Global health inequalities and the need for solidarity: a view from the Global South

Although the world has experienced remarkable progress in health care since the last half of the 20th century, global health inequalities still persist. In some poor countries life expectancy is between 37‐40 years lower than in rich countries; furthermore, maternal and infant mortality is high and there is lack of access to basic preventive and life‐saving medicines, as well a high prevalence of neglected diseases, HIV/AIDS, tuberculosis, and malaria. Moreover, globalization has made the world more connected than before such that health challenges today are no longer limited within national or regional boundaries, making all persons equally vulnerable. Because of this, diseases in the most affluent countries are closely connected with diseases in the poorest countries. In this paper, we argue that, because of global health inequalities, in a situation of equal vulnerability, there is need for global solidarity not only as a means of reducing health inequalities, but also as a way of putting up a united force against global health challenges. We argue for an African approach to solidarity in which the humanity of a person is not determined by his/her being human or rational capacity, but by his/her capacity to live a virtuous life. According to this view of solidarity, because no one is self‐sufficient, no individual can survive alone. If we are to collectively flourish in a world where no individual, nation or region has all the health resources or protection needed for survival, we must engage in solidarity where we remain compassionate and available to one another at all times.     

Ecosystem Approaches to Health for a Global Sustainability Agenda

International research agendas are placing greater emphasis on the need for more sustainable development to achieve gains in global health. Research using ecosystem approaches to health, and the wider field of ecohealth, contribute to this goal, by addressing health in the context of inter-linked social and ecological systems. We review recent contributions to conceptual development of ecosystem approaches to health, with insights from their application in international development research. Various similar frameworks have emerged to apply the approach. Most predicate integration across disciplines and sectors, stakeholder participation, and an articulation of sustainability and equity to achieve relevant actions for change. Drawing on several frameworks and on case studies, a model process for application of ecosystem approaches is proposed, consisting of an iterative cycles of participatory study design, knowledge generation, intervention, and systematization of knowledge. The benefits of the research approach include innovations that improve health, evidence-based policies that reduce health risks; empowerment of marginalized groups through knowledge gained, and more effective engagement of decision makers. With improved tools to describe environmental and economic dimensions, and explicit strategies for scaling-up the use and application of research results, the field of ecohealth will help integrate both improved health and sustainability into the development agenda.     

Global Health Care Justice,Delivery Doctors and Assisted Reproduction: Taking a Note From Catholic Social Teachings

This article will examine the Catholic concept of global justice within a health care framework as it relates to women's needs for delivery doctors in the developing world and women's demands for assisted reproduction in the developed world. I will first discuss justice as a theory, situating it within Catholic social teachings. The Catholic perspective on global justice in health care demands that everyone have access to basic needs before elective treatments are offered to the wealthy. After exploring specific discrepancies in global health care justice, I will point to the need for delivery doctors in the developing world to provide basic assistance to women who hazard many pregnancies as a priority before offering assisted reproduction to women in the developed world. The wide disparities between maternal health in the developing world and elective fertility treatments in the developed world are clearly unjust within Catholic social teachings. I conclude this article by offering policy suggestions for moving closer to health care justice via doctor distribution.     

A call for diversity,equity, and inclusion: Highlights from the Consortium of Universities for Global Health 2021 conference

Beryne Odeny reports from the CUGH 2021 virtual conference.

