for all of the major donor states—Denmark, France, Germany, Norway, Sweden, and the United Kingdom—would surely include diminished willingness and capacity to underwrite the WHO and a long list of other health and development multinational institutions. More broadly, there could well be ripples felt across economies all over the world, including in some poor nations that are members of the Commonwealth, resulting in lowered state capacity to finance domestic health programs.

In the lead-up to the Ise-Shima summit, the Japanese Ministry of Foreign Affairs has deployed teams of diplomats and top health experts all over the world, seeking insights into the handling of the Ebola epidemic and related notions of "health security."

Keizo Takemi, a prominent member of the House of Councillors, says that "health is an area where Japan [has] a comparative advantage over other nations," because it achieved universal health care during its dismal postWorld War II period and today enjoys the longest life expectancy in the world. The Abe government has given the Sustainable Development Goals (SDGs) top priority in its foreign assistance agenda, especially for global achievement of universal health coverage. Takemi has successfully pushed for a G7 agenda that features a strong focus on strengthening the International Health Regulations, building better epidemic responses, reforming the WHO, and erecting viable health systems in every country.

Of course, in the lead-up to last year’s G7 summit in Germany, Chancellor Angela Merkel ordered similar studies of the Ebola outbreak response, and called for WHO reform, but no real resources were committed to the problems by the G7 leaders. Last week, in contrast, the Abe government set a high bar for Ise-Shima, promising $1.1 billion in global health financing, including:

  • $800 million to the Global Fund to Fight AIDS, Tuberculosis and Malaria;
  • $76 million to GAVI (global alliance of vaccinators);
  • $130 million for combating neglected tropical diseases (NTDs);
  • $50 million to the WHO emergency response contingency fund;
  • And another $50 million for the World Bank’s brand new Emergency Financing Facility for epidemics.

It is unlikely the Obama administration, which has not managed to raise funds from a divided Congress for America’s Zika fight, will be able to make dramatic new financial commitments. 

Figure 1.1, Ise-Shima Progress Report

In the face of Brexit threats, David Cameron’s UK government is also limited. Merkel’s popularity has plummeted in Germany since last year’s Elmau summit, thanks to backlash against the influx of Middle Eastern refugees, and she will no doubt await the Brexit outcome before making large financial commitments that might not be desired by the German people. And Germany is already the most generous G7 donor, as measured by overseas aid as a percentage of national gross domestic product, as illustrated in this Ise-Shima chart

Since 2008, the G7 nations have disbursed $31 billion to multilateral global health programs. During that time, the United States has contributed a combined bilateral and multilateral total of $47.4 billion, or 62 percent of the combined multi- and bilateral contributions of the full G7, totaling $75.3 billion.      

We shall know by the end of the week whether G7 nations are prepared to proportionally match Japan’s commitments.

Japan has made health a central issue every time it has hosted the G7, and can claim credit for using the Okinawa summit to push creation of the Global Fund. But when then G8 leaders gathered in Okinawa in 2000, the world economy was booming, and the eight nations were in generous moods. Today’s worldwide political and economic landscape is far more complex, and rife with resentment and risk. The remarkable scale of concentration of global wealth in the top 5 percent wealthiest households of nearly every nation that has transpired since the 2008 financial crisis has ignited anger throughout the world. Political pundit Andrew Sullivan characterizes the global mood as "ripe for tyranny." The Washington Post claims Americans are tired of "messy democracy," and Canadian Prime Minister Justin Trudeau warns that paying ransoms for release of citizens captured by terrorists is spawning linkage between political, religious, and criminal organizations. Okinawa occurred in the nostalgic days before the September 11 attacks, the 2004 al-Qaeda–inspired train bombings in Madrid, the 2005 subway and bus assaults in London right up to the series of horrible Islamic State killings in Paris last November. As has been the case with all recent G7 summits, terrorism and economics will dominate in Ise-Shima. But the Abe government offers a glimmer of hope for more.

