H5N1

The Lancet Commission on 21st-Century Global Health Threats

Via The Lancet, December 15, 2022: The Lancet Commission on 21st-Century Global Health Threats. 

The world has lived through an extraordinary global health threat, the COVID-19 pandemic, leading to nearly 20 million deaths, staggering economic losses, a generational decline in human capital, and the first decline in global life expectancy since 1950 (the first year when UN estimates were published). Another major threat, climate change, now has broad scientific, political, and social recognition. The spectre of nuclear confrontation has re-emerged as a serious threat during the ongoing Russian invasion of Ukraine. 

The three Cs—COVID-19, climate change, and conflict—highlight that the steady global health progress of the past 70 years will not necessarily continue in the next 70 years. But there are many other threats beyond the three Cs that threaten to undermine future global health progress, including rising antimicrobial resistance, increasing obesity, inverted population pyramids, eroding sexual and reproductive rights for women, food insecurity, and fraying multilateralism. How global health advances or retreats will depend crucially on the multiplicity of these threats and how they intersect. 

The global community and many nations have launched commissions, task forces, and panels to draw lessons from the COVID-19 pandemic. The Pan-European Commission on Health and Sustainable Development explored the post-pandemic world for Europe and made far-reaching recommendations based on a One Health lens. The Independent Panel for Pandemic Preparedness and Response and the G20 High Level Independent Panel on Financing the Global Commons for Pandemic Preparedness and Response called for the creation of new institutions and financing mechanisms to prepare the world for new pandemics and other threats. 

Multiple commissions, task forces, and panels have addressed climate change, including two Lancet Commissions, and the Intergovernmental Panel on Climate Change produces regular multistakeholder assessments. These global convenings have been mirrored by multiple national reviews. Although there are high-profile initiatives for pandemics and climate change, other threats have received less widespread attention or have been debated largely in academic subdisciplines.  

Governments, international organisations, and local communities will need to manage multiple threats at the same time. Many of these threats interact and lead to complex health, economic, social, and geopolitical consequences. Climate change, population growth, and political fragility may coincide leading to large-scale migration. Food systems can be designed to improve health, reduce poverty, and slow climate change, or the reverse.  

Specific and cross-cutting technologies and policies are needed to reduce the risk of emerging threats or to decrease the harms from threats as they unfold. The most important strategies for risk and harm reduction are unlikely to emerge if each threat is examined in isolation from the others.  

We have established the Lancet Commission on 21st-Century Global Health Threats to examine the broad set of threats facing the world over the rest of the century. This long perspective is needed since threats such as climate change, food systems, antimicrobial resistance, or inverted population pyramids require many decades for actions to alter future trajectories. The Sustainable Development Goal focus on 2030 is an important motivator for immediate policy action, but a longer-term perspective is needed to fully assess and respond to emerging threats.

This Commission's work will be informed by diverse expertise. The Commission members are drawn from many distinct groups: current and former heads of state, intergovernmental organisation leaders, leaders of public health institutions, global health funders, global health thought leaders, and civil society and youth organisations. The Commission represents a diverse group with gender parity and regional balance so that many perspectives are brought to bear on finding cross-cutting tools and solutions for future threats. The Commission will meet over the next 2 years to assess the evidence produced by various working groups and will release its analysis and recommendations by the end of 2024.

WHO sees October COVID surge in Ukraine, cites polio concerns

Via Reuters: WHO sees October COVID surge in Ukraine, cites polio concerns. Excerpt:

JERUSALEM, Sept 12 (Reuters) - The World Health Organisation expects a rise in COVID-19 in Ukraine to peak in October, possibly bringing hospitals close to their capacity threshold, WHO's director-general Tedros Adhanom Ghebreyesus said on Monday.  

"We are now seeing an increase in cases of COVID-19 in Ukraine. We project that transmission could peak in early October and hospitals could approach their capacity threshold," Ghebreyesus told WHO'S Regional Committee for Europe conference in Tel Aviv.  

"Oxygen shortages are predicted because major supply sources are in occupied parts of the country," he said. Oxygen is essential for patients with a range of conditions, including COVID-19 and those with other critical illnesses stemming from complications of pregnancy, childbirth, sepsis, injuries and trauma.  

