H5N1

Once the breadbasket of Africa, Zimbabwe now on brink of man-made starvation, UN rights expert warns

Via the UN Office of the High Commissioner of Human Rights, a warning about a story far graver than Ebola: Once the breadbasket of Africa, Zimbabwe now on brink of man-made starvation, UN rights expert warns. Excerpt and then another link:

GENEVA / HARARE (28 November 2019) - Despite the constitutional protection of the right to food and a sophisticated set of human-rights based national laws and policies, man-made starvation is slowly making its way in Zimbabwe, said the UN expert of the right to food after visiting the country from 18 to 28 November 2019.  

"More than 60% of the population of a country once seen as the breadbasket of Africa is now considered food-insecure, with most households unable to obtain enough food to meet basic needs due to hyperinflation," said Hilal Elver, Special Rapporteur on the right to food, presenting a preliminary statement at the end of an 11-day visit. 

"In rural areas, a staggering 5.5 million people are currently facing food insecurity, as poor rains and erratic weather patterns are impacting harvests and livelihoods. In urban areas, an estimated 2.2 million people are food-insecure and lack access to minimum public services, including health and safe water.  

"These are shocking figures and the crisis continues to worsen due to poverty and high unemployment, widespread corruption, severe price instabilities, lack of purchasing power, poor agricultural productivity, natural disasters, recurrent droughts and unilateral economic sanctions." 

Elver said women and children were bearing the brunt of the crisis. 

"The majority of the children I met were stunted and underweight," she said. "Child deaths from severe malnutrition have been rising in the past few months. 90 % of Zimbabwean children aged six months to two years are not consuming the minimum acceptable diet.  

"I saw the ravaging effects of malnutrition on infants deprived of breast feeding because of their own mothers' lack of access to adequate food. 

"In a desperate effort to find alternative means of livelihood, some women and children are resorting to coping mechanisms that violate their most fundamental human rights and freedoms. As a result, school drop-outs, early marriage, domestic violence, prostitution and sexual exploitation are on the rise throughout Zimbabwe."  

Elver said people she met in the drought-affected areas of Masvingo and Mwenezi, located in the driest regions of the country, told her they ate only one portion of cooked maize a day. Women, the elderly and children are barely able to meet their minimum food needs and are largely dependent on food assistance, while most of the men are abroad seeking work, she added. 

"Without access to a diversified and nutritious diet, rural Zimbabweans, particularly younger children, barely survive," she said, adding that the agricultural and food system needs immediate reform.  

"I strongly urge the Government to take the necessary measures to reduce the country's dependence on imported food, particularly maize, and to support alternative wheats to diversify the diet. The Government should create the conditions for the production of traditional seeds to ensure the country's self-sufficiency and preparedness for the climate shocks that hit the country." 

The Special Rapporteur said the crisis in Zimbabwe's cities was no less severe than in rural areas.

"I witnessed some of the devastating consequences of the acute economic crisis in the streets of Harare, with people waiting for hours on long lines in front of gas stations, banks, and water dispensaries," she said. 

"The Zimbabweans I spoke to in Harare and its suburbs explained that even if food was widely available in markets, the erosion of their incomes combined with an inflation skyrocketing to over 490%, made them suffer from food insecurity, also impacting the middle-class. 

Elver also said that she received "disturbing" information that public hospitals have been reaching out to humanitarian organizations after their own medicine and food stocks were exhausted.  

Elver also received indication that the distribution of lands or food had been manipulated for political ends throughout the last two decades, favoring those who support the ruling political party. 

"I call on the Government of Zimbabwe to live up to its zero hunger commitment without any discrimination," Elver said.

Meanwhile, The Zimbabwean reports striking doctors say poor conditions in hospitals are causing a "silent genocide":

The senior doctors described the situation at the country’s hospitals as a silent genocide, saying doctors are forced to work without basics such as bandages, gloves, and syringes.

“We have watched the past few months as the situation in our hospitals continues to deteriorate.

“In March this year, the situation in hospitals deteriorated to the point where there were no bandages, gloves, and syringes available forcing senior doctors to highlight the dire situation publicly. It is important to find out why this has taken so long to be resolved as a silent genocide continues to be perpetrated upon the people of Zimbabwe,” the statement said.

