Without any doubt, it is a success for South Africa, India and other co-sponsors of the TRIPS Waiver proposal, along with progressive political, professional and civil society voices, that the United States of America changed its position on the TRIPS Waiver. The waiver proposes a time-limited waive of patents and other rights related to essential health products for COVID-19 in the World Trade Organisation (WTO) TRIPS agreement.
The TRIPS Waiver proposals are now moving to text-based negotiations. If historical experience on access to medicines and the current power relations are anything to go by, the waiver proposers have grabbed the tail of the proverbial tiger in pushing for more distributed production of vaccines, diagnostics and therapeutics. What is to be done now that the US has agreed to talks?
It is important to understand that this stage does not represent agreement on the waiver. It has now merely advanced as an agenda item for discussion. The terms of the waiver have yet to be worked out. Even once agreed, implementation demands rapid support to increase production capacities for the range of products and systems that are able to distribute them, particularly in resource constrained settings. For all products covered, and particularly for vaccines and therapeutics, the waiver time frame and production capacities would need to be able to deal with current and emergent viral mutations and the updates required for a potentially endemic situation of an evolving virus.
Much remains to be done and the convergence of progressive forces that have pushed the waiver to this point need to robustly take on these remaining challenges to realise equitable access to vaccines, diagnostics and therapeutics.
The text-based negotiations and counter-lobbying by big pharma and others pose a risk of the proposals being diluted. As faced by HIV treatment activists in struggles over access to medicines, the proposals will face an incremental detraction from the largely wealthy countries seeking to preserve economic interests. Germany, the influential European power, remains opposed to the waiver, notwithstanding the US change in position. The tables seem to have turned on this. In the HIV-related Doha negotiations in 2001, the US played the ‘bad cop’ and the Europeans the ‘good cop’. While the European Parliament is largely supportive of the waiver it has limited legislative power, as intellectual property is in the European Commission’s domain. Further, the US trade representative to the WTO has said these negotiations will take time, as if they and not they virus are setting the timeline.
Already, the revisions that South Africa and India have made point to some of the areas that may be weakened: The duration of the waiver, with proposals for 3 years subject to renewal, must be adequate for the distributed transfer of capacities in an evolving situation. The necessary scope of technologies -vaccines, diagnostics, medical devices and therapeutics – is in the revised text and should not be whittled down. It is unclear if it will apply to patents only, or as in the current waiver proposal, to other key elements of intellectual property such as trade secrets, industrial designs and copyright.
The struggle for access to HIV-related medicines has much to teach. Two agreements were reached at the WTO, the 2001 Doha Declaration on Public Health, and the 2003 ‘August 30th Decision’. Both were victories to build on, but proved to fall short in meaningfully addressing access. They allowed rich countries that could not be seen to deny access to HIV treatments to virtue signal, but sustained hurdles for countries in applying the flexibilities they provided. This largely sustained dependency on imports for the lower income countries most affected by HIV.
The Doha declaration did establish the important principle of trade agreements being “interpreted and implemented in a manner supportive of WTO members' right to protect public health”, and levered improved, albeit not universal, access to HIV-related medicines. But, as the current pandemic has shown, they do not provide adequate measures for vaccines, diagnostics and other technologies essential for a public health response, and did not adequately shift priorities, power or production capacities to address unfair barriers in global trade rules to meeting public health challenges.
While the World Health Organisation (WHO) Director General has stood fast in articulating support for the waiver and called the inequity in vaccine access ‘vaccine apartheid’, WHO has less power in this debate and lacks the enforcement mechanism that the WTO has for its rules. WHO was out-manoeuvred by the Gates Foundation and rich countries’ preference for the ACT-Accelerator and COVAX at a time when the deeper proposals for patent pooling and technology transfer were made through the COVID-19 Technology Access Pool (C-TAP). The delay in enabling distributed production and weakness of COVAX is already evident in the shortfalls in supplies reaching low and middle income countries through COVAX, more sharply now with the pandemic demand in India restricting vaccine exports. The African Union recently warned African countries that delays in supplies may mean that they will need to restart their two dose vaccine programmes, or complete them with one dose vaccines that may not be distributed until late 2021. This global failure to meet health need makes virtue signalling on solidarity at the same time as self-protecting a profitable system reliant on patents and other monopoly rights particularly hollow. This is especially so in the context of the massive amounts of public funding that enabled innovations and the public support in opposing high income western countries for the waiver.