Russia's February invasion of Ukraine has greatly impacted healthcare, with the WHO confirming more than 500 attacks on health infrastructure there, resulting in some 100 deaths. Ghebreyesus also said that the war could increase polio spread. 

"We are also deeply concerned about the potential for the international spread of polio due to the gaps in immunization coverage and mass population movement linked to the war," he said.  

Ukraine has low vaccination coverage for both COVID and polio, an infectious disease mainly affecting children that can cause paralysis and kill in rare cases. Two cases of polio were reported in Ukraine in 2021.

Cholera fears prompt quarantine in Ukraine's Mariupol

Via The Washington Post: Cholera fears prompt quarantine in Ukraine's Mariupol; country prepares for disease outbreaks. Excerpt:

In Mariupol — the ruined and Russian-occupied port city in Ukraine’s southeast — fears of constant bombardment have given way to silent threats: Bacteria-laced water and deadly cholera outbreaks.  

The city’s exiled local leaders have voiced concern about the water supply for weeks, and on Monday, mayoral aide Petro Andryushchenko said that decomposing bodies and piles of garbage are contaminating drinking sources, leaving residents vulnerable to cholera, dysentery and other ailments.

The Russian officials now running the city recently imposed a quarantine, Andryushchenko said in an appearance on Ukrainian television. He did not elaborate on the measures, and his statement could not be independently verified, but he said the humanitarian situation there was getting worse.  

“Spontaneous burials are still in almost every yard in Mariupol,” the city council wrote in an update on Telegram. “Bodies are rotting under the rubble of hundreds of high-rise buildings. And it literally poisons the air.”  

Public health experts have warned that warming weather and prolonged warfare could expose Ukraine — its soldiers and civilians — to infectious diseases, potentially ushering in a new phase of the conflict that forces authorities to contend with outbreaks of illness while fending off Russia’s invasion. The most at-risk areas, officials have said, are the country’s occupied regions, where long bouts of fighting have left sanitation systems in ruins.  

Cholera, which spreads through contaminated food and water, is an acute diarrhoeal infection that can be fatal if left untreated.  

The Mariupol council predicted thousands more civilian deaths if an outbreak were to rage uncontrolled, which would bring more tragedy to a city that has already endured some of the most brutal bombing of the Russian campaign. The near-constant shelling, which allowed Moscow to claim full control of Mariupol last month, reduced much of the city to rubble and has destroyed water and sewer infrastructure, along with medical facilities, the council said.  

To get access to clean water, Mariupol residents must queue for hours, Andryushchenko said on Telegram, and it has only been available every two days at most.  

In a news briefing Monday, Ukraine’s chief sanitary doctor, Ihor Kuzin, said national authorities began monitoring potential cholera outbreaks across the country on June 1. He said Mariupol’s situation is especially dire.  

“We can’t be 100 percent sure that there will be disease outbreaks,” he said. “But all prerequisites for them are already there.”

Ukraine: Almost 14 million displaced by war

Via Reliefweb: Statement by Amin Awad, Assistant Secretary-General and United Nations Crisis Coordinator for Ukraine marking 100 days since the onset of the Russian invasion of Ukraine on 24 February - Ukraine.

Today marks 100 days since the start of Russia’s invasion of Ukraine on 24 February. This invasion of Ukraine is a violation of its territorial integrity and of the Charter of the United Nations.  

This war has taken an unacceptable toll on people and engulfed virtually all aspects of civilian life. This war has and will have no winner. Rather, we have witnessed for 100 days what is lost: lives, homes, jobs and prospects. We have witnessed destruction and devastation across cities, towns and villages. Schools, hospitals and shelters have not been spared.  

Families and communities have been disrupted and uprooted. In just over three months, nearly 14 million Ukrainians have been forced to flee their homes, the majority women and children – a scale and speed of displacement not witnessed in history.  

More than 3 million children saw their education suspended – an entire generation of children whose future hangs in the balance. All over the country, hundreds of thousands of people do not have access to water and electricity, and millions do not know where their next meal is coming from. 15.7 million people are in need of humanitarian support now, with numbers growing.  

