News Flash 468: Weekly Snapshot of Public Health Challenges

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

News Flash 468

Weekly Snapshot of Public Health Challenges


Exclusive: United States Fast Tracks Proposal to Change WHO Rules on International Health Emergency Response

Commission sets out strategy to promote decent work worldwide and prepares instrument for ban on forced labour products

Webinar registration Wemos: Review of initiatives for global access to and finance for medical products against Covid-19 Wednesday 2 March 2022 Time: 3:00 – 4:30 PM (CET)

Save the Date! On 2 March 2022 GI-ESCR is launching the report ‘The failure of commercialised healthcare in Nigeria during the COVID-19 pandemic’ with a press conference in Lagos, Nigeria

It’s Time to Take Coronavirus in Africa Seriously

WHO: Statement on Omicron sublineage BA.2

Audio Interview: Understanding the Omicron Variant of SARS-CoV-2

In year 3 of the pandemic, the challenges facing WHO are in plain sight

Vaccine advocacy groups press Biden to break WTO deadlock

Landmark ‘TRIPS Waiver’ must be agreed now: no time to lose

Three key elements for a successful waiver

Moving forward on goal to boost local pharmaceutical production, WHO establishes global biomanufacturing training hub in Republic of Korea

With technology transfer, 120 companies in low- and middle-income countries could manufacture mRNA vaccines

Africa’s COVID-19 fight bolstered with tech transfer

Nigeria’s COVID Vaccine Drive Gets a Boost as African Leaders Push 70% Vaccination Target

EMA recommends approval of Spikevax for children aged 6 to 11

EMA recommends authorisation of booster doses of Comirnaty from 12 years of age

Effectiveness of the BNT162b2 Vaccine after Recovery from Covid-19


No One Is Safe Until Everyone Is Safe? Reporting a Polio Outbreak at Snail’s Pace

Finally Cause for Optimism About TB Vaccine Research, Says Fauci

After Taliban promises made in Geneva, now what?

The EU’s summit of magical thinking on Africa

Il cancro, metastasi della globalizzazione

European medicines regulatory network adopts EU common standard for electronic product information

Improving Maternal and Newborn Health Outcomes in Europe by Serge Moubarak 

More than half of parents and pregnant women exposed to aggressive formula milk marketing – WHO, UNICEF

Children with Disabilities are Not Problems to Solve, but Potential to Nurture, says Nujeen Mustafa

It’s time for action on COP 26 pledges, says ClimateWorks chief

US, Egypt launch group to prepare for COP27 climate summit

Social Impacts on Coral Reef Dependent Human Activities by Siga Tamufor 

Wildfires are getting more extreme and burning more land. The UN says it’s time to ‘learn to live with fire’

In this age of climate crisis, humanitarians need to learn to love tech










Social Impacts on Coral Reef Dependent Human Activities

Millions of people today depend primarily on the goods and services offered by coral reefs. The keys aspects of the ecosystem impacted by climate change tends to impact the society too. To understand how climate change will impact human communities, it is important to consider the multiple pathways through which impacts can manifest, especially indirect, direct and bi-directional linkages among distinct components of social-ecological systems

 By Siga Tamufor

Nature Conservationist

Social Impacts on Coral Reef Dependent Human Activities

(i.e., Human Migration, Socio-Economic Disparities and Public Health)


According to Hoegh-Guldberg, climate change has rapidly emerged as one of the major long-term threats to coral reefs (Hoegh-Guldberg et al 2007). Various studies have quantified the ecological impacts of disturbance on coral reefs and examined how anticipated increases in ocean temperature, acidity and the increasing frequency of high-intensity storm events will impact coral communities (De’ath et al 2012).

Aside from fisheries impacts, little is known about how climate change may impact coral reef dependent human societies and the major drivers and pathways through which this may operate (Carpenter et al 2009). Millions of people today depend primarily on the goods and services offered by coral reefs. The keys aspects of the ecosystem impacted by climate change tends to impact the society too (Allison et al 2009).

However, climate change may not only interrupt the flow of goods and services to society, but may also alter how people interact with reefs, creating potential pathways from society to ecosystems (Butler and Oluoch-Kosura 2006). To understand how climate change will impact human communities, it is important to consider the multiple pathways through which impacts can manifest, especially indirect and bi-directional linkages among distinct components of social– ecological systems (Cinner et al 2015). The direct impacts of increased Sea Surface Temperature (SST) in tropical oceans can also affect human health. For example, increasing SST can result in increased phytoplankton blooms that are related to incidents of shellfish poisoning (Allison et al 2009) and conditions conducive to cholera outbreaks since the Vibrio cholerae bacterium blossoms in warmer waters (Ceccarelli and Colwell 2014). Microbial outbursts lead to socioeconomic impacts of human health-related incidents like health-related costs, loss of labor productivity, loss of a food source, loss of reef fish sales in both local and international markets, and changes to the social, cultural and traditional characteristics of fishing communities (Rongo and van Woesik 2012). These impacts affect human health directly, but also indirectly through a loss of tourism.

Damage to reefs from storms can also directly affect societal well-being because tourists may stop visiting certain reefs that have experienced severe storm damage, with flow-on effects to tourism-dependent livelihoods (Blythe et al 2013).

The relative importance of different linkages and major impact pathways varies according to the specific climate drivers being considered. For example, sea level rise is likely to only have strong direct impacts on societal well-being but limited direct impacts on reef ecosystems. In contrast, ocean warming will have direct impacts to multiple components of coral reef ecosystems, with flow-on effects to societal well-being.



 Allison, Edward H., Allison L. Perry, Marie-Caroline Badjeck, W. Neil Adger, Katrina Brown, Declan Conway, Ashley S. Halls, et al. 2009. “Vulnerability of National Economies to the Impacts of Climate Change on Fisheries.” Fish and Fisheries 10, no. 2: 173–96.

Blythe, Jessica L., Grant Murray, and Mark S. Flaherty. 2013. “Historical Perspectives and Recent Trends in the Coastal Mozambican Fishery.” Ecology and Society 18, no. 4.

Butler, Colin D., and Willis Oluoch-Kosura. 2006. “Linking Future Ecosystem Services and Future Human Well-Being.” Ecology and Society 11, no. 1. 110130.

Carpenter, S. R., H. A. Mooney, J. Agard, D. Capistrano, R. S. DeFries, S. Diaz, T. Dietz, et al. 2009. “Science for Managing Ecosystem Services: Beyond the Millennium Ecosystem Assessment.” Proceedings of the National Academy of Sciences 106, no. 5: 1305–12.

Ceccarelli, Daniela, and Rita R. Colwell. 2014. “Vibrio Ecology, Pathogenesis, and Evolution.” Frontiers in Microbiology 5, no. May.

Cinner, Joshua Eli, Morgan Stuart Pratchett, Nicholas Anthony James Graham, Vanessa Messmer, Mariana Menezes Prata Bezerra Fuentes, Tracy Ainsworth, Natalie Ban, et al. 2015. “A Framework for Understanding Climate Change Impacts on Coral Reef Social– Ecological Systems.” Regional Environmental Change 16, no. 4: 1133–46.

De’ath, G., K. E. Fabricius, H. Sweatman, and M. Puotinen. 2012. “The 27-Year Decline of Coral Cover on the Great Barrier Reef and Its Causes.” Proceedings of the National Academy of Sciences 109, no. 44: 17995–99.

Hoegh-Guldberg, O., P. J. Mumby, A. J. Hooten, R. S. Steneck, P. Greenfield, E. Gomez, C. D. Harvell, et al. 2007. “Coral Reefs under Rapid Climate Change and Ocean Acidification.” Science 318, no. 5857: 1737–42.

Rongo, Teina, and Robert van Woesik. 2012. “Socioeconomic Consequences of Ciguatera Poisoning in Rarotonga, Southern Cook Islands.” Harmful Algae 20, no. December: 92– 100.

Improving Maternal and Newborn Health Outcomes in Europe

…In order for countries to achieve Universal healthcare, a focus on maternal and newborn health is imperative.  Universal healthcare coverage is part of the aim of the UN Sustainable Development Goal 3, which is related to healthcare…

…To this end, PerkinElmer held a thought leadership event to bring together doctors, patient organisations and policy makers, and gather their valuable insights on the way forward. “What the current gaps that we need to address are and what we can learn from the past” was one of the several key topics discussed by the opinion leaders…

…We noted that several pregnancy related conditions, such as preeclampsia and placenta praevia, can have disastrous effects on women if they are not diagnosed early enough to ensure proper management and treatment. We also know that some places in Europe still face clear challenges in achieving effective management of antenatal care to ensure healthy newborns…

By Serge Moubarak

Vice President & General Manager, PerkinElmer, Europe, Middle East, Africa & India (EMEAI)


Improving Maternal and Newborn Health Outcomes in Europe


COVID-19 has unfortunately set us back from the great strides that were being made to save and improve the lives of at-risk pregnant women, mothers and babies across different countries in Europe. It is therefore imperative that we renew our focus on improving health outcomes.