It can of course be argued that diplomacy involves compromise and that radical change demands sustained struggle. But the process is itself taking place in a space that is biased towards existing wealth. Negotiations at the WTO run on arcane principles and are largely not transparent. The rich countries hold much sway, including through supportive WTO officials. Important negotiations take place in so-called ‘green rooms,’ where experience indicates that consensus is achieved largely by excluding dissenters from the table. A current proposal by some high income countries to prioritise voluntary licensing arrangements as a solution is a symptomatic treatment, still under the control of big pharma, fails to address the causes of import dependency in Africa and other low and middle income countries and should not be used as a lever to delay or focus attention away from the waiver.
Proposers and supporters of the Waiver have grabbed the tail of the tiger. If the proposals are to avoid a death by a thousand cuts, this is the time to intensify focus. The transparency of these negotiations at the WTO and active vigilance, support and sustained activism will be essential to ensure that the outcomes achieved protect the public health rights and aspirations that have been behind the TRIPS Waiver to date.
Editorial
The Independent Panel for Pandemic Preparedness and Response (https://theindependentpanel.org), tasked by WHO with reviewing the global management of the COVID-19 pandemic has fulfilled its terms of reference. But despite the best efforts of the panelists, it did not meet the moment. The world might still need an Independent Panel -- but one that is transparent, accountable and participatory.
This Independent Panel report does summarize many of the issues the world has witnessed in the past 14 months: weak pandemic preparedness, lugubrious bureaucracies, and government passivity. It poetically describes global inequalities, including the stark sacrifices of healthcare workers. However, its narrow recommendations sidestep many of these tough challenges in favour of expanding global governance: a Global Health Threats Council with heads of state, adopting new global statements and treaties, greater funding and authority for WHO, and a massive new $10 billion pandemic financing facility. It calls for countries to unite to establish a new international system for outbreak monitoring and alerts.
Some of these recommendations are sensible, others less likely, but in seeking to avoid assigning blame, the panel ducks accountability, and its vision falls short of the scale of the problems revealed by COVID-19.
The recommendations on vaccine access exemplify this. The panel urges funding for COVAX, a worthy goal; but COVAX’s 20% coverage targets cannot reach global herd immunity and prevent the spread of potentially dangerous new variants, and there is no clear plan for the remaining 80%. The panel called for high-income countries to speedily negotiate an intellectual property waiver and donate 1 billion doses by September 1 to low- and middle-income countries. Given the global need of 10 billion doses today, as Madhu Pai argued in his powerful intervention at the launch event of the report, this is vaccine charity, not vaccine equity. The panel does not address the stark inequalities among countries that have fueled the virus.
Troublingly, considering that several of the panelists have been outspoken human rights advocates in the past, the Independent Panel also sidestepped numerous grave human rights abuses in the COVID-19 pandemic: praising the world’s most brutal authoritarian lockdowns as models, without a single caveat about government overreach. In particular, as critics have pointed out, the report omits mention of Chinese suppression of health data, though it is well-documented that this has caused numerous real headaches for WHO.
In March 2020, China’s State Council cracked down on independent research, issuing a directive requiring political vetting of any research on the coronavirus. A Chinese scientist publishing the coronavirus genome sequence on an open platform had his laboratory closed. Over 800 Chinese individuals were sanctioned by police for COVID-related speech, and individual citizen journalists were disappeared while patients who organized online had their chat groups deleted. This is all consistent with the modern history of China’s health system struggling with whether to report up or censor outbreak alerts, from HIV to SARS to, most recently, H1N1.
Given this tortured history with health data, which has been repeated in other countries, it would have been reasonable for the Independent Panel to query when and whether the world will learn of the next outbreak of a new virus. If a UN panel cannot state that suppression of scientists is incompatible with the International Health Regulations, or even with the founding principles of the UN itself, how many doctors might hesitate to blow the whistle?