Butembo: Ebola at the base of the fall in sales in economic enterprises

Via Radio Moto Butembo-Beni: Butembo: Ebola at the base of the fall in sales in Economic Enterprises (Polycarpe NDIVITO). The Google translation:

Ebola against trade. This is the reality of many economic operators in Beni, Butembo and Lubero. For more than a year of this epidemic, the sale has fallen in the economic enterprises of the region. 

It is a bitter fact communicated by the President of the Federation of Enterprises of Congo, Butembo-Lubero FEC grouping. In an interview with RMBB Thursday, November 14 in his office work, Polycarpe NDIVITO KIKWAYA noted that stockpiles of goods hang in warehouses these days for lack of large buyers.  

The boss of Butembo-Lubero's patronage shows that the renting of some hotels and the attendance of some restaurants by agents of the response to Ebola are not business. The movements of merchants who stocked up on various items in Butembo had already decreased since the beginning of the Beni massacres. They experienced a new fall with the epidemic of Ebola reported in Mangina the 1st August 2019, laments Polycarp NDIVITO KIKWAYA. 

After Ebola and the massacres, FEC President Butembo-Lubero hopes that trade will flourish again in the region.

Saudi Arabia: The direct medical costs of MERS

Via Infection and Drug Resistance, the best research report I have yet seen on the MERS epidemic: Estimation Of Direct Medical Costs Of Middle East Respiratory Syndrome. The abstract:

Background: Among the countries affected by Middle East respiratory syndrome (MERS), Saudi Arabia was impacted the most, with 2,058 cases reported as of June 2019. However, the impact of the MERS epidemic on the Saudi economy is unknown. 

Purpose: The present study aimed to evaluate the direct medical costs associated with the management of MERS cases at a tertiary referral hospital in Riyadh, Saudi Arabia. 

Methods: The study involved a retrospective chart review of confirmed cases of MERS coronavirus (MERS-CoV) infections in a tertiary care referral center in Riyadh, Saudi Arabia, from January 2015 to October 2018. The collected data included sociodemographic characteristics, medical information, and the cost of hospitalization of each patient as estimated by micro-costing. 

Results: A complete set of relevant information was available only for 24 of 44 identified MERS-CoV cases. Patients were mostly females, and the mean age was 52 years. Diabetes, hypertension, and chronic kidney disease were the most frequent comorbidities. The length of hospital stay varied from 1 to 31 days, averaging 4.96 ± 7.29 days. Two of the 24 patients died. The total cost of managing a MERS case at the hospital ranged from $1278.41 to $75,987.95 with a mean cost of $12,947.03 ± $19,923.14. 

Conclusion: The findings of this study highlight the enormous expenses incurred by the Saudi health care system due to the MERS-CoV outbreak and the importance of developing an enforceable nationwide policy to control MERS-CoV transmission and infection.

Be cautious with the precautionary principle: Evidence from Fukushima Daiichi nuclear accident

Via the National Bureau of Economic Research, a cautionary tale: Be Cautious with the Precautionary Principle: Evidence from Fukushima Daiichi Nuclear Accident. The abstract, and then a comment:

This paper provides a large scale, empirical evaluation of unintended effects from invoking the precautionary principle after the Fukushima Daiichi nuclear accident. 

After the accident, all nuclear power stations ceased operation and nuclear power was replaced by fossil fuels, causing an exogenous increase in electricity prices. This increase led to a reduction in energy consumption, which caused an increase in mortality during very cold temperatures. 

We estimate that the increase in mortality from higher electricity prices outnumbers the mortality from the accident itself, suggesting the decision to cease nuclear production has contributed to more deaths than the accident itself.

I've been thinking a lot lately about the inevitably higher costs of a sustainable economy of the kind envisaged by the "Green New Deal" advocates. This study tends to confirm my suspicions that without an equal level of prosperity for everyone, sustainability will be impossible.