The first virtual Consortium of Universities for Global Health (CUGH) 2021 conference was held in March, 2021 [1]. Two weeks of satellite symposia culminated in this highly prestigious conference, which drew an eclectic group of renowned speakers, global health leaders, program implementers, researchers, and students from across the globe. There were more than 5000 delegates from diverse disciplines including public health, politics, education, medicine, planetary health, and finance. Top of the agenda was addressing critical gaps in global health and development against the backdrop of the COVID-19 pandemic.CUGH is an organization of over 170 academic institutions and organizations throughout the world, engaged in addressing global health challenges [1]. The 2021 conference was meticulously and creatively planned as was evidenced by the dynamic virtual platform, which hosted several global leader interviews, general sessions, 40 concurrent sessions, 7 plenary sessions, over 700 poster programs, and the Pulitzer Center Film festivals–yes, movies were on the menu [2]. Best of all, the platform held up, with minimal technical difficulties. The conference agenda had curated sessions carefully customized to varying attendee interests and expertise. Participants could seamlessly and discreetly shuttle between sessions.The inaugural interviews, with Dr. Anthony Fauci of the United States and Dr. Hugo Lopez-Gatell of Mexico, set the tone with emphasis on a much-needed global response to the ongoing pandemic. “2020 was a watershed moment in Global Health,” said Dr. Fauci. The COVID-19 pandemic indiscriminately unveiled the fragility of health systems in high income countries (HIC) and low- and middle-income countries (LMICs) alike. He unpacked the origins, evolution, and contention around current public health mandates such as mask wearing. He discussed vaccines–exploring vaccine manufacturing in LMICs, open patents, implications of emerging COVID-19 variants, and advice on curbing the prevailing vaccine infodemic (i.e., pandemic of misinformation) [2–4]. Dr. Lopez-Gatell described the pandemic as a “massive social event” fueled by deficits in health systems, politics, and governance, and by the growing tide of non-communicable diseases (NCDs) [5]. In a brief video recording, Dr. Tedros Adhanom Ghebreyesus, WHO’s Director-General, implored global partners to sign the COVID-19 Declaration on vaccine equity which he termed “the defining challenge of 2021” [6].The post-pandemic forecast for global health was dire. COVID-19 has disrupted decades of progress toward attainment of Universal Health Care (UHC) and it will be doubly difficult to restore, by 2035, health indicators to their levels prior to the pandemic [7–9]. A modelling study by Dr. Wenhui Mao of Duke University showed that, even in the most optimistic scenario, it may not be possible to achieve UHC in the next decade without breakthrough technologies and exceptional political commitment. Among four critical indicators of TB mortality rate, HIV mortality rate, under 5 mortality ratio, and maternal mortality ratio, Dr. Mao found that only the HIV indicator had potential for recovery by 2035.The metaphorical elephant in the room, and now its opposite, “the elephant not in the room”, respectively encapsulate two themes: neocolonialism and equity, especially for marginalized groups. Neocolonialism–a progeny of colonialism–resulting from sustained global North-South power imbalances, manifests in low prioritization of the most pressing challenges and diseases in LMICs. Equity was a poignant theme across the CUGH sessions and satellite symposia. Sessions were dedicated to exploring the hegemonic structures and institutional systems that underpin adverse health system performance and outcomes. A sampling of wide-ranging topics on global challenges exacerbated by neocolonialism and inequities comprised: a) elevating the visibility and power of researchers in LMICs, including fragile and conflict affected settings, through equitable access to funding, research autonomy and leadership, access to scholarly publishing, and senior authorship of research articles [10]; b) training next-generation global health professionals and building capacity for resource-challenged settings to address NCDs, including cancer care [5]; c) the Latin American and Caribbean health crises drawn by social gradients and inequities; d) navigating conflicting interests between public health and the corporate food industry; e) the dearth and role of women leaders in global health and in the COVID-19 response; f) the disproportionate incidence of HIV in adolescent girls and young women in sub-Saharan Africa (SSA) [11]; g) the disparate burden of neonatal mortality in LMICs and marginalized communities within HIC; and h) leveraging the power of film to evoke emotion and induce a consolidated response to global challenges. In addition, various facets of the human ecosystem were unpacked including climate change, biodiversity preservation, political climate, and the global kleptocracy, with attention to their implications for the health of the most marginalized populations.Despite the highlighted issues, there is, potentially, a panacea for these inequities and challenges. One speaker, Dr. Lisa Adams of Dartmouth College, proposed a paradigm shift that summarized a wide range of deliberations–“moving global health out of the realm of charity into global citizenship, security, human rights, equal partnership, and interdisciplinary collaboration between LMICs and HICs.” Moving forward, more deliberate effort should be given to some elements. First, rethinking governance and funding at a global level while promoting the autonomy of LMICs and conflict-affected settings to drive their health agenda–independent from HIC interests. Bringing the elephant into the room by making equal space for LMICs to set the agenda at global tables of discussion around funding, research, and development will be pivotal to dismantling neocolonialism. Furthermore, funders and partners should work with in-country systems in LMICs as opposed to bypassing them. This is essential to building resilient health systems unified at national levels to allow for cross-discipline collaborations and swift responses to health threats. Rwanda is a laudable example, having swiftly remodeled its existing health systems including routine electronic information systems for nationwide COVID-19 surveillance, testing, contact tracing, and vaccination. Second, investing time to build trusting relationships between researchers or implementers and policy makers by upholding a participatory approach to research and implementation of evidence-based practices. This is essential globally, to support development of global public goods such as vaccines, free from market dynamics and aimed at universal and equitable access. Third, introduce policies that engage economies to produce with less fragmentation of nature and reduced pollution. These include protected area management, financing of nature-positive projects, and conservationist work for natural capital preservation. Global and public health practitioners need to educate and empower citizens to choose healthy and ecologically sustainable consumption practices. Fourth, promoting development of novel technologies for preventing HIV infection, such as broadly neutralizing antibodies, could overturn the unequal burden of HIV in adolescents and young women in SSA. Finally, HIC have a lot they can learn from LMICs. COVID-19 evidently demonstrated that a country’s Global Health Security Index ranking is not necessarily commensurate to its degree of success in handling pandemics, among other public health threats [8,12,13].Throughout the conference, it was apparent that equity and collectivity in global health are necessary–not optional. Dr. Elvin Geng of Washington University, St. Louis remarked that the path to equity should be measurable with routinely incorporated metrics that track interventions to redress inequity and foster accountability. To achieve this, the tools of implementation science can be employed at both regional and global levels [14]. Overall, the remarkable interlacing of diverse disciplinary sessions at CUGH 2021 not only brought to light pressing world problems but equipped participants with a wellspring of potential remedies and collaborative opportunities. The panelists and speakers effectively portrayed the layered and multidimensional nature of global challenges underscoring the need for similarly multifaceted solutions. CUGH 2021 sparked thought-provoking discourse around global health strategies and re-invigorated the collective passion of global health experts, novices, and everyone in between, to build forward better.     

