Turbulences in Uganda’s Global Aid Construct

At a time when to care about Uganda’s health system a model shift is required to be drawn for the coverage and effectiveness of aid to yield more productive results, this paper scrutinizes the changes, the form, and the applicability of external financing for health to Uganda and evaluates the level of influence of new alternatives available for health sector development

By Michael Ssemakula

Health Rights Advocate

Human Rights Research Documentation Center (HURIC), and PHM-Network, Uganda

Turbulences in Uganda’s Global Aid Construct

Is the Contemporary Aid Effective Enough to Transform Uganda’s Health System to Achieve UHC?


Over the last sixty-two years, Africa land mass has received an enormous share of foreign aid of over one-trillion US-Dollars (USD). This has intently been given to fight absolute poverty, hunger, and disease, humanitarian causes such as addressing internal conflicts, child labor and human trafficking to lessen the contemporary cross-Atlantic slave trade, and debt reliefs through the multi-lateral debt relief initiatives to expand the fiscal spaces of the resource poor countries especially in the sub-Saharan Africa, the world’s poorest region. Uganda in a particular has been in position to improve its health through Development Assistance for Health (DAH) for activities within health sector such as population programmes and Health Development Aid (HDA) from external resources in form of financial or in-kind aid that is directed to fund health-allied activities such as water and sanitation programmes (F, 2016). But, the disease burden continues to thrive in Uganda despite of all the multi-million dollar donations from external assistance for health.

The paper scrutinizes the changes, the form, and the applicability of external financing for health to Uganda and evaluates the level of influence of new alternatives available for health sector development. Aid has been contracted significantly for health sector projects’ support and enhancing national budget expenditures towards health to expand our fiscal space and attain the Sustainable Development Goals’ agenda…. which are supposed to guide countries to improve their health and development at large, to leave no one behind. But grants and loans given to accelerate health accessibility and poverty reduction programs have shown low propensity in health sector improvement. Case in line, Mulago Specialized Women and Neonatal Health Hospital in Uganda was renovated partly through the support of the donor’s aid to improve reproductive and maternal health services, but it has continued to set exorbitant fees for patients to access health thus expanding the inequality gap in accessing health in impoverished communities, and worsening the public decry, according to a report by (Atwine, 2018).  Over eras-of-time, health has been renowned to be a significant component for Gross Domestic Product (GDP) growth and economic development as a populace in good health can raise the productivity and efficiency of the State’s labor force while plummeting poverty. Therefore it is imperative to view access to good adequate health as a fundamental basic human right enshrined in the international covenant on social economic and cultural rights, a fulfillment and global commitment for both developed and countries in low-levels of economic transition.

Uganda needs approximately USD 15 billion to achieve affordable, acceptable and accessible health for all Ugandans through well planned holistic pre-payment mechanisms such as the National Health Insurance Scheme and Uganda National Minimum Health Care Package in our health system that can cover all citizens in their diverse income stratas. This comes at the time when donor environment over time has reformed the mechanisms through which they fund programmes. In Uganda, Structural Adjustment Programmes and State Wide Approaches were widely applied in many sectors like health and education (which were centralized systems of funding that circled macroeconomic policies in their operations such as retrenchment policies, liberalization and privatization drives to make state governments more efficient), to now project based form of funding which has been incorporated in projects like Global Financing Facility of the World Bank group and European Union Emergency Trust Fund for Africa (EUTF). All these models have been designed by the donor communities and the recipient state governments to improve health systems and infrastructure developments in the resource limited settings like Uganda, but the inequality gap in health accessibility does not correlate with the amount of aid pumped into the countries’ health sectors and other health-related activities to achieve Universal Health Coverage (UHC). The state is nevertheless the chief actor in the strengthening of the development assistance for health processes to maximize the health outcomes. Therefore the link between donors and state’s health sector should be purely interpreted as a cordial relationship formed to increase free-of-cost health service provision, through establishment of a strong health infrastructural system and well streamlined strategy for the proper utilization of development aid assistance.

Uganda has applied a queue of health development strategies and policies such as the Health Sector Development Plans and so many others to improve health with more than 45% dependence on aid from donors, foundations, philanthropists, and non-government organizations (Health, 2014/15 & 2015/16). The state of poor health system in Uganda and other countries in the East African bloc amidst the increasing donor funding is attributed to a multiplicity of factors. Research shows the contemporary aid given in most of times is largely shrouded with donor interests. Further, it is being taken as a conduit for expansion of influence and conglomerates of the multinational private companies especially the pharmaceutical corporations; this is because many of these leverage on the partnerships they have with the global financing trust funds through contract provision of certain services such as, infrastructure development, medicines and technologies. They eventually price their services or health products so highly thereby enlarging the health accessibility disparity in the vulnerable communities, which is contrary to the principles of public health. Unendurable conditionalities are part of the mix in the aid construct which in most cases are hard to meet to yield the desired results. For instance, the Global Financing Facility (GFF´s) Results-Based Financing (RBF) model in its monitoring framework which focuses on specific indicators to determine fund disbursement at health facility and district level has been encircled with many inadequacies in Uganda.  The approach is meant to increase the motivation of healthcare workers and the financial autonomy of healthcare facilities, in order to improve performance of health systems and ultimately improve the health outcomes. However, emerging evidence of this financing approach reveals an irregular performance record. In adding, the broad implementation of RBF across a feeble or unprepared health care system raises many concerns. Experience shows that health facilities with existing poor performance levels will simply not succeed in creating a sufficient inflow of funds through RBF mechanism. Struggling health centres failing to reach RBF targets risk penalization through aid-cuts for failure to meet the set targets as part of the conditionalities in this funding modality, thereby demoralizing health workers and creating greater inequity as these health centres and the populations they serve are left behind, (Paul E, 2018).

Apparently, NGOs and the third-sector which are essentially the second engine of the health sector functioning in Uganda have a remarkable role to play as their sovereignty and self-sufficiency raises above the state’s; this is reflected through the variance in support towards the health sector by the government and the donor community. Uganda has experienced so many periods of incapacity to meet the required global financing commitments to health to provide its primary health care services to the society, which has prompted the donors (internally and externally) and lenders of all sorts to intervene through credits, grants, aid and others. Aid given to economies in transition such as those in the great-lakes region of Africa, is majorly destined to assist these states to undertake and complete their health and development projects. These aids usually come from the ex-colonial monopole and partnership financing initiatives to fortify bilateral-ties and advance donor interests. In sub-Saharan Africa, foreign aid now comes in numerous forms but the most common one is through partnership trust funds like Global fund, Global Alliance for Vaccines and Immunizations (GAVI); International Monetary Fund (IMF) through World Bank Group, European Union Emergency Trust Fund for Africa, and Global Financing Facility of the World Bank Group. These support projects that involve investment in health (such as advancing Primary Health Care, health infrastructure development and health system upgrade: case in line Uganda upgraded health centres in 2018 in different levels to revive its referral system), technical assistance of the various projects, budget support, debt reliefs through multilateral debt relief initiatives; not to mention investing in people to harness better social welfare provision and improve our Human Development Index, bio-diversity protection and climate change, support to non-state institutions involved in the human development and humanitarian causes, food security, migration problems, and so on. However, due to the dynamics in the contemporary aid, a lot of inadequacies surround aid given. There is always a lacuna in its effectiveness, delays and postponements in execution of projects due to aid’s volatility and unpredictability.

Currently, most of the aid financing modalities intends to leverage on lending. For instance, the Global Financing Facility project on Reproductive Maternal Newborn Child and Adolescent Health and Nutrition (RMNCAH+N), being implemented in Uganda and other sub-Saharan Africa states, links its grant money to World Bank lending. At the onset, an average of USD $1 of a GFF grant was matched with USD $4 of a World Bank loan. Three-years ahead, this fraction has almost doubled, ascending to USD $1: USD $7. With several GFF eligible and qualified countries already worryingly and severely indebted, additional increases in nation’s indebtedness are troubling. In the long-term, such heavy dependence on credit risks forming untenable loan repayment burdens. If the countries prioritize the servicing of these debts, this may force governments into resolutions to cut their spending in other areas, such as indispensable essential social services. Ultimately, this undermines or weakens health systems.

Conclusion and Recommendation

To care about our health system, a model shift is required to be drawn for the coverage and effectiveness of aid in Uganda to yield more productive results. Therefore close monitoring of aid especially in form of credit both short- and long-term effects is crucial. In countries such as Uganda where the risks of debt increases are deemed high, aid structures need to be revised and implement measures to protect the delivery of essential health services for the long-term. Establishment of strong robust evaluation mechanisms, and adaptation of design and implementation modalities is required. This can be backed by continuing a thorough and transparent review of health and equity outcome data under performance-centric schemes on aid effectiveness.



Atwine, A. (2018). Public anger as Govt sets exorbitant charges for new Mulago women hospital. Kampala: daily post Uganda.

F, N. (2016). Failure of Foreign Aid in Developing Countries: A Quest for Alternatives. Accra: Business and Economics Journal.

Health, M. o. (2014/15 & 2015/16). National Health Expenditure. Kampala: Ministry of Health.

Paul E, A. L. (2018). Performance-based financing in low-income and middle-income countries: isn’t it time for a rethink? BMJ global health, pg e000664.



