Achieving global mortality reduction targets and universal health coverage: The impact of COVID-19

Wenhui Mao and coauthors discuss possible implications of the COVID-19 pandemic for health aspirations in low- and middle-income countries.

Summary points

• The Coronavirus Disease 2019 (COVID-19) pandemic threatens progress toward a “grand convergence” in global health—universal reduction in deaths from infections and maternal and child health conditions to low levels—and toward achieving universal health coverage (UHC).
• Our analysis suggests that COVID-19 will exacerbate the difficulty of achieving grand convergence targets for tuberculosis (TB), maternal mortality, and, probably, for under-5 mortality. HIV targets are likely to be met.
• By 2035, our analysis suggests that the public sectors of low-income countries (LICs) would only be able to finance about a third of the costs of a package of 120 essential non-COVID-19 health interventions through domestic sources, unless the country increases significantly the priority assigned to the health sector; lower middle-income countries (LMICs) would likewise only be able to finance a little less than half.
• The likelihood of getting back on track for reaching grand convergence and UHC will depend on (i) how quickly COVID-19 vaccines can be deployed in LICs and LMICs; (ii) how much additional public sector health financing can be mobilized from external and domestic sources; and (iii) whether countries can rapidly strengthen and focus their health delivery systems.

     

COVID-19 and indirect health implications in Africa: Impact,mitigation measures,and lessons learned for improved disease control

Seth Inzaule and co-authors discuss implications of the COVID-19 pandemic for health in African countries.

Summary points

• Coronavirus Disease 2019 (COVID-19) and the mitigation measures taken to limit its spread have significantly disrupted other essential health services in Africa. This disruption has threatened the control of major high-burden diseases such as HIV, tuberculosis (TB), and malaria as well as the prevention of maternal and child mortality.
• While the 2020 WHO global reports for HIV, TB, and malaria show progress in control of these diseases in African countries, there are still significant gaps in meeting the global targets. Similarly, modeling studies predict that most African countries are unlikely to meet the Sustainable Development Goals (SDGs) 2030 targets for reductions in maternal and child mortality under the current rate of progress.
• Prediction models and emerging empirical data indicate that the implemented mitigation measures against COVID-19 such as travel restrictions and lockdowns as well as the repurposing of health resources and suspension of prevention programs such as immunizations will lead to an increase in new infections and deaths, significantly reversing the gains achieved in the control of these health challenges.
• A more comprehensive COVID-19 response that minimizes indirect deaths is therefore warranted in Africa. These include implementing WHO recommendations that limit contact with the clinic where possible, such as multimonths drug dispensing, self-testing, virtual platforms for case management, community- and home-based prevention, and care services such as home distribution of test kits, vaccines, treatment, and mosquito nets.
• This is in addition to ensuring effective implementation of COVID-19 infection prevention and control measures in healthcare facilities including providing healthcare workers with personal protective equipment and prioritizing them for COVID-19 immunization.
• There is also a need to incorporate aggressive recovery plans to reverse the lost gains in disease control efforts and put African countries back on course toward achieving the global targets. This includes leveraging on the wider COVID-19 response enablements such as the increased political will and global solidarity funding efforts to support a more comprehensive response that accounts for the indirect public health effects of the pandemic.

     

Building global health research capacity to address research imperatives following the COVID-19 pandemic

Peter Kilmarx and Roger Glass discuss strengthening health research capabilities as a response to the COVID-19 pandemic.