However, this aversion to sensitive political realities threads through the report, which mentions human rights only once, at the end. The report does describe staggering global inequalities, but without recommendations, though these could have been drawn from many sources: guidance from the UN Human Rights Office, from UNAIDS, from global associations of nurses and other medical workers, or even from the panel’s own commissioned background papers .
These omissions are concerning, but rather than blaming the panellists, we might reflect on the largely closed process. A process grounded in a robust, public consultation with civil society and community voices, frontline health care workers and trade unions, might have produced a different result.
To put an end to and recover from a catastrophe on the scale of COVID-19 requires greater scope. A democratic and public review of what happened and what did not happen in each region, with the public participating to reflect on what we lived through and bore witness to, could build the global public momentum for real learning and change.
Such open and transparent processes have taken place effectively as part of transitional justice in many countries. For example, we can reflect on the Global Commission on HIV and the Law: a global commission on a pandemic hosted by UNDP, it included regional desk reviews based on open submissions, public hearings recorded and archived online, and participation of community activists, who could then use the recommendations and tools that came out of the process to advocate for law and policy reforms at the national level. Its reports continue to be a reliable – and independent -- resource for scholars, officials, policymakers and activists.
An independent commission on pandemic policy could enable wider consultation that creates a lasting historical record, greater trust in science, and a global movement for transformational change. Are we ready to face the difficult truths that such a panel might show us?
This oped is reproduced with permission from Geneva Health Files Newsletter #57 (https://genevahealthfiles.substack.com/p/at-risk-covax-plans-to-vaccinate ) The report of the Independent Panel for Pandemic Preparedness and Response ‘COVID-19: Make it the Last Pandemic’ is included in this newsletter issue and the launch of the report can be viewed at https://www.youtube.com/watch?v=_-OSqIrF0qA&t=2662s. Please send feedback or queries on the issues raised in the oped to the author at sara.davis[at]graduateinstitute.ch.
There is no doubt that the COVID-19 pandemic has affected working people. In September 2020, the International Labour Organisation (ILO) reported that beyond workers exposure to COVID-19 infection in their living and working conditions and experience of COVID-19-related disease, workplace closures and job losses have significantly reduced workers’ incomes.
An EQUINET information sheet included in this newsletter, produced jointly with the Southern African Trade Union Co-ordination Council (SATUCC), outlines how COVID-19 has affected working people in the East and Southern Africa region, and the responses to these impacts.
Publicly reported data on COVID-19 is not disaggregated by economic activity or occupation. It is thus difficult to know how the pandemic has differently affected different categories of workers. Health workers (HWs) are, however, widely understood to be at greater risk of infection due to the nature of their work, especially when they work without adequate personal protective equipment (PPE) or in conditions that lack adequate infection control measures.
However other workers are also at risk, such as those who work in crowded, poorly ventilated workplaces. The Minerals Council of South Africa reported in June 2020, for example, that mineworkers had twice the rates of infection than the general population. Carers, vendors or service providers who are in common contact with the public may also have higher risk of exposure. There is a gender dimension to this, as many of these workers are women. Most HWs are female and African countries that disaggregate their data found that 72% of all HWs testing positive for COVID-19 were women.
Migrant labour is common in the region. Migrant workers have faced challenges in accessing services or been trapped when lockdowns close borders on them. Border closures and costs of testing can lead to crowding at borders and an increase in use of irregular travel routes across frontiers, as was reported when migrants returned home at the end of 2020.
While remote work is indicated as an option to prevent transmission, only about 10% of workers are estimated to be able to do this in the region, largely those at higher incomes who can afford data charges to the internet. This is not possible for most workers. While workers are increasingly aware of what raises their risk of infection, the precarious nature of many jobs and incomes in the region mean that many continue to work in environments that they know put them at risk. As a union official from the metal workers union in South Africa (NUMSA) noted: “The workers are aware that these are extremely dangerous spaces, but decide to risk it simply because they don’t have the means to stay in isolation, feed their children, or care for themselves without due pay.”
Beyond the risks of infection, the response to COVID-19 has raised its own stresses for working people. Lockdowns and blocks in supply chains have disrupted jobs, livelihoods and mental health.