Health Breaking News 326

Health Breaking News 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

Health Breaking News 326


WHO Places Emphasis on IPC, AMR and UHC by Garance F Upham 

Democracy Matters in Global Health 

Establishing Credibility and Legitimacy: Seven Challenges for David Malpass 

EU’s ‘Tobin tax’ now expected to collect only €3.5 billon 

International Clinical Engineering and Health Technology Management Congress October 21st -22nd 2019 Rome, Italy 

Almost 7% of EU imports are counterfeit and pirate goods 

NICE refuses to release survival data for breast cancer drug 

DRC Ebola: latest numbers as of 19 March 2019 

Ebola Epidemic in Congo Could Last Another Year, C.D.C. Director Warns 

Ebola is Still Stalking Africa. Who’s Supporting Front-line Work to Stop More Outbreaks? 

Doubling down on Ebola 

Gavi@20: What’s Next for Global Immunization Efforts 

In Madagascar, 1,100 measles deaths are more about money than ‘vaccine hesitancy’ 

Africa: ‘Exciting’ News in Fight Against Drug-Resistant TB 

New WHO recommendations to accelerate progress on TB 

Study shows dramatically shorter treatment for Chagas disease could be just as effective, and significantly safer 

Strategy for a globally coordinated response to a priority neglected tropical disease: Snakebite envenoming 

The 2018 Nigeria HIV/AIDS Indicator and Impact Survey (NAISS): Results and Implications for Nigeria’s HIV Program 

Yemen’s health system fragmentation during the conflict: The impact on the health and nutrition status of a vulnerable population 

Severe mental illness and substance use disorders in prisoners in low-income and middle-income countries: a systematic review and meta-analysis of prevalence studies 

Re-imagining global health through social medicine 

WHO guideline on health policy and system support to optimize community health worker programmes 


Human Rights Reader 476 

Sex Workers’ Untold Stories 

Fighting the World’s Largest Criminal Industry: Modern Slavery 

Cost-effectiveness of financial incentives for improving diet and health through Medicare and Medicaid: A microsimulation study 

World Bank Doubles Pledge to Climate Efforts in Africa 

Young climate activists around the world: why I’m striking today 

The climate strikers should inspire us all to act at the next UN summit 

As children strike around the world, Oxfam calls for climate action 

Climate Change Also Affects Mental Health in Mexico 

Environmental degradation threat to health, says UN 

EU Parliament votes for 55% emissions cuts by 2030 

How Political Correctness Can Change Society’s Views On Mental Health

At a time when youth mobilisation worldwide is urging governments to take on their duties at last and tackle global health threats with no delay, PEAH is pleased to publish an appeal by a fifteen-year-old health advocate aimed at curbing mental health stigma

By Tiffany Osibanjo

Youth Councillor (St Albans and Harpenden), Young Commissioner and Health Ambassador, St George’s School

Hertfordshire, England


How Political Correctness Can Change Society’s Views On Mental Health


Depression and anxiety rates have increased by 70% among the adolescent in the past 25 years. 1 in 4 people experience mental health problems in the UK every year, and some figures suggest that 70% of children and young people don’t receive the help they need at a sufficiently early age. These statistics prove that urgent attention and prioritization for mental health is required. Too many teenagers are afraid to talk about mental health for fear of being judged or treated differently.

The problem at hand could partly be rectified by encouraging society to join the discussion on mental health, where talking about our issues and anxieties becomes the norm. This is where political correctness should be one of the solutions we are looking for.

Political correctness is usually a term that’s referred to as avoiding language and demonstrations of insult to those, suffering discrimination or are, at a disadvantage in society. An example of ‘politically correct behaviour’ may be: Asking a person about their ‘partner’, instead of using gendered terms that may be of insult. Unfortunately, many believe political correctness is a term that many hide behind to escape the harsh truths of reality that there is inequity in society.

However, instead of using the term to draw controversy and debates, it can be one of the solutions for the stigma surrounding mental health. As a united society, the world leaders could encourage the discussion of mental health and its urgent prioritization through the use of ‘politically correct ‘language. Instead of political correctness being a term used for avoiding insulting language, it could be a term for promoting positive demonstrations of support, through words, actions and possibly social media to ensure a socially sustainable society.

Political correctness when used effectively, can make one’s transition into modern society easier and help reduce social isolation. In mental health terms, this may help reduce the stigma significantly, and make the other interventions and solutions more effective such as youth focus groups.

Youth focus groups have started emerging including youth councils, which could be used as a platform to drive this initiative. I also turn to global leaders to initiate other local and community programmes involving the youth; to discuss the challenges and solutions to mental health and possibly use testimonies of those previously suffering mental health issues to create hope and change for the future.

Change may happen soon through the prioritization of mental health for a better future and a better world.



https://au.reachout.com/articles/whats-the-deal-with-political-correctness  – reachout.com

https://www.independent.co.uk/life-style/health-and-families/features/teenage-mental-health-crisis-rates-of-depression-have-soared-in-the-past-25-years-a6894676.html – The Independent

https://www.mentalhealth.org.uk/a-to-z/c/children-and-young-people. – mental health foundation








Is Wealth Good for Your Health? Some Thoughts on the Fateful Triangle of Health

By conflating literature data, this article adds food for thought to the awareness that '...the connections between climate change and wealthy lives are real, the connections between wealthy lives and health benefits are real as well, as are the connections between wealthy lives and environmental degradation... The problem is that these connections are easy to understand but also easy to ignore and difficult to act on in everyday life'. 

A really tough, much conflicting issue for which a leap of political will to find non-destructive ways of increasing incomes and material well-being is required at a time when '...the Sustainable Development Goals provide direction for where a healthful development could be going, though they leave unexplained how the world is supposed to generate sufficient economic growth to eliminate extreme poverty by 2030 (Goal 1) while at the same ensuring universal access to affordable, reliable and modern energy services (Goal 7.1.) and mobilizing $100 billion annually by 2020 from all sources to address the needs of developing countries regarding climate change mitigation and adaptation (Goal 13A).'

By Iris Borowy *

Distinguished Professor, Center for the History of Global Development

Shanghai University

Is Wealth Good for Your Health? Some Thoughts on the Fateful Triangle of Health 


It is easy to forget to what degree good health is of recent origin. Gapminder provides an interactive timeline for life expectancy for many countries beginning with the nineteenth century. Though exact data are difficult to find or non-existent for large parts of the world for long periods and it is misleading to assume that lives were the same in all places at all times, there is good evidence that, until about 300 years ago, frequent hunger, chronic malnutrition, impaired immune systems and stunted growth were facts of life for the majority of people. But, of course, within their own times, general people’s height was not considered stunted, parents losing several of their children in infancy was not considered abnormal and short lives were not considered short. It is only in hindsight that we gain this perspective, knowing how long people can live, how tall they can grow and how many children can survive, given the circumstances.  In what Robert Fogel and Dora Costa have called the a technophysio evolution, a drastic change in human environments have enabled people in industrialized countries to double their lifetime and increase their body weight by 50 percent. But what exactly, has brought about these immense health improvements? Fogel and Costa argue that it was a combination of more food, better living conditions, more leisure time and better medical care. In simple terms, they argue that increased incomes have provided people with the opportunity to improve their living conditions to such an extent as to live vastly longer and healthier lives.

But is it really increased wealth that has brought about these changes? In part, the answer seems a no-brainer: rich people can afford to live in healthier environments, eat healthier food and live in healthier housing than poor people. High-income societies can provide better quality preventive and therapeutic health care, offer better and more extensive education for men and women, invest more in health-related research and afford more extensive social servicess such as unemployment benefits and old-age pensions than low-income societies. In short, people in rich Japan (84.2 years) can expect to live more than thirty years longer than in poor Lesotho (52.9 years), today. People in wealthy countries also tend to lead safe lives, at comparatively little risk of being killed either by others or by themselves, as the list of world death rate rankings for violence/homicide and suicide reveals. As use of the interactive statistical tools provided by gapminder shows, virtually all health-related indicators are in some way positively correlated to incomes. If we had a choice where we would like to be born, there is little doubt that most of us would opt to be born as well-off people in high-income countries, where our lives would in all likelihood be long, safe, and healthy, unthreatened by famine, malnutrition, economic insecurity, and a host of preventable diseases. This view has perhaps been most poignantly expressed in a paper entitled “Wealthier is Healthier”, published in 1993 by leading World Bank economists Lant Prichett and Lawrence Summers in preparation of a World Bank World Development Report dedicated to health. In illustration, they stated that if “income were one percent higher in the developing countries, up to 33,000 infant and 53,000 child deaths would be averted annually.” So, the easy answer is: of course, wealth is good for health. Nevertheless, there is a more complicated side to this.

The question of whether higher income improved health became the object of targeted research the context of a debate among historians about the reasons for population growth in industrialized countries. It focused on Britain, initiated by a series of publications between 1955 and 1980 by medical historian Thomas McKeown, who aimed to show that the main reason was a decline in mortality rates brought about by improving living standards, notably better nutrition, resulting from better economic conditions. His main point at the time was that medical interventions, widely believed to be key at the time, had had little impact, if any, but his argument was subsequently picked up by neo-liberal proponents of market-driven economic growth and invoked against state programs.  This “McKeown Thesis” stimulated further studies into the reasons for historical mortality decline and into the determinants of past and present life expectancy. One of the outcomes of this field of study was the Preston Curve, a graph which combines income, measured as per capita GDP, on the x-axis, with life expectancy at birth, on the y-axis. This graph, repeated for different points in time, consistently results in a positive correlation between income and life expectancy, though the vertical movement of the curve in time indicates that there are also other factors at work, unrelated to income, so that similar levels of income allowed longer lives in 1960 than in 1930, and longer in 1990 than in 1960.