Justice and Medical Research: A Global Perspective

Economic globalization has profound implications for health. The scale of injustice at a global level, reflected in inexorably widening disparities in wealth and health, also has critical implications for health related research – in particular when the opportunities for exploiting research subjects are carefully considered. The challenge of developing universal guidelines for international clinical research is addressed against the background of a polarizing, yet interdependent, world in which all are ultimately threatened by lack of social justice. It is proposed that in such a world there is a need for new ways of thinking about research and its relevance to health at a global level. Responsibility to use knowledge and power wisely requires more radical changes to guidelines for research ethics than are currently under consideration.     

The Global Health Impact Index: Promoting Global Health

Millions of people cannot access essential medicines they need for deadly diseases like malaria, tuberculosis (TB) and HIV/AIDS. There is good information on the need for drugs for these diseases but until now, no global estimate of the impact drugs are having on this burden. This paper presents a model measuring companies’ key malaria, TB and HIV/AIDS drugs’ consequences for global health (global-health-impact.org). It aggregates drugs’ impacts in several ways–by disease, country and originator-company. The methodology can be extended across diseases as well as drugs to provide a more extensive picture of the impact companies’ drugs are having on the global burden of disease. The study suggests that key malaria, TB and HIV/AIDS drugs are, together, ameliorating about 37% of the global burden of these diseases and Sanofi, Novartis, and Pfizer’s drugs are having the largest effect on this burden. Moreover, drug impacts vary widely across countries. This index provides important information for policy makers, pharmaceutical companies, countries, and other stake-holders that can help increase access to essential medicines.     

Global Environmental Change and Population Health: Progress and Challenges

Escalating global environmental change (GEC) over the past century has been driven largely by rapid industrialization, population growth, overconsumption of natural resources, and associated waste disposal challenges, as well as the inappropriate uses of technology. These changes are already having and will increasingly continue to have significant impacts on human health and well-being. How to tackle these issues is an important challenge to scientists, policy-makers, and the general public. Scientific consensus now exists that GEC and population health are linked, even though the details and mechanisms underlying this link remain to be both explicated and quantified. In this article we provide an overview of progress and challenges in the area of GEC and population health since the late 1980s, highlighting some of the main landmarks in this area and recommending directions for future research.     

Patterns and Emerging Trends in Global Ocean Health

International and regional policies aimed at managing ocean ecosystem health need quantitative and comprehensive indices to synthesize information from a variety of sources, consistently measure progress, and communicate with key constituencies and the public. Here we present the second annual global assessment of the Ocean Health Index, reporting current scores and annual changes since 2012, recalculated using updated methods and data based on the best available science, for 221 coastal countries and territories. The Index measures performance of ten societal goals for healthy oceans on a quantitative scale of increasing health from 0 to 100, and combines these scores into a single Index score, for each country and globally. The global Index score improved one point (from 67 to 68), while many country-level Index and goal scores had larger changes. Per-country Index scores ranged from 41–95 and, on average, improved by 0.06 points (range -8 to +12). Globally, average scores increased for individual goals by as much as 6.5 points (coastal economies) and decreased by as much as 1.2 points (natural products). Annual updates of the Index, even when not all input data have been updated, provide valuable information to scientists, policy makers, and resource managers because patterns and trends can emerge from the data that have been updated. Changes of even a few points indicate potential successes (when scores increase) that merit recognition, or concerns (when scores decrease) that may require mitigative action, with changes of more than 10–20 points representing large shifts that deserve greater attention. Goal scores showed remarkably little covariance across regions, indicating low redundancy in the Index, such that each goal delivers information about a different facet of ocean health. Together these scores provide a snapshot of global ocean health and suggest where countries have made progress and where a need for further improvement exists.     