'Under threat': Why experts say US import of Canadian drugs could put supply at risk

Via CBC News: 'Under threat': Why experts say U.S. import of Canadian drugs could put supply at risk. Excerpt:

U.S. President Donald Trump is calling for quicker action to allow Canadian drugs to be imported into the U.S. But experts say the move has the potential to put our drug supply at risk of further shortages in the future.  

On Monday, Trump called on U.S. Health Secretary Alex Azar to speed up efforts to allow for cheaper drugs from Canada, after the U.S. Department of Health and Human Services began taking steps last July to allow states, wholesalers and pharmacists to import some drugs from Canada.  

"We've never been under threat in this way before," said Dr. Sandy Buchman, president of the Canadian Medical Association (CMA). 

"We're only about a 10th of the size, so any kind of raiding of our drug supply is really going to have a major impact." 

Why does the U.S. want to import Canadian drugs? 

Canada, like most other industrialized countries, has price controls in place over drugs. But the U.S. does not, leaving their drug prices to be set by pharmaceutical companies. 

U.S. presidential hopeful Bernie Sanders travelled to southern Ontario this summer on an "insulin caravan" with a group of people with diabetes in order to purchase the drug more cheaply. 

In the U.S., the average cost of a vial of insulin is about $340 ($450 Cdn). In Canada, the same vial will be about $30.  

The CMA was one of 15 groups representing patients, health professionals, hospitals and pharmacists that warned Health Minister Ginette Petitpas Taylor of the potential for increasing drug shortages due to U.S. importation.   

Drug shortages already have a "detrimental impact" on the delivery of patient care in Canada, Buchman said, and the U.S. is interested in our supply because they pay some of the highest drug prices in the world. 

"I think it's seen as a quick and easy solution. Because our drug prices are cheaper than in the U.S., because they don't put any kind of controls on their drug prices," he said.  

"Just the size of the U.S. and what potentially they could do — I think that's very frightening for a lot of Canadians.… It's kind of like a storm coming. How bad a storm is it going to be? Is it going to be a major hurricane, or is it going to be downgraded?"

WHO: Ebola virus disease – Democratic Republic of the Congo

WHO has published its weekly update: Ebola virus disease – Democratic Republic of the Congo. Excerpt:

The number of confirmed cases of Ebola virus disease (EVD) has been relatively low in recent weeks, with 15 new confirmed cases reported in North Kivu and Ituri provinces during the epidemiological week of 7 October through 13 October (Figure 1). These encouraging signs are offset by a marked increase in case incidence in Biakato Mine Health Area, Mandima Health Zone. During the past 21 days (from 25 September through 15 October), a total of 50 confirmed cases were reported from ten health zones (Table 1, Figure 2), of which two-thirds (62%, n=31) were reported from or had transmission links to Biakato Mine Health Area. 

Issues with access and security are impacting case finding and investigations, contact tracing, safe and dignified burials, decontamination of affected residences, and vaccination rings in parts of Mandima Health Zone. This is reflected in the decline in the proportion of confirmed cases listed as contacts (from 57% to 13%) and increase in the proportion of cases dying outside of Ebola Treatment Centres or Transit Centres (from 14% to 27%) this past week. This is further demonstrated by the relatively low numbers of alerts reported in the two areas over the past 42 days, with 32% less than the expected number.  

A recent qualitative investigation in these health zones indicated that there is poor understanding among the population and local health workers of the transmission mechanism and symptoms of the disease, compounded with an environment of mistrust surrounding the origin of the disease, and reason for vaccination. This may impact the reporting of cases and engagement with response activities. Less than half of the respondents indicated that they would call a hotline if a member of their community was suspected of having Ebola, and almost half reported that they would encourage a family member to go to a Treatment/Transit Centre if they were suspected of having Ebola. 

Furthermore, less than half of individuals interviewed understood the functions of different interventions in the response, and less than 5% were involved in the response. This investigation highlights the importance of engaging communities in response activities in the upcoming weeks. 

As of 15 October, a total of 3227 EVD cases were reported, including 3113 confirmed and 114 probable cases, of which 2154 cases died (overall case fatality ratio 67%). Of the total confirmed and probable cases, 56% (n=1811) were female, 28% (n=918) were children aged less than 18 years, and 5% ((n=162) were health workers. 