A SATUCC study found that by mid-2020 over 42 000 labour contracts had been suspended in Mozambique; 680 000 employees had lost jobs in Malawi, and 70 000 in Zambia. An East African Confederation of Trade Unions (EATUC) assessment found that already by mid-May 2020, one million informal jobs and over 200 000 formal jobs had been lost in Kenya in the wake of the pandemic. The pandemic meant that 68% of people with disabilities in Kenya were not able to work and perceived their jobs to be insecure due to their disability. Where COVID-19-related messages have induced fear of outsiders, migrant workers may be stigmatized. Migrant job losses are reported to have reduced remittances that many families in the region rely on.
There is now guidance, including from the ILO and World Health Organisation, on the public health, workplace infection control and personal protective equipment measures required for different employment settings. Some ESA governments have also reduced income tax and VAT, provided wage subsidies and distributed food and other basic goods, as important areas of support for working people.
However, there has often been a gap between guidance and practice, and schemes have not always reached the most insecure workers who need them the most. HWs in Zimbabwe, Kenya and South Africa have protested over lack of PPE, and the ILO reports that migrant workers often do not access the testing, treatment, wage subsidy and other social protection measures that are provided to other workers. Informal sector workers have difficulties with the formal documentation that social protection systems ask for. Vital information does not effectively reach workers with disabilities if it is not made available in sign languages, video captioning, or other forms that they can access.
Trade unions have engaged on these issues, even though the pandemic has undermined union communication and operations. Beyond their contribution to national task forces on COVID-19 in some countries, unions have engaged when employers have taken wage subsidies but still imposed unpaid leave on or retrenched workers, or failed to provide PPE. Unions have also flagged wider concerns, such as how the conditions accompanying with international funding of rescheduled debt repayments may further undermine employment and the funding of public services.
While there is now a significant focus on access to vaccines and technologies, a comprehensive public health response to the pandemic, including to distribute vaccines, depends on formal and informal, male and female workers from many sectors, and the full involvement and protection of communities.
This link between workers and communities is fundamental. As a union shop-steward noted in the recent Alternative Mining Indaba, “in the day I am a mineworker, but when I go home to my family I am the community.”
Working people of different types fill the gaps in the social protection systems in the region so that vulnerable people in communities are not further impoverished by the pandemic. The economic recovery that is now critical in our region will not be possible without workers and communities. It will also not be meaningful unless it is a recovery of the productive opportunities, jobs, incomes, capacities and protection of all working people in the region.
For emerging public health professionals like ourselves, the COVID-19 pandemic has lifted a smokescreen on inequities in health and made clear that we need to invest in and strengthen our health systems. While the pandemic is all consuming, other challenges have not stopped, and we face public health demands on many fronts. Antimicrobial resistance, social injustice, forced displacement, non-communicable diseases, and climate change are real concerns.
While it should not have taken a pandemic to provoke self-reflection, it has opened a window of opportunity for new thinking, to transcend silos that have traditionally existed within public health, and to re-imagine a world where health systems work for all and not just for some.
This takes leadership. So as emerging public health professionals in the International Working Group for Health Systems Strengthening (IWG) we have been exploring and stimulating open discussion between ourselves on what it takes to build the sort of bold, committed, responsible and innovative health leadership that can face such challenges in a world that we see as ever-changing and often chaotic. We also do this by learning from health trailblazers that have accumulated experience, such as in a fireside chat we held at the end of 2020 on the theme ‘Looking Back, Looking Forward’ (at https://iwghss.org/2021/02/09/iwg-fireside-chat/).
These interactions have pointed to the importance of core values as the basis for a leadership that can guide efforts and rally others to collaborate on a common cause. We have seen how public health efforts to tackle challenges advance when collective success is valued over individual success. In public health, the success of one requires the success of many. We also understand that health leadership means building people-centered comprehensive public health systems, where public health professionals consider, dialogue and work with the members of the community as the most critical aspect of every intervention or initiative they work on.
These insights led us to reflect on what health leadership means for us as emerging public health professionals, as we move forward on our career paths.
First, we believe that we need to understand the history that lies behind today’s realities and power, if we are to understand how the work we do will confront or shape this distribution of power. For example, colonial legacies that informed the emergence of global ideas in health persist today and continue to affect power imbalances across gender, race, and geography, among others. We see this when northern institutions and knowledge sources frame the dominant narrative in a way that minimizes the rich history of leadership and innovation in the global south. It is our responsibility to understand this history of health and development and what it has meant for public health today, to shape the actions we take.