Vaccines and global health

Vaccines have made a major contribution to global health in recent decades but they could do much more. In November 2011, a Royal Society discussion meeting, 'New vaccines for global health', was held in London to discuss the past contribution of vaccines to global health and to consider what more could be expected in the future. Papers presented at the meeting reviewed recent successes in the deployment of vaccines against major infections of childhood and the challenges faced in developing vaccines against some of the world's remaining major infectious diseases such as human immunodeficiency virus (HIV), malaria and tuberculosis. The important contribution that development of more effective veterinary vaccines could make to global health was also addressed. Some of the social and financial challenges to the development and deployment of new vaccines were reviewed. The latter issues were also discussed at a subsequent satellite meeting, 'Accelerating vaccine development', held at the Kavli Royal Society International Centre. Delegates at this meeting considered challenges to the more rapid development and deployment of both human and veterinary vaccines and how these might be addressed. Papers based on presentations at the discussion meeting and a summary of the main conclusions of the satellite meeting are included in this issue of Philosophical Transactions of the Royal Society B.     

Monitoring Progress towards Universal Health Coverage at Country and Global Levels

Universal health coverage (UHC) has been defined as the desired outcome of health system performance whereby all people who need health services (promotion, prevention, treatment, rehabilitation, and palliation) receive them, without undue financial hardship. UHC has two interrelated components: the full spectrum of good-quality, essential health services according to need, and protection from financial hardship, including possible impoverishment, due to out-of-pocket payments for health services. Both components should benefit the entire population.This paper summarizes the findings from 13 country case studies and five technical reviews, which were conducted as part of the development of a global framework for monitoring progress towards UHC.The case studies show the relevance and feasibility of focusing UHC monitoring on two discrete components of health system performance: levels of coverage with health services and financial protection, with a focus on equity. These components link directly to the definition of UHC and measure the direct results of strategies and policies for UHC. The studies also show how UHC monitoring can be fully embedded in often existing, regular overall monitoring of health sector progress and performance. Several methodological and practical issues related to the monitoring of coverage of essential health services, financial protection, and equity, are highlighted. Addressing the gaps in the availability and quality of data required for monitoring progress towards UHC is critical in most countries.

Summary Points

• The overall goal of universal health coverage (UHC) is that all people obtain the good-quality essential health services, including promotion, prevention, treatment, rehabilitation, and palliation, that they need without enduring financial hardship.
• A global UHC monitoring framework, developed by WHO and the World Bank Group in interaction with the process that led to this PLOS Collection, was used in 13 country case studies, underpinned by five technical reviews.
• The UHC monitoring framework focuses on the simultaneous monitoring of coverage of the population with essential health services and with financial protection against catastrophic out-of-pocket health payments, stratified by wealth quintile, place of residence, and sex.
• Most countries focus on regular monitoring of a set of tracer indicators for priority health services, as well as the occurrence of financial hardship and impoverishment due to out-of-pocket health expenses. The indicators generally follow international standards of measurement and can be used for global comparisons.
• Most countries do not have an explicit framework for UHC monitoring. The monitoring of UHC is, however, partially embedded in regular overall health sector progress and performance reviews which include health system inputs, service delivery, and health status indicators.
• There are major gaps in the availability and quality of data required for monitoring progress towards UHC. Countries mostly rely on international survey programs or national surveys to obtain disaggregated data on coverage and financial protection indicators, complemented by health facility data, but often the frequency and contents of these surveys are not sufficient to meet the country''s information needs.
• Monitoring progress towards the two components of UHC will be complementary and critical to achieving desirable health outcome goals, such as ending preventable deaths and promoting healthy life expectancy, and also reducing poverty and protecting household incomes.