(Preston Curve. Source: http://www.ganfyd.org/index.php?title=File:PrestonCurves.png)

While compelling (and frequently cited), the graph is also a drastic simplification of the relation between economic level and health. The curve does not explain causality (is health better because of high incomes, or are incomes higher because of better health?), nor show to what extent both income and health may be the impacted by another independent variable. The Prichett-Summers article,  cited above, readily acknowledged but then discarded those points. Most importantly, the curve connected only one manifestation of health (life expectancy) with only one possible variable (national income), reducing a highly complex condition to a seemingly simple unilateral relation.

Among experts of public health, the complexity of factors affecting health had been well established since the nineteenth century. But it took fifteen years before there was a visualization that could rival the Preston curve. In 1991, Göran Dahlgren and Margaret Whitehead published a background paper for WHO Europe on Policies and strategiesto promote social equity in health, which focused on equity levels as important predictors of health, citing, among others, the demonstrable impact of housing, education, food and labor. While the paper is no longer broadly known, its legacy lives on in the drawing it included and which has become the frequently cited standard view of the social determinants of health.

Source (for instance): http://hiaconnect.edu.au/resources/about-hia/

Subsequently, these factors have received further recognition. In 2001, the Commission on Macroeconomics and Health, instituted by Gro Harlem Brundtland as Director-General of the World Health Organizations, issued a report on Macroeconomics and Health: Investing in Health for Economic Development, which highlighted the importance of population health as a crucial driver of the economic development especially of low-income countries, effective reversing the perspective on the relation between income and health. Seven years later, another high-level WHO commission, the Commission on Social Determinants of Health, issued its final report, which spelled out a series of factors related to socio-economic conditions and governmental policies and their impact on health, pointing out, among other aspects, the importance of early life conditions and societal power structures.

Thus, the lively McKeown debate of past decades has been put to rest in the sense that it is beyond doubt that the declining mortality and expanding life expectancy in Britain (and, by implication, elsewhere) cannot be explained by one cause alone but that they have been affected by numerous factors, including (but not limited to) state programs such as vaccinations, changing agricultural practices, sanitation and water safety measures, urbanization, migration, marriage patterns, and changing incomes due to industrialization. The debate is not over in the sense that within this field, many questions remain open. Often, as different dynamics have been at work at different times, the relative significance of individual factors for specific cases is still quite unclear. Sometimes the same factor can have contradictory effects, such as the significance of declining grain prices, which made both bread and gin more affordable to working class Britons, thus simultaneously improving nutrition and fostering alcoholism. As a result, revisiting old debates mainly leads to new, still more complicated debates.

Regarding the effect of wealth and income on health, one particularly perplexing finding of the analysis of past demographic data has been that the robust positive cross-country correlation with national income and life expectancy cannot be confirmed in longitudinal studies. On the contrary, gaining incomes and wealth seem to have a downright negative influence on people’s health. In a phenomenon called “ante-bellum-puzzle” in the United States and “early-industrial-growth-puzzle” in Europe, it was found that in numerous countries, periods of economic growth and rising incomes coincided with shrinking body heights, indicating that young people at an age of growth suffered from impaired nutrition, higher diseases burdens and generally impaired health status. Similarly, mortality rates increased during times of economic expansion in OECD countries after 1960. Paradoxically, while being wealthy seems good for health, getting wealthy is not. In fact, it is getting poorer that may be good for your health. With the notable exception of suicides, important health indicators have repeatedly been found to improve during periods of economic crisis, leading two researchers to conclude that, counterintuitively “population health tends to evolve better during recessions than in expansions.” This discrepancy has been explained by the social disruptions, the increased workload, and the growing stress, which frequently go hand-in-hand with economic expansions, which have serious but temporary negative effects on health,  while declines in working hours, road traffic and high-fat diets can reduce health burdens.

This seeming paradox points to time as an important, and sometimes neglected, aspect of the relation between wealth and health. In simplistic terms, one could say that the parents, who are working hard to earn the money necessary for good food, a nice home and a good school for the children while paying taxes to a welfare state, are sacrificing some of their own health for the health benefits their children will be able to enjoy. There is enough truth in this stereotype to make this part of the larger picture, but it is by no means all of it. To begin with, people’s lives also influence the health not only of their own children but also of strangers separated from them both in time and place. And secondly, such influence can be – and is! – negative as well.

The Relation over Time

As I have argued elsewhere, the industrialization, which formed the basis for the historically unprecedented rise in material wealth, was built in parts on the death of millions of indigenous people in North America (resulting mainly from Old World epidemics and making possible large-scale emigration from Britain and investment in labor-saving technology) and on slavery (producing the cotton which fed the British textile industry). In ways that are impossible to quantify, these deaths form part of a development that tangibly prolonged and improved the lives of future generations like our own today – and therefore, arguably, part of the relation between wealth and health.

The relation becomes even more complicated when including environmental factors in the consideration. The environment plays multiple roles in this connection as a supplier of resources for the economy which underpins societal wealth, as a provider of food and other crucial necessities for healthy lives, and as a recipient of the wastes generated by populations and their wealth. Here, I argue that the relation between health and the states of the economy, on the one hand, and of the environment, on the other, are caught in a fateful triangle.

As the research on the social determinants of health, cited above, has amply shown, people’s health depends crucially on their economic status, including employment, working conditions, private incomes that allow comfortable living standards and national incomes that allow effective social services. In a quasi confirmation of the Preston Curve, this point is born out by recent ranking of countries according to their health based on a series of indicators including life expectancy, tobacco use, obesity, access to clean water and sanitation. All but two of the 37 highest-ranking countries were categorized as high-income countries by the World Bank. The exceptions are Cuba and Costa Rica, two countries that prioritize public health. The list also confirms that money is not everything, or these two cases would not exist and the rich United States would not end up on place 35. But clearly money matters. With the same two exceptions, all these countries also rank among the highest third in a ranking of countries according to their ecological footprint. Ecological footprint is a controversial measurement of human (over-)use of Earthly resources. It has been criticized as overly simplistic, misleading or insufficiently transparent. But another indicator has a yet been found that would translate the complexity of environmental degradation into a single measurement, however imperfectly. Besides, for the question of the environmentally destructive effect of present economic practices, the weakness of the ecological footprint is hardly reassuring since, if anything, it seems to undercount the real extent of damage being done.  Overall, it is difficult to avoid the impression that wealth comes with some degree of long-term environmental destruction.

With regard to health, this finding is serious since health also depends on crucial environmental determinants including clean air, clean water and a reasonably stable climate. Again, the differences within this group are substantial and worth studying. (For instance, Spain, which topped the list of healthy countries, takes a remarkably low 66th place in the ranking of the countries according to ecological footprint.) Nevertheless, the correlations strongly suggest that population health is best in those countries that also go furthest in sacrificing environmental integrity  for economic well-being. This leads to a paradoxical finding: in a fateful health triangle, economic wealth is both good and bad for health, and probably both at the same time.

The Fateful Health Triangle: Iris Borowy

Sometimes, the connection is relatively straight-forward. One example is ambient air pollution. Ambient air pollution emanating from vehicles, power plants, industry, households and biomass burning is to a large extent a function of an emerging economy. The burden is highest in low and, especially, in middle income countries. The health burden is immense. According to WHO, in 2016, ambient air pollution was responsible for 4.2 million deaths, including about 16% of the lung cancer deaths, 25% of chronic obstructive pulmonary disease (COPD) deaths, about 17% of ischaemic heart disease and stroke, and about 26% of respiratory infection deaths.

It has been argued that these burdens decline with further economic growth, as advanced economies rely more strongly on cleaner energy and more energy-efficient technology. This effect, known as the Environmental Kuznets Curve, has been cited as a refutation that “environmental degradation is an inevitable consequence of economic growth.” If this argument was true, environmental destruction would resemble high work stress as something related to rapid economic growth rather than mature wealth and, therefore, a regrettable but necessary but temporary health burden.

However, the empirical basis is weak and often inconclusive. While such a correlation (an initial rise of the environmental burden with economic growth, followed by a decline with further growth) has been documented for some selected forms of environmental burdens, notably some urban air pollutants. But for others, such as carbon emissions and solid waste, no turning point has been observed so far, it is unclear when – if ever – such a turning point will occur, nor is it clear whether past turning points have reflected a real decline in pollution or a relocation of pollution generation to other – presumably poorer – places. In other words, it is unclear if or to what extent environmental degradation is a function of the overall size of the economy and/or to its form or to the nature of specific forms of pollution.

One useful interpretation of these connections has been Environmental Risk Transition theory, developed in the 1990s by Berkeley professor Kirk Smith. It postulates different types of environmental health risks with different reactions to economic growth: 1. Traditional health risks, acting at the household level (e.g. access to water, sanitation, indoor air pollution), which decline with rising incomes, 2. Transitional health risks acting at the community level (e.g. industrial pollution), which behave according to the Environmental Kuznets Curve, and 3. Modern health risks, acting at the global level (e.g. climate change, ozone layer depletion), which keep rising with growing incomes.

Environmental Risk Transition Theory: https://en.wikipedia.org/wiki/Environmental_risk_transition#/media/File:Etransition.png

According to this theory, these health risks differ not only in response to economic growth but also in space and temporality: while traditional risks tend to have local and immediate effects, the impact of modern risks is global and delayed. This changed character has muddled the picture and has made it more difficult to grasp the connections or, conversely, has made it possible to select specific connections in line with ideological policy preferences. Thus, the perceived relation between level of income and health has been used as an argument against policies designed to counter climate change, lest they slow economic growth.