One hundred days on, the war ravages unabated especially in the east of the country. And with winter coming, millions of civilian lives could be in peril.  

The United Nations agencies and humanitarian partners in Ukraine continue supporting those whose lives have been shattered by war. In the past 100 days, we have provided immediate humanitarian aid to some 8 million people across the country, including in besieged cities in the east of Ukraine.  

At the same, the United Nations are pursuing every pathway to mitigate the global ramifications of the war’s devastating impact on food security by seeking to unblock critical grain and commodity trade.  

Our tireless efforts to respond to the war’s devastating impact will continue, robustly and stead-fast.  

But above all we need peace. The war must end now.

Canada is failing Ukrainians displaced by Russian invasion, former head of Doctors Without Borders says

Via The Globe and Mail: Canada is failing Ukrainians displaced by Russian invasion, former head of Doctors Without Borders says. Excerpt:

Ottawa needs to do more to help Ukrainian refugees navigate the complexities of paperwork and logistics to come to Canada, the former head of Doctors Without Borders says, lest it reprise past blunders.  

“We know the failures in Afghanistan of not living up to our promises. And we cannot repeat history,” said Joanne Liu, a Montreal emergency physician who returned recently from three weeks in Ukraine, where she was struck by the warm reception to her Canadian passport.  

Many in the country remember early Canadian promises to stand by Ukraine, making Canada “a place of promise, a place of hope,” Dr. Liu said. “We have to live up to our promise,” she added, pointing to bureaucratic obstacles Ukrainians must navigate before coming to Canada.  

“We absolutely need to lift the red tape. For people who are seeking to come here, it’s not good enough to just say, ‘Well, we have extended the hours of our consulates.’ ”  

For example, Ukrainians need better linguistic support to complete paperwork in an unfamiliar language, she said. “You have to facilitate it. That means you should staff better, you should have people who speak the language.”  

In early March, the Canadian government said it was creating a telephone hotline as “a dedicated service channel for Ukraine immigration inquiries.” That line offers service in French and English only, and suggests anyone who speaks another language write in using a web form. The Globe and Mail called the number six times on Friday, but was not able to reach anyone. When The Globe selected an option for callers “regarding the situation in Ukraine,” the hotline hung up each time.  

Global Affairs Canada referred questions to Immigration, Refugees and Citizenship Canada, which did not immediately respond to a request for comment on Friday.

COVID-19 is in for the long haul

Here's a screenshot of this evening's Johns Hopkins Coronavirus COVID-19 (2019-nCoV) dashboard:

It's notable for several reasons. First, the US is now far back in the 28-day case count—seventh, behind Germany, South Korea, Russia, Vietnam, France, and Brazil.

 

Second, almost all the case and mortality numbers are likely severe undercounts, since so many countries have simply abandoned any pretence of testing and contact tracing. I would not be shocked if the true number of cases were around 1.5 billion, and deaths close to 20 million.

 

The numbers for Russia (3.7 million cases in the last 28 days, 20,000 deaths) and Ukraine (458,000 cases, 3,800 deaths) are especially implausible, given the events of the past 15 days. But we'll surely see an explosive growth in cases as over 2 million Ukrainians move through Europe in search of refuge.

 

The early-success countries have largely succumbed to Omicron. While China pursues its zero-COVID policy, it's still recorded 539,000 cases and 2,600 deaths. Hong Kong has seen 533,000 cases in 28 days, and 2,600 deaths. Vietnam racked up 26 million cases in the last 28 days, and 2,400 deaths. New Zealand had 267,000 cases and 12 deaths; it had only 38,900 cases in the previous 23 months of the official pandemic.

 

The graphs on the right tell us that the Omicron spike has fallen sharply from its peak of 23,333,000 in the week ending January 23; we're now at 10,706,000 as of the week ending March 6. That looks impressive, but it's still about 5 million more than the three previous waves.

 

Omicron also drove a spike in deaths, peaking at 75,000 in the week of February 13 and now fallen to 50,400. Meanwhile, vaccinations have fallen from a recent high of 257,000 in the week of February 6 to 105,600 in the week ending March 6.