     

Twenty-first century vaccinomics innovation systems: capacity building in the global South and the role of Product Development Partnerships (PDPs)

The availability of sequence information from publicly available complete genomes and data intensive sciences, together with next-generation sequencing technologies offer substantial promise for innovation in vaccinology and global public health in the beginning of the 21st century. This article presents an innovation analysis for the nascent field of vaccinomics by describing one of the major challenges in this endeavor: the need for capacities in "vaccinomics innovation systems" to support the developing countries involved in the creation and testing of new vaccines. In particular, we discuss the need for understanding how institutional frameworks can enhance capacities as intrinsic to a systems approach to health technology development. We focus our attention on the global South, meaning the technically less advanced and developing nations in Africa, Asia, and Latin America. This focus is timely and appropriate because the challenge for innovation in postgenomics medicine is markedly much greater in these regions where basic infrastructures are often underresourced and new or the anticipated institutional relationships can be fragile. Importantly, we examine the role of Product Development Partnerships (PDPs) as a 21st century organizational innovation that contributes to strengthening fragile institutions and capacity building. For vaccinomics innovation systems to stand the test of time in a context of global public health, local communities, knowledge, and cultures need to be collectively taken into account at all stages in programs for vaccinomics-guided vaccine development and delivery in the global South where the public health needs for rational vaccine development are urgent.     

Towards a Better Integration of Global Health and Biodiversity in the New Sustainable Development Goals Beyond Rio+20

In June 2012, Brazil hosted Rio+20, the United Nations Conference on Sustainable Development (UNCSD) marking the 20th anniversary of the 1992 Earth Summit. The Rio+20 outcome document entitled The future we want provides general guidance to shape sustainable development policies, but fell short of providing legally binding agreements or pragmatic goals. Negotiators agreed to develop a process for the establishment of new Sustainable Development Goals (SDGs), building upon the Millennium Development Goals, and setting the foundation for the post-2015 UN development agenda. Our objective is to argue that discussions beyond Rio+20 and toward the adoption of SDGs offer a critical opportunity to re-assess the major challenges for global health and sustainable development. There is an urgent need to translate the general aspirations put forth by Rio+20 into concrete health outcomes and greater health equity. The way toward the post-2015 SDGs will likely be more effective if it highlights the full gamut of linkages between ecosystem processes, anthropogenic environmental changes (climate change, biodiversity loss, and land use), socio-economic changes, and global health. Negotiations beyond Rio+20 should strongly acknowledge the global health benefits of biodiversity protection and climate change mitigation and adaptation strategies, which reduce diseases of poverty and protect the health of the most vulnerable. We argue that health and ecosystems are inextricably linked to all development sectors and that health should remain a critical priority for the upcoming SDGs in the context of global environmental change.     

Special Issue Editor’s choice: Global child health from birth to adolescence and beyond

Caitlin Moyer discusses PLOS Medicine’s Special Issue on Global Child and Adolescent Health.

In a new PLOS Medicine special issue, entitled “Global Child and Adolescent Health: From Birth to Adolescence and Beyond”, guest editors Zulfiqar Bhutta, Quique Bassat, and Kathryn Yount bring to the forefront new research to illuminate global challenges for achievement of child and adolescent health and survival goals, and novel ways to address these challenges. The research articles in this special issue cover a broad range of current threats to child and adolescent health and wellbeing around the globe, shining a spotlight on the health impacts of pollutions, climate change, injury, violence, infectious diseases, undernutrition, and adolescent pregnancy. It is important to identify the gaps in knowledge that stand in the way of ensuring that all children and adolescents have the opportunity to survive, grow, and achieve developmental, social, and academic milestones. These studies further this goal by investigating new strategies that may be adopted to address these areas of need.     

Global human security in the post–COVID-19 era: The rising role of East Asia

Kenji Shibuya and coauthors discuss the potential contribution of East Asian countries to global health in the light of COVID-19.

Summary points

• East Asia, comprising the 10 ASEAN countries, China, Japan, and the countries of the Korean peninsula, has achieved comparatively good outcomes during the ongoing Coronavirus Disease 2019 (COVID-19) pandemic.
• This can be explained by sociological imprinting of and learning from past outbreaks, as well as competent governance.
• Concomitantly, East Asian nations have also been expanding capacity in global health development and diplomatic outreach, although there is as yet no coherent regional bloc vision, shared strategy, or a common set of operating principles, thus limiting synergistic impact.
• We believe that concrete next steps to bolster cooperation and extend influence could include the establishment of an East Asian Center for Disease Control, joint work in health and human security by the Asian Development Bank (ADB) and Asian Infrastructure and Investment Bank, and a region-wide research funding programme.
• Much, however, depends on evolving geopolitics writ large, notably the instability and reorientation of global alliances, which have the potential to adversely affect relations between neighbouring East Asian member states.
• Health diplomacy for global human security has the potential to become a stabilising influence and can be a topic around which all actors can more comfortably rally.