Research and development of new tools and interventions are necessary to improve global health, as has been made apparent by the Coronavirus Disease 2019 (COVID-19) pandemic [1]. As of mid-July 2021, there have been nearly 190 million cases reported worldwide and more than 4 million deaths; and yet, less than a year after the outbreak was first reported, in an unprecedented global effort, researchers had developed home rapid self-tests [2], established treatment protocols proven effective to improve survival [3], and discovered highly effective vaccines that are already being produced and administered at a large scale [4].The COVID-19 pandemic also illustrates the importance of having research capacity in place as a critical element of pandemic preparedness. China, with its robust research capacity, was able to rapidly sequence the novel Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus in January 2020 [5] and quickly share the results, thereby jumpstarting global development of diagnostic tests and vaccines. In contrast, when outbreaks have occurred in countries with less research capacity, the development of countermeasures—diagnostics, therapeutics, and vaccines—may be delayed. We examined the relationship between a country’s preexisting research capacity and the output of scientific publications in PubMed by the country’s scientists following an outbreak. In the first 2 years after the Ebola outbreak was recognized in Guinea, only 42 papers on Ebola were published with authors with a Guinean affiliation, and there were significant challenges in launching Ebola treatment and vaccine studies. From Brazil, with its strong research infrastructure, 312 publications about Zika were authored by scientists with a Brazilian affiliation in the 2 years after that outbreak was detected, and substantial progress was made in rapidly characterizing the newly recognized, diverse clinical manifestations. Finally, authors affiliated with a Chinese institution published 8,921 articles on COVID-19 since the current outbreak was recognized, with remarkable progress in developing medical countermeasures.Anticipating significant progress in controlling COVID-19 in 2021, what are the future priorities for global health research? A helpful guide is the 2019 report of the Global Burden of Diseases, Injuries, and Risk Factors Study [6]. This comprehensive synthesis showed that the largest absolute increases in number of disability-adjusted life years between 1990 and 2019 mostly included noncommunicable diseases, i.e., ischemic heart disease, diabetes, stroke, chronic kidney disease, and lung cancer. These illnesses have overlapping risk factors—hypertension, high fasting plasma glucose, high body mass index, tobacco use, and ambient air pollution—which are also highly prevalent and mostly increasing over time [7], further suggesting important areas for research. Notably, some of these diseases and risk factors are also predisposing factors for more severe COVID-19 and prolonged symptoms post-COVID-19.Many other critical COVID-19 research questions in the NIH-Wide Strategic Plan for COVID-19 Research [8] remain unanswered, and new urgent questions have arisen. These include the following: What can we learn from how genetic and other factors explain the high individual variation in the clinical course of COVID-19 to improve treatment interventions? How can diagnostic tests be optimized for home use and low-resource settings, and can testing platforms be created for rapid adaptation with new emerging pathogens? With the potential for waning immunity and immune escape variants, what strategies will be needed for COVID-19 vaccine booster doses? Lastly, how best can public health interventions and medical countermeasures be delivered to reduce poor outcomes, especially in racial/ethnic minority and other vulnerable populations?Several other important perspectives on threats to global health cut across multiple disease entities and provide useful frameworks and new imperatives for prioritizing global health research. The One Health concept encompasses interconnections between humans, animals, plants, and the environment and embraces a transdisciplinary approach to address major emerging threats including zoonotic diseases (e.g., COVID-19), vector-borne diseases, antimicrobial resistance, food safety, and environmental contamination [9]. Another framework is Planetary Health, which focuses on the already large and growing health impacts of our extensive disruptions of earth’s systems, especially climate change, but also declining biodiversity, increasing pollution, and shortages of fresh water, land, and ocean resources [10]. In addition, humanitarian crises such as armed conflicts, natural disasters, and disease outbreaks are impacting more people than ever before. New research approaches and partnerships are needed to address evidence gaps and to establish capacities for future challenges [11]. The impact of COVID-19 on routine health services is a striking current example. Lastly, implementation research on promoting the uptake of evidence-based interventions and policies into routine healthcare and public health settings is needed across each of these fields of health research to address persistent gaps between the promise of proven effective innovations and their successful implementation, especially in underserved and marginalized populations that have been more severely impacted by COVID-19 [12].We believe the greatest priority should be on building health research capacity in low- and middle-income countries (LMICs) where the health burdens and threats are greater and research capacity is often lower than in higher-income countries. Basic pillars of capacity are needed to establish a robust, responsive research environment. Foremost among these is human capacity. Over decades of experience, we have learned that developing research leaders in LMICs requires well-trained individuals with protected time to conduct research and with strong mentorship and networking with both international and local scientists. It is encouraging to see such investigators trained in other research topics such as HIV and tuberculosis now emerge as leaders in their country’s response to the COVID-19 pandemic in Asia, Africa, and the Americas [13]. Other critical capacities include laboratory testing, data management and statistical analysis, clinical trial and community research site development, behavioral and social science, community engagement, ethical review boards, and regulatory systems. A promising emerging approach is to use basic metrics of national and institutional health research capacity to help coordinate and increase efficiency of capacity building efforts, identify and support countries with lowest capacity levels, and facilitate increased research on national health priorities [14]. As we have seen with COVID-19, these capacities can also be rapidly brought to bear to address new health threats. Notably, of the 30 countries taking part in the SOLIDARITY trial of COVID-19 treatment, 16 are LMICs [15]. A critical limitation and emerging priority underscored by COVID-19 is in vaccine research, development, and manufacturing capacity, especially in Africa [16].COVID-19 has necessitated many other substantial changes in our usual practices of global health research, some of which are likely to persist. Use of digital platforms for telecommunications has exploded. In many settings, telework and distance learning are proving to be very effective and sometimes preferable to the expense and risk of face-to-face meetings. We have seen greater participation in many webinars and network meetings, especially from early-career and LMIC colleagues who did not have the time or the budget for in-person meetings [17]. Importantly, the environmental costs of these virtual meetings are also much lower. Along with increases in telemedicine, there have also been advances in teleresearch whereby participants can be enrolled or followed via their mobile phones, potentially decreasing the costs and barriers to participation and improving study retention. The speed of research, formation of collaborations, and communication of results have all increased remarkably with digital collaboration platforms and rapid publication, including publication of preprints, which are now available on PubMed [18]. International collaboration and coordination in research and regulatory processes have also been critical to the rapid development of medical countermeasures through platforms such as the Access to COVID-19 Tools (ACT) Accelerator of the World Health Organization [19] and the Accelerating COVID-19 Therapeutic Interventions and Vaccines (ACTIV) public–private partnership led by the National Institutes of Health [20].Unfortunately, there has also been an “infodemic” of misinformation (i.e., any false information) and disinformation (deliberately false or misleading information) around the source and impact of COVID-19 and the science of its prevention and treatment [21]. This is not a new phenomenon, but with the growth of digital platforms with domestic and international rivalries, a major threat has emerged requiring research to better understand and counter that threat.Finally, COVID-19 is likely to recalibrate perspectives of levels of expertise in north–south relationships among higher- and lower-income countries. At the time of this writing, the public health, healthcare system, and policy approaches in the COVID-19 response of many high-income countries in the north have greatly underperformed in comparison to some lower-income countries in the global south, especially in regard to protecting vulnerable and marginalized populations. This has increased momentum to democratize global health, with the recognition that a new sense of humility and equity will be critical to understand all of the lessons to be learned and improve global health following COVID-19. We applaud the growing role of LMIC scientists in setting the global health research agenda [22].In conclusion, while the COVID-19 pandemic has already taken a devastating global toll on global health and well-being, it has also provided a strong example of the importance of health research capacity as an essential element of pandemic preparedness. The world faces a wide range of health challenges, from chronic diseases and risk factors to emerging global threats. Building research capacity, especially in countries with lower levels, while learning the lessons of COVID-19, must become a higher priority to achieve our current shared global health goals while increasing resilience to address future health threats.     

Universal healthcare coverage and health service delivery before and during the COVID-19 pandemic: A difference-in-difference study of childhood immunization coverage from 195 countries

BackgroundSeveral studies have indicated that universal health coverage (UHC) improves health service utilization and outcomes in countries. These studies, however, have primarily assessed UHC’s peacetime impact, limiting our understanding of UHC’s potential protective effects during public health crises such as the Coronavirus Disease 2019 (COVID-19) pandemic. We empirically explored whether countries’ progress toward UHC is associated with differential COVID-19 impacts on childhood immunization coverage.Methods and findingsUsing a quasi-experimental difference-in-difference (DiD) methodology, we quantified the relationship between UHC and childhood immunization coverage before and during the COVID-19 pandemic. The analysis considered 195 World Health Organization (WHO) member states and their ability to provision 12 out of 14 childhood vaccines between 2010 and 2020 as an outcome. We used the 2019 UHC Service Coverage Index (UHC SCI) to divide countries into a “high UHC index” group (UHC SCI ≥80) and the rest. All analyses included potential confounders including the calendar year, countries’ income group per the World Bank classification, countries’ geographical region as defined by WHO, and countries’ preparedness for an epidemic/pandemic as represented by the Global Health Security Index 2019. For robustness, we replicated the analysis using a lower cutoff value of 50 for the UHC index. A total of 20,230 country-year observations were included in the study. The DiD estimators indicated that countries with a high UHC index (UHC SCI ≥80, n = 35) had a 2.70% smaller reduction in childhood immunization coverage during the pandemic year of 2020 as compared to the countries with UHC index less than 80 (DiD coefficient 2.70; 95% CI: 0.75, 4.65; p-value = 0.007). This relationship, however, became statistically nonsignificant at the lower cutoff value of UHC SCI <50 (n = 60). The study’s primary limitation was scarce data availability, which restricted our ability to account for confounders and to test our hypothesis for other relevant outcomes.ConclusionsWe observed that countries with greater progress toward UHC were associated with significantly smaller declines in childhood immunization coverage during the pandemic. This identified association may potentially provide support for the importance of UHC in building health system resilience. Our findings strongly suggest that policymakers should continue to advocate for achieving UHC in coming years.

In a difference-in-difference study, Sooyoung Kim and colleagues study associations between progress toward universal healthcare coverage and childhood immunizations before and during the COVID-19 pandemic.     

Addressing power asymmetries in global health: Imperatives in the wake of the COVID-19 pandemic

Seye Abimbola and co-authors argue for a transformation in global health research and practice in the post-COVID-19 world.