The World Humanitarian Summit

The New York Times described the entire humanitarian response superstructure as one resting on thin ice—an apt metaphor in the age of climate change. Everything from superstorms fueled by the impact of record-breaking rises of world temperature to mass exodus of war refugees from the Middle East is plaguing the planet. In its report to the World Health Assembly, the WHO leadership lists a staggering number of catastrophic problems the agency addressed in 2015, including outbreaks of Ebola, Zika, yellow fever, and a laundry list of diseases among refugees: thirty-two acute emergencies and nineteen protracted emergencies, in forty-seven countries. The earthquake in Nepal, cholera in Iraq, nearly absolute devastation of health facilities in Yemen, civil war in the Central African Republic, targeted bombings of clinics and hospitals throughout Syria, floods in Malawi, Cyclone Pam, the impact of El Niño droughts and severe weather events all over the world … the list goes on, and on, and on.

But the UN humanitarian agencies and peacekeepers have largely lost credibility, amid evidence of incompetence, corruption, and even soldiers operating under the UN flag maintaining brothels and raping children. The world has borne witness to mass convoys of food and medical supplies effectively stranded by government haggling, bombings, and ineptitude. Worse, the world has grown inured to the images of refugees drowning in the Mediterranean, children turned back at gunpoint from the Turkish border, babies left to bake in 110 degree sun under sheets of plastic stretched over a piece of Middle Eastern desert.

There is no reason to hope that the summit will produce anything of consequence. Few of the major humanitarian nongovernmental organizations are attending, the Obama administration is sending only low-level diplomatic personnel, and the host nation, Turkey, is itself evicting tens of thousands of Syrian war refugees.

Ending on a hopeful note

So far, the Zika fight, despite the U.S. Congress, has been marked by solid scientific advances and cooperation. In addition to the rapid epidemiological delineation of the virus’s causative role in the terrible neurological and congenital symptoms of infection, a number of findings and commitments have unfolded, the likes of which could have saved lives in early 2014 had they then been directed to Ebola. These include:

  • The U.S. Defense Department has put $1.76 million in special funding to military laboratories to expand Zika virus surveillance worldwide;
  • Joint Brazilian-U.S. research has pinpointed actual mRNA-to-protein genetic signaling that is critical to Zika damage in the brain;
  •  The U.S. CDC has developed rapid PCR diagnostic tests that can detect the virus in blood, semen, and urine;
  • An online tool can show policymakers which Zika interventions are cost-effective;
  • The Federal University of Goias in Brazil and World Community Grid, a philanthropic initiative of IBM, created a tool "that enables anyone with a computer or Android device to donate their unused computing power to scientific research. Using the massive computational power donated by hundreds of thousands of volunteers, the researchers will be able to virtually screen millions of chemical compounds to search for those that could potentially vanquish the Zika virus;"
  • IBM scientists also created a macromolecule that, in lab tests, blocks the virus;
  • Researchers at UC San Diego figured out how to make "mini-brains" (hint: think 3D printing) to actually watch the virus block neuron firing in real time;
  • Experiments with the bacteria Wolbachia in dengue show it is possible to infect mosquitoes and thereby block their ability to spread the virus—now researchers are trying the approach to stop the spread of Zika;
  • Several companies have developed genetically modified mosquitoes that are unable to reproduce, in some cases using CRISPR-Cas9 techniques;
  • A research team created a mouse strain that can be infected with Zika, allowing rapid testing of drugs and observing the impact of the virus on the neurological system;
  • Another team has managed to experimentally infect rhesus macaques with Zika, proving the virus causes observed brain damage;
  • The U.S. Food and Drug Administration has already approved a diagnostic test for Zika;
  • A point-of-care hand-held diagnostic prototype has been developed.

There are many more innovations and discoveries that have unfolded rapidly—too many to list. And that, my friends, is the good news.

Finally, on a sober note, Leonard Rubenstein of the Johns Hopkins Program on Human Rights, Health and Conflict and a team of collaborators just issued a must-read report, No Protection, No Respect: Health Workers and Health Facilities Under Attack 2015 And Early 2016. Exhaustively researched, the report details bombings, assassinations, kidnappings, and murders of health-care workers, medical convoys, hospitals, clinics, and other facilities dedicated to health care around the world, demonstrating that the protections guaranteed under the Geneva Convention have been abandoned. This is the sort of report every person concerned with health issues should read, share, and promote.

As always, we will endeavor to keep you informed about these and other issues in global health.



Laurie Garrett
Senior Fellow for Global Health
Council on Foreign Relations

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