Secondly, in our reflections, we perceive that we must constantly return to our values and convictions. These are not just words to write down, but actions to live by, whether in the organizations we work in, the work we do, or in our interactions with people. For example, ‘respect for diversity, equity, and equality’ is a core value for IWG, so we see that we need to reflect this in our own processes, by giving space for different perspectives, and co-producing outcomes that are the result of a united team effort that captures the diversity among all our members.
Finally, in the face of pressures to compete, we see finding your team and collaborating as a critical feature of leadership in health. Health systems that work for all need diverse, empowered voices that work as a team, where we keep asking who is at the table, and more importantly, who is not at the table; and why. Having a collaborative, interdisciplinary, diverse team seems to not only strengthen practice, but also to mitigate blind-spots that may otherwise be ignored, particularly in efforts to advance justice and equity.
As emergent public health professionals we appreciate that the field we are in is complex and dynamic, but also fulfilling. What we think and do now is shaping our futures, but also the future of public health. Ultimately, it is up to each of us to be the change we want to see around us. The pandemic has opened a window of opportunity for us to step up and step into a more just vision for public health. Now, it is our turn as young professionals to make that vision happen.
Please send feedback or queries on the issues raised in the two editorials to the EQUINET secretariat: admin@equinetafrica.org.
The COVID-19 pandemic and its socioeconomic consequences have affected all Eastern and Southern African (ESA) countries. The long-term impacts still remain to be seen. While COVID-19 affects everyone, it does not affect everyone equally. It has entrenched and exacerbated the extreme inequalities and injustices that existed before the pandemic.
The collective insecurity generated by the pandemic requires a decisive public health response. This response has, however, tended to apply centralised, top-down and undemocratic decision-making, often using ‘war’ narratives that prompt or reinforce fear, and that promote individual self-protection. Reactive interventions have not adequately taken local conditions and rights into account, prevented longer-term harms to health, including from gender violence, nor protected income, food security or social trust.
However, the pandemic also offers an important opportunity to demonstrate that alternative, people-centred, democratic and collective responses are possible. Indeed they are essential, not just to prevent and contain infection and mitigate the impact of the pandemic, but also to ‘build back’ using a stronger, more compassionate and equity-driven form of public health.
In October, EQUINET published 42 case studies of community action on COVID-19 that collectively demonstrate examples of this (see https://tinyurl.com/yxrekzre). The case studies come from different settings, income levels and dimensions of the response. They show innovative and solidarity-based approaches to prevent and care for COVID-19, to address social needs and hold states accountable. They provide a powerful argument for public participation and collective action in health.
One of the case studies, the Cape Town Together Community Action Network (CAN), tells the story of a self-organising network that emerged in March 2020 in South Africa as a community-led response to COVID-19.
In early March, it was clear from other countries that formal responses would struggle to keep up with the pace of the virus. As a network of autonomous, neighbourhood-level groups working together to respond to local challenges as and when they emerge, Cape Town Together felt that bottom-up community organising could spread faster than the virus and could rapidly identify and respond to its emerging health, social and economic impacts.
The Community Action Networks (CANs) actively work against a tendency to centralise planning, decision-making and management. They reject hierarchies of knowledge, resources and power. Each neighbourhood CAN operates independently and autonomously, while drawing on the collective energy and wisdom of the network as a whole. The hyper-local nature of the CANs allows for street-level organising, reminiscent of anti-apartheid activism. Generosity, trust and solidarity are important foundational principles. The CANs prioritise relationships over bureaucracy. They are enabled by inter-personal connections built during lockdown conditions largely through online co-learning, WhatsApp groups and Zoom meetings.
At the peak of the pandemic this decentralised, self-governing structure provided vital support where formal social safety nets failed, including public health guidance, mask-making clubs, community gardens, community care centres for COVID-positive people who could not safely self-isolate at home, and food and medicine deliveries to elderly people.