To this end, PerkinElmer held a thought leadership event to bring together doctors, patient organisations and policy makers, and gather their valuable insights on the way forward.

“What the current gaps that we need to address are and what we can learn from the past” was one of the several key topics discussed by the opinion leaders. We noted that several pregnancy related conditions, such as preeclampsia and placenta praevia, can have disastrous effects on women if they are not diagnosed early enough to ensure proper management and treatment.

We also know that some places in Europe still face clear challenges in achieving effective management of antenatal care to ensure healthy newborns. We believe that every aspect of the care pathway from pregnancy to antenatal care, to post-natal care, is important in ensuring the health of mothers and babies.

Placenta health

The success of pregnancy is dependent on three factors: the baby, the placenta and the mother. Every one of them must be in good health to secure a healthy outcome for both the mother and the baby. Assessing the baby and ignoring the umbilical cord and the placenta would result in an incomplete picture. Problems with placental health are by far more common than pregnancies with Down’s Syndrome or birth defects.


Stillbirth is one of the pregnancy related outcomes that still represents a challenge in Europe. There are no international guidelines for the prevention of stillbirths, and there are variations in Europe. There is, however, data available on the stillbirth rates in the continent, which are maintained by the European Perinatal Statistics.


In Europe, over five million babies are born each year, and two to eight per cent of pregnancies – which equates to more than one in 50 pregnant women – are affected by preeclampsia. When preeclampsia develops, it is considered as a serious condition that needs immediate treatment, often leading to premature births. Thus, preeclampsia not only affects the mother, but also the baby and the outcome of the pregnancy. Preeclampsia and preterm birth are also associated with the development of chronic illnesses and metabolic diseases in later life.

Screening for preeclampsia in the first trimester of pregnancy is a simple and cost-effective procedure consisting of a simple blood sample, combined with maternal history and blood pressure measurement. It provides the necessary information to predict the risk of developing preeclampsia with a high detection range. Screening has the potential to protect hundreds of thousands of mothers and babies from this life-threatening disorder.[1]

Preeclampsia affects quite a number of pregnancies and can be linked to an increased risk of adverse pregnancy outcomes such as fetal growth restriction, pre-term birth and stillbirth.[2] Through prevention, early diagnosis, and treatment some of these health conditions that women face can be alleviated.  There are tests on the market showing that placental growth has a great potential in ruling out preeclampsia.

With currently used methods, only about 40 per cent of the women that are at high-risk of developing preeclampsia before week 37 are identified in early pregnancy and there is no proper preventive care in place. Statistics in many European countries reflects the limited achievements in this field. Finding biomarkers to improve on the low percentage of identification was a key objective when PerkinElmer started a research collaboration programme with Professor Poston, Shannon and Robson in 2004.

ASPRE was a Seventh Framework Programme (FP7) EU funded, randomised control trial (RCT) to examine the efficacy of Aspirin to treat women identified as high-risk of preeclampsia in the first trimester of pregnancy between 11-14 weeks gestation. Using a combination of maternal history, an ultrasound marker, blood pressure and a biochemical marker, and placental growth factor, they were able to detect 75 per cent of women who would develop preeclampsia before 37 weeks.[3]

The high-risk group, which was 10 per cent of the pregnant population, were given 150mg Aspirin daily. The results exceeded expectations: overall, 62 per cent of preterm preeclampsia cases which would develop before 37 weeks gestation and 89 per cent of the most serious cases which develop before 32 weeks gestation were prevented. In pregnancies at high-risk of preeclampsia, administration of aspirin reduces the length of stay for the babies in the neonatal intensive care unit by approximately 70 per cent. The ASPRE study was published and acclaimed as the most important breakthrough in obstetrics in the past 20 years, by the editor of the American Journal of Obstetrics and Gynaecology.

Preeclampsia does have long term consequences, again, for mother and baby. The mother could develop cardiovascular diseases, hypertension, heart failure or suffer a stroke. Newborns could also suffer from cardiovascular problems. Therefore, it is imperative that health systems prioritise screening and diagnosis of preeclampsia. The implementation of a first trimester preeclampsia screening programme and adopting better preeclampsia management practices will improve pregnancy outcomes, and this will have a positive impact on the economic burden to country healthcare systems. 

Newborn screening for rare disorders

Centers for Disease Control and Prevention (CDC) and other public health bodies around the world hail newborn screening as one of the 10 great public health achievements of the 20th century. Many developed countries have built upon that success and added additional conditions for screening. A heel prick bloodspot screening test taken by a health professional is all that is required to diagnose disorders on babies. After this simple procedure, biochemical blood tests are performed on the dried blood sample to diagnose a number of serious disorders.

Newborn screening has the ability to save babies from severe and life-limiting conditions. Rare diseases can be both life-limiting and life-threatening, and disproportionately affect children. Seventy-five per cent of rare diseases affect children and more than 30 per cent of children with a rare disease die before their fifth birthday.[4]

After birth, many babies are healthy and will not have any conditions that could be identified by newborn screening tests. However, for those babies who do have health problems, the benefits of screening can be enormous. Early diagnosis and treatment can improve the affected babies’ health and prevent severe disability or even death in some instances.

Newborn babies can be screened for over 50 potentially life-threatening disorders. Many countries in Europe screen for 20 or more conditions, while parents in the US have the option to test for more than 50 conditions.

Apart from the diagnosis and treatment of these rare disorders such as metachromatic leukodystrophy (MLD) and severe combined immunodeficiency (SCID); efforts are underway to gain adoption of the diagnosis of spinal muscular atrophy (SMA) in Europe and globally.


In order for countries to achieve Universal healthcare, a focus on maternal and newborn health is imperative.  Universal healthcare coverage is part of the aim of the UN Sustainable Development Goal 3, which is related to healthcare.  There are targets that relate to maternal and infant mortality reduction. 

The relevant targets are:

3.1 By 2030, reduce the global maternal mortality ratio to less than 70 per 100,000 live births.

3.2 By 2030, end preventable deaths of newborns and children under 5 years of age, with all countries aiming to reduce neonatal mortality to at least as low as 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births.[5] Without a global focus on these areas goal 3 will not be achieved.

All in all, having a focus on the prioritisation of services and care for pregnant women, mothers and babies will provide better outcomes.

We look forward to working in collaboration with key stakeholders to improve health outcomes for pregnant women, mothers, and babies.



[1] Rolnik DL (2017) ASPRE trial: Performance of screening for pre-term preeclampsia. Ultrasound Obstet Gynecol. 2017 Jul 25. doi: 10.1002/uog.18816

[2] Ankita Malika,1, Babban Jeeb,1, Satish Kumar Guptaa,⁎ Preeclampsia: Disease biology and burden, its management strategies with reference to India. Pregnancy Hypertension 15 (2019) 23–31

[3] Rolnik DL (2017) ASPRE trial: Performance of screening for pre-term preeclampsia. Ultrasound Obstet Gynecol. 2017 Jul 25. doi: 10.1002/uog.18816


[5] United Nations Sustainable Development Goals –

News Flash 467: Weekly Snapshot of Public Health Challenges

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

News Flash 467

Weekly Snapshot of Public Health Challenges


WHO: public health round-up

Guterres opens Global Disability Summit with inclusivity call

Webinar registration Misdiagnosis, Toxic Treatments, and Deadly Insects: Meet the Authors of “The Kissing Bug” and “Life Lessons from the Amazon.” Feb 17, 2022 01:00 PM in Eastern Time (US and Canada

Health inequity focus in pandemic preparedness and response plans

South Africa Says ‘No Hesitation’ on Joining African Medicines Agency – WHO Head Tours Cape Town mRNA Vaccine Hub

Media briefing on the mRNA vaccine technology transfer hub in South Africa

South Africa’s mRNA hub progress is foundation for self-reliance

BioNTech To Ship Modular mRNA Vaccine Facilities in Containers to African Countries to Jump-start Production

Africa CDC – Mastercard Partnership Helps Improve Vaccine Uptake – Only 0.5% of Doses Received are Wasted

EU set to bin 25 million more vaccine doses than it has donated to Africa this year

EMA: Safety of COVID-19 vaccines

Protection against SARS-CoV-2 after Covid-19 Vaccination and Previous Infection


World Bank says debt crisis in lower-income nations is ‘alarming’ 

How the concept of WHO-listed authorities will change international procurement policies for medicines

20-tool checklist for diagnosing, treating and preventing AIDS

What Is Harm Reduction?