 

Yet many countries are effectively declaring the pandemic over, making masks and distancing optional, junking vaccine passports, and dropping regular reports by public health officials. Governments seem to think COVID-19 can now sink back into the background noise with other diseases, while we turn our attention to war and inflation and the next election.

 

On February 1, Johns Hopkins reported 381,232,070 cases, so we have seen almost 72 million cases of COVID-19 in the past six weeks alone. Even if the Omicron spike continue to drop, the next six weeks will see tens of millions more cases, and likely another 40 or 50 thousand people now alive will be dead before May 1. 

 

We are nowhere near the end of the pandemic. In fact, I expect it will in many ways get worse as healthcare systems really do collapse, and as sequelae like Long COVID affect more and more cases. The pandemic that began two years ago really is in the for long haul.

Thoughts on six million deaths

Above is a screenshot from this morning's Johns Hopkins COVID-19 dashboard. We have reached 6 million deaths in two years, and half a billion cases don't seem that far away. But the most alarming development in the pandemic is that we in the West, and many other countries, appear to have normalized COVID-19.

On January 30, the weekly case count reached 23 million; yesterday, March 6, it was down to 10,693,000. That's a dramatic fall, but it's still higher than any previous peak in the pandemic. The highest death count was 100,000 in the week ending January 21, 2021. This past week, it was 50,000.

 

These are of course official numbers; the true case counts and mortality are generally assumed to be two to three times higher.

 

Yet the US, Canada, and many other countries are dispensing with "restrictions." The US has dropped to fourth place in the tally of cases, well behind Germany, Russia, and South Korea. The Americans have endured almost 80 million cases and nearly a million deaths, but seem to think they can now go back to business as usual. 

 

Russia counted 4 million cases in the past 28 days, a quarter of its total 16 million cases, and has lost 350,000 lives to COVID-19. Yet it has launched a war against Ukraine that seems sure to result in far more deaths from disease than from combat. Over a million Ukrainians have sought shelter in neighbouring countries, whose healthcare systems will soon be overwhelmed yet again by rising case counts. 

 

No one seems to care. We appear to have decided that fighting a war is more interesting and important than fighting a pandemic, and it lets us ignore the suffering that continues in countries far from the Black Sea. 

 

It's quite an achievement for a coronavirus no one knew about a couple of years ago: worldwide spread, a Holocaust's worth of deaths, and now acceptance as just another fact of life in the 21st century. I will not be surprised if some preprint soon reports on a new neurological effect of SARS-CoV-2: the stupefaction of all human beings, whether they test positive or not.

Reducing the risks of nuclear war to humanity

Via The Lancet: Reducing the risks of nuclear war to humanity.

On Feb 27, 2022, Russia's President Vladimir Putin ordered Russian nuclear forces to be placed on “the special regime of combat duty”. This decision increased the alert status of Russian nuclear forces from a peacetime status to a pre-combat status, creating the legal conditions for any further instruction to launch missiles. Presumably Putin's move is intended to create fear and uncertainty, intensify pressure on Ukraine and the North Atlantic Treaty Organization (NATO) allies and partners, reduce resistance to Russian attacks in Ukraine, and extract concessions in negotiations.  

But these threats represent an absolutely unacceptable escalation of his invasion of Ukraine. The threat of nuclear weapons ratchets up tensions and increases the anxiety and stress that every soldier, resistance fighter, civilian, and politician is experiencing. This threat is also likely to affect analysis and decision making by all parties to the conflict in regard to the potentially far-reaching impacts of decisions. Indeed, history has shown us the risks that these types of situations can pose.  

Since the 1960s the assumption by nuclear armed states was that the prospect of mutually assured destruction would guarantee that nuclear weapons are never used. Nuclear war was believed to be so catastrophic that no leader would ever dare use their nuclear arsenals. More recently, in January, 2022, all the nuclear weapons states that are signatories to the Nuclear Non-Proliferation Treaty (China, France, Russia, the USA, and the UK) reiterated the Reagan–Gorbachev statement that “a nuclear war cannot be won and must never be fought”.  