The Director-General will reconvene the Emergency Committee under the International Health Regulations (IHR), as three months have passed since the declaration of the public health emergency of international concern (PHEIC) on 17 July. The committee will review progress in the implementation of the Temporary Recommendations issued by the Director-General on 17 July, discuss whether the event still constitutes a PHEIC, and if yes, advise for new or updated Temporary Recommendations under the IHR. The current recommendations are available here as will be the upcoming statement. 

Under Pillar 1 of the current Strategic Response Plan, the estimated funding requirement for all partners for the period July to December 2019 is US$ 287 million, including US$ 140 million for WHO. As of 17 October 2019, US$ 69.5 million has been received by WHO, with additional funds committed or pledged. Further resources are needed to fully fund the response through to December 2019 and into Q1 2020. 

Under Pillar 5, Regional Preparedness, the funding requirement for all partners is US$ 66 million, of which WHO requires US$ 21 million. As of 17 October 2019, WHO has received US$ 4.3 million. While some additional pledges are in the pipeline, increased funding for preparedness in neighboring countries is urgently needed. WHO is appealing to donors to provide generous support. A summary of funding received by WHO since the start of this outbreak can be found here.

WHO AFRO: Ebola virus disease outbreak in DRC - Sitrep 63 (2019)

WHO AFRO has published Ebola Virus Disease Outbreak in DRC - Sitrep 63 (2019). Excerpt:

In the past week, from 7 to 13 October, 15 new confirmed Ebola virus disease (EVD) cases were reported from five health zones in two affected provinces in the Democratic Republic of the Congo. While it is encouraging to see another week of relatively low numbers of newly confirmed cases, these are occurring in a concentrated area where limited access and insecurity pose challenges for the response. In such environments, risks of resurgence remain very high, as do the risks of re-dispersion of cases. For example, this past week, several people who were eventually confirmed as positive for EVD sought healthcare in health zones which are no longer experiencing ongoing transmission, such as Beni. 

The proportion of confirmed cases listed as contacts has decreased in the past week from 57% to 13%, the lowest since mid-January. The majority (87%) of confirmed cases in the past week had links to the Biakato Mines Health Area in the Mandima Health Zone, with the remaining confirmed cases linked to the Mambasa Health Zone. Insecure environments in both Mandima and Mambasa Health Zones can diminish response activities related to disrupting transmission chains such as contact tracing, linkage of cases, safe and dignified burials, decontamination of affected residences, and vaccination rings. 

In the 21 days from 23 September to 13 October, the number of affected health areas has decreased, with 22 health areas and 10 health zones reporting new cases. During this period, a total of 49 confirmed cases were reported, with the majority coming from the health zones of Mandima (43%; n=21 cases), Mambasa (12%; n=6 cases) and Oicha (12%; n=6 cases). 

As of 13 October 2019, a total of 3220 EVD cases were reported, including 3106 confirmed and 114 probable cases, of which 2150 cases died (overall case fatality ratio 67%). Of the total confirmed and probable cases, 56% (1806) were female, 28% (915) were children aged less than 18 years, and 5% (162) were healthcare workers. 

Following the declaration of the Ebola outbreak in the Democratic Republic of the Congo as a public health emergency of international concern (PHEIC) on 17 July 2019, the Director-General will reconvene the Emergency Committee under the International Health Regulations (IHR) on 18 October to review and potentially update the Temporary Recommendations made, and determine if the event still constitutes a PHEIC. 

Under Pillar 1, the public health pillar of the Strategic Response Plan, the estimated funding requirement for all partners for the period July to December 2019 is US$ 287 million, including US$ 140 million for WHO. As of 15 October 2019, US$ 65.8 million has been received by WHO, with additional funds committed or pledged. 

Further resources are needed to fully fund the response through to December 2019 and into Q1 2020. Under Pillar 5, the Regional Preparedness pillar, the funding requirement for all partners is US$ 66 million, of which WHO requires US$ 21 million. As of 15 October 2019, WHO has received US$ 3.8 million. While some additional pledges are in the pipeline, increased funding for preparedness in neighboring countries is urgently needed. WHO is appealing to donors to provide generous support.