Preventing tooth decay in resource-limited settings

Why NICE’s Lack of Data Transparency Undermines Priority Setting in Low- and Middle- Income Countries

Decolonising EU-Africa Relations Is A Pre-Condition For A True Partnership Of Equals

The impact of insecurity on access to care in the local health system of Djenné, Mali – and what is being done about it

Initiatives for Catalytic Investment for Rural Africa by Florence Gune

Report finds rampant abuse of women in African parliaments

Somalia hit by worst drought crisis in a decade: NGO

Opinion: How to protect global food policy from corporate capture

Peasants Marginalized by Big Farmers

Malnourished Afghan Children in The Grasp of Measles Outbreak

Facilitating progress towards SDG2: Zero Hunger

Enough of the abuse and crimes: it’s time to green justice

Speech by President von der Leyen at the One Ocean Summit

ONE OCEAN SUMMIT – An Opportunity For Blue Transformation

UN report to sound alarm on impacts of climate change

Key lawmaker tables radical overhaul of EU’s renewable energy directive

Green Deal: EU invests over €110 million in LIFE projects for environment and climate in 11 EU countries









Since January 2020, official sources reported 360 million COVID 19 infections and 5.6 deaths with COVID-19 infection. While the distribution of mortality has no relation with national average GDP pc, the world has responded a scope of lockdown measures and through the development and distribution of COVID 19 vaccines, with very high degrees of impact on inequity. There are uncertainties in the real incidence (probably much higher than reported) and case fatality rates (probably much lower) and the risk benefit of natural immunity vs. induced immunity by COVID vaccines, disaggregated by age and risk factors. The analysis of the burden of disease (in life years lost) points at 1.9% of the global burden of ill health. The estimated cost-utility (economic cost per life year prevented) of the mentioned preventive measures (lockdown and vaccination) has been much higher than indicative national thresholds in low and middle-income countries. Even in high-income countries, the economic contraction derived from lockdown is above the reference cost-utility thresholds while universal vaccination is very close to the mentioned threshold set in some countries. The opportunity cost of the economic lockdown vs. ethical redistribution is of 4.9 million while that of the overall vaccination is of over 2 million, 2.4 million for those under 60 years of age. The only intervention with no opportunity cost is the vaccination of people older than 60 years and/or with risk factors, which has a net saving effect of close to 0.5 million deaths.  This analysis points at COVID 19 equitable vaccination of all persons older than 60 years, regardless the country or income group, as the most efficient and ethical use of the global economic resources to prevent loss of human life due to COVID 19. While vertical and systematic interventions may be pertinent in epidemic contexts (as the evolution in incidence and fatality is unknown), the analysis questions the pertinence of COVID 19 vaccination in people younger than 60 years in a stable endemic situation and in relation to other more cost effective public health interventions lacking coverage in low-income countries

By Juan E. Garay, MD MPH MSc

Co-founder and member of the Steering Committee, Sustainable Health Equity Movement

Professor ad-honorem, UNACH, Chiapas, Mexico, Visiting Professor of Global Health, Escuela Nacional de Sanidad, Spain


The study here is an update to a version already published on PEAH
Scene setting

Global health in equity: Equity is the fair distribution of inequality. It is the measure of the only international commitment in global health, Article 1 of the Constitution of the World Health Organisation: “the best possible health for all”. We have defined the best feasible level of health as the one of “HRS” countries or regions with : (1) life expectancy higher than the international average (H: healthy), (2) flow of economic resources (GDP per capita) and wealth (assets) below the international average (R: Replicable in terms of economic resources) and (3) with availability (bio-capacity per capita) and use of natural resources (carbon footprint and ecological footprint) below the ecological sustainability thresholds- or planetary boundaries (S : Sustainable in the use of natural resources)[1].

We compared the mortality rates disaggregated by age and sex with those observed in each country of such HRS references. The excess mortality constitutes the net (number of deaths) or relative (proportion of deaths in excess, from the total) burden of health inequity. Based on available data on national averages, the net burden of inequality between 2016 and 2020 was on average 16.11 million annual deaths and the relative burden, 28 % (32 % for women and 23 % for men)[2]. Eighty four per cent of the net burden/excess mortality (13.53 million deaths) took place in countries with GDP per capita lower than the healthy-replicable-sustainable (HRS) references, which we defined as the ‘dignity threshold’, of around $10.7 per day (5.7 times higher than the ‘poverty threshold’ defined by the World Bank). When we studied the symmetrical level of the dignity threshold GDP pc above the international average we found out that no country with average GDP pc above such level (which we call “excess threshold”) has respected, during 60 years, the planetary boundaries. On the other side, average life expectancy (proxy for wellbeing) does not improve with GDP pc above the excess threshold[3]. More than half of the world’s population live in countries with GDP pc below the dignity threshold (in the deficit area). For them, the average income levels (related to access to knowledge and basic goods) are below those required (dignity threshold) to enable health and life expectancy that is feasible (indeed, with less than half of global economic resources) and sustainable for the next generations, as the WHO constitution states. The economic redistribution needed to ensure all countries have national average GDP pc above the mentioned dignity threshold (and economic conditions to prevent those 13.53 million deaths per year) is equivalent to 7.77 % of global GDP, 10.6 % of the GDP above the excess threshold (as opposed to the current 0.18 % ODA). Regarding the intergenerational prospects of health inequity (between the present one and coming generations), the current CO2 emission trend (after the COVID 19 lockdown emissions returned to their average growth rate) will cause some 220 million excess deaths during the rest of the century, hitting the least polluting countries harder (“exponential inequity”).

COVID-19 and equity: available data point at a distribution of COVID 19 attributed mortality by demographic, geographical and economic factors, as follows:

Demographic distribution: Half of all deaths have occurred in patients aged over 85, above the highest national average of life expectancy (Japan, 84.36), two-thirds in patients aged over 80 (above the average of high-income countries), 80 % in patients aged over 72 (above the international average of life expectancy) and 95 % in patients aged over 60 years[4]. That explains the correlation COVID 19 related mortality rate by country and its median age. As the following graph shows, one third of the international variability of COVID 19 mortality could be explained by the median age.

Figure 1: Cumulative mortality 2020-2021 per million per COVID-19 vs median age, by country

Geographical distribution: The following map shows the distribution of deaths per million by national averages, with higher rates in the Americas, Europe, Russia and Southern Africa Cumulative mortality rate per Covid per national average [5].

As shown in the graph below, the cumulative mortality rate for COVID-19 is unrelated to the GDP per capita (r2 = 0.023).

Figure 2: Cumulative mortality 2020-2021 per million per COVID-19 vs GDP pc, by country

Reported vs estimated public health COVID 19 indicators

Analysis of the magnitude (and distribution) of the pandemic

Any cause of loss of health (risk factor or disease) is measured in relation to others by incidence (cases/population), fatality (deaths/cases) and the “burden of disease” (healthy life years lost by that cause, in the population).

  1. Incidence: Diseases causing acute infections such as COVID-19 are better measured by regular sero-prevalence studies which allow the estimate of the cumulative proportion of people which have been already infected (with presence of IgG antibodies). During 2020, the pandemic year prior to COVID 19 vaccination, sero-prevalence studies could have estimated the real incidence of the disease. In contrast, the reporting systems varied between countries as they screened either symptomatic cases, serious cases or primary or secondary contacts. Those daily reports of “new infections”, largely biased and non-comparable between countries have received the focus of the media and the attention of societies around the world. Even in the same country, the case detection system varied, so the comparison between pandemic waves is also biased. In the few[6] (and hardly disseminated and discussed) sero-prevalence studies conducted, the real cumulative incidence of the pandemic was between 2 and up to 10 times higher[7] than the officially reported one. Although the official WHO consolidated data show a cumulative incidence of 323 million cases, applying the ratio of sero-prevalence studies/reported cases in the populations thus studied and on a weighted basis (according to population sizes), the real cumulative incidence may be of more than 1,600 million, as shown in Table 1. The distribution of the incidence rate in the population is uncertain due to the lack of population studies, but it seems to have been affecting more young people as the pandemic evolved.

Figure 3: Incidence of COVID-19 data and estimation by sero-prevalence studies

  1. Case-Fatality: In addition to the underestimation of the cases described above (denominator of case fatality), the number of deaths by COVID-19 was most likely so biased. After two years of pandemic, the question of either death with COVID-19 or death by COVID-19 arises[8]. Following infection or vaccination it seems the virus genome can, by reverse transcriptases, integrate into the human genome and express mRNA (PCR positive) and Receptor Binding Protein (positive antigen test) without the presence of active viruses in the body[9]. On the other hand, even in the presence of active infection (if demonstrated by viral culture), the virus may be asymptomatic or only cause mild (as shown in the sero-prevalence studies described above) symptoms and not be the main or direct cause of severity or death. Most of the deaths attributed to COVID-19 have been in the elderly and with underlying pathologies, any of them potentially also lethal. As the pandemic evolved and affected a larger cumulative proportion of the population, and as other clinical symptoms and signs were attributed to the virus, the proportion of those deaths where the presence of COVID 19 antigen or PCR was either not related to active infection or not the primary or final cause of death may have increased. Therefore, the reported mortality attributed to COVID 19 may have been overestimated. The real mortality rate could only be known by autopsy series, which were rarely performed or published during the pandemic, due to the collapse of the health system itself. In the few unpublished autopsy series, around 40 %[10] of the deaths attributed by COVID-19 were actually due to other causes, in particular the complications of hypertension, obesity and diabetes and undiagnosed cancers. Inversely, there may be countries where there is an under-reporting of mortality in general and of mortality certificates with accurate diagnosis of cause of deaths and the reported COVID 19 mortality rates may be a gross underestimate and explain, partly, the much lower rates in sub-Saharan Africa. As regards the assumptions that there is an underestimation of COVID-19 deaths in relation to the levels of excess mortality above the baseline levels, it is unclear whether it is due to the pandemic effect or the lockdown measures and their multiple health effects, as described below. Taking into account the previously estimated incidence according to population sero-prevalence studies and the mortality adjusted to the proportion of deaths directly caused by COVID-19 among those attributed to it, the case fatality could be as low as 0.33 %, very similar to seasonal flu. The distribution of the case fatality rate in the population is, in any case, very uneven, showing variations from less than 1 per 1,000 cases in under 30 years of age to more than 20 % for patients over 80 years of age. It seems that case fatality of the disease has been decreasing, due to a growing share of infections in the youth, the effects of the pathogenicity of evolving variants (as recently observed in Omicron), the effects of natural and induced immunity and the effectiveness of treatments.