A few weeks after South Africa initiated its hard lockdown, 47% of households were suffering from extreme food insecurity. Across Cape Town, CANs distributed food parcels and established community kitchens. With rapid communication across the network, CANs shared experience and resources, learned from each other and worked with public health services to follow COVID-19 safety protocols in the community kitchens. Beyond the hot meals provided, the community kitchens became safe, organic spaces, enabling protective behaviours and information sharing. They responded to local social needs in a way that was inclusive, welcoming and free of stigma and shame.
The CANs generated community-level intelligence. In their inclusion of community members, researchers and local public servants, they enabled informal communication. They built trust between communities and health system actors, through dialogue and co-learning forums between CANs and health sector decision-makers. They made input into educational materials developed by the health department. With the lived local realities of those most affected by the pandemic often very different to that of health department officials, these connections proved invaluable in framing appropriate measures.
The CANs aim to support and not substitute state efforts, and this was initially possible. However, the shortcomings within state efforts became a subject of an increasingly politicised debate. For example, some CANs and local civil society organisations formed a coalition that protested the unlawful eviction of residents in informal settlements. Political actors reacted by asserting that the CANs were acting unlawfully and presented a political threat. When another CAN renovated a badly vandalised and unused public community hall, the local ward councillor accused them of unlawfully occupying the space.
Such tensions may be inevitable where community initiatives highlight deficits in state responses and provide different approaches. Bottom-up initiatives such as the CANs call for and contribute to alternative forms of governance that celebrate, enable and invest in community-led public health responses.
The case studies in the EQUINET report show that community-engaged and -led responses and relationships are more likely when they build on prior histories of social networking and organisation around social justice. The relationships, the citizen scientist and activist leadership, the connections with public, professional and civil society organisations and prior activities on different dimensions of wellbeing enabled a relatively rapid, collectively-organised range of health responses to the pandemic. Information technology was used to organise collective understanding and action. The case studies also show the importance of investing in comprehensive primary health care systems for an effective and equitable response to pandemics. If we continue to frame our health systems only in terms of efficiency-led measures to treat particular diseases and top-down responses to emergencies, we weaken the ability mobilise the relationships, capacities and creativity within communities, networks and service personnel, or the multi-sectoral responses needed to prevent and address the many health challenges we face from such crises.
We hear many negative stories about COVID-19. Yet these compassionate stories of equity, rights-driven and holistic responses also need to be documented and told. They show a solidarity-driven response to COVID-19, and that people are subjects not objects in health.
Please send feedback or queries on the issues raised to the EQUINET secretariat: admin@equinetafrica.org. For more information on the CANs please visit the https://capetowntogether.net/ and https://www.facebook.com/groups/CapeTownTogether
A growing group of public health, social justice and human rights advocates, including a number from EQUINET, have released a Call to Action to heads of state and government at the 3-4 December UN General Assembly Special Session on COVID-19 to promote comprehensive, equity-focused and participatory public health approaches in countering the pandemic, drawing on and using diverse sources of knowledge, disciplines and capabilities.
The Call builds on a recent commentary by on Reclaiming Comprehensive Public Health in BMJ Global Health (the link is included in a later section in this newsletter) and contributions by a group of people working in public health from different regions globally, including a number from east and southern Africa. Over 250 individuals and leading organisations and networks have signed the Call so far and signatories are still invited. The full Call is at https://bit.ly/RCPHcall together with a link to sign on and other resources.
Equity issues infuse our experience of COVID-19 in the region and globally. It should also infuse the response.
It is not well measured in the aggregate data commonly reported, nor in the media profile given to individual cases in elite groups, but COVID-19 spreads through and worsens social inequality. While the first spread of the pandemic may have come through richer, more mobile people and while all social classes have been affected by COVID-19, it would appear that the spread of the coronavirus exploits and exacerbates the social inequalities in the way we live, work, trade and travel in the region.
People living in lower income areas are often crowded in smaller, poorly ventilated homes, with many generations living in the same crowded home, without safe water supplies to wash hands and immune systems are already battered by undernutrition, infectious and chronic diseases. Crowded transport systems, dusty, poorly ventilated working environments and pollution from cooking fuels and houses sited near landfills and industries raise the risk of respiratory diseases, asthma and occupational lung diseases, making people more susceptible to severe effects of the virus. If resilience refers to the ability to restore the ‘normal’ that we had before COVID-19 and all the inequalities that put people at risk, then we should not aim for resilience. We should aim for change.