MSF: Ebola response overshadows DRC's fragile health system

Thanks to Mary Marshall for sending the link to this important report from MSF.org: Ebola response overshadows DRC's fragile health system. Excerpt (but read the whole story):

For health centres and hospitals in the region, the scale-up of the internationally funded Ebola response can be a blessing or a curse. 

Where Ebola response teams and international organisations set up isolation and treatment facilities, they often improve infrastructure, pay extra staff, and support primary healthcare services. 

But the health workers needed in the response are almost exclusively hired from other health centres and hospitals in the area, which are now facing critical staff shortages.  

At the General Hospital in the main village of Mabalako, these gaps are strikingly evident. Over half of the doctors and nursing staff are missing, and no one has sufficient time to watch over patients in the four wards around the big courtyard.

As extra wages with the Ebola response tend to be higher and more reliable, many of the remaining staff are disappointed that they were not selected, and moral and motivation are low. 

In the hospital, the staff shortages, unavailable treatments, and missing salaries are a deadly mix.  

“We lost children in the paediatric ward because they were not put on the correct malaria treatment straight away – an error that could have been avoided with the right human resources and more vigilance,” said MSF doctor Brian Da Cruz, who is supporting the two remaining doctors in charge of an operating theatre, maternity department, paediatric clinic, and a regular ward with more than 40 beds. 

The hospital also has a basic isolation zone for patients with infectious diseases, but the small structure has no changing rooms, no decontamination zone, and there is no safe access for families to visit patients.  

As suspect Ebola patients are taken to another, better equipped structure, its rooms are currently used to observe four children with measles, a vaccine-preventable, but highly infectious disease leading to regular epidemics in the DRC. 

On the opposite side of the courtyard, MSF drilled a borehole and installed a water point, which is in permanent use by people living in the neighbourhood for clean drinking water.

While MSF’s support was mostly focused on improving infrastructure and working alongside the remaining staff in health centres and the regional hospital, the team is currently evaluating a different model, including a regular payment scheme to supplement staff salaries and offer bedside training. 

“We are discussing playing a stronger role in the hospital and the three health centres we support, by taking supervisory responsibility, offering training on the job, and ensuring patients have access to free care while staff are getting paid,” explained MSF project coordinator Amandine Colin. 

Back in Metale, MSF community outreach specialist Wivine Bokotogi hands a set of flashcards on malaria prevention and treatment to two local health promoters. 

Malaria is another major health burden at risk of being neglected as the attention and resources chase after the Ebola epidemic. In the DRC, malaria accounted for 13 per cent of deaths in children under five years old in 2016, and up to half of the people screened in Ebola treatment centres last year tested positive for malaria alone. 

“We train the local health promoters on key messages to prevent malaria, including instructions to cover stagnant water sources, use mosquito nets, and take children to the nearest health centres so they can be treated in time,” said Wivine.

Effect of economic recession and impact of health and social protection expenditures on adult mortality

Via The Lancet Global Health, an important study: Effect of economic recession and impact of health and social protection expenditures on adult mortality: a longitudinal analysis of 5565 Brazilian municipalities. The summary:

Background 

Economic recession might worsen health in low-income and middle-income countries with precarious job markets and weak social protection systems. Between 2014–16, a major economic crisis occurred in Brazil. We aimed to assess the association between economic recession and adult mortality in Brazil and to ascertain whether health and social welfare programmes in the country had a protective effect against the negative impact of this recession. 

Methods 

In this longitudinal analysis, we obtained data from the Brazilian Ministry of Health, the Brazilian Institute for Geography and Statistics, the Ministry of Social Development and Fight Against Hunger, and the Information System for the Public Budget in Health to assess changes in state unemployment level and mortality among adults (aged ≥15 years) in Brazil between 2012 and 2017. Outcomes were municipal all-cause and cause-specific mortality rates for all adults and across population subgroups stratified by age, sex, and race. 