On one level, the argument is a foolish, since the health repercussions of climate change are beyond doubt. Climate change is predicted to negatively affect health of millions of people by increasing direct heat related illnesses and deaths, by exacerbating respiratory diseases, by changing conditions for vector- and water-borne diseases, by increasing forced migration and related disruptions and violence and by impairing mental health. WHO expects that between 2030 and 2050, climate change will cause approximately 250 000 additional deaths per year, from malnutrition, malaria, diarrhoea and heat stress and will incur costs of between two and four billion dollars per year.  Among public health experts, the effects are considered so significant that institutions like Harvard University have begun offering classes on the topic. In 2009, the Lancet Commission called climate change “the biggest global health threat of the 21st century”, a verdict that has been adopted by others since.

However, on another level, it is also true that the health damages of climate change will disproportionately affect the poor and that  – expensive –  adaptation measures (such as dams in protection against rising sea levels) and effective health and social services (such as vaccinations and other prevention measures against re-emerging infectious diseases) will go a long way to mitigate the health effects of climate change. So, calling for measures to boost incomes is not senseless. It only shows the size of the predicament. Indeed, modern health risks are most painfully felt by those societies in low-income countries that are still struggling to free themselves from the health effects of the traditional and transitional environmental risks. One study, published in 2008, analyzed the effects of three burdens, unsafe water, sanitation and hygiene, indoor air pollution from solid fuel use and outdoor air pollution (i.e. a mixture of traditional and transitional health risks), and found that it is low income countries that “suffer the most from environmental health factors, losing up to 20 times more healthy years of life per person per year than high income countries.” To this effect of a double burden will increasingly be added the third burden of climate change. If poor countries can increase their national incomes, chances are they will be better able to address all forms of environmental health risk – while at the same time making some of them bigger.

On other words, the connections between climate change and wealthy lives are real, the connections between wealthy lives and health benefits are real as well, as are the connection between wealthy lives and environmental degradation, though not necessarily at the same time and in the same place. The problem is that these connections are easy to understand but also easy to ignore and difficult to act on in everyday life. The wealth-related health benefits I enjoy when I take a taxi to the airport and then a plane to fly to a conference which I need to attend as part of the academic job which gives me material comfort and emotional support (and enables me to write this paper),  are far removed from the health damages experienced by the peasant in Africa, who finds he can no longer feed his children because climate change has dried up his fields, or by the home owner in the Seychelles who will find his house disappearing in floods caused by rising sea levels in fifty years. This connection is so indirect, it might as well not exist. So far, nobody has found a convenient illustration similar to the others included in this paper.  Nevertheless, in billions of faint, indirect connections between here and the other side of the world and between now and the future, the wealth which supports health of people today is tied to the health of people many generations from now. Thus, just like a full consideration of the relation between wealth and health should extend into the past, it must also extend into the future.

The solution, obviously, would be to find non-destructive ways of increasing incomes and material well-being. So far, human history provides little experience in this regard, which could serve as guidelines. The Sustainable Development Goals provide direction for where a healthful development could be going, though they leave unexplained how the world is supposed to generate sufficient economic growth to eliminate extreme poverty by 2030 (Goal 1) while at the same ensuring universal access to affordable, reliable and modern energy services (Goal 7.1.) and mobilizing $100 billion annually by 2020 from all sources to address the needs of developing countries regarding climate change mitigation and adaptation (Goal 13A). Maybe it is possible. But it would require an enormous leap of political will, and it would lead humanity into uncharted ground. The pessimistic view is that humanity has never known a level of material wealth comparable to today without the massive use of fossil fuels. Keeping a similar level without fossil fuels, and without other forms of environmental degradation, would be a revolution. The optimistic view is, humanity has known revolutionary changes in the past.


An important component of a transition towards a health regime beyond the Fateful Health Triangle might be to change common concepts of “development”, “developed” and “developing” countries. Clearly, the model to emulate cannot be those countries that combine high health levels with economic practices that will be detrimental to people’s health, now and in the future. The countries that come closer to serving as examples may be outliers such as Cuba and Costa Rica, mentioned above, and others that are nudging closer to a system of good health and a good material living standard with little environmental destruction.

It would be helpful to have an indicator that actually measures – and thereby provides direction for – such a development. The Happy Planet Index, developed by the new economics foundation, has precisely this aim, combining life expectancy with declared life-satisfaction, inequality and the ecological footprint. The 2016 data give Costa Rica the highest score, followed by Mexico, Colombia, Vanuatu and Vietnam. But even in Costa Rica, the ecological footprint is considered surpassing the country’s biocapacity quite considerably.

There is not much of a conclusion to the paper except that given that non-negotiable relations between health and its economic and environmental determinants we need to look for a system that brings these determinants into harmony. To do this, we probably need to begin by changing our attitude towards economic growth. Economic growth has taken us far. Thanks to growth many people have longer, healthier lives than ever before in history. And if we do not manage to change the nature of growth, it will be thanks to economic growth that these health levels will be compromised again in the future.



* In part, this article makes use of material presented in more detail in: Iris Borowy, “Economic growth and health: evidence, uncertainties and connections over time and place.” In: Iris Borowy and Matthias Schmelzer (eds.), History of the Future of Economic Growth. Historical Roots of Current Debates on Sustainable Degrowth. Milton Park: Routledge 2017, 129 – 153.


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WHO Barcelona course on health financing for universal health coverage 18 – 22 March 2019 Coordinated Universal Time Barcelona, Spain 

The second Africa Health Forum – Achieving Universal Health Coverage and Health Security in Africa: The Africa we want to see 26 – 28 March 2019 Coordinated Universal Time 

2019 Medicines For Europe Legal Affairs Conference 

WHA Resolution For Transparent Drug Pricing: Italy Speaks Out 

UNDP, Unitaid, and WHO caught in Big Pharma’s crosshairs 

Why Africa Matters To The United States And How President Donald Trump’s New Africa Strategy Falls Short 

Improving Global Health Supply Chains through Traceability 

Connectivity of rapid-testing diagnostics and surveillance of infectious diseases 

What next in the fight against Lassa fever? 

MSF condemns ‘militarised’ response to Ebola outbreak 

DRC Ebola latest numbers as of 13 March 2019 

Mosquito-killing drug cuts malaria by a fifth in children 

Measles and the Threat of the Anti-vaccination Movement 

Vaccine cuts child pneumonia cases by a quarter 

Age distribution, trends, and forecasts of under-5 mortality in 31 sub-Saharan African countries: A modeling study 

The world is not prepared for a global flu pandemic, experts warn 

The Aids endgame: how the UK and US are committed to wiping out HIV 

U.S. Federal Funding for HIV/AIDS: Trends Over Time 

MSF Access Campaign analysis of the MPP Licence Agreement with AbbVie for glecaprevir/pibrentasvir (G/P) 

The World Needs Better Drugs for TB. We Have a Proposal—and We Need your Feedback 

iBreastExam for Breast Cancer Detection in Low Resource Settings by Sumedha Kushwaha and Garima Kumar 

Breast Cancer Patients Weigh In On Addressing Financial Burdens 

Clinical trials in New Zealand: Huge transparency gaps 

Horizon scanning: How shoddy clinical trial reporting undermines health policy making 

Can public-private partnerships deliver gender equality? 

Making tax work for women’s rights 

Celebrating International Women’s Day in London 

Engaging citizens for evidence-informed health policies in Lebanon 

EU citizens need health and well-being as a policy priority, stakeholders say 

Opinion: How can European development finance institutions align with the Paris climate goals? 

127 Countries Now Regulate Plastic Bags. Why Aren’t We Seeing Less Pollution? 

Brazilian city’s pollution spreads to untouched Amazon rainforest 

WHO Places Emphasis on IPC, AMR and UHC

An effective health service needs to be able to prevent and manage infections” thus starts a very excellent draft WHO discussion paper: “Tackling AMR while making progress towards UHC”

By Garance F Upham

Vice-President, World Alliance Against Antibiotic Resistance (WAAAR

Editor in Chief AMR CONTROL 

Ex-Member Steering Committee, Patients for Patient Safety, WHO Patient Safety Program (2004-2014)

WHO Places Emphasis on IPC, AMR and UHC


This week and last, three news confirmed our hunch: the WHO is beefing up its commitment to infection prevention and control (IPC).

– Dr. Hanan Balkhy, was named Assistant Director-General (ADG) Antimicrobial Resistance, which places greater emphasis on AMR, as well as raising up on the agenda the urgency of IPC, since Dr Balkhy is a world renown cheffe in implementation of IPC, having lead the Saudi Arabia’s struggle against the MERS-CoV  spread.

Previously, AMR had a low profile in the leadership group, since it fell under a very general heading of Strategic Initiative with the Italian ADG, Dr. Ranieri Guerra, now leading WHO’s preparations for the UN high-level meeting on Universal Health Coverage at the UN General Assembly in NYC this fall. Of note, Italy is today leading in an effort to bring drug pricing under control. Will Dr. Guerra follow his own government’s radical turn, or his own sentiment, whatever it may be?

If, as the Interagency Coordination Group-IACG reports tend to indicate as well as the general background rumors, AMR was to acquire dominance in global health to the point of demanding much greater visibility and funding, Hanan will have the awesome task of preventing a replay of what happened with HIV/AIDS: the creation of the GFATM, UNAIDS and UNITAID which all in all contributed to weakening of the WHO since 1996 and of the national ministries of health in their responsibility and funding to face deadly disease problems, even if the three, of course, did contribute to the necessary action. Perhaps the wisest comment came from Peter Sands (just as he was to assume his role as director of the Global Fund) when he said that to combat HIV, TB, Malaria, people should think of first dealing with the millions of cases of ordinary infectious diseases, because to do that would, indeed, affect our global capacities to roll back and treat the “HIV-TB-Malaria”.