Nonetheless, documentary research and testimonies have revealed occasions during the decades after the Cuban missile crisis when nuclear weapons were very nearly used as a result of misperceptions and misinterpretation of signals. In 1983, for example, the NATO Able Archer military exercise increased the fear level in the Soviet Union to such an extent that Russian nuclear forces were mobilised. Also in 1983, satellite signals that appeared to be incoming nuclear missiles from the USA to the Soviet Union nearly led to a launch-on-warning response from Moscow. The decision not to do so rested largely on the decisions of one individual, lieutenant colonel Stanislav Petrov. Even after the end of the Cold War, when tensions were low, a Norwegian rocket was initially feared to be an incoming nuclear weapons attack in Russia.  

In the case of nuclear weapons, such mistakes, if they lead to inadvertent use, can never be small or put right. Any use of so-called tactical nuclear weapons (in the low kiloton range) in battle situations would also risk rapid escalation to large-scale nuclear war. The overwhelming humanitarian catastrophic impact of a nuclear weapon is too great to allow these weapons into stressful conflict situations in which such mistakes will occur. Humanity has not avoided nuclear war thus far because of wise leaders, sound military doctrine, or infallible technology. As former US Defense Secretary Robert McNamara observed: “We lucked out. It was luck that prevented nuclear war.”  

An estimated 200 000 people died within 5 months of the nuclear bombs dropped on Hiroshima and Nagasaki, Japan, in 1945 and many survivors suffered long-term effects, including increased risk of leukaemia, other types of cancer, and effects on mental health. The world's nuclear armed states currently have a combined arsenal of around 12 700 nuclear weapons. According to the Federation of American Scientists, the USA deploys 1644 and Russia deploys 1588 strategic warheads on bombers and missiles, many with an explosive power of 100 kilotons or more. Both countries are modernising their nuclear delivery systems.  

If a single warhead of 100 kilotons exploded over a major city it would kill hundreds of thousands of people outright and injure many more, overwhelming the health-care system of an entire nation.  

Even a small-scale nuclear war, involving 250 of the deployed nuclear weapons in the NATO and Russian arsenals, or as might take place between India and Pakistan, would be expected to result in sufficient dust and smoke blocking solar radiation to cause major climate disruption that would trigger a global famine, putting billions of people at risk and destroying modern civilisation.  

A large-scale nuclear war would create a nuclear winter, with temperatures falling an average of about 10°C across the globe, and could kill most of humanity over 10 years. 

The threat by Putin has exposed the weakness of the belief system in nuclear deterrence. Such an approach can never be risk free and the consequences of failure of this strategy are catastrophic. This realisation should lead to more nations signing and ratifying the Treaty on the Prohibition of Nuclear Weapons (TPNW), which currently has 86 signatories and 59 states parties, but that will take time, even with political will. In the near term, it is essential that leaders refrain from exacerbating tensions by implying that such weapons have a military purpose and that immediate steps are taken to reduce the risks of miscommunication and error potentially leading to tragedy on a vast scale.  

NATO and Russia must explicitly renounce any use of nuclear weapons in the conflict in Ukraine. They must join with the other nuclear armed states, at the earliest possible moment, in support of the aims of the TPNW, to commence negotiations for the complete, verifiable elimination of all nuclear weapons.

Fire breaks out at Zaporizhzhya nuclear power plant

Google Maps

Via The Guardian: Fire breaks out at Zaporizhzhya nuclear power plant. This sounds like Chernobyl, but on purpose:

A fire has broken out in Europe’s largest nuclear power plant located in Zaporizhzhya, according to an announcement from the mayor of the nearby town of Enerhodar.  

“As a result of continuous enemy shelling of buildings and units of the largest nuclear power plant in Europe, the Zaporizhzhia nuclear power plant is on fire,” Enerhodar Mayor Dmytro Orlov said on his Telegram channel, citing what he called a threat to world security. He did not give details, Reuters reports.  

Orlov recorded a short video message which has now been shared my multiple local Ukrainian media outlets, urging Russian troops to immediately stop shelling the plant.  

Orlov earlier said Ukrainian forces were battling Russian troops on the city’s outskirts. and reported that a Russian military column was heading toward the nuclear plant. Loud shots and rocket fire were heard late Thursday.  