Figure 4: Fatality calculated by official data and estimated by the adjustment of COVID-19 mortality and the highest estimated incidence level

  1. Burden of disease: The loss of life years is measured in each disease by the difference between the age of death for the cause studied, in this case the COVID-19 infection, and the average life expectancy in a given population[11]. Global comparative studies use as a reference the highest national average life expectancy. As the average age of death has been (according to studies in the United States) 71.63 years, the average each death by COVID-19 has caused the loss of 12.73 life years in relation to the mentioned reference. As the cumulative number of deaths has been around 5.12 million in 2020-2021, the pandemic has caused the loss of around 65.16 million life years due to premature death in the last two years, i.e. 0.0041 life years per person and year (day and a half per person and year). Such number would be lower if the reference was the world’s average life expectancy (72 years), the weighted average of life expectancy according to the number of deaths per country (some 76 years) or the life expectancy of the infected patients, whose frequent underlying pathologies may influence much lower life expectancy without COVID 19 infection. This burden of disease is higher in the countries with the highest reported death rate per COVID-19. Peru, with the highest rate – 6,200 deaths per million inhabitants- would have a burden of disease of around annual 0.0124 life years per person (about 4.5 days per person per year). The burden of disease also varies according to age, with some100 times less in those under 60 (90 % of the world’s population and less than 10 % of COVID-19 deaths). While the long-term impact on disability is still poorly known, its impact on the burden of disease may be counterbalanced by the very controversial lower weight of life years in older age and, in any case, the disability of a high proportion of COVID-19 deaths in patients with co-morbidity due to other causes and thus already a baseline degree of disability. Compared to the overall burden of disease (some 1,706 million-life years due to premature death)[12] COVID-19 caused on average 1.9 % of the overall burden of disease in the last two years. In relation to the most important causes of loss of life years due to premature death, the following list shows the proportion that COVID-19 accounts for each of the causes, according to the diagnostics with COVID-19 and the estimated direct deaths by COVID-19 (60 % of the latter)[13].

Table 1: Overall loss of life years due to pandemic related to other diseases

Cause YLLs (000s) COVID-19 as% of top channels Estimated 60 % due to COVID-19
All Causes 1706631 1.91 % 1.14 %
Neonatal conditions 183207 17.79 % 10.68 %
Ischaemic heart disease 175605 18.56 % 11.13 %
Stroke 122115 26.69 % 16.01 %
Lower respiratory infections 105006 31.03 % 18.62 %
Diarrhoeal diseases 68394 47.65 % 28.59 %
Road injury 62279 52.33 % 31.40 %
Tuberculosis 61751 52.77 % 31.67 %
Chronic obstructive Pulmonary dis. 54573 59.71 % 35.84 %
Congenital anomalies 45199 72.10 % 43.26 %
Cirrhosis of the liver 42111 77.39 % 46.43 %
Trachea, bronchus, lung cancers 40849 79.78 % 47.87 %
HIV/AIDS 36131 90.19 % 54.12 %
Diabetes mellitus: 34171 95.37 % 57.23 %
COVID-19 32588 100.00 % 60.00 %
Kidney diseases 32023 101.76 % 61.07 %
Self-harm 30937 105.34 % 63.20 %
Malaria 30855 105.62 % 63.38 %
Interpersonal violence 25699 126.80 % 76.08 %
Colon and rectum cancers 20570 158.42 % 95.06 %
Hypertensive heart disease 20482 159.10 % 95.46 %
Stomach cancer 19893 163.81 % 98.30 %

Compared to the loss of life years due to risk factors, the table below shows that the burden of COVID-19 disease is lower than that of the top 7 risk factors. It is striking and worrying to see that the risk factors that lead to much higher loss of human life than COVID 19 trigger far lower investments in research and public health interventions.  On the contrary, for many of those risk factors, the private sector invests in marketing much higher than the public health authorities does in prevention of unhealthy life styles based on processed foods high in sugar and salt, tobacco – including second-hand tobacco -, air pollution, interruption of breastfeeding and hyper-medication. Those risk factors lead to obesity, glucose intolerance and hypertension, the main risk factors associated with COVID 19 mortality. Among the causes of highest loss of human life are also those related to global inequities such as malnutrition, lack of access to safe water and sanitation or the shortage of iron and vitamin A. The lockdown measures imposed to control the pandemic by COVID-19 may have significantly increased the loss of life years due to sedentary lifestyles and increased international and subnational inequity. It is unclear whether the control measures have been responsible for less or more life years lost than the virus would have caused itself. Interestingly, as the main mechanism of severe disease and death in COVID-19 infections is the severe inflammatory response (“cytokines’ storm”) it remains to be seen whether the social response causing greater damage than the pandemic itself.

There is a link between the burden of disease in life years operated by COVID-19’s premature death and the other causes globally

Table 2: Overall loss of life years due to pandemic for the main risk factors

Cause YLLs (000s) COVID-19 as% of top channels Estimated 60 % due to COVID-19
 High -lic blood pressure — 217963088 14.95 % 8.97 %
 Smoking — 182478302 17.86 % 10.71 %
 High fasting plasma glucose — 170573442 19.10 % 11.46 %
 High body-mass index — 147694484 22.06 % 13.25 %
 Air pollution — 147418240 22.11 % 13.26 %
 Child wasting — 90994816 35.81 % 21.50 %
 Environment particulate matter pollution — 83047567 39.24 % 23.55 %
 Diet high in sodium — 70398895 46.29 % 27.78 %
 Diet low in fruits — 64806281 50.29 % 30.17 %
 Unsafe water source — 63892348 51.00 % 30.60 %
 Household air pollution from solid fuels — 59472096 54.80 % 32.88 %
 Drug use — 41658227 78.23 % 46.94 %
 Unsafe health — 41474867 78.57 % 47.15 %
 Secondhand smoke — 36316502 89.73 % 53.84 %
 Diet low in vegetable— 34210780 95.26 % 57.15 %
 Iron deficiency — 33661690 96.81 % 58.08 %
 Vitamin A deficit — 28992388 112.40 % 67.44 %
 LOW physical activity — 23655862 137.76 % 82.65 %
 Child stunting — 19406872 167.92 % 100.76 %
 Non-exclusive breastfeeding — 14248898 228.71 % 137.22 %

The following table summarises the above indicators of magnitude of the pandemic by official data (reported by countries and WHO) and the estimates by population studies and in-depth analysis of cases described above:

Table 3: Measures of the magnitude of the COVID19 pandemic: Official vs estimate data

cumulative impact annual mortality Fatality3 Annual Sickness Load (FMC)4
official data 323000000 2770000 1.72 %
estimates 16150000001 16620002 0.33 % 33240000

(1.1-1.9 % of the total)

1: Estimates by multiplying the reported incidence rate by the weighted average incidence ratio of population sero-prevalence studies/official case reports.

2: The average annual mortality attributed to COVID-19 is multiplied by the proportion of deaths seen in autopsy series as directly caused by COVID-19 (60 %)

3: This is the ratio between deaths and incidence.

4: Here only estimated for life years lost because of premature death: Number of deaths due to the difference between the maximum life expectancy and the average death age during the pandemic.
Analysis of the anti-pandemic measures

Any public health intervention (prevention, treatment and rehabilitation) is decided in relation to others (given the resources always limited) according to risk/benefit (harm vs. good), cost-utility ( cost of intervention in relation to the prevention or recovery of healthy life years that would be lost without such action) and opportunity-cost ( relation to the impact of other potential interventions with the same level of resources).

The distribution of a health problem, including the effect of the selected interventions, is measured by unfair or preventable inequalities (inequity) through the “burden of health inequity” (excess deaths or loss of healthy life years in relation to feasible and sustainable levels of health for all).