Summary points

• The Coronavirus Disease 2019 (COVID-19) pandemic, the Black Lives Matter and Women in Global Health movements, and ongoing calls to decolonise global health have all created space for uncomfortable but important conversations that reveal serious asymmetries of power and privilege that permeate all aspects of global health.
• In this article, we, a diverse, gender-balanced group of public (global) health researchers and practitioners (most currently living in the so-called global South), outline what we see as imperatives for change in a post-pandemic world.
• At the individual level (including and especially ourselves), we emphasise the need to emancipate and decolonise our own minds (from the colonial conditionings of our education), straddle and use our privilege responsibly (to empower others and avoid elite capture), and build “Southern” networks (to affirm our ownership of global health).
• At the organisational level, we call for global health organisations to practice real diversity and inclusion (in ways that go beyond the cosmetic), to localise their funding decisions (with people on the ground in the driving seat), and to progressively self-decentralise (and so, divest themselves of financial, epistemic, and political power).
• And at both the individual and organisational level, we emphasise the need to hold ourselves, our governments, and global health organisations accountable to these goals, and especially for governance structures and processes that reflect a commitment to real change.
• By putting a spotlight on coloniality and existing inequalities, the COVID-19 pandemic inspires calls for a more equitable world and for a decolonised and decentralised approach to global health research and practice, one that moves beyond tokenistic box ticking about diversity and inclusion into real and accountable commitments to transformative change.

     

Bibliometric analysis of global scientific research on carbapenem resistance (1986–2015)

Background

Antimicrobial resistance is a global public health challenge and carbapenem resistance, in particular, is considered an urgent global health threat. This study was carried out to give a bibliometric overview of literature on carbapenem resistance. In specific, number of publications, top productive countries and institutes, highly cited articles, citation analysis, co-authorships, international collaboration, top active authors, and journals publishing articles on carbapenem resistance were analyzed and discussed.

Methods

Specific keywords pertaining to carbapenem resistance were used in Scopus database. Quantitative and qualitative analysis of retrieved data were presented using appropriate bibliometric indicators and visualization maps.

Results

A total of 2617 journal articles were retrieved. The average number of citations per article was of 21.47. The growth of publications showed a dramatic increase from 2008 to 2015. Approximately 9 % of retrieved articles on carbapenem resistance were published in Antimicrobial Agents and Chemotherapy journal. Retrieved articles were published by 102 different countries. The United States of America (USA) contributed most with 437 (16.70 %) articles followed by China with 257 (9.82 %) articles. When productivity was stratified by population size, Greece ranked first followed by France. Greece also ranked first when data were stratified by gross domestic product (GDP). Asian countries have lesser international collaboration compared with other countries in the top ten list. Five of top ten productive institutes were Europeans (France, the UK, Greece, Italy, and Switzerland) and two were Asians (China and South Korea). Other active institutes included an Israeli and a Brazilian institute. Four of the top ten cited articles were published in Antimicrobial Agents and Chemotherapy journal and two were published in The Lancet Infectious Diseases.

Conclusion

There was a dramatic increase in number of publications on carbapenem resistance in the past few years. These publications were produced from different world regions including Asia, Europe, Middle East, and Latin America. International collaboration needs to be encouraged particularly for researchers in Asia. Molecular biology and epidemiology dominated the theme of the top ten cited articles on carbapenem resistance. This bibliometric study will hopefully help health policy makers in planning future research and allocating funds pertaining to carbapenem resistance.

     

Achieving global equity for COVID-19 vaccines: Stronger international partnerships and greater advocacy and solidarity are needed

Peter Figueroa and co-authors advocate for equity in the worldwide provision of COVID-19 vaccines.

Many may not be aware of the full extent of global inequity in the rollout of Coronavirus Disease 2019 (COVID-19) vaccines in response to the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) pandemic. As of June 20, 2021, only 0.9% of those living in low-income countries and less than 10% of those in low- and middle-income countries (LMICs) had received at least 1 dose of a COVID-19 vaccine compared with 43% of the population living in high-income countries (HICs) [1] (Fig 1). Only 2.4% of the population of Africa had been vaccinated compared with 41% of North America and 38% of Europe [1,2] (S1 Fig). Primarily due to the inability to access COVID-19 vaccines, less than 10% of the population in as many as 85 LMICs had been vaccinated compared with over 60% of the population in 26 HICs [1]. Only 10 countries account for more than 75% of all COVID-19 vaccines administered [3]. This striking and ongoing inequity has occurred despite the explicit ethical principles affirming equity of access to COVID-19 vaccines articulated in WHO SAGE values framework [4,5] prepared in mid-2020, well prior to the availability of COVID-19 vaccines.Open in a separate windowFig 1Proportion of people vaccinated with at least 1 dose of COVID-19 vaccine by income (April 14 to June 23, 2021).Note: Data on China appeared on the database on June 9, hence the jump in upper middle-income countries. COVID-19, Coronavirus Disease 2019. Source: https://ourworldindata.org/covid-vaccinations.The COVID-19 pandemic highlights the grave inequity and inadequacy of the global preparedness and response to serious emerging infections. The establishment of the Coalition for Epidemic Preparedness Innovations (CEPI) in 2018, the Access to COVID-19 Tools Accelerator (ACT-A), and the COVID-19 Vaccines Global Access (COVAX) Facility in April 2020 and the rapid development of COVID-19 vaccines were all positive and extraordinary developments [6]. The COVAX Facility, as of June 2021, has delivered approximately 83 million vaccine doses to 75 countries, representing approximately 4% of the global supply, and one-fifth of this was for HICs [7]. The COVAX Facility has been challenged to meet its supply commitments to LMICs due to insufficient access to doses of COVID-19 vaccines with the prerequisite WHO emergency use listing (EUL) or, under exceptional circumstances, product approval by a stringent regulatory authority (SRA) [8,9]. Because of the anticipated insufficient COVID-19 vaccine supply through the COVAX Facility, the majority of nonvaccine-producing LMIC countries made the decision, early in the COVID-19 pandemic, to secure and use vaccines produced in China or Russia prior to receipt of WHO EUL or SRA approval. Most of the vaccines used in LMICs as of June 20, 2021 (nearly 1.5 billion doses of the 2.6 billion doses administered) were neither WHO EUL or SRA approved at the time they were given [10]. This may raise possible concerns with respect to the effectiveness, safety, and acceptability of individual vaccines used by many countries [8,9].     

Social justice now for an equitable tomorrow: Reflections from the Consortium of Universities for Global Health Conference 2022

PLOS Medicine editors Beryne Odeny and Callam Davidson report from the Consortium of Universities for Global Health conference.