According to a Telegram message posted by an employee at the plant, Russian troops fired at the nuclear facility. “Attention! Equipment of the Russian Federation is firing at the Zaporozhye NPP. There is a real threat of nuclear danger at the largest nuclear power plant in Europe. We demand a ceasefire from heavy equipment at the Zaporozhye NPP!”  

Ukrainian news agencies UNIAN and Hromadske also report that a fire has started at the nuclear power plant.   

The city on the Dnieper River accounts for one-quarter of the country’s power generation.

What was the plague of Athens?

In February I'll be teaching a 4-session course for our local ElderCollege: Perspectives on Pandemics. The first session will deal with outbreaks we know of in antiquity, and one of the most momentous of those was the plague of Athens. While it was not a pandemic, its focus on Athens weakened the city's military strength, demoralized and divided the population, and killed its leader Pericles; Athens and its empire never recovered, and eventually lost the war to Sparta and its allies. 

Background: In the second year of the Peloponnesian War (430 BCE), Sparta's army invaded Attica. Pericles adopted a defensive strategy, bringing rural residents into Athens. These tended to crowd into Piraeus, the harbour district, living in shacks and huts. Meanwhile, Pericles focused on building up the Athenian navy. His policies were unpopular, especially with wealthy landowners whose farms were now ravaged by the Spartans, and he was even ousted from power on a charge of embezzlement. Later he was re-elected to power, but he and members of his family contracted the plague also, and he died of it. 

Could it have been the ancestor of some modern disease, or an early variant of a modern disease? Or is it more likely a one-off that mercifully died out? Here are the symptoms as described by Thucydides (who survived it) in the Penguin Books edition translated by Rex Warner, 1954. 

“At the beginning the doctors were quite incapable of treating the disease because of their ignorance of the right methods. In fact mortality among the doctors was the highest of all, since they cam more frequently in contact with the sick.”

Origins: Ethiopia to Egypt, Libya, and much of Persia. Appeared suddenly in Athen in Piraeus (which was crowded with rural refugees who lacked adequate housing); then in upper city. That year saw no other serious outbreaks, but all who had any kind of previous illness caught the plague.

“In other cases, however, there seemed to be no reason for the attacks. People in perfect health began to have burning feelings in the head; their eyes became red and inflamed; inside their mouths there was bleeding from the throat and tongue, and the breath became unnatural and unpleasant.

“The next symptoms were sneezing and hoarseness of voice, and before long the pain settled on the chest and was accompanied by coughing. Next the stomach was afflicted with stomaches aches and with vomitings of every kind of bile that has been given a name by the medical profession, all this being accompanied by great pain and difficulty. In most cases there were attacks of ineffectual retching, producing violent spasms; this sometimes ended with this stage of the disease, but sometimes continued long afterwards.

“Externally the body was not very hot to the touch, no was there any pallor; the skin was rather reddish and livid, breaking out into small pustules and ulcers. But inside there was a feeling of burning, so that people could not bear the touch even of the lightest lien clothing, but wanted to be completely naked, and indeed most of all would have liked to plunge into cold water. Many of the sick who were uncared for actually did so, plunging into the water-tanks in an effort to relieve a thirst which was unquenchable …. Then all the time they were afflicted with insomnia and the desperate feeling of not being able to keep still.

“In the period when the disease was at its height, the body, so far from wasting away, showed surprising powers of resistance to all the agony, so that there was still some strength left on the seventh or eighth day, which was the time when, in most cases, death came from the internal fever. But if people survived this critical period, then the disease descended to the bowels, producing violent ulcerations and uncontrollable diarrhea, so that most of them died later as a result of the weakness caused by this.

“For the disease, first setting in the head, went on to affect every part of the body in turn, and even when people escaped its worst effects, it still left its trace on them by fastening upon the extremities of the body. It affected the genitals, the fingers, and the toes, and many of those who recovered lost the use of these members; some, too, went blind. There were some also who, when they first began to get better, suffered from a total loss of memory, not knowing who they were themselves and being unable to recognize their friends.”

Psychological effects: “The most terrible thing of all was the despair into which people fell when they realized that they had caught the plague; for they would immediately adopt an attitude of utter hopelessness, and by giving in in this way, would lose their powers of resistance. Terrible, too, was the sight of people dying like sheep through having caught the disease as a result of nursing others.”