In AMR, it seems to us important that WHO claims and retains global leadership, and be the funnel to funding.

The other news from the WHO reorganization pointing in the same direction are:

– Dr Mike Ryan was moved to become the Director the Health Emergency Department; as indicated in my previous blog article, his understanding of IPC as the only way to stop Ebola outbreaks, and his comments on WHO Director-General Dr Tedros having witnessed this in the Democratic Republic of Congo (DRC), indicates a commitment to IPC at the highest level of the WHO.


– Dr Alessandro Cassini (lead author of the report in The Lancet ID on the majority of AMR infections being acquired nosocomially, i.e. in health centers contaminations) is moving from the European Centers for Disease Control-ECDC to the WHO, this week, to beef up an IPC department which has had little staff and power over the past years.

Now, as I wrote earlier : “Dr Ryan could be the harbinger of a massive change in the WHO leadership on the need for IPC, which could come back to the forefront as a specialized department under the Emergency Health Department.

However, for that Member States would have to understand and fund that initiative.”

Or to put it otherwise: Member States could /should fund the WHO core, and the WHO stay on track to prioritize the 3 billion initiative. Dr Tedros and his team are said to hope for “emerging countries” to come forward.

An effective health service needs to be able to prevent and manage infections” thus starts a very excellent draft WHO discussion paper: “Tackling AMR while making progress towards UHC”.

Sources and references

For the WHO listing of the new leadership:


For the new hot discussions on prices and access to medicines in general and cancer in particular:


Entitled: Improving the transparency of markets for drugs, vaccines and other health-related technologies,” the resolution, to be discussed at the 72nd session of the WHA, asks national governments to demand greater price transparency as part of regulatory processes and also gives WHO a clear global mandate to track and compare drug prices nationally and worldwide.

The Italian lead initiative comes on the heels of the very hot discussions in and around the Executive Board meeting at WHO HQ this winter on the Cancer resolution (EB144/18 Cancer medicines,), and analysis of the high profitability of cancer drugs (14 USD profits for each dollar invested, https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2720075)
See pre-EB preparatory discussions on: https://agenparl.eu/who-opens-discussions-on-roadmap-for-improving-access-to-medicines/

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WHO: public health round-up 

New WHO structure revealed 

Accelerating universal health coverage: a call for papers 

Social innovation: engaging communities in improving their own health 

Open letter to CEPI Board Members: Revise CEPI’s access policy 

Norway has invested 200 million euros in epidemic preparedness, but are they getting what they’re paying for? 

From Ebola to Antimicrobial Resistance: Coming Into a Health Center Could Kill you! by Garance F Upham 

‘A slow-burn crisis’: how Ebola will take months to resolve 

Latest numbers from DRC Ebola as of 5 March 2019 

Governance for health: the HIV response and general global health 

H.I.V. Is Reported Cured in a Second Patient, a Milestone in the Global AIDS Epidemic 

Testing everyone for HIV leads to drop in infection by a third 

Countdown to 2030: eliminating hepatitis B disease, China 

New data platform supports global control of schistosomiasis and soil-transmitted helminthiases 

Full G-FINDER 2018 report 

Prevention and control of noncommunicable diseases: lessons from the HIV experience 

European Patent Office Report Compares Compulsory Licensing Practices By Country 

Will US Drug Pricing Politics Change Intimidation Practices Globally? 

A Shortfall In Innovation Is The Cause Of High Drug Prices 

Open letter supporting Italy’s proposed resolution on Improving the transparency of markets for drugs, vaccines and other health-related technologies  

The Edge Walkers: How a Global Women’s Fund Sustains Grassroots Work 

The Future Women Want: Free of Violence 

Q&A: The African Union Development Agency takes shape 

Is trade with India changing Africa’s health care landscape? 

UK launches global fund to help end ‘period poverty’ by 2050 

EU’s agricultural policy can be reformed for better health, ENVI vote testifies 

Fixing food systems in 80 steps: time for a Common Food Policy for the EU 

Tackling the Global Syndemic of obesity, under-nutrition and climate change 

Transition to a planetary health diet: lessons from the Danish Whole Grain Partnership 

22 of world’s 30 most polluted cities are in India, Greenpeace says 

iBreastExam for Breast Cancer Detection in Low Resource Settings

The ‘gold standard’ for breast cancer detection, i.e. routine mammography, is unsustainable for low- and middle income countries, inaccessible to rural areas and requires highly trained radiologists to interpret images. 

Under these circumstances, iBreastExam usefulness is emphasized here as a FDA cleared, hand-held, battery powered and fully wireless, mobile health (mHealth) solution for clinically effective breast lesion detection in low resource settings

By Sumedha Kushwaha (BDS, MDS) Head, Division of Public Health 

and Garima Kumar (BDS, MPH) Product Specialist

UE LifeSciences India Pvt. Ltd. 

iBreastExam for Breast Cancer Detection in Low Resource Settings


What is the global scenario of breast cancer in LMIC’s?

Breast cancer is the most commonly occurring cancer among women in India. According to the Ministry of Health, there is an occurrence rate of 25.8 per 100,000 women and mortality rate of 12.7 (Health Ministry Report). Every year around 150,000 are newly detected and 70,000 lose their life to the disease. This actually means for every 2 women newly diagnosed with breast cancer, one woman is dying of it (World Health Organization – Cancer Country Profiles, 2014). The mortality due to breast cancer is rapidly increasing because of its diagnosis at an advanced stage. As per World Health Organization (WHO), Breast Cancer accounted for 21.5% of all deaths (326,300 females) due to cancer in 2014 in India. Survival rate is poor in India with only 66.1% women surviving (2010-2014) and here more women die due to breast cancer in India than any other country. It has thus become an emergency because of its acuteness in developing countries. Projection estimates show that unless timely interventions are made, the number of breast cancer cases in India is estimated to double by 2020 (World Health Organization – Cancer Country Profiles, 2014).

Existing modalities to detect breast cancer

Self Breast Examination– It’s a highly subjective test.

Clinical Breast Examination– Subjective, a trained professional is required to carry out screening, over-burdened doctors and nurses.

Mammography– Globally, mammography is the standard technique to detect breast cancer. In India, however, because of its high cost, decreased doctor:population ratio, even reduced radiologist:population ratio, lack of trained staff, poor supply of electricity and lack of connectivity in rural areas, mammography is not a very successful technique. The machine becomes portable only when carried in a mobile medical unit, which further increases the cost. The worrisome situation is breast cancer occurrence in premenopausal women or <40 years of age, where the dense breast tissues make screening difficult, leading to the false negativity of presence of malignant lesion. The associated pain and radiation due to mammography leads to even further increased stigma attached to the disease.

Ultrasound– Requires a clinical setup with a trained radiologist. Also, there is a PC-PNDT Act in India due to high rate of female foeticide which makes the ultrasound sparsely available in rural outreach communities.

In the Indian context, there is stigma and shyness towards breast health check up. Indian females has a fear of what would be the outcome if diagnosed with cancer, acting as a major barrier to screening, early detection and treatment. Three considerable arguments that are mainly put forward by females are: personal responsibility if diagnosed with cancer, belief in and despair of the inescapability from disability and death, suspicion of cancer transmission which eventually turns out to be limiting factors in early detection.

What is the solution?

Need of the hour is to make the society believe in the ancient saying that ‘prevention is better than cure’. As breast cancer still holds the stigma, the breast health wellness test should be made acceptable to women; to accomplish this the scan should be safe, accessible and affordable. With these specifications behaviour towards health security can be changed.

The horrific statistics and the dismal response to it motivated the founders of UE LifeSciences to design a solution; here comes iBreastExam as a breakthrough to help in curbing this menace by early detection practice leading to early plus better treatment and longer survival. This is UE LifeScience’s Falgship product that finally came into existence in 2009 after years of research with a mindset that screening should not be limited to a certain population.

This is a handheld, mobile connected device, commercially available since 3 years that seeks to bring screening to areas with limited access. It was developed to quickly, easily and accurately detect abnormality in women’s breast by any healthcare giver/trained social workers. This is acceptable to women as it is painless, radiation free and present at cheaper cost as compared to other modalities thus making it a perfect pre-screening tool.

It can be kept in any primary setting as a point of care device with no requirement of any medical professional to deliver the test; making it more accessible and helping greatly in funnelling down the detected females for next line of diagnosis.

UE LifeSciences believes in providing holistic and comprehensive solution to breast cancer screening through SEWA Model. Sewa in Hindi actually means selfless service to the community. SEWA stands for Screening, Education, Wellness and Awareness led by iBreastExam.

“Every woman above age 30 should have access to routine breast health examination to ensure that breast cancer gets detected early. In India there are approximately 190 million women who can be benefitted with iBreastExam with the help of both public and private healthcare providers,” says UE LifeSciences, cofounder, Mihir Shah.

How does the health innovation product iBE work? How is it different from other screening modalities?

iBreastExam (iBE) uses patented innovative piezoelectric ceramic sensor that can assess tissue elasticity in real time. Tumours are harder than normal breast tissue and the sensors in the device can ‘feel’ them out, quickly and without any pain or radiation. UE LifeSciences trains qualified personnel employed by these healthcare providers to offer the iBE test to women who are seeking a safe and objective breast health exam. iBE provides a clinically effective, US FDA cleared, and CE marked, preliminary screening exam for breast cancer for the nearly 1 billion women around the world who have no access to a safe and reliance early screening test.