“Healthy People, Healthy Planet & Social Justice,” was the theme of the second virtual Consortium of Universities for Global Health (CUGH) 2022 conference, held from March 28 to April 1, 2022. In the face of escalating global health and security challenges, this bold theme and the associated agenda (https://cugh.confex.com/cugh/2022/meetingapp.cgi) were welcomed with great anticipation by thousands of stakeholders from 135 countries across the globe. As adeptly put by Dr. Peter A Singer, Special Advisor to the Director General of WHO, the fundamental question at the heart of social justice is simple: “Do we value every human life equally?”. In answering this question, we must acknowledge that what we now consider to be the discipline of global health is in fact anchored by deep and tortuous colonialist roots that continue to bear the fruits of injustice to this day. Over the course of the conference, speakers conceptualized a human rights framework for rethinking global health. This perspective piece presents a curated synopsis of the main CUGH conference and preceding satellite sessions.The conference commenced with a call from Thuli N. Madonsela, Former Public Protector of South Africa, to uphold the sacrosanct respect for human life given the interconnectedness of humanity’s existence on our shared planet. Her insights on social justice as interpreted within the framework of Ubuntu philosophy brought a breath of fresh air to the debate on neo-colonialism. Thuli’s keynote concluded with an optimistic outlook: “Investing in justice today is like throwing a javelin into the future, one that will become the guardrail for sustainable development.”Globalization has brought tremendous advances in industry, commerce and trade, and eye-watering financial gains for some in both high income countries (HICs) and low- and middle-income countries (LMICs). Alongside these gains, global openness has contributed to the swift spread of the most formidable maladies of the present day, not least of which are the dual epidemics of COVID-19 and non-communicable diseases (NCDs), climate change and global warming, global corruption, conflict and wars, and ensuing humanitarian crises [1,2]. Pervasive health inequities which compound the toll of these calamities are a stark reminder of how global health has failed the most vulnerable. The COVID-19 pandemic continues to be the litmus test against which our truest values are tested. “If we can’t handle COVID-19, what does it mean about our approach to tackling climate change?”–this was a germane question from a speaker reflecting on inequitable vaccine distribution [3,4].Comparable to other health sectors awash with global funding, the global COVID-19 vaccine delivery effort has created fertile ground for corruption, due to a toxic combination of high commodity demand, unprecedented resource allocation, and perennially weak health systems with fragmented supply chains [5,6]. It has been shown that corruption can fuel vaccine hesitancy by creating suspicion and mistrust in science and government. This has been witnessed in some countries in Asia, despite commendable levels of vaccine coverage. In contrast, the long-standing National Immunization Program in Brazil created a culture of vaccination and helped minimize hesitancy (despite the influence of the country’s present leadership) [7]. Other factors beyond vaccine-specific factors include contextual, individual, and group influences that can inform hesitancy; these additional factors can be exploited to undergird vaccine efforts–barbers delivering vaccines, and outreach efforts by Buddhist monks, for example.Beyond the COVID-19 pandemic is the rise of Commercial Determinants of Health (CDoH). CDoH refer to approaches used by corporate sectors to promote products that are detrimental to health [8]. These products include processed foods and drinks, alcohol, and tobacco–factors that are fueling the rising burden of NCDs–more so in LMICs and among the socially disadvantaged in HICs, who bear the largest brunt of related mortality [9]. Unrestrained access to and use of harmful products such as heavy metals and asbestos, pose a threat to poor and vulnerable communities in proximity to mines and industries. These injustices are propagated by powerful corporates that stealthily evade restrictive public health policies to protect their profit margins [10]. A downstream impact of the surge of NCDs in LMICs, is the intense suffering among those dying from terminal illnesses due to the unethical lack of access to palliative care. There is a dearth of palliative resources, including trained health providers, particularly in low resource contexts such as fragile and conflict settings, and among ethnically diverse groups in HICs [11].The COVID-19 and NCDs conundrums are accompanied by another global health woe–namely the paternalist nature of HIC support for LMICs. Paternalistic support presents in the form of tied aid and technical support which have been used to determine the seat of power, with regard to who holds the money, who generates knowledge, who practices, who publishes, and, ultimately, who thrives in the global health ecosystem. This is demonstrated by institutionalized power asymmetries across funding, academic research, and global health priority setting, which disproportionately favor researchers from HICs at the expense of those from LMICs. To date, less priority has been accorded to health issues of concern, beyond infectious diseases, in the poorest parts of the world such as cancer among other NCDs. Conditionality and increased vertical funding have been shown to limit LMICs’ autonomy to finance their primary health challenges and are linked to reduced government health expenditure with commensurate increases in out-of-pocket/ household expenditure. The health sector is known to be highly corrupt as well as it is well-resourced (accounting of 10% of overall GDP spending) [12]. The lethal mixture of politics, power, and corruption in LMICs is a brewing pot for injustice as it perpetuates a vicious cycle of poverty and disease among the most vulnerable.Tackling corruption at international and national levels requires multisectoral attention to wider issues of global security, giving people a voice and providing the backing of legal frameworks, to demand accountability and transparency without fear of retaliation. Empowering global health stakeholders and civil societies to engage corporate and political sectors in planetary and global health discourse is an essential tool for fostering health equity, environmental justice, and social justice in business paradigms [2,8]. In this way, leaders can be enlightened and held accountable for performance of equity-based indicators e.g., proportion of specific global goods going to LMICs. Within the global health fraternity, decolonizing global health through inclusive partnerships is necessary to remove longstanding hierarchies in decisional spaces, and shift the balance of power so that more indigenous community actors can define their problems and find relevant solutions [13]. Inspirational stories of the national COVID-19 taskforce in Uganda demonstrate how active communities can promote vaccine uptake [14]. Scaling up community-led integrated health care efforts can extend beyond the pandemic and may even accelerate realization of the UN Sustainable Development Goals. Sustainable funding streams, training, and capacity development to create a robust workforce and enabling environments to host research in LMICs should be at the center of the global health agenda. Other considerations would include leveraging integrated digital and information systems that foster inclusion of marginalized populations in program planning and service delivery, and in so doing uphold equity and inclusion in health system strengthening globally.Decolonizing global health and upholding social justice will be crucial to containing the impending NCD tsunami, pandemics beyond COVID-19, and climate change. However, throwing off the pernicious colonial legacy presents one of the biggest challenges in global health. No one is exempt from the experience of neo-colonialism regardless of location; thus, all hands are needed on deck to disrupt and resist its existence. Dr. Madhukar Pai of McGill University in Montreal, Canada, and colleagues emphasized that allyship is invaluable to this end–it seeks to identify what the most privileged can do to elevate the voices of those suffocating under the weight of injustice [15]. Beyond speaking up against inequities, meaningful allyship needs disruptive change, sometimes as far as ceding positions of power. The global health community is at a crossroads, a defining moment since its existence, and needs to decide which way to proceed–whether to remain passive to entrenched notions of polarization or to embrace a disruptive paradigm shift that defends social justice and secures sustainable development for all. The question remains–are we ready to shift?     