  1. Risk-benefit: Prevention and treatment measures against COVID-19 have mainly been lockdowns on mobility and contact in the population, vaccination and treatment. There are significant uncertainties in the level of positive impact of each of these measures, especially if disaggregated by age and health conditions, and even more in their negative impact. To study the impact of a public health measure, a population group (cohort) is monitored over time or compared between a population in which (case) the measure is applied and a population with similar demographic and epidemiological characteristics without such intervention (control). As regards lockdown measures, in most cases, they were generalise, regardless of the incidence and case fatality in each age, sex and health baseline condition group (not well known or published, as described above). Hence, it is not easy to analyse the disaggregated positive impact by population groups. On the other hand, the evolution of natural or induced immunity (the latter after 2021) and the pathogenicity of evolving variants of the virus makes it difficult to estimate by cohorts the impact of each preventive measure. When comparing two populations, as countries, with different prevention policies we find the bias of different demographic, socio-economic and epidemiological situations, and even the information systems themselves. For example, the evolution of incidence and mortality following the lockdown measures between countries in Europe (with high lockdowns) and Africa (with low lockdowns or means to do so) does not seem to indicate a benefit in lockdown measures. On the contrary, the comparison between China and the United States or Europe indicates the opposite. As regards the comparison of incidence and mortality risks among persons using or not using different types of masks in open air spaces, is no significant relative risk evidence to claim that they protect against infection or reduce mortality[14]. As regards the adverse effects of these measures, it can be estimated that global lockdowns accounted for at least 3.363 % of global economic contraction. Such economic loss has been highly uneven (see the inequity analysis below), increasing (through the increase of people under the above-mentioned dignity threshold) possibly up to 10 % the burden of health inequity, some 1.6 million deaths per year and some 56 million life years lost, higher than the COVID-19 direct burden of disease. Another risk of lockdown measures lacking enough analysis is the impact of sedentary life styles in physical health[15] and social isolation on the state of mental health, especially of older people and youth. There are worrying reports on the increase in chronic disease morbidity in the elder and anxiety, depression and suicide rates, particularly among young people[16]. The risk-benefit of the lockdown measures is, hence, unknown yet, but there are signs it may have caused more harm than good. On top of this concern, there is an unmeasured and possibly unmeasurable burden of suffering caused by the systematic lockdown and social distancing taken to the extreme: the dimension of loneliness and related anxiety of the very high proportion of COVID 19 deaths who passed away far from their loved ones. In terms of vaccination, efficacy studies are carried out in case control surveys (costly phase III clinical trials mainly by pharmaceutical corporations) which rendered national and WHO pre-qualification through the assessment of clinical, laboratory and manufacturing practices. The nine WHO prequalified vaccines demonstrated a reduction in mortality above 90 % in vaccines based on mRNA channelled through nano-particles (Pfizer, Moderna) and 60-90 % in viral vectors (Astra Zeneca and Jansen) and 60-70% in attenuated virus-based vaccines (Sinopharm, Sinovac)[17]. Only one protein-based vaccine, Novavax, has been WHO pre-qualified but its coverage is still minimal. Other 24 vaccines have been approved by national regulatory agencies and are awaiting approval by the WHO such as the Russian Sputnik (very similar to Astra Zeneca), three Cuban COVID vaccines and Corbevax (based on proteins). Over a hundred vaccine candidates are pending completion of phase III trials. While some vaccines had a time-gap of less than 2 months from national regulatory approval for emergency use to WHO prequalification, others are still to be approved by WHO after over one year. The cost of scientific writing for peer reviewed high impact journals, the dossiers to apply for prequalification and the inspection of sites and products prevents or delays the process when vaccines are developed in low-income countries. Vaccine induced immunity decreases over time and requires revaccination[18]. In addition to the individual benefit of vaccination in reducing mortality, there is a potential benefit in transmission to third persons (externality), if it reduces the viral burden on mucous membranes. This benefit is limited in vaccinated people[19], who continue to carry the virus on mucous membranes with viral loads that have not been statistically proven to be lower than in unvaccinated pre-infected (with natural immunity). There is very little published and socialized information on natural immunity but recent results on cohorts of people infected with COVID-19 demonstrate better[20],[21] and longer duration[22] (by memory cells in bone marrow studies) than induced immunity. The status of pre-infection or presence of IgG antibodies against COVID 19 antigens should therefore be granted equal mobility rights as vaccinated persons. At present pre-infected persons have no rights of mobility, need recent compulsory PCR –ve or their mobility is restricted to six months after infection, in contrast with the mobility rights of vaccinated persons. This discrimination is against recent evidence of protection through natural immunity. On the other side, pre-infected persons do not gain any further protection by COVID vaccines17 hence the state of pre-infection could or should exempt from the need of vaccination and even less any legal enforcement of compulsory vaccination[23]. Some predict that by March 2022, 60 % of the world’s population will have been infected with COVID-19 variant Omicron[24]: Their exemption from vaccination would have a very important social, economic and political impact. As regards the risk of vaccines, there is lack of transparency in pharma vaccine clinical trial dossiers[25]. On the other side, the very short duration of their follow-up before approval disables any mid- or long-term safety assurance. There are reports of serious side-effects and deaths directly linked to vaccination[26] and myocarditis in young[27] people, indicating 0.0000462 deaths (46 per million) per vaccine[28]. These data enable estimates of risk-benefit, even with only one year of evolution after vaccination, and by age groups, given their very different fatality rate as above mentioned, and pose the question on their use in young people and even more in children. Given the short monitoring period, the risk of vaccination in the medium to long term is even more uncertain, in particular by the novel mechanism of mRNA or DNA based vaccines and their potential interaction with the human genetic structure[29]. Fragments of viral mRNA are known to find reverse transcriptase enzymes and integrate into the human genome in the natural infection process, so vaccination with mRNA copies at much higher concentration than a natural infection may potentially mean reverse transcription into DNA and integration into the human genome of germ cells and even haploid gametes, with potential long term reproductive effects. Although this risk has been considered minimal given the volatility of mRNA in blood circulation, the risk of genetic alteration and its long-term effects in relation to oncogenesis (e.g. HBV[30], HCV, papilloma[31])[32], autoimmune or degenerative processes (as recently seen between Epstein Bar virus and multiple sclerosis[33]) cannot be fully excluded. In terms of treatments, statistically significant effect on reducing mortality has been proven in intensive care and ventilation (CPAP[34] and assisted) in cases of respiratory failure and in nirmatrelvir-ritonavir[35] treatment in severe cases (every 12 hours for 5 days) at a cost of about USD 500 per patient[36]. The risk benefit is deemed sufficient to justify such therapies in severe cases.
  1. Cost utility: Utility is measured in life years that an intervention protects (prevents loss) or recovers (by treatment). As mentioned above, there is no absolute evidence of the usefulness of the generalised lockdown measures, as there are no case studies on control and validity of cohorts to demonstrate this, even less disaggregated by age and risk factors, and the uncertainty of risk-benefit for groups with lower risk of COVID-19 related mortality, as discussed above. Even assuming that the lockdown measures could have halved the transmission of the virus and its consequent mortality, the burden of the disease prevented would have been around 32.58 million life years. The global lockdown has caused at least 3.363 % on average annual GDSP[37], or about USD 2.85 trillion. Therefore, the cost utility of the overall lockdown may be around $87,210 per life year potentially lost by COVID-19. Compared to other public health measures, the World Bank and WHO consider relevant interventions of less than $150 per life year in low-income countries and below $500 per ADV in middle-income countries[38]. By comparison, the threshold for utility cost of interventions in the UK public system is $27,400[39] and can reach $100,000 in US private insurance[40], governed by studies of intention to pay by life year. It is striking to see what is the value (or the cost worth investing) of one year of life according to the income levels and the strong correlation with GDP per capita. It is even more telling when we estimate that value to a human life taking into account the world average life expectancy: from some $10,500 in a low-income country to some $ 7 million in high income groups in high income countries. The global lockdown has been most expensive public health intervention in history and at a highest cost per life year, over 5,800 times higher than public health interventions advised by WHO and World Bank in low-income countries. In terms of vaccination, the cost of the available vaccines together with that of distribution by the health system is about $50 per dose. At one dose per six months according to current frequency, the annual cost is around $100 per person. Assuming efficacy rates of 90% in preventing mortality, it could prevent some 29.3 million life years meaning that the of the overall cost utility would be around $26,620 per life year, which is less than the lockdown but still far above the recommended cost utility of public health programmes in middle- and low-income countries. Vaccination of the population over 60 years of age or with risk factors would cost ten times less (as it accounts to 10% of the world’s population) and result in an impact of 90 % of the overall vaccination (as 90% of deaths take place in older than 60 years). Such strategy would also ease the concerns of the risk-benefit considerations described above. The cost utility of vaccination of the population over 60 years of age would therefore be $2,957 per life year. Taking into account the reported benefits of vaccine manufacturing corporations (around $30,000 million for the 12,000 million doses sold), the possible production cost of the vaccines would be around $1.3 per vaccine (sold now at $15-25 per dose). Hence, the cost utility of vaccination over the age of 60 in the world with off-patent vaccines would be $147 per life year, in the affordability range of public health interventions regardless the income levels. In terms of treatment, the cost of entering ICUs and applying mechanical ventilation (CPAP and assisted) during the average 6-day duration, is about 7,500 per patient (in high-income countries the average is $30,000 per admission). Pfizer’s nirmatrelvir-ritonavir is sold at about $500 per treatment course in severe cases. Reducing the mortality if severe cases by 80 % would prevent the loss of some 26 million life years at a cost of about 144,000 million, (10 % of the 160 million cases diagnosed per year x 8 days of average stay in ICUs and treatment of nirmatrelvir-ritonavir). The cost utility of the treatment of severe cases is around $5,538 per life year, beyond the economic reach of low-income or middle-income countries.