As shown in the image1, iBE software is a interface to perform breast examination, review the breast examination, store the examination data, store manual clinical examination data, document data for follow-up and print the final report. It includes data tracker also which will serve as a cancer registry: region wise, age wise and involves many more variables. This will truly develop better understanding of disease to make better health care decisions.

Image 2 

iBE showed sensitivity of 84% and Specificity of 94%to detect clinically relevant  breast lesions. Specifically, iBE performed 19% better than an expert clinician breast exam (CBE) . As demonstrated in clinical studies iBE can objectively detect non-palpable lesion with efficacy better than CBE (Image 2).

Please find below references to the articles from global publications that have covered iBE.

  1. Somashekhar SP, Vijay R, Ananthasivan R, Prasanna G. Noninvasive and low-cost technique for early detection of clinically relevant breast lesions using a handheld point-of-care medical device (iBE): prospective three-arm triple-blinded comparative study. Indian J GynecolOncol. 2016;14:26.
  2. Broach et al. cost-effective handheld breast scanner for use in low-resource environments: a validation study .World Journal of Surgical Oncology (2016) 14:277
  3. Xu et al. Breast tumor detection using piezoelectric fingers: first clinical report.J Am Coll Surg. 2013 Jun;216(6):1168-73
Till now how far has the device reached?

New technologies with the potential to improve the healthcare of population through faster diagnostic and more effective care are continuously being introduced. Health care stands to benefit from the constant developments and technological innovations in life in general and in health sciences.

With recent recognition from WHO iBE has been recognised as Innovative Health Technology for low resource settings.

“With presence in 12 countries we have been able to bring breast health check-up to over 200,000 women. Our work has resulted in over 120 breast cancers being detected and those women to receive treatment early,” says UE LifeSciences, cofounder, Mihir Shah.

Regulatory Approvals



Inclusion in

WHO compendium of innovative health technologies for low-resource settings, 2016- 2017 









About the authors

Dr. Sumedha Kushwaha (BDS, MDS, Fellow-School for Social Entrepreneurs, Fellow- Atal Incubation Centre) is a public health professional, working towards a cancer free world. She heads the division of Public Health for UE LifeSciences India Pvt. Ltd. She has authored various international research publications and books. Her spare time is usually devoted to her Not for Profit Organization called ATTAC- Aim to Terminate Tobacco and Cancer.

Dr. Garima Kumar (BDS, MPH) is currently working as Product Specialist at UE LifeSciences India Pvt. Ltd. She is passionate towards community work. She is keen to apply evidence based methods of behavioural change in community.

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What is this thing called neoliberalism? (With apologies, and gratitude, to Cole Porter) 

The US Affordable Care Act: Reflections and directions at the close of a decade 

An economy that serves the people: new UN guidance to anchor policy-making to human rights 

Asian NGOs Raise Concern Over IP And Seeds In RCEP Trade Deal 

IMF Conditionalities Still Under the Fire of Criticism by Daniele Dionisio 

European Parliament push for a more ambitious EU health budget in 2021-2027 

New Research Study Describes DNDi As A “Commons” For Public Health 

Report from two EU agencies confirms superbugs as a rising threat 

How clean water can be the most powerful weapon against superbugs 

Novartis secures FDA innovation prize for 30-year-old drug 

Congress is grilling pharma CEOs. Here are 8 ideas for bringing down drug prices 

How High Drug Prices Inflate C.E.O.s’ Pay 


Cancer drug pricing gets in the way of treatment in developing countries 

Global fund for hepatitis prepares for rollout 

Research Roundup: SFOPs funding for FY19, Lassa fever outbreak in West Africa, and new TB drug may shorten treatment time 

Nationwide measles and rubella immunization campaign reaches 11.6 million children in Yemen 

WHO calls for more money in fight against Ebola as violence hampers response once again 

Latest numbers from DRC Ebola as of 26 February 2019 

WHO publishes new estimates on congenital syphilis 

Enteric infection and dysfunction—A new target for PLOS Neglected Tropical Diseases 

Faced with unreasonable medicines prices, the Netherlands introduces pharmacy exemption in patent law 

UK government promises national strategy to boost clinical trial reporting 

The Oversell And Undersell Of Digital Health 

Human Rights Reader 474 

North Korea’s silent health crisis 

UN says North Korea has asked for help on food shortages 

UN probes substandard food aid for mothers and children  

Billions at risk from heat stress at home 

Why Should Governments Refill the Green Climate Fund’s Coffers? 

With Oceans in Grave Danger, Some Donors See Hope in Tech Solutions 

From Ebola to Antimicrobial Resistance

 “The mothers in Congo care a lot for their babies and young children, that is why they bring the babies into health centers whenever sick, they really really do care for them, and the children get contaminated in health centers... they come out with Ebola!

Dr. Mike Ryan, WHO Assistant Director General for the Department of Health Emergencies

By Garance F Upham

Vice-President, World Alliance Against Antibiotic Resistance (WAAAR

Editor in Chief AMR CONTROL 

Ex-Member Steering Committee, Patients for Patient Safety, WHO Patient Safety Program (2004-2014)

From Ebola to Antimicrobial Resistance: Coming Into a Health Center Could Kill You!

Is WHO Now Placing Hygiene As a Global Priority? Will Governments Listen?

The views expressed below are those of the Author and do not engage her Board or the WAAAR



The January 2019 World Health Organization (WHO) Executive Board (EB) meeting heard with some amazement that: “More than 85%, even 86%, of Ebola cases in Beni, Democratic Republic of Congo, have been acquired in health systems.” , as Dr. Mike Ryan, WHO Assistant Director General for the Department of Health Emergencies, testified, on Jan 28, in Geneva’s WHO headquarters to the EB, striking like a thunderbolt in clear skies.

He was just back from the Democratic Republic of Congo (DRC), testifying to the by-yearly meeting of the EB attended by the 34 Member States delegations of countries this year (at the level of the minister of health, and/or the director of national health services, and/or director of international cooperation, and approximately the 30 representatives of non-EB members).

And just in case this startling fact escaped the attention of some dozing bureaucrats, Mike went on: “The mothers in Congo care a lot for their babies and young children, that is why they bring the babies into health centers whenever sick, they really really do care for them, and the children get contaminated in health centers… they come out with Ebola!” [1]

He testified as to the progress made in stopping the epidemics in many locations while highlighting that outbreaks still occur in some places.

Clearly, he was telling the world that there would be no Ebola epidemic if healthcare systems were not as filthy as they can be, and therefore were TRANSMITTERS AND AMPLIFYERS OF EBOLA, or of any other hard to treat disease for that matter!

Speaking to people on his way out of the EB room (reserved for state representatives as civil society members-such as myself, in a delegation with Medicus Mundi, as WAAAR is not yet accredited to the WHO-), Dr. Ryan explained how his WHO team were able to stop the epidemic in Beni and most other places of outbreaks by enlisting Congolese people to draft basic prescriptions on hygiene and Infection Prevention and Control (IPC) and enforcing them while training staff.

He added that waste management remains a big hurdle, as children are prone to play in open air hospital refuse, with used syringes and bloody remains!

Dr. Ryan’s statements were indeed all the more remarking that the role of health centers worldwide in the spread of hard to treat, or outright non-treatable and often deadly diseases, is hardly ever talked about except, sometimes, in the specialized literature.

The WHO website on Ebola throughout the massive epidemic that struck West Africa in 2014-2015 never even mentioned “patient to patient transmission” or the role of un-hygienic health centers and notably dirty injections.

Meanwhile, the media was then, and is today, full of articles on Ebola as the result of poor people’s ignorance (sic), refusal to admit disease (sic), or reluctance to bury their dead in our Western ways, resisting to healthcarers sometimes with extreme violence, at times destroying health centers. Such articles are too numerous to be listed here.

Back in November, Dr. Peter Salama, recently made the third Deputy Director General by the DG Dr. Tedros Adhanom Ghebreyesus, started to publicly mention the role of health centers as “transmitters” and “amplifiers” of Ebola, notably to children, but was cautious not to offend the RDC authorities in mentioning private unregulated health centers as transmitters. [2]

Dr. Ryan did not take such precautions and spoke of health care centers overall as guilty of spreading diseases.

Let us quote (1970s early Ebola discoverer) Susan P. Fisher-Hoch writing in 2005 on the history of nosocomial outbreaks of Virus of Hemorrhagic Fevers (VHF) such as Ebola, or Lassa, flaring up in Nigeria today, and other VHF: “Poor people are uneducated, not stupid. Even in the remotest settings, the community grasps very quickly that the hospital is where people become infected with VHFs, so they immediately desert the hospital, and even hide their sick from medical personnel. » [3]

In the light of Fisher-Hoch’s understanding, and considering that the region has been plunged into a horrible civil war, with 4 million women subjected to rape and torture as acts of war over the past decades, the fact that populations could engage in violence against Ebola teams is very regrettable, sometimes atrocious,  but hardly surprising. The press, there too, which massively covered the Nobel Prize to Dr. Denis Mukwege [4] , doesn’t place this violence neither in the context of dangerous health structures, nor of the war-like situation in this part of the world. We can only hope that the elections recently held be a harbinger of less violence in the DRC and the region. We can only admire those Congolese people helping to vaccinate, attempting to treat, trying to implement IPC in life threatening situations.