Ozobranchus jantseanus (Clitellata: Ozobranchidae) from Reeve’s Turtle,Mauremys reevesii: New Annelid Fauna in Korea

Turtle leeches have not been recorded in Korea, although they occur in geographically adjacent countries including China and Japan. This study describes a turtle leech, Ozobranchus jantseanus (Clitellata: Ozobranchidae), found from Reeve’s turtle (Mauremys reevesii) in Korea. Of the 143 Reeve’s turtles collected from the freshwater reservoir in Jinju City, Gyeongsangnam-do, Korea, 95 unidentified leeches were found in 8 (5.6%) individuals. The leeches had 22 somites with 11 pairs of externally exposed branchiae, body-sized posterior suckers, and spines on the dorsal surface. We identified these leeches as Ozobranchus jantseanus Oka, 1912 (Clitellata: Ozobranchidae). This species of turtle leeches found in Korea may fill the gap in the biodiversity of East Asian annulus.     

Diagnostic testing holds the key to NTD elimination

“Fit-for-purpose” diagnostic tests have emerged as a prerequisite to achieving global targets for the prevention, control, elimination, and eradication of neglected tropical diseases (NTDs), as highlighted by the World Health Organization’s (WHO) new roadmap. There is an urgent need for the development of new tools for those diseases for which no diagnostics currently exist and for improvement of existing diagnostics for the remaining diseases. Yet, efforts to achieve this, and other crosscutting ambitions, are fragmented, and the burden of these 20 debilitating diseases immense. Compounded by the Coronavirus Disease 2019 (COVID-19) pandemic, programmatic interruptions, systemic weaknesses, limited investment, and poor commercial viability undermine global efforts—with a lack of coordination between partners, leading to the duplication and potential waste of scant resources. Recognizing the pivotal role of diagnostic testing and the ambition of WHO, to move forward, we must create an ecosystem that prioritizes country-level action, collaboration, creativity, and commitment to new levels of visibility. Only then can we start to accelerate progress and make new gains that move the world closer to the end of NTDs.

Ahead of the second-ever World Neglected Tropical Disease (NTD) Day in January 2021, and amid the global Coronavirus Disease 2019 (COVID-19) crisis, the World Health Organization (WHO) launched a new roadmap for the prevention, control, elimination, and eradication of NTDs—a group of 20 diseases affecting more than one billion people worldwide [1]. Diagnostic testing is central to safeguarding decades of progress in NTDs and must be strategically leveraged to reach the goals laid out in the new NTD roadmap.Stepping back, we recognize the massive progress that has been made to combat NTDs. Today, 500 million fewer people need treatment for these debilitating diseases than in 2010, and 40 countries or areas have eliminated at least one of the 20 [1]. Yet, despite these gains, NTDs continue to impose a devastating human, social, and economic toll on the world’s poorest and most vulnerable communities [2–6]. COVID-19 is compounding the situation by wreaking havoc on health systems, which impacts progress on NTDs: this includes interruptions to mass treatment campaigns for diseases controlled through preventive chemotherapy (PCT) or individual case management interventions, as well as rerouting the already sparse available funding and resources [7].Diagnostic testing has been central to the COVID-19 response even with the introduction of vaccines. The rapid ramp up of research and development (R&D), the scaling up of low-cost and decentralized testing, and country-led approaches to tailored testing strategies for COVID-19, as well as lessons learned, can also provide new thinking around testing for NTDs. The new NTD roadmap offers a series of multisectoral actions and intensified, cross-cutting approaches to get us back on track—with diagnostics central to unlocking and accelerating this progress [1].However, the NTD roadmap shows that, of all 20 diseases or disease groups, just 2 (yaws and snakebite envenoming) are supported by adequate and accessible diagnostic tools. Six have no diagnostic tests available at all, with tools for each of the remaining conditions in urgent need of adaptation, modification, and/or improved accessibility (likely a more cost-effective option than the development of new diagnostics for these NTDs) [1]. This has to change. NTDs cannot continue to be neglected in favor of other competing priorities, or we risk losing the progress made to date.Until the COVID-19 pandemic thrust testing into the spotlight, diagnostics have been a “silent partner” in healthcare, receiving little by way of international attention and funding, specific country strategies, and dedicated budget lines. NTDs are no exception. Just 5% of the (limited) funding made available to NTDs has been invested in new diagnostics, compared with 44% and 39% on basic research and medicines and vaccines, respectively [1]. For most NTDs, diagnostics are a market failure situation, and as such, are not commercially viable enough to attract private investment. Consequently, very few diagnostic developers engage in this area—contrary, for example, to COVID-19, where developers are in the hundreds. Furthermore, as some diseases approach the last mile of elimination, falling infection rates precipitate the need for increasingly sensitive tests [1]. But progress in R&D is slow and fragmented, with a lack of engagement and coordination between governments, industry, donors, and development actors, leading to the duplication—and potential waste—of scant resources. While serial testing using multiple diagnostic tools or techniques can compensate for low sensitivity [8], such approaches are associated with increased costs of testing, sample collection, and transportation.Closing the diagnostic gap then, is a prerequisite to achieving the global ambition for NTDs, with the new NTD roadmap giving a blueprint for action. It is for this reason that we call on governments, industry, donors, and development actors to

• Prioritize country-level diagnostic action: As we enter a new era in NTD management and control, we need to shift from traditional, donor-led models to country-driven initiatives. Government ministries must engage with, and advocate on behalf of, their poorest and most vulnerable populations so that no one is left behind. Political frameworks should prioritize diagnostics for NTDs in line with local disease burdens, and as part of fully funded, national health action plans that include a commitment to seeing the process through. Capacity building for diagnostics is also essential at country, sub-regional, and regional levels, including the establishment of laboratory networks, so that testing can be implemented in field settings.
• Collaborate and create: There is never going to be a one-size-fits-all for NTD diagnostics. If targets are to be achieved, we need global frameworks that enable industry, manufacturers, and pharmaceutical companies to engage in the whole process, from R&D to supply chain logistics. Companies need to share knowledge, learnings, and innovation across multiple diseases. This will mean breaking silos and finding new ways to harness the power of existing products, technologies, and infrastructures. Further, it will mean creating economies of scale through regional manufacturing hubs and finding new, cross-cutting approaches to drive systemic change. To obtain the maximum access to technology and relevant intellectual property rights for NTD diagnostics, it is important to ensure that such rights are broadly available (non-exclusively) in NTD-endemic countries and are affordable (e.g., zero royalty rights).
• Commit to new levels of visibility: The resources needed to realize that this ambition is limited, with a lack of visibility around the diagnostic landscape undermining progress in NTD management and control. Creating an ecosystem with visibility, transparency, and integration at its core will help streamline programmatic action, reduce the risk of duplication, and leverage the full potential from this limited pool. To do this, industry, donors, and other development actors must provide the information needed to map both funding and product landscapes. Using this information to create a virtual product pipeline will bring an unprecedented level of transparency to diagnostic developments—harmonizing multisectoral efforts and creating a robust information platform from which new collaborations, synergies, and innovation can grow. Developing an online open-access diagnostic pipeline for WHO NTD roadmap priority pathogens would serve multiple purposes: (i) drive advocacy to address critical product and funding gaps; and (ii) reduce the likelihood of duplication of efforts. Together, this would strengthen partnerships across all stakeholders, from donors to industry partners, to accelerate development, evaluation, and adoption of diagnostic solutions for NTDs. The newly established NTD Diagnostic Technical Advisory Group (DTAG) to WHO NTD department has already identified the priority diagnostic needs for NTD programs not only in terms of developing new tools, but also the accessibility of existing tools [9]. Several sub-groups that focus more narrowly on single diseases or specific topics (i.e., skin NTDs or cross-cutting) have been established and have been tasked to develop tool and biomarker agnostic target product profiles (TPPs), which are now available (for the most part) on WHO website for use by any diagnostic manufacturer to support development of their specific technology. Alignment with these diagnostic priorities by all stakeholders is strongly recommended to facilitate attainment of WHO 2030 NTD roadmap goals.