Figure 5: Estimates of cost utility of the measures taken to fight the COVID-19 pandemic in relation to the utility cost thresholds used in countries according to income per capita

  1. Opportunity Cost: Comparing the cost of COVID-19 control strategies (or loss of economic income) and its impact on the prevention or recovery of healthy life years with those of other public health interventions lacking coverage enables to estimate the cost in life years, and in saved lives, of an excessive cost utility to tackle the COVID-19 pandemic. There are still many prevention and treatment interventions for the main causes of loss of healthy life years (see Table 1: Infectious diseases (diarrhoea, respiratory, malaria, tuberculosis, HIV and HBV) and chronic non-infectious diseases (diabetes, hypertension and its consequences of cardio and cerebrovascular diseases, kidney diseases, lung, colon, prostate and breast cancer),. The average cost utility of those interventions is around $1,000 per life year in low- and middle-income countries. The cost and economic loss of the global lockdown could have, if used in ethical redistribution, reduced almost half of the economic inequity gap above mentioned and prevent around 224 million indirect life years and some 5 million deaths. Regarding vaccination, the full coverage of vaccination would cost some $780,000 million for the protection of some 29.3 million-life years. The selective vaccination coverage of all people over 60 years of age in the world -10 % of the global population –, regardless their nationality and income, would cost some $78,000 million (possibly ten times less deducting the massive profits of corporations) and save some 27.8 million life years. It would also ease the mobility of the youth and, monitored by periodic IgG testing, enable the development of natural immunity and their involvement in social and caring services for the elder, reducing the profound suffering from lonely deaths, as mentioned above. This option is considered highly controversial, but the risk benefit, cost utility opportunity cost and -see below- equity analysis call for age-selective vaccination to be considered. The opportunity cost of vaccinating all under-60 years was above 2.4 million deaths.

Figure 6: Opportunity cost in life years and deaths avoided by decisions of high utility cost vs different COVID 19 measures

The following chart summarises the indicators analysed in relation to the measures taken and currently in force and imposed even through mandatory compliance laws:

1: Estimating that half of the deaths that have occurred may have been prevented by lockdown

2: Estimating 90 % average efficacy of the current available vaccines

3: Taking into account that over 90% of deaths are in people over 60 years old, and that they account for 10 % of the world’s population.

4: Taking into account that < 10 % of deaths are in people under the age of 60, and that they account for 90 % of the world’s population.

5: Taking into account 60 % effectiveness of intensive care treatment in patients with COVID-19 severe disease..

6: Assuming that the lockdown has increased the overall burden of health inequity by 10 %.

7: By attributing the mortality rate observed in the United States attributed to COVID -19 vaccination.

8: The former applied to the proportion of people over 60 years of age..

9: The former applied to the proportion of people below 60 years of age...

10: It results from applying 5 % mortality rate due to side effects of ICU treatments in severe cases.

11: Overall economic loss divided by the potential benefit described above.

12: It results from applying the vaccine and distribution system cost of approximately $50 per dose and two doses per year to the entire world population and divided by the potential benefit described above.

13: Idem at 10 %, over the age of 60.

14: Same as 90 % below the age of 60.

15: Same as for severe cases.

16: It results from applying the economic losses of the overall lockdown to equitable economic redistribution and its potential impact.

17: The cost of each intervention is applied to measures with a weighted average utility cost among high-income countries (10 % of the world’s population), a cost utility of $30,000 per life year, middle-income countries (40 %), of 500 $ and low-income countries (50%) of $150.

18: This is the result of subtracting the potential impact on other interventions from the measure itself for COVID-19.

19: It results from estimating preventative deaths by dividing the opportunity cost in life years by the average age of premature deaths (half of the world average life expectancy: 35 years).
  1. Equity in public health measures: There is a clear correlation between GDP per capita and COVID-19 vaccination coverage (r2 = 0.4769: Almost half of the change can be explained by GDP per capita). Assuming its effectiveness in reducing morality by 90 % for those infected, the vaccination deficit would have resulted in an unjust and preventable excess of 2,056,462 deaths to date.

Figure 7: Number of COVID 19 vaccines administered per 100 inhabitants vs national average GDP pc


While we cannot be sure (partly due to the absence of population seroprevalence studies) of the real COVID-19 incidence (most probably underestimated by official data) or its case fatality (most probably overestimated), available data during 2020 (without vaccination) and 2021 (with availability of vaccines even with high unjust access) point at a loss of around 32,580,000 life years in the world population. This burden is 1.96 % of the loss of life years for all diseases. Moreover, recent studies suggest that direct virus mortality may really be some 60 % of the reported (co-morbidity with positive PCR), so the proportion of the loss of life years due to the pandemic would be lower, some 0.76 % of the total. In relation to the risks that cause the greatest loss of life years, the pandemic has resulted in less than 10 % of the loss of life years due to the effect of either tobacco, agro-industry diets (in both cases with massive marketing funding) or sedentarism, exacerbated by the widespread lockdown measures.

As regards the measures taken against the pandemic at global level and at national and sub-national levels, these have led to an unprecedented cost or economic loss in the history of public health, which deserves consideration without prejudice or ideological, economic or political bias. The studies of efficacy and effectiveness of lockdown and vaccination have not reported results disaggregated by age groups, and by general and COVID-19-specific immunity status and risk factors. On the other side, the short, medium and long-term side-effects of lockdown on physical, mental and social health and indirect health due to economic contraction, as well as those through vaccination, are not entirely known, less so in the medium and long term. The cost utility of the measures taken is of $87,210 per year of life protected by the lockdown, $23,620 for global vaccination and $5,538 for treatment of severe cases. These levels are far above the thresholds of cost utility recommended by the WHO and the World Bank (and the influence of the latter by conditional credits) for low-income ($150 per life year) and middle-income countries ($500 per life year) and even for high income countries regarding vaccination in all age groups. The opportunity cost of lockdown measures in relation to the lack of economic fair redistribution may have resulted in 5.2 million deaths. The opportunity cost of COVID 19 vaccination in all age groups in relation to the lack of coverage of other much more efficient (cost-effective) public health interventions -in particular in low-income countries-, is of over 2 million deaths. The only public health intervention that has no opportunity cost in relation to other global health challenges is the selective vaccination for older than 60 years regardless country or income group.

The impact of the pandemic on global equity suggests that, while there is no higher burden in low-income countries (discriminated against in the right to health as described above), the effects of the economic contraction will most likely increase overall economic inequity and hence inequity in health by some 10%. Besides, inequitable vaccination coverage, biased towards middle-income and high-income countries, has led to an unfair and preventable excess of 2,056,462 deaths in lower-middle-income countries and low-income countries during 2021-2022.

  1. Global redistribution of economic resources towards global economic equity that can prevent more than 10 million unfair deaths per year.
  2. Promote healthy lifestyles correlated with sustainable ecological and carbon footprint for new generations and prevent more than 2 million deaths per year due to the effects of climate change in the rest of the century, progressively higher and hitting the least polluting countries harder[41].
  3. Global equitable financing of a Global Research and Public Goods Fund, outlawing knowledge patents for vital and life-saving knowledge and goods (oxygen, water, food, essential medicines).
  4. Access to serological tests on a regular basis to identify persons and groups protected by natural immunity, by vaccine-induced protection or non-immune and their risk and responsibility to avoid infecting other persons or loving care for severe patients.
  5. Comprehensive access to effective and safe vaccines (including the support to the pre-qualification processes for vaccines from low-income countries, as the Cuban protein-based COVID 19 vaccines).
  6. Global sequential coverage prioritizing non-immune persons over 60 years old and/or with risk factors, rather than the present inequity pattern of income and nationality.
  7. Assess the pertinence of vaccination in younger age groups in terms of risk/benefit, cost-effectiveness and opportunity in relation to other global health challenges. 

This must be based on an open and uncensored, evidence-based debate based on the universal right to health and the ethical principle of equity.



[1] For the period 1960-2010 there were 14 countries with constant HRS criteria, for 1960-2015, 7 countries and for the 1960-2020 period only one country.


[3] The region of Ipeiros in Greece has an annual GDP pc below the excess threshold and life expectancy above the best national average, Japan.