While the constituent countries of East Asia share common elements of history and culture, there is great diversity and rapid transition in social systems, economic development, demography, and epidemiological profiles (S1 Table). These factors fundamentally lead to the full range of major global health challenges, including those concerning epidemics and pandemics of novel and reemerging pathogens.Here, in the light of Coronavirus Disease 2019 (COVID-19), we discuss East Asia’s experience in this and past major outbreaks, its capacity and willingness to share best practice and support global health development, and the regional bloc’s potential in reshaping the global architecture for human security.Geographically and ethnoculturally, East Asia has conventionally referred to the region comprising China, Japan, Republic of Korea (South Korea), Democratic People’s Republic of Korea (North Korea), and Mongolia. More recently, the term has been broadened to encompass Southeast Asia (viz the 10 member states of ASEAN, the Association of South East Asian Nations), largely due to expanded regional economic cooperation and latterly for geopolitical reasons.     

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?     

Attention to Local Health Burden and the Global Disparity of Health Research

Most studies on global health inequality consider unequal health care and socio-economic conditions but neglect inequality in the production of health knowledge relevant to addressing disease burden. We demonstrate this inequality and identify likely causes. Using disability-adjusted life years (DALYs) for 111 prominent medical conditions, assessed globally and nationally by the World Health Organization, we linked DALYs with MEDLINE articles for each condition to assess the influence of DALY-based global disease burden, compared to the global market for treatment, on the production of relevant MEDLINE articles, systematic reviews, clinical trials and research using animal models vs. humans. We then explored how DALYs, wealth, and the production of research within countries correlate with this global pattern. We show that global DALYs for each condition had a small, significant negative relationship with the production of each type of MEDLINE articles for that condition. Local processes of health research appear to be behind this. Clinical trials and animal studies but not systematic reviews produced within countries were strongly guided by local DALYs. More and less developed countries had very different disease profiles and rich countries publish much more than poor countries. Accordingly, conditions common to developed countries garnered more clinical research than those common to less developed countries. Many of the health needs in less developed countries do not attract attention among developed country researchers who produce the vast majority of global health knowledge—including clinical trials—in response to their own local needs. This raises concern about the amount of knowledge relevant to poor populations deficient in their own research infrastructure. We recommend measures to address this critical dimension of global health inequality.     

Health System Challenges in Organizing Quality Diabetes Care for Urban Poor in South India

Background

Weak health systems in low- and middle-income countries are recognized as the major constraint in responding to the rising burden of chronic conditions. Despite recognition by global actors for the need for research on health systems, little attention has been given to the role played by local health systems. We aim to analyze a mixed local health system to identify the main challenges in delivering quality care for diabetes mellitus type 2.

Methods

We used the health system dynamics framework to analyze a health system in KG Halli, a poor urban neighborhood in South India. We conducted semi-structured interviews with healthcare providers located in and around the neighborhood who provide care to diabetes patients: three specialist and 13 non-specialist doctors, two pharmacists, and one laboratory technician. Observations at the health facilities were recorded in a field diary. Data were analyzed through thematic analysis.

Result

There is a lack of functional referral systems and a considerable overlap in provision of outpatient care for diabetes across the different levels of healthcare services in KG Halli. Inadequate use of patients’ medical records and lack of standard treatment protocols affect clinical decision-making. The poor regulation of the private sector, poor systemic coordination across healthcare providers and healthcare delivery platforms, widespread practice of bribery and absence of formal grievance redress platforms affect effective leadership and governance. There appears to be a trust deficit among patients and healthcare providers. The private sector, with a majority of healthcare providers lacking adequate training, operates to maximize profit, and healthcare for the poor is at best seen as charity.

Conclusions

Systemic impediments in local health systems hinder the delivery of quality diabetes care to the urban poor. There is an urgent need to address these weaknesses in order to improve care for diabetes and other chronic conditions.     