• Establish NTD biobanks: Biobanks are required for the clinical evaluation and validation of new diagnostic tests. Establishing local biobanks would support a country-driven approach as well as allowing for head-to-head comparisons between tests and assessments of cross-reactivity across different NTDs.
• Invest in existing diagnostics: The development of new diagnostics is a complex process, and the time from development to implementation can be lengthy. Training laboratory staff in the use of existing diagnostics and the establishment of robust quality control systems are effective approaches to achieving shorter-term improvements.

There is a long road ahead, but the past 10 years have shown us what can be achieved when governments, industry, donors, and development actors are bound by a shared, global goal. As we look forward to the next decade, we must prioritize country-level action, collaboration, creativity, and commitment to new levels of visibility, if we are to finally end the neglect of NTDs.     

Regional TMPRSS2 V197M Allele Frequencies Are Correlated with COVID-19 Case Fatality Rates

Coronavirus disease, COVID-19 (coronavirus disease 2019), caused by SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2), has a higher case fatality rate in European countries than in others, especially East Asian ones. One potential explanation for this regional difference is the diversity of the viral infection efficiency. Here, we analyzed the allele frequencies of a nonsynonymous variant rs12329760 (V197M) in the TMPRSS2 gene, a key enzyme essential for viral infection and found a significant association between the COVID-19 case fatality rate and the V197M allele frequencies, using over 200,000 present-day and ancient genomic samples. East Asian countries have higher V197M allele frequencies than other regions, including European countries which correlates to their lower case fatality rates. Structural and energy calculation analysis of the V197M amino acid change showed that it destabilizes the TMPRSS2 protein, possibly negatively affecting its ACE2 and viral spike protein processing.     

Healthcare utilization and maternal and child mortality during the COVID-19 pandemic in 18 low- and middle-income countries: An interrupted time-series analysis with mathematical modeling of administrative data

BackgroundThe Coronavirus Disease 2019 (COVID-19) pandemic has had wide-reaching direct and indirect impacts on population health. In low- and middle-income countries, these impacts can halt progress toward reducing maternal and child mortality. This study estimates changes in health services utilization during the pandemic and the associated consequences for maternal, neonatal, and child mortality.Methods and findingsData on service utilization from January 2018 to June 2021 were extracted from health management information systems of 18 low- and lower-middle-income countries (Afghanistan, Bangladesh, Cameroon, Democratic Republic of the Congo (DRC), Ethiopia, Ghana, Guinea, Haiti, Kenya, Liberia, Madagascar, Malawi, Mali, Nigeria, Senegal, Sierra Leone, Somalia, and Uganda). An interrupted time-series design was used to estimate the percent change in the volumes of outpatient consultations and maternal and child health services delivered during the pandemic compared to projected volumes based on prepandemic trends. The Lives Saved Tool mathematical model was used to project the impact of the service utilization disruptions on child and maternal mortality. In addition, the estimated monthly disruptions were also correlated to the monthly number of COVID-19 deaths officially reported, time since the start of the pandemic, and relative severity of mobility restrictions. Across the 18 countries, we estimate an average decline in OPD volume of 13.1% and average declines of 2.6% to 4.6% for maternal and child services. We projected that decreases in essential health service utilization between March 2020 and June 2021 were associated with 113,962 excess deaths (110,686 children under 5, and 3,276 mothers), representing 3.6% and 1.5% increases in child and maternal mortality, respectively. This excess mortality is associated with the decline in utilization of the essential health services included in the analysis, but the utilization shortfalls vary substantially between countries, health services, and over time. The largest disruptions, associated with 27.5% of the excess deaths, occurred during the second quarter of 2020, regardless of whether countries reported the highest rate of COVID-19-related mortality during the same months. There is a significant relationship between the magnitude of service disruptions and the stringency of mobility restrictions. The study is limited by the extent to which administrative data, which varies in quality across countries, can accurately capture the changes in service coverage in the population.ConclusionsDeclines in healthcare utilization during the COVID-19 pandemic amplified the pandemic’s harmful impacts on health outcomes and threaten to reverse gains in reducing maternal and child mortality. As efforts and resource allocation toward prevention and treatment of COVID-19 continue, essential health services must be maintained, particularly in low- and middle-income countries.

Tashrik Ahmed and co-workers study health-care use and maternal and child health outcomes across low- and lower-middle-income countries during the COVID-19 pandemic.     

Retrospective analysis of census data on general practitioners who qualified in South Asia: who will replace them as they retire?

ObjectivesTo determine the number and geographical distribution of general practitioners in the NHS who qualified medically in South Asia and to project their numbers as they retire.DesignRetrospective analysis of yearly data and projection of future trends.SettingEngland and Wales.SubjectsGeneral practitioners who qualified medically in the countries of Bangladesh, India, Pakistan, and Sri Lanka and who were practising in the NHS on 1 October 1992.Results4192 of 25 333 (16.5%) of all unrestricted general practitioners practising full time on 1 October 1992 qualified in South Asian medical schools. The proportion varied by health authority from 0.007% to 56.5%. Roughly two thirds who were practising in 1992 will have retired by 2007; in some health authorities this will represent a loss of one in four general practitioners. The practices that these doctors will leave seem to be in relatively deprived areas as measured by deprivation payments and a health authority measure of population need.ConclusionMany general practitioners who qualified in South Asian medical schools will retire within the next decade. The impact will vary greatly by health authority. Those health authorities with the greatest number of such doctors are in some of the most deprived areas in the United Kingdom and have experienced the most difficulty in filling vacancies. Various responses will be required by workforce planners to mitigate the impact of these retirements.