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[22] Turner, J.S., Kim, W., Kalaidina, E. et al. SARS-CoV-2 infection induces long-lived bone marrow plasma cells in humans. Nature 2021

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Initiatives for Catalytic Investment for Rural Africa

To address under-five mortality in sub-Saharan Africa, there is need to improve the quality of postnatal care (PNC) services by adapting an integrated service delivery model, which will include improving access to lifesaving vaccines including their timely delivery; access to nutrition services including infant young child feeding and growth monitoring; increased uptake and use of early infant diagnosis of HIV; community education; and post-natal checks for mothers. 

Because resources are finite, this initiative should integrate services and prioritize vulnerable communities

By Florence Gune

Human Resources Intern

United Nations Population Fund – UNFPA

New York, USA

Initiatives for Catalytic Investment for Rural Africa


Sub-saharan Africa, including countries in southern Africa, continues to be the region with highest under-five child mortality rate in the world.  In 2018, 1 in 13 children in sub-Saharan Africa died before their 5th birthday. For example, the under-five (U5) mortality rates for Malawi, South Africa, Tanzania, and Zambia were 49.7, 33.8, 53 and 57.8 deaths per 1,000 live births respectively in 2018. These U5 mortality rates were in part due to high prevalence of infectious but preventable diseases, HIV, poor quality of care with an underlying low socioeconomic status. To address these challenges, there is need to improve the quality of postnatal care (PNC) services by adapting an integrated service delivery model, which will include improving access to lifesaving vaccines including their timely delivery; access to nutrition services including infant young child feeding and growth monitoring; increased uptake and use of early infant diagnosis of HIV; community education; and post-natal checks for mothers.

Because resources are finite, this initiative should prioritize vulnerable communities. Immunization is among the most accessed public health interventions in southern Africa; therefore, ensuring that access to lifesaving vaccines is integrated within PNC services provides a platform for delivery of other essential health services such as nutrition screening, prevention and care services; diagnosis and care for HIV infected children; birth registration. These interventions are low cost but have high returns on investment.

Investing in improving quality of PNC services especially by integrating services will reduce morbidity and prevent unnecessary deaths. In addition, improving PNC services helps improve quality of care and is a critical step in building resilient health systems because of addressing human resources constraints; information systems for planning and monitoring; supply systems including access to basic health commodities; community engagement; and highlighting issues of program governance.

While addressing PNC service would be an important pillar in reducing U5 mortality, there is need to identify and leverage strategic entry points, which include piggybacking already high uptake of vaccination at the facility and community level and use of existing HIV awareness, prevention and care structures. The strategy here is to use supports as a catalytic investment to trigger domestic investment from country governments or potential private sector entities to incrementally support and eventually champion this initiative.

The implementation of this initiative will require identifying relevant partners, which should be contingent on defining the program context. Aware that over half of the global population live in urban areas with increasing numbers in slum environments (hard-to-reach populations affected by multiple deprivations) and in hard-to-reach rural remote areas, the partners to help facilitate this approach of integrated PNC services would need to be those who have expertise in these settings. In addition to working with governments, the partners should be resourceful in implementing this initiative and targeting the most vulnerable in urban and rural poor communities.

It is important that best practices and challenges from this initiative are documented and disseminated in the region, therefore academia will need to be engaged to shepherd the evidence and knowledge generation.





News Flash 466: Weekly Snapshot of Public Health Challenges

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

News Flash 466

Weekly Snapshot of Public Health Challenges


Meeting registration: HUMAN RIGHTS AND HIV IN THE DIGITAL AGE: WHAT ROLE FOR THE UN AND GOVERNMENTS? 22 February 2022, 14:00 – 15:30. This event is co-organised by the Global Health Centre, the Digital Health and Rights Advisory Group, UNDP, and STOPAIDS. Online event, 2pm CET

African Union calls for bolstered health emergency infrastructure

Africa CDC is Elevated to Status of Continental Public Health Agency

Why International Geneva’s ‘human dimension’ bodes well for environmental peacebuilding

Inadequate State Response to Protect Life and Health in Times of COVID-19 as a Violation of Human Rights Obligations – the Example of Poland

People’s Health Dispatch Bulletin #18: New waves of resistance

The inequality crisis in East Africa. Fighting austerity and the pandemic

EU wants pandemic treaty to ban ‘wet markets’, reward virus detection

An International Treaty on Pandemic Prevention?

COVID vaccine tracker should be applied to 40 other vaccines, says ECDC

EMA evaluating data on booster dose of COVID-19 vaccine Comirnaty in adolescents

M. le Président, Covax et le système des brevets sont en échec face à la pandémie, il faut lever les brevets !

Wemos: Review of initiatives for access to Covid-19 innovations

Without shared tech, South Africa’s mRNA COVID-19 jab faces 2-year lag

Even if Moderna Declines – Other Pharma Partners Now Poised to Join South African mRNA Vaccine Hub Initiative

South Africa must urgently revoke patents on key COVID-19 treatments and vaccines

Ending the pandemic is not a matter of chance; it’s a matter of choice

Health Brief: Unequal access to vaccines takes root in EU-AU summit

Health inequity focus in pandemic preparedness and response plans

The COVID-19 Vaccine Rollout Was the Fastest in Global History, but Low-Income Countries Were Left Behind

Two Years into COVID Pandemic, 92 % of Countries Still Face Significant Health Service Disruptions

COVID-19 response: effectiveness of weekly rapid risk assessments, Italy

Uche Amazigo: neglected tropical diseases in the pandemic

Maintaining essential tuberculosis services during the COVID-19 pandemic, Philippines

Access to eye care during the COVID-19 pandemic, India

Childhood immunization during the COVID-19 pandemic: experiences in Haiti, Lesotho, Liberia and Malawi

National policy responses to maintain essential health services during the COVID-19 pandemic

EMA: Public consultation on reflection paper on prophylactic use of antimicrobials in animals

Initiation of DARWIN EU® Coordination Centre advances integration of real-world evidence into assessment of medicines in the EU

Actions for decolonizing global health

Improving Communities’ Livelihood, Healing and Reconciliation in Rwanda by Innocent Musore 

Global Integrity Day–9 June 2022

Air Pollution Costs Wider Mideast $141 Billion, World Bank Says

‘Whole Life Cycle of Plastics’ Approach Could Reduce Pollution – WWF expert

One Health: Placing Human, Animal, and Environmental Issues at the Heart of COVID-19 Recovery in the Asia-Pacific Region












Improving Communities’ Livelihood, Healing and Reconciliation in Rwanda

As a peacebuilding and development organization operating in Rwanda and DRC in Eastern Kivu, GER-Global Initiative for Environment and Reconciliation supports post-conflict communities toward reconciliation and environmental protection. Its programs facilitate community knowledge exchange and intergenerational learning dialogues, with a focus on the next generation as an agent of change. As part of this, GER raises awareness in the promotion of agro-ecology and climate change adaptation, zero waste and pollution, by empowering communities on environmental issues and the use of local knowledge in environmental conservation, the proper use of natural resources and respect to the biodiversity with gender consideration.

Find the story here as a first-hand snapshot on GER-Rwanda 2021 field engagement and practices

By Innocent Musore

Executive Director
Global Initiative for Environment and Reconciliation-GER
Kigali City, Rwanda

Improving Communities’ Livelihood, Healing and Reconciliation Rwanda


  1. GER-Rwanda background 

Since 2016, GER-Rwanda has been in collaboration with the African Biodiversity Network (ABN). Our work together and collaboration is contributing to promote agroecology in Rwanda and connecting people with nature. Our work focuses include; sustaining community-seed systems, reviving indigenous-seeds, community knowledge-exchange, bridging the knowledge-gap between young people and elders through facilitated community-dialogues. Our mandate is to improve people’s relations and lives. In 2021 we worked with communities from three districts namely Bugesera (Eastern Province), Gasabo (City of Kigali) and Ruhango District (Southern Province), where we reached 167 beneficiaries (103F, 64 M). Three (3) Community learning centers were established and continue to  help the communities by providing them with fruit-trees and even other trees, making organic fertilizer to increase production and sharing knowledge and experience.

2. Testimonies

 Reviving indigenous seeds story! 

“My name is Mpamyabigwi Aphrodice, I am a farmer by profession that deals in both crop and livestock farming. I am 75 years old. I have always loved this occupation since I was young. I have also done other occupations, that is to say I was once a pastor but this did not stop me from doing crop-farming nevertheless because of the passion I have towards this occupation. I have experienced seasons of drought, deadly pests throughout the years in this occupation and the various ways of dealing with all these because of the longtime of expertise. In collaboration with other farmers, we could always look out and source for expertise in the agricultural sector so that they would guide us on the modern ways of farming but keeping in mind biodiversity and indigenous-seeds conservation”.

His view on artificial (inorganic) fertilisers and pesticides 

Insights on the spraying of artificial crop pesticides and vigorous application of inorganic fertilizers that he says that not only results into toxicity of the soil for plant growth but also lead to extinction of nutrients responsible for crop growth.