Application of Ethical Principles to Research using Public Health Data in The Global South: Perspectives from Africa

Existing ethics guidelines, influential literature and policies on ethical research generally focus on real‐time data collection from humans. They enforce individual rights and liberties, thereby lowering need for aggregate protections. Although dependable, emerging public health research paradigms like research using public health data (RUPD) raise new challenges to their application. Unlike traditional research, RUPD is population‐based, aligned to public health activities, and often reliant on pre‐collected longitudinal data. These characteristics, when considered in relation to the generally lower protective ethico‐legal frameworks of the Global South, including Africa, highlight ethical gaps. Health and demographic surveillance systems are examples of public health programs that accommodate RUPD in these contexts. We set out to explore the perspectives of professionals with a working knowledge of these systems to determine practical ways of appropriating the foundational principles of health research to advance the ever growing opportunities in RUPD. We present their perspectives and in relation to the literature and our ethical analysis, make context relevant recommendations. We further argue for the development of a framework founded on the discussions and recommendations as a minimum base for achieving optimal ethics for optimal RUPD in the Global South.     

Honing the Priorities and Making the Investment Case for Global Health

In the aftermath of the Ebola crisis, the global health community has a unique opportunity to reflect on the lessons learned and apply them to prepare the world for the next crisis. Part of that preparation will entail knowing, with greater precision, what the scale and scope of our specific global health challenges are and what resources are needed to address them. However, how can we know the magnitude of the challenge, and what resources are needed without knowing the current status of the world through accurate primary data? Once we know the current status, how can we decide on an intervention today with a predicted impact decades out if we cannot project into that future? Making a case for more investments will require not just better data generation and sharing but a whole new level of sophistication in our analytical capability—a fundamental shift in our thinking to set expectations to match the reality. In this current status of a distributed world, being transparent with our assumptions and specific with the case for investing in global health is a powerful approach to finding solutions to the problems that have plagued us for centuries.When we have proactively set our sights on large and defined obstacles to human wellness, the global health community has been able to chart a course toward lasting, widespread impact. However, few would argue that the global health community’s response to Ebola—while ultimately effective—was the optimal way to anticipate and address a global health crisis. Comprehensive analyses have been conducted on what worked well and what didn’t [1]. Despite all the failings that led to over 11,000 deaths and an estimated US$1.6 billion in costs to the economy in Guinea, Sierra Leone, and Liberia, the global community did come together and help turn the tide against the epidemic—albeit more slowly than what could have been possible with a better-prepared world [2,3]. Major funding commitments were made when the reality and urgency of the epidemic became evident [4]. Another point that may not be widely known is that the private sector responded to the challenge by directing significant resources to develop vaccines, drugs, and diagnostics at an unprecedented pace. As a result, we now have four vaccine candidates, three therapeutics in Phase III clinical trials, and six diagnostics authorized for emergency use by WHO [5].At the turn of the millennium, the global community sought to address the far more complex problem of vaccination coverage. In 2000, the glaring disparity in vaccine access between wealthy and developing nations led to the formation of Gavi, the Vaccine Alliance [6]. After 15 years, Gavi has helped create a roadmap for countries to ramp up their immunization programs—reaching nearly half a billion additional children with vaccines [7]. Through its multisector partnership, Gavi not only addressed the huge challenge of improving childhood vaccination coverage, but it also provided certainty to the private sector, encouraging it to manufacture products for developing country markets and to make them affordable. In 2015, donors came together again and made US$7.5 billion in pledges, the largest ever financial commitment to support childhood immunization [8].We can find a comparable example in the sobering problem of tuberculosis (TB), in which the battle is being fought with a decades-old and unwieldy six-month treatment regimen of diminishing efficacy due to multidrug resistance. In 2013, TB made an estimated 9 million people sick, and 1.5 million people died from the disease [9]. However, the fight against TB is being reinvigorated. The TB Drug Accelerator (TBDA) is a groundbreaking partnership among eight pharmaceutical companies, seven research institutions, and a product development partnership funded by the Bill & Melinda Gates Foundation [10]. By driving collaboration and data sharing atypical of its partners, the TBDA’s overall goal is to create a new TB drug regimen that cures patients in only one month, replacing the outmoded intervention we have today. While the structure and purpose of the TBDA took rigorous iteration to get where it is today, the data and expertise shared among its partners has already identified compounds that could potentially lead to a more effective treatment.Although it might seem that the motivations behind the investments in these three cases are different—a potential regional or global health catastrophe in the case of Ebola, a humanitarian imperative underlying Gavi, and a dual global drug resistance threat and humanitarian basis for the TBDA—there is a common thread. These examples show that when there is imminent and clear