While there has yet to be an evaluation of the Merck Ebola vaccine efficacy, administered in concentric circles of contacts (and possibly soon adding other vaccines – the Russian EB delegation asked Dr. Tedros to do so), the fact is that massive efforts are deployed, and it may be the case that, without the vaccinations, we would already be in the 10 000 cases range as in Western Africa.

Dr Ryan could be the harbinger of a massive change in the WHO leadership on the need for IPC, which could come back to the forefront as a specialized department under the Emergency Health Department.

However, for that Member States would have to understand and fund that initiative.

How can governments talk of Global Health Security while ignoring the fact that filthy under-equipped health structures with staff untrained in basic hygiene procedure would have been spreading common disease, dangerous diseases (Hepatitis C, HIV, Tuberculosis, now Ebola) and the entire array of drug-resistant diseases (AMR infections) or, tomorrow, bioweapons?

Back in 2015, Dr. Brima Kargbo, Chief Medical Officer, Sierra Leone, explained to an overflow room side event at the UN: “Health carers who died of Ebola were not working in specialized Ebola centers, but in regular health care, because in the later there is not the minimum in terms of IPC, such as gloves, in those places.“

The event entitled:  “From Ebola to AMR: the Urgency of IPC” (May 2015 World Health Assembly, WHA, United Nations, Geneva) was co-chaired by the Republic of South Africa and the USA, a WAAAR initiative. [5]

From Ebola to AMR Infections, the role of health structures?

Just published in the Lancet Infectious Disease this fall, a thorough study by the European Centers for Disease Control – ECDC revealed that the majority of antimicrobial resistant infections were contracted in healthcare in the EU and associated European countries region in 2015: ECDC estimated that 426 000 patients contracted an AMR infection during care!

 “Findings From EARS-Net data collected between Jan 1, 2015, and Dec 31, 2015, we estimated 671 689 … infections with antibiotic-resistant bacteria, of which 63·5% (426 277 of 671 689) were associated with health care. (…)”

“Considering that, in our study, a large proportion of the burden was due to health-care-associated bloodstream, respiratory tract, or surgical site infections, and that more than half of health-care-associated infections are considered preventable, reducing the burden of antibiotic-resistant bacteria in the EU and EEA through enhanced infection prevention and control measures could be an achievable goal.”

Published in the Lancet, this study, signed by the Burden of AMR collaborative group of the ECDC, [6] was among the most discussed of AMR publications in recent years. However, unfortunately, the discussion centered on the exact numbers more than on the amazing fact: Health structures’ weak or non-existent IPC are largely responsible for the global AMR crisis!

We recalled the outburst of Dr. Dominique Monnet, Head, Antimicrobial Resistance & Healthcare-Associated Infections Programme of the ECDC, (among the co-authors of this 2015 new publication). We were in the last meeting of the DRIVE-AB in Brussels (fall of 2017), debating on Market incentives mechanisms and so forth, and from the round table, Dr Dominique Monnet drew the attention on the room to the basics, and took the risk of sticking out: “Without more efforts on infection prevention and control, any new antibiotics will be like pouring oil on the fire!” (quote from memory).

IPC neglected in national AMR plans to implement GAPAMR

The 2015 UN adopted Global Plan of Action on AMR (GAPAMR) placed Infection prevention and control on top of the agenda. But the UN General Assembly of 2016 on AMR largely ignored this with, I counted, 6 countries mentioning IPC out of over 120 in their statement.

In mid 2018, a meeting of all WHO regions representative experts estimated that there was a real dearth of action:

• Improved communication to policy makers who do NOT think that IPC is important is a key next step
• While IPC core components are important for any country, LMICs would benefit from guidance on minimum IPC requirements (which is not always as expensive as we think)
• Cost of not preventing HAIs (Hospital Acquired Infections) is very high
• Need more research and data on the economic case and cost of HAIs, cost-benefit and cost-effectiveness of IPC interventions
• Need to develop the case to demonstrate that IPC can be low-cost.

Yet another 2019 AMR Resolution

We are in 2019 and that same EB which heard the report on Ebola, or passed and drafted the very good resolutions on WASH (acronym for Water-Sanitation-Hygiene) and on Patient safety, also drafted a Resolution on AMR, which should make participants cry over the sacrifice of their lunchbreak meals (spent in side room debating) because it requires WHO and member states to do more monitoring of antibiotic (AB) use but nowhere does it mention that lack of IPC is the DRIVER of AMR epidemics worldwide.

In it, IPC and WASH are only mentioned as obvious ways to reduce the burden of infectious diseases. [7] Where are you Jim?

Jim O’Neill, in his remarkable AMR Review, had a much better understanding of IPC. [8] [9] see Chapter 6, with annex from the London School of Economics.

Yet, internally the WHO draft (not yet published) on Universal Health Coverage (UHC) and AMR, are excellently drawing attention to that fact. But not Member States declarations, because, coming from Ministries of Health, it is difficult to admit to being part of the problem!

A while back, notable author Dr. Timothy Walsh (discoverer of NDM-1 in India) with co-authors involved in AGISAR WHO, such as Dr Peter Collignon, wrote of CONTAGION as the master word to understand. They wrote that AMR infections spread is not correlated with antibiotic consumption but with risks of transmission either from un-hygienic health care centers or from the environment (lack of waste treatment for husbandry, hospital refuse or antibiotic pharmaceutical production units. [10]

And what of FECAL threat?

In the early years of our understanding of hygiene, the term “fecal threat” (Péril Fécal) came up first with the recognition that contamination from human or animal feces of hands, food, water, was the very important channel for the spread of disease.  It is surprising how Ebola contamination (and AMR diseases’ transmission) is just about never mentioned.

WAAAR Vice President and IPC French leader Dr. Vincent Jarlier pointed out that even in hospitals contamination with basins is neglected [11]

Meanwhile, our schools and public places toilets are filthy, even in the USA or the EU, and in emerging countries the situation is terrible.

Fecal threat is generally not mentioned in Ebola, notwithstanding the fact that Ebola victims excrete large quantities of virus in diarrhea/and vomiting and the risks of contamination via this route remain high, hence the space suites. The talk of “cuts” on carer’s hands is just ridiculous.

Studies on Ebola transmission show well that, in cases of intra-familial contamination, it is the carers in contact with excreta who get contaminated, from the 70s until today. [12]

Further, the WHO policy of concentric circle vaccinations with Merck’s Ebola rVSV-ZEBOV vaccine (and soon the Russian vaccines as well, if we understand well the 2019 EB discussions) appears to have reduced the number and intensity of the outbreaks.

In the case of AMR infections, the threats are so vast that, while indeed vaccines [13] need to be developed and used rapidly even in husbandry (the success story of salmon vaccinations), the dangers are really diverse and it’s hard to predict where next threat will come from. That means the threat to populations – in the absence of a massive IPC effort, with adequate funding ­­­- is much greater than vis à vis Ebola!

In a pre WHA meeting organized with the Geneva Global Health Hub, G2H2, and the WAAAR Alliance, we sought to spur awareness and brainstorming on these issues with about 50 NGOs represented in attendance. A debate round table was organized with two WHO leaders in AMR: Dr Marc Sprenger, head of AMR Secretariat and Awa Aidara Kane, lead of WHO AGISAR, with Dr. Murfin Purdue, head of REACT Africa and of the Ecumenical Pharmaceutical network.

It included our NGO President (and architect of our national 2015 Preservation of AB Plan) Dr Jean Carlet as well as Mrs Mireille Martini, economist from Finance Watch and the Stiglitz Commission.

I chaired and in introduction, I showed a Bamako 2015 video of the major hospital in an extremely disastrous state, a video done by angry health carers in the face of neglect, just 3 years ago. It speaks for itself. [14]

A review of the litterature would be of interest?

A through review of core topics addressed in the literature and top policy discussions or recommendations would probably come down to: 1) the need for new economic models, 2) the necessity for stewardship, better management of antibiotics, 3) the urgency to reduce AB consumption in human health, 4) the recommendation for patients to abstain from pressuring prescribers for antibiotics, from buying AB over the counter, and from failing to go to the end of their prescriptions (yet all studies point to the need to shorten prescriptions, which are more efficient and less wasteful when shorter), 5) the need to stop/curtail use and overuse of AB in agriculture, from meat to fisheries and from wheat to, even, bio fruits and vegetables (use of glyphosate, recently registered as an antibiotic, and use of streptomycin on bio fruit trees…), 6) reducing pollution of heavy metals and biocides,7) establishing waste management of AB production in emerging countries, 8) management of hospitals waste and 9) waste management of husbandry.

Then, perhaps, infection control would appear!

Among the many examples of priority settings on producing new ABs, the Recent Letter to the Senate [15]

The draft recommendations of the Interagency Coordination Group (IACG) are similarly conceived. The not-too-well informed policy maker will come away convinced that a better management of antibiotics and funding R&D for new products is the most important way to face the rise in AMR infections. Of course IPC is mentioned but it comes only second, in such a way as to understand that reducing infections will reduce the need for antibiotics, obviously true. But health structures are not presented as drivers of AMR outbreaks in communities!