Key messages

• Currently, one in six general practitioners practising full time in the NHS qualified medically in a South Asian medical school; two thirds are likely to retire by 2007
• It is unlikely that doctors who qualify in South Asia will be a source of general practice recruitment in the future
• The posts from which South Asian qualifiers are retiring may be more difficult to fill because they are often in practices in areas of higher need
• There is extreme variation in the proportion of total general practitioners who are South Asian qualifiers; flexibility for policy responses should be maintained

     

Mild manifestations of COVID-19 in healthcare workers

Medical staff treating Coronavirus Disease 2019 (COVID-19) patients are at high risk for exposure to Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), and many have been infected, which may cause panic among medical workers, their relatives, health professionals, and government leaders. We report the epidemiologic and clinical characteristics of healthcare workers and that the majority of infected medical staff had milder symptoms/conditions with a better prognosis than admitted patients. Timely improvement to medical staff’s working conditions such as allowing adequate rest and providing sufficient medical protection is extremely important.     

Does Marriage Really Matter to Health? Intra- and Inter-Country Evidence from China,Japan, Taiwan,and the Republic of Korea

Background

The health benefits of marriage have been demonstrated mainly by studies on Western populations. This study aims to test whether the benefits are also valid in East Asian populations.

Methodology/Principal Findings

Individuals (n = 8,538) from China, Japan, Taiwan, and the Republic of Korea were sampled from the 2006 East Asian Social Survey. The association between self-rated health status and two marriage-related independent variables was analyzed using multivariate logistic regression models. In a two-level analysis for individuals from all countries, married individuals were more likely to report very good or good health compared to their never-married counterparts [odds ratio (OR) 1.56; 95% confidence interval (95% CI) 1.16−2.10]. However, the addition of marital satisfaction disintegrated the significant association of marriage with self-rated health. Married individuals in satisfying marriages were more likely to report very good or good health compared with never-married individuals (OR 1.85; 95% CI 1.37−2.50). In contrast, married individuals in dissatisfying marriages were as likely to report very good or good health as never-married individuals (OR 0.78; 95% CI 0.50−1.24). In a one-level analysis for each country, the importance of marital satisfaction varied greatly across countries. Unlike in other countries, in Japan, married individuals in dissatisfying marriages were about half as likely to report very good or good health as never-married individuals (OR 0.51, 95% CI 0.31−0.83), thereby showing no significant benefits from marriage with regard to self-rated health.

Conclusion/Significance

The present study of East Asian countries suggests that marital satisfaction is of greater importance in determining self-rated health than marriage itself, and that the importance of marital satisfaction varies across countries. Further research is required to better understand the relationship between marital satisfaction and self-rated health in different socio-cultural settings, and to establish effective social policies aiming at improving public health.     

COVID-19 and global equity for health: The good,the bad,and the wicked

Elvin Geng and co-authors discuss monitoring and achieving equity in provision of vaccines for COVID-19.

Many problems underscored by the Coronavirus Disease 2019 (COVID-19) pandemic, and highlighted in other papers in this collection [1], center on addressing the grossly unequal availability of vaccine around the world. The problem of equity in the public health response fits Rittel and Webber’s conceptualization of “wicked problems” [2] that describe complex issues that defy conventional scientific analyses. Wicked problems have many characteristics, but three stand out when contemplating an equitable response to the COVID-19 pandemic. First, wicked problems have no definitive problem statement because understanding the problem is the crux of the problem itself. Is an equitable response to COVID-19 the problem, or is inequity in vaccines a symptom of larger inequity in health, economic, and societal systems? And is the problem equity in distribution, or is the root problem scarcity due to unfair trade arrangements? Second, in wicked problems, the elusive problem formulation precludes a shared understanding of success, or even progress, by stakeholders. What would constitute an acceptably equitable response? How would we measure progress without a unified direction? Third, in wicked problems, the absence of a shared agenda (and measures of progress) undermines aligned and effective action. Without true consensus that a fair allocation of vaccines across countries is based on population size instead of disease burden (as proposed by COVAX), targets based on progress toward such a distribution would lack real commitment from global stakeholders. The answers are as critical as they are elusive, not only for how the COVID-19 pandemic evolves, but also for whether we learn from it to better navigate future threats.COVID-19 is not the first wicked problem evident in global public health, however, and the recent past may offer some lessons. Three decades ago, HIV presented an urgent, complex, dynamic, and wicked threat to health around the world in which global inequities were stark and unacceptable. In 2004, 39 million people were living with HIV, 4.9 million new infections occurred, and 3.1 million died of HIV (comparable to the approximately 3.1 million COVID-19 deaths by April 16, 2021) in that year, the vast majority of new infections (>95%) and deaths (>95%) occurred in lower and middle-income countries. At the time, lifesaving antiretroviral therapy was available only in high-income countries, where it was expensive, delivered by highly trained specialists, and accompanied by sophisticated monitoring requirements (e.g., quantitative HIV plasma RNA levels and genotypical analysis). Naysayers warned that providing treatment throughout the world to close these major gaps would lead to “antiretroviral anarchy” and widespread drug resistance. To make progress against HIV, and increase equitability around the world, the world faced many of the same problems that we face today. Was the crux of problem access to antiretrovirals or to medications more generally? Should the priority be on treatment or prevention? Was this a public health problem at all or actually one of poverty and extractive economic systems? Three decades later, HIV treatment is widely available around the world, mostly free of charge, delivered by a robust healthcare workforce, based on stable global financing, and supported by the highest levels of global governance. With all the flaws of the response, from the vantage point of the present, it is clear that progress and greater equity in the response to the HIV epidemic have occurred.In the HIV response, this progress toward a global response was anchored by advocates and activists who successfully put HIV at the center of political agenda and crafted a globally shared commitment to offer treatment to every person living with HIV anywhere in the world in need [3,4]. This shared formulation of the problem (and therefore shared goals) was a critical first step in the global HIV treatment response. Even though the objective to treat all who needed treatment is crystal clear in retrospect, it was one of many competing perspectives. A few advocated a larger scope (i.e., global progress on a wider range of health conditions), while many championed smaller and “more feasible” objectives, (i.e., emphasizing prevention only without treatment). Yet, the goal to treat every person was ultimately adopted by governments, civil society, and the global agencies and therefore carried legitimacy and force. The Joint United Nations Programme on HIV/AIDS (UNAIDS) was established in 1994 through a UN resolution approved by all 193 member states to provide coordinated and aligned actions on HIV at the highest levels. The Global Fund for HIV, TB, and Malaria was created in 2002 to raise, manage, and disburse billions in funding for these priority pandemics. The first Global AIDS Coordinator to oversee the US government’s investment of billions of dollars to address HIV in 2006 reported directly to the US President, elevating the visibility and prioritization of the HIV response where it was most severe.This shared agenda to treat all in need was accompanied by the emergence of a remarkable visual heuristic that provided a shared roadmap for progress:—HIV treatment cascade—a simple and immediately accessible representation of the fraction of individuals living with HIV who are diagnosed, linked to care, started on treatment, retained, and virally suppressed. While subject to a range of criticisms (e.g., the cascade does not represent time, real journeys are cyclical), the heuristic rapidly became a universal mental model of the implementation needs for success in the global treatment response for HIV. Today, this framing is shared by virtually all health officials, healthcare workers, implementers, policy makers, and even elected officials addressing HIV anywhere in the world [5]. The shared understanding of the public health approach allowed a remarkable fluency (or 95-95-95 in some places) of action and alignment of goals across the public health environment [6,7]. Comparisons of the cascade in different regions has also sharpened the focus on equity when large differences are apparent.Finally, the HIV response has used the cascade framework to define clear targets and extract commitments from elected leaders to meet those targets, thereby enabling measurable progress. The overarching UNAIDS strategy for HIV treatment, called “90–90–90," refers to targets in this cascade—that 90% of individuals living with HIV are diagnosed, 90% of diagnosed are on treatment, and 90% of those on treatment are suppressed. Today, virtually every country, state, county, and public health jurisdiction in the world is expected to know how much progress is being made toward 90–90–90 in their own jurisdictions. The International Association of Physicians in AIDS Care’s Fast-Track Cities initiative is one of a number of global policy initiatives based explicitly on obtaining commitments from political leaders and elected officials to meet 90–90–90 cascade targets [8]. The initiative has enrolled over 350 cities around the world—with the mayors of London, Paris, and other cosmopolitan cities all vocal advocates of 90–90–90. Because the cascade is reported, progress toward 90–90–90 can be widely assessed, creating some basis for accountability.Each of these 3 steps have implications for progress against the problem of an equitable global COVID-19 response. At present, the working global targets for distribution of vaccine have been put forth by COVAX, an alliance between GAVI, Coalition for Epidemic Preparedness, and WHO. COVAX seeks to allocate vaccine to cover 20% of the population in all countries. Yet, is a 20% floor targeting success or capitulating to failure? Is its distribution schema based on population fair, or, as proposed by others, should it be based on COVID-19 disease burden [9]? In order to answer these, and many other critical questions of shared global significance, the issue of equity must take center stage in the global policy making conversation at the highest levels. Ottersen and colleagues observed that “conflicts in interests and power asymmetries” between transnational actors on health (e.g., governments, corporations, and civil society) demand institutions to negotiate, articulate, and advocate for collective interests [10]. While the institutional arrangements may take various forms, a high-level UN meeting to establish a common agenda for equity in the global COVID-19 response attended by all 193 member states—as has been done before for HIV, TB, noncommunicable diseases, and antimicrobial resistance—is a minimum step.Like the HIV cascade, consensus for a more equitable COVID-19 response must be accompanied by meaningful, interpretable, publicly facing, and credible metrics that explicitly depict equity [11]. Many candidate metrics for that exist, but more work needs to be done to identify a consensus-based set. For example, the Lorenz curve, which has long been used in economics, could be used to depict the distribution of vaccine globally; as depicted in Fig 1, the Gini index has changed little over time, indicating sluggish, if any, progress toward equitable vaccine distribution. Other candidate metrics include adaptations of the Gini coefficient and/or the Palma ratio (the ratio of the richest 10% of the countries share of vaccines to the poorest 40%’s share). Measures based on Atkinson index could be promising because they would weight changes among those with less as compared to changes among those with relatively more [12]. Such shared mental models of the roadmap, in turn, can be used to demand concrete commitments from global agencies, national governments, and other actors, including from industry.Open in a separate windowFig 1Lorenz curve and Gini coefficient as examples of potential metrics explicitly depicting equity of global distribution of COVID-19 vaccine.COVID-19, Coronavirus Disease 2019; GDP, gross domestic product.Sometimes, change occurs quickly during windows when the right problems, politics, and policy converge [13]—the COVID-19 pandemic presents a critical threat but also potentially a window to catalyze international collective action that can shape the post-COVID-19 landscape and ensure that global responses to future health threats are more equitable and effective. The barriers to using these steps to achieve greater equity in the global response to COVID-19 are myriad: Not all influential actors globally prioritize equity; agreement on metrics may be elusive; low-quality data behind metrics can mislead; and mechanisms for social accountability often fail [14]. Yet, the alternative is more daunting—the absence of a conversation, metrics, and mechanisms for global equity that is commensurate with its unequivocal place at center of global stage will set a dire path for the future. Not everything in the HIV response has gone well—indeed, opportunities for progress have been missed—but the response demonstrates that wicked problems are not completely intractable, but only if we are committed enough to change them.     