need, we have been able to mobilize resources and construct creative partnerships to create an impact. Summers et al. make the compelling case for investing in global health by showing the general economic benefit of those investments [11]. Similarly, others have claimed a substantial return on investment in specific areas of health science as a motivation for future investments [12]. These cases are fairly general in their content, and we see modern investors in global health (whether countries or philanthropists) as being much more demanding in terms of wanting to know exactly how their resources are deployed and the impact that could be expected.At the Bill & Melinda Gates Foundation, we are exploring a set of approaches that start with our current (and improving) knowledge of the state of the burden of diseases relevant to low- and middle-income countries (LMICs) and comparing the potential interventions we have to reduce this burden along a number of dimensions. The ultimate objective is to arrive at a view of the actionable priorities that we can support at any one time in order to maximize our impact on health and wellbeing in communities with the highest burden. This approach has some parallels with portfolio analysis in the biopharmaceutical industry [13], but the very sparse and poor quality of the underlying primary data in global health means that, at best, we can rely on this as a rough guide and a mechanism for exposing outliers in cost, effectiveness, and impact (Fig 1). This approach provides a framework for comparison across diverse categories through a metric that is understandable. More importantly, it forces us to state our assumptions explicitly for debate and reconciliation. However, we also need to be cautious about any notion that the complex sociopolitical environments we work in and the fluctuating humanitarian crises that arise can ever be reduced to simple algorithms for decision-making.Open in a separate windowFig 1Portfolio analysis for global health impact.Cost per disability-adjusted life year (DALY) averted is the incremental cost to deliver incremental DALY savings versus only the standard of care. Probability of success is the estimate of probability of technical and regulatory success (PTRS) informed by industry benchmarks and expert opinion. NRRV: Non-replicating rotavirus vaccine. Both the cost and the probability of success are dynamic values and subject to change with information that is constantly evolving.Although our understanding of the burden of disease has improved tremendously at a national and subnational level for important pathogens, as evidenced by a recent integration of our knowledge of the spatial distribution of the risk of malaria in sub-Saharan Africa [14], we need to invest much more heavily in obtaining better primary data. We therefore recently launched CHAMPS, the Child Health and Mortality Prevention Surveillance Network [15]. CHAMPS will be a network of disease surveillance sites in LMICs that will help gather accurate data about how, where, and why children are getting sick and dying. For the first time in history, pathology-based surveillance will be used to track the causes of childhood mortality, complementing and improving upon existing cause-of-death information from verbal autopsy surveys and vital statistics. Through geospatial modeling and mapping, these new surveillance data will provide an increasingly broad and accurate picture to guide more effective use of the scarce resources for prevention and treatment.Improved data can also help drive progress against less familiar health challenges such as neglected tropical diseases (NTDs) [16]. Until recently, little was known about the geographical distribution of NTDs. Because of weak surveillance systems, the scarcity of geospatial mapping was greatest in sub-Saharan Africa, which has hampered deployment of effective programs. To address this, a WHO African Region-led effort has conducted thousands of field surveys using mobile phone data capture to complete the picture of NTDs across Africa. In addition to guiding disease control efforts, such as targeting of mass drug administrations only to places that need them, this mapping provides, for the first time, the necessary central database to allow analysis of program performance and to make projections of likely outcomes, including the probability of disease elimination.The framework we use to evaluate this data has a few simple dimensions: cost per disability-adjusted life year (DALY) averted, probability of technical success, and, at a more strategic level, whether our resources fill a real gap in the funding landscape (Fig 1). There are many alternative metrics, but we have chosen this scheme for its simplicity and augment it with additional analyses when these make sense. An important part of the framework related to work that might only be completed well into the future is understanding the spectrum of potential trajectories for future disease burden. Thus, forecasting becomes an essential element of decision-making; for this, we need to go beyond only linearly extrapolating future outcomes based on past trends. Much more sophisticated forecasting that integrates all significant covariates of the main outcome is becoming available [17] and will be increasingly useful for decision-making and the longitudinal evaluation of projects to assess whether interventions are shifting the envelope of outcomes in a positive direction.The system described above, which is already in use across parts of our global health portfolio, makes us optimistic that we can, in the near future, expand this approach to the entire portfolio and arrive at a more systematic way of understanding the inherent values and risks of a given intervention. This will also give us a clear picture of the huge and urgent problems in global health, paired with more deeply evaluated and cost-specific solutions, as well as a forecast of the negative consequences of inaction. Much as the world, or parts thereof, were mobilized by the Ebola crisis, the childhood vaccination gap, and the TB epidemic, we would then have maximized the likelihood of accessing new resources for potential solutions to ongoing global health crises.