The Ad Hoc IACG on Antimicrobial Resistance

The Ad Hoc Interagency Coordination Group on Antimicrobial Resistance, commonly known as IACG, just released its draft recommendations in January 2019 (to be presented to civil society on Feb 25 at the WHO for discussion). In them, access to antimicrobials and their prudent use come in as the first recommendation (A1), and IPC is subsumed under that:

Recommendation A1: The IACG calls on all Member States to ensure equitable and affordable access to existing and new quality-assured antimicrobials and their prudent use by competent, licensed professionals across human, animal and plant health.
This recommendation must be supported by efforts both to reduce the need for antimicrobials and improve access through:
a. Lowering the prevalence of infection through clean water, sanitation and hygiene;
b. Decreasing the likelihood of diseases and their spread through delivery of existing vaccines and strengthening infection prevention and control measures; “[16] 

IPC comes back and again in the text, but it is never said that poor levels of hygiene and unsafe injections, unsafe use of sharps, lack of workforce training, lack of investigations of outbreaks, lack of staff and especially lack of well trained staff, all of that does play the key role in AMR infections explosive spread globally. To repeat what Dr. Monnet said: Without strong IPC, new antibiotics will be fuel on the fire.

At present, all partnership initiatives focus on “new fuels” and superbly ignores the situation: degradation in the EU, catastrophic in LMIC. And similarly in agriculture: while calls to reduce AB in meat production is very important, notably for Critical AB, the urgency of not throwing waste into the environment comes in second, while it should be first.

Nowadays, in families in France or the US, all the talk is on the bad cold, the flu like illnesses or the mild to severe gastroenteritis making the rounds of the schools and how the children bring these back into families. CONTAGION is a household word. But in the sheltered areas of policy makers, the word contagion is basically ignored.

Member States Ministers of Health don’t understand the issues well yet, neither does not-for-profit civil society generally (always sharpening the knives on “access” but forgetting transmission), while among the private sector the pharmaceutical manufacturers dominate, while the IPC related industrial groups tend to complain in private rooms.

Hopefully, the WHO may take the lead in putting IPC as one of the core element to achieve real Universal Health Coverage!

India recently adopted a national IPC Plan within which antibiotic stewardship was integrated as a component. While it awaits each national Indian states endorsement and, above all, implementation (and big investments!), the thought was right: stewardship is subsumed under IPC as a necessary complement. Not the reverse!

We must protect patients, and carers alike. We must prevent dangerous viruses such as Ebola, Lassa, Nipah, Hep.C or HIV from being spread via health structures, and we must prevent antibiotic resistant infections from exploding via filthy health structures. Resisting and rolling back AMR threat demands it, and massive investments to that effect. After that we can talk of adding new antibiotics to our medical care armada. The reverse will only exacerbate the problem, as Dr. Monnet understood it, and could well mean a situation out of control.

Ben Stockton, with the Bureau for Investigating journalism, is an exception in the media, his articles on AMR are relevant and well conceived. I especially liked the one on the role of Water, which I saw after I had completed this article. See: https://www.thebureauinvestigates.com/stories/2019-02-13/ghana-superbugs-water
References and subparagraphs

[1]  One may still hear him directly in the live webcast, Jan 28th, second morning session, about 48 mn into the proceedings).

[2]  Huffington Post: Series of War Zone Attacks Puts DRC Ebola Outbreak On ‘Edge of Crisis’  and also https://www.huffingtonpost.com/entry/ebola-democratic-republic-congo-outbreak-second-largest_us_5bfdf54be4b0d23c21379bd7?guccounter=1

In the DG Tedros new organization of the WHO there are three very important Deputy DG. Dr. Peter Salama is directly on step higher than Dr. Ryan in the WHO hierarchy. The other two DDGs are the remarkable Dr Soumya Swaminathan, in charge of Programs, that is, with the very difficult role of implementing all that which the Member States want but are not ready to pay for, and the big UHC drive, and a lot of monitoring and accountability. Dr Soumya was previously the DG of the Indian Medical Research Institute.

And the English, Mrs. Jane Ellison, Deputy Director General for Corporate Operations.

[3] Susan P: Fisher-Hoch, British Medical Bulletin 2005; 73 and 74:123-137.           https://doi.org/10.1093/bmb/ldh054 

In her BMJ article she writes: « With the knowledge of the practices and consequences of poor practice in Africa, and now in Asia, we have to conclude that transmission of blood-borne viruses in medical facilities of all kinds is probably common within the endemic area of the haemorrhagic fever viruses. Indeed, hepatitis C virus (HCV) and human immunodeficiency virus (HIV) may be the viruses most commonly spread by this method. The difference with the haemorrhagic fever viruses is that the consequences of haemorrhagic fever viruses are immediately noticeable, whereas with HCV and HIV it takes years, even decades, for the transmission to be appreciated. »

Susan P Fisher Hoch was co-discoverer of Ebola when it first emerged in the mid 70s. Her book “Virus Hunters”, co-authored with husband McCormick is a must to read.

[4]  https://www.nobelprize.org/prizes/peace/2018/mukwege/55721-denis-mukwege-nobel-lecture-2/

[5]  WAAAR organized event with EB member and AFRO group leader the Republic of South Africa, the DG of Health Services, Mrs Precious Matsoso, head of delegation, and the USA WHA’s delegate representative, Dr Mitchell Wolfe (now at CDC Washington and then Deputy Assistant Secretary for Global Health). Besides WHO DG Dr. Margaret Chan, who gave a short introduction, the main speaker for WHO was Dr. Edward T. Kelley, Director Service Delivery and Safety.

[6]  “Findings From EARS-Net data collected between Jan 1, 2015, and Dec 31, 2015, we estimated 671 689 … infections with antibiotic-resistant bacteria, of which 63·5% (426 277 of 671 689) were associated with health care.(…)” 

Title of article: “Attributable deaths and disability-adjusted life-years caused by infections with antibiotic-resistant bacteria in the EU and the European Economic Area in 2015: a population-level modelling analysis”
Alessandro Cassini, Liselotte Diaz Högberg, Diamantis Plachouras, Annalisa Quattrocchi, Ana Hoxha, Gunnar Skov Simonsen, Mélanie Colomb-Cotinat, Mirjam E Kretzschmar, Brecht Devleesschauwer, Michele Cecchini, Driss Ait Ouakrim, Tiago Cravo Oliveira, Marc J Struelens, Carl Suetens, Dominique L Monnet, and the Burden of AMR Collaborative Group 5 Nov 2018, The Lancet ID.


A newsy report on the above: https://ecdc.europa.eu/en/news-events/33000-people-die-every-year-due-infections-antibiotic-resistant-bacteria

[7]  http://apps.who.int/gb/e/e_eb144.html, see RESOLUTION EB144/R11

[8]  AMR Review, https://amr-review.org/Publications.html, see Chapter 6, 22 March 2016 – Infection prevention, control and surveillance: Limiting the development and spread of drug-resistance, with annex from the London School of Economics (Study by LSE Master’s in Public Administration students on the cost and benefit of WASH interventions in Brazil, India, Nigeria and Indonesia main report.)

[9]  Interview with Lord Jim O’Neill in AMR Control http://resistancecontrol.info/introduction/is-that-all-very-little-investment-needed-to-save-us-100-trillion-in-amr-costs/http://resistancecontrol.info/introduction/is-that-all-very-little-investment-needed-to-save-us-100-trillion-in-amr-costs/

[10]  « Reduction of antibiotic consumption will not be sufficient to control antimicrobial resistance because contagion—the spread of resistant strains and resistance genes—seems to be the dominant contributing factor. Improving sanitation, increasing access to clean water, and ensuring good governance, as well as increasing public health-care expenditure and better regulating the private health sector are all necessary to reduce global antimicrobial resistance »

Title of article:  Anthropological and socioeconomic factors contributing to global antimicrobial resistance: a univariate and multivariable analysis
Peter Collignon, John J Beggs, Timothy R Walsh, Sumanth Gandra, Ramanan Laxminarayan. Lancet Planet Health 2018; 2: e398–405 https://www.thelancet.com/journals/lanplh/article/PIIS2542-5196(18)30186-4/fulltext

[11] https://waaar.org/node/100

http://resistancecontrol.info/amr-control-2018-contents/ Page 42 «CONTAINING CROSS-TRANSMISSION OF MULTI-RESISTANT BACTERIA: A PRIORITY FOR CONTROLLING RESISTANCE IN HEALTHCARE CENTRES». Also in the original French, whole book visible at https://view.pagetiger.com/AMR/AMR2018 page 100.

[12]  Bulletin of the World Health Organization, 61 (6): 997-1003 (1983) Ebola virus disease in southern Sudan: hospital dissemination and intrafamilial spread. ROY C. BARON,’ JOSEPH B. MCCORMICK,2 & OSMAN A. ZUBEIR

[13]  http://resistancecontrol.info/2018-uk-contents/ See page 60,  Chatham House

Establishing the importance of human and animal vaccines in preventing antimicrobial resistance

[14]  Report on the event :  http://amr-times.info/ and (www.g2h2.org),

The Bamako video (in French but easy to understand in watching): a striking video of Gabriel Touré Tertiary Hospital in Bamako, Mali / extravagant level of…filth! https://player.vimeo.com/video/135319492

2013: 110 000 cases of hospitalized patients / Hospital has 450 beds, it is the main tertiary care hospital of the country. Hospital waste are dumped in the courtyard along with human feces, all toilets are clogged up and closed, garbage is not collected except by families of patients… Premature babes sleep on the floor! And health staff is angrily testifying of neglect!

[15]  See the « Joint Letter to the Senate-Help and Finance re-economic Incentives for antibiotics, Feb 5, 2019, which can be read on: https://www.pewtrusts.org

[16]    https://www.who.int/…/Draft_IACG_recommendations_for_public_discussion_29011…