We used fixed-effect panel regression models with quarterly timepoints to assess the association between recession and changes in mortality. Mortality and unemployment rates were detrended using Hodrick–Prescott filters to assess cyclical variation and control for underlying trends. We tested interactions between unemployment and terciles of municipal social protection and health-care expenditure to assess whether the relationship between unemployment and mortality varied. 

Findings 

Between 2012 and 2017, 7 069 242 deaths were recorded among adults (aged ≥15 years) in 5565 municipalities in Brazil. During this time period, the mean crude municipal adult mortality rate increased by 8·0% from 143·1 deaths per 100 000 in 2012 to 154·5 deaths per 100 000 in 2017. An increase in unemployment rate of 1 percentage-point was associated with a 0·50 increase per 100 000 population per rter (95% CI 0·09–0·91) in all-cause mortality, mainly due to cancer and cardiovascular disease. 

Between 2012 and 2017, higher unemployment accounted for 31 415 excess deaths (95% CI 29 698–33 132). All-cause mortality increased among black or mixed race (pardo) Brazilians (a 0·46 increase [95% CI 0·15–0·80]), men (0·67 [0·22–1·13]), and individuals aged 30–59 years (0·43 [0·16–0·69] per 1 percentage-point increase in the unemployment rate. 

No significant association was identified between unemployment and all-cause mortality for white Brazilian, women, adolescents (aged 15–29 years), or older and retired individuals (aged ≥60 years). In municipalities with high expenditure on health and social protection programmes, no significant increases in recession-related mortality were observed. 

Interpretation 

The Brazilian recession contributed to increases in mortality. However, health and social protection expenditure seemed to mitigate detrimental health effects, especially among vulnerable populations. This evidence provides support for stronger health and social protection systems globally.

Worst global health news of the year

Via the UN, Secretary General António Guterres has published his Remarks to the Fifth Committee of the General Assembly on the Proposed Programme Budget for 2020. Excerpt, with my bolding, and then a comment:

Earlier this year, I proposed measures to resolve the financial crises facing our Organization.  

You have responded positively to some of the proposals for the peacekeeping budget, which will reduce, but not cancel completely, the debt to troop- and police-contributing countries – for which I am grateful.  

But we have not yet addressed the regular budget crisis, and the situation continues to deteriorate. 

This month, we will reach the deepest deficit of the decade. We risk exhausting the closed peacekeeping cash reserves, and entering November without enough cash to cover payrolls. 

This situation would have been much worse if I had not worked since January to curtail spending, align our real vacancy rate with the approved rate, and manage cash on a month-by-month basis. Without these steps, we would not have had, I repeat, we would not have had the liquidity to support the opening of the General Assembly debate and the mandated high-level meetings last month. 

Last week, I was forced to introduce extraordinary measures to cope with the record-level shortage of cash. Vacant posts cannot be filled, travel will be limited to essential travel only, meetings may have to be canceled or deferred, webcasting of non-mandated events will not be available, and support to meetings will have to be adjusted. The Secretariat will no longer be able to support any non-mandated events after 6 p.m. These steps will affect our operations in New York, Geneva, Vienna and Nairobi and at the regional commissions. 

Our work and our reforms are at risk. 

As I introduce the 2020 programme budget proposals, I reiterate my call on you to recommit to paying your financial obligations on time and in full. I thank those Member States that have done so. I also thank those that continue to make every effort to do so, notwithstanding the difficult economic conditions they face. I equally urge you to consider measures to ease the structural impediments preventing us from managing the resources more effectively. 

The full and efficient implementation of our programme of work depends on the financial support of Member States through the adoption of realistic budget levels and the provision of timely contributions to ensure a stable financial situation throughout the year. 

I look forward to your full and enthusiastic support.

This is not just the Ebola response that's running out of money—it's the whole UN. The health consequences scarcely bear thinking about: shelter, food security and basic nutrition and education among refugees, internally displaced people, and disaster survivors; surveillance and response to countless outbreaks around the world; long-term studies of population health. 

You can add to this list. A major factor appears to be the nonpayment of UN dues by the United States, but a quick scan of today's major American media shows little or no mention of the shortfall, let alone the Trump administration's responsibility for it. 

 

The repercussions will be felt all over the world.