He further points out that, most farmers are using these pesticides because they lack access to organic fertilisers (manure), “…from my experience and research conducted, the reason as to why most of the farmers use these artificial fertilisers and pesticides is all due because of lack of access to supply of natural fertilisers (manure).” “I only use organic manure to enhance soil-fertility and add nutrients in  the soil to boost crop-growth, organic materials and fertilisers improve the soil-texture, allowing it to hold water longer, and increase the bacterial and fungal activity in the soil which is not the case with artificial fertilisers,” he concludes.

We visited his banana plantation farmland where we witnessed large bunches of bananas per tree. He attributes this to the application of organic fertilisers (manure) rather than inorganic fertilisers and pesticides.


 He says,” this should not just be all about words, but first do it and impact them with your actions. The youth passing by my farms and asking me curiously how I did all this and I redirect them melts my heart every day”. “Farming offers the young     generation a chance to make a difference by growing enough food to feed the world. Those who become farmers now have the opportunity to be the generation to end world hunger and alleviate malnutrition, as well as helping the country adapt to climate change.” he adds.

“During our last training sessions provided by GER-Rwanda in Bugesera we were advised to enhance growing back of the indigenous crop species. The crop that I selected was sorghum which has had periods of extinction over time because, truth to be told, the young ones know nothing about sorghum, this was proved by the youth grazing the sorghum grass that I had planted, am trying as much as I can to sensitise people in my community about how sorghum is grown and am so very sure as time goes by, am looking forward to promote sorghum growing in my growth in my plantations.” He concludes.

Agroecology farmers awarded as champions in their communities

GER-Rwanda produced a video documentary for the five champion farmers of Agroecology in Rwanda who are improving the food system and building community resilience to the effects of climate change with Agroecology practices. Champion farmers are among the beneficiaries of GER-Rwanda’s Agroecology Projects which are based in Ruhango District, Bugesera District, Gasabo District and Musanze District. These farmers were awarded to help them keep promoting agroecology practices and making their work places as community learning centres. They are helping communities to acquire knowledge through practices and communities gain some indigenous seeds from these champions.

The output is a mini documentary (55 minutes) that clearly presents farmers’ efforts in adapting and mitigating effects of climate change, improving food-security and trying to alleviate poverty among small-scale farmers. The documentary is available on the YouTube channel of GER-Rwanda.

3. Agroecology to support social cohesion

Six interactions were facilitated at community level. These interactions have yielded fruitful impacts so far i.e.

  1. Communities are playing a role to restore their relationship,
  2. Activities are bringing them together and improving their relations broken by the 1994 genocide against the Tutsi,
  3. People open up and shared painful experience to heal and
  4. It is helping to restore trust and working together to overcome its long-lasting
  5. Communities are also working to revive indigenous seeds, and they advance their knowledge on agroecology as they are also teaching others in their respective settings through their community.

In addition to the above, they further highlighted that activities bringing them together  thus fostering improved relations at household and societal level. Since the Rwandan society is facing with gender- based violence (GBV) and family conflicts, the project improved the collaboration of men and women for their family development. The project also improved community relations through sharing the production of their vegetables with those who were not reached by the project.

GER-Rwanda started initiatives of improving nutrition within schools using agroecology practices; where we seek to instill this knowledge among young generations and ensure that children will scale these practices in their respective families.

More still GER-Rwanda initiatives are geared to sustaining cultural-biodiversity whereby linkage of activities to key national events such as “Umuganura” Day a public holiday in Rwanda, observed on the first Friday in August. Also known also as Thanksgiving Day or National harvest day, it is a celebration of the beginning of the harvest. These initiatives also convene the youth to engage and contribute to social- cohesion and biodiversity so as to ensure a sustainable future led by the youth.

4.  Way Forward

Innocent Musore, the Executive Director of GER-Rwanda, highlighted that it is needed  to keep supporting the promotion of agroecology practices in grassroots communities, evaluating their impacts in improving the food-system and livelihoods, climate-change resilience and supporting knowledge transfer between young people and elders.

We have also to assess how these agroecology practices enhance social-cohesion, gender-equality, and resolve conflicts between people and nature. We need to engage men and women for a dialogue on post-harvest conflicts and pay attention to gender-issues in conservation activities. We need to raise advocacy to mainstream agroecology in the existing policy and District Development Plans (DDPs).

In order to further foster ownership and sustainability of the project activities and initiatives, GER-Rwanda will use practical knowledge and skills from beneficiaries’ i.e Small-scale services and synergize them with skills and knowledge of youth in agricultural higher institutions of learning to share knowledge from grassroots levels and use it in boosting cultural bio-diversity engagements from grassroots to national levels. This will further documentation of evidence-based results to be used for research on community research-centers and stakeholder engagements. More still there should be strengthened mechanisms to use community-based centers, success stories and testimonies as benchmarks for members of the academia and researchers to scale-up advocacy for bio-diversity.




News Flash 465: Weekly Snapshot of Public Health Challenges

News Flash Links, as part of the research project PEAH (Policies for Equitable Access to Health), aim to focus on the latest challenges by trade and governments rules to equitable access to health in resource-limited settings

News Flash 465

Weekly Snapshot of Public Health Challenges


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Public Health, Climate Change and Strategic Litigation

We are all aware of the health impacts of climate change. But how do we get governments to act? This blog post aims to alert public health academics and practitioners to the opportunities for ‘strategic litigation’, which uses individual cases to bring about broader social change, to hold governments and private sector polluters to account for health-harming pollution and climate change

By David Patterson LLM. MSc.

Global Health Law Groningen Research Centre


Public Health, Climate Change and Strategic Litigation 

Building a Powerful Alliance between Public Health Practitioners, Communities, and Legal Advocates


Mosquitoes winging their way north across Europe bringing dengue. Floods and drownings. Heat stress. Mental anguish and despair. We are all aware of the health impacts of climate change. But how do we get governments to act? Ballot box pressure (in democracies) does not guarantee results as shorter-term concerns distract from our overheating planet. No easy answers, but experience from other public health challenges and the environmental movement provides clues and inspiration.

In 2021 the Faculty of Public Health (UK) hosted a webinar on Public Health, Climate Change and Strategic Litigation The edited recording is now available online. The webinar aimed to alert public health academics and practitioners to the opportunities for ‘strategic litigation’, which uses individual cases to bring about broader social change, to hold governments and private sector polluters to account for health-harming pollution and climate change. The webinar was co-hosted by the Global Health Law Groningen Research Centre and the ‘law and public health’, ‘environment and health’ and ‘ethics and public health’ sections of the European Public Health Association.[i]

Rosamund Adoo-Kissi-Debrah recounted how air pollution in London led to the death of her daughter, Ella. Crucially, the coroner agreed: Ella’s death certificate now records air pollution as a contributing factor. The expert testimony of leading immunopharmacologist and asthma expert Sir Stephen Holgate was essential to this legal precedent. In the webinar, Sir Stephen noted how today much air pollution is largely invisible and hence neglected – yet ‘breathing clean air is a right, just as we have the right to clean water.’ Making the link with climate change, Dr Maria Neira, WHO’s climate change and health champion, presented the ‘health argument for climate action’, which WHO took to CoP26.

But governments have long been aware of the short- and long-term health impacts of air and other environmental pollution. What else can be done? Strategic alliances between public health actors, civil society organizations, environmental activists, and legal academics and practitioners are using court action to highlight government inaction and industry abuses. Marlies Hesselman, lecturer at the University of Groningen, Netherlands, reviewed four recent and current cases where governments have been called to answer before international courts and tribunals for health harms related to climate change.

Scientific evidence of the health impacts is a crucial component. Irmina Kotiuk, senior lawyer with ClientEarth’s Clean Air Program, noted the crucial role for public health specialists as experts in strategic litigation to address environmental pollution – building on the experience of tobacco and asbestos. She urged nurses and doctors to record evidence in medical files which can later be used in expert testimony. Richard Harvey, barrister and legal counsel for Greenpeace, drew parallels between tobacco companies’ infamous denials of the link between smoking and ill-health, and today’s spin from fossil fuel companies.

Restating the problem in ever greater detail is not a strategy for change

Dr Marina Romanello, Research Director for Lancet Countdown, reiterated the health impacts of climate change and the destruction of our health through fossil fuel industry subsidies. Yet the Lancet Countdown 2021 report on health and climate change makes no reference to the role of the law (other than to the International Health Regulations), let alone to the hundreds of current and recent legal cases on climate change, easily searchable through online databases.

Restating the problem in ever greater detail is not a strategy for change. We need to combine the credibility and authority of hard science with the legal skills of seasoned national and international litigators and the experience in social mobilization tested and proven by other social movements – all adapted to today’s online, COVID-19 constrained world. Dr Neira remarked that ‘People working in the environment say we need to hear more from the public health community – because you are still trusted – politicians will listen to you.’

Public health researchers and practitioners, working alongside affected communities, can provide vital evidence in legal action to force government action on climate change and pollution. But to get there, we need stronger bridges between public health, environmental, and legal communities.


[An earlier version of this comment appeared in Better Health for All in November 2021]

[i] EUPHA section membership is free and not limited to public health practitioners or people resident in Europe.