Mitochondrial DNA sequence analysis from multiple gene fragments reveals genetic heterogeneity of Crassostrea ariakensis in East Asia

The native Asian oyster, Crassostrea ariakensis is one of the most common and important Crassostrea species that occur naturally along the coast of East Asia. Molecular species diagnosis is a prerequisite for population genetic analysis of wild oyster populations because oyster species cannot be discriminated reliably using external morphological characters alone due to character ambiguity. To date there have been few phylogeographic studies of natural edible oyster populations in East Asia, in particular this is true of the common species in Korea C. ariakensis. We therefore assessed the levels and patterns of molecular genetic variation in East Asian wild populations of C. ariakensis from Korea, Japan, and China using DNA sequence analysis of five concatenated mtDNA regions namely; 16S rRNA, cytochrome oxidase I, cytochrome oxidase II, cytochrome oxidase III, and cytochrome b. Two divergent C. ariakensis clades were identified between southern China and remaining sites from the northern region. In addition, hierarchical AMOVA and pairwise Φ _ST analyses showed that genetic diversity was discontinuous among wild populations of C. ariakensis in East Asia. Biogeographical and historical sea level changes are discussed as potential factors that may have influenced the genetic heterogeneity of wild C. ariakensis stocks across this region.     

Phylogeography of the Asian lesser white-toothed shrew, <Emphasis Type="Italic">Crocidura shantungensis</Emphasis>, in East Asia: role of the Korean Peninsula as refugium for small mammals

Many peninsulas in the temperate zone played an important role as refugia of various flora and fauna, and the southern Korean Peninsula also served as a refugium for many small mammals in East Asia during the Pleistocene. The Asian lesser white-toothed shrew, Crocidura shantungensis, is a widely distributed species in East Asia, and is an appropriate model organism for exploring the role of the Korean Peninsula as a refugium of small mammals. Here, we investigated phylogenetic relationships and genetic diversity based on the entire sequence of the mitochondrial cytochrome b gene (1140 bp). A Bayesian tree for 98 haplotypes detected in 228 C. shantungensis specimens from East Asia revealed the presence of three major groups with at least 5 subgroups. Most haplotypes were distributed according to their geographic proximity. Pairwise F_ST’s and analysis of molecular variance (AMOVA) revealed a high degree of genetic differentiation and variance among regions as well as among populations within region, implying little gene flow among local populations. Genetic evidence from South Korean islands, Jeju-do Island of South Korea, and Taiwan leads us to reject the hypothesis of recent population expansion. We observed unique island-type genetic characteristics consistent with geographic isolation and resultant genetic drift. Phylogeographic inference, together with estimates of genetic differentiation and diversity, suggest that the southern most part the Korean Peninsula, including offshore islands, played an important role as a refugium for C. shantungensis during the Pleistocene. However, the presence of several refugia on the mainland of northeast Asia is also proposed.