There are also social inequalities in a response to COVID-19 that provides less access to and continuity of care for COVID-19 and other health problems. It raises burdens on those who are already more vulnerable. As is happening in all countries affected by austerity, the chronic underfunding of and weaknesses in our public health services undermine care for poorer communities and protection of the health workers who work in them, notwithstanding the efforts being made by health ministries and other stakeholders. Private providers have expanded their role, but often without adequate public co-ordination and leadership and generally unaffordable for low income communities and enterprises. As noted by UNFPA, women represent a large share of health and social sector workers who are more at risk, while increased household tensions during lockdowns are increasing domestic and gender violence.
We are learning that a well-funded public health infrastructure is essential to keep all healthy and safe, that investing in prevention is primary and that transparency on resource flows is critical. Globally, with protectionist responses from high income countries, patent barriers and past policies of importing rather than locally producing medicines and other health technologies in the region, ESA countries, like poor households, are last in the purchase queue. ESA countries are often dependent on charitable contributions or rising debt to obtain health technologies that should be regarded as a right and as public goods. Global mechanisms that depend on charity and two tier systems risk aggravating inequality in access across countries.
Without a vaccine, the response has largely been one of command and control, sometimes militarised, putting whole sectors, areas and communities into lockdown. Many households in the region already live hand-to-mouth and do not have the social security to stop work, or the means to work remotely, so lockdowns increase income inequality. Restrictions on public transport without safe alternatives leave poor households trying to reach essential services stranded. Macro-economic concerns have motivated formal sectors like mining to restart, but do not address these socio-economic insecurities in more marginalised communities. Migrants returning home or located away from home are sometimes stigmatised and treated more as a public health risk than a vulnerable community.
These inequities call for local, national and regional responses. Social isolation measures have proved critical for the technical response to COVID-19. Yet for people who are compelled to work to secure daily incomes for their families, dialogue to find the best ways to protect both public health and livelihoods would seem to be more effective and sustainable than criminalising their actions. A biosecurity, top-down, secretive and militarised response to COVID-19 in the name of public health damages the trust, participation and collective solidarity that are essential for effective public health. In part this reflects whose knowledge and experience counts. Importing modelled concerns from high income countries on the adequacy of hospital resources can focus attention away from areas that the specific epidemiological and health system conditions in the region demand. While journal articles and scientific advisors compete for political attention, the experience, ideas and agency of those directly affected by the epidemic is often marginalised.
Yet there are many positive experiences in the region to report. Public officials, health workers, volunteers, including community health workers and health facility committees, have worked overtime to reach households, trace contacts and organise responses. Communities have formed solidarity networks to support vulnerable households with food and care and have held the state accountable for interventions. Parents have schooled children and teachers have found alternative ways to teach students during lockdowns. Small enterprises and local universities have produced affordable face masks and other technologies; local producers have switched lines to produce ventilators and local artists have produced music and murals to promote social awareness. Communities have provided support for returning migrants; diaspora and local people have crowd funded for support initiatives and local enterprises have contributed to solidarity funding of health technologies. COVID-19 has provoked social attention on health worker and gender rights. It has shown that ignoring social inequalities in health and their determinants and under-investing in comprehensive primary health care and public health threaten our society and economies as a whole.
We need to measure, publicly report on and visibly address these dimensions of inequality and to integrate the experience and ideas of all those affected. Not doing so undermines the effectiveness of our current and future responses. As Anand Giridharadas has said: “Your health is as safe as that of the worst-insured, worst-cared-for person in your society. It will be decided by the height of the floor, not the ceiling”. Even while African political leaderships are calling for global leaders to stop the debt outflow and patent and procurement barriers that are undermining responses within the region, we need to also confront the inequality that COVID-19 is intensifying within our countries.
So we are reaching out to you! Are you working on or concerned by any of these dimensions of inequality? Are there others that you want to raise? If so, please share your concerns, ideas and work! As a community that promotes equity values, EQUINET would like to learn more, share more, inform and voice more on these issues. If you have blogs, webinars, poems, art, stories, case studies, published work or videos on these issues or other equity concerns in the region that you want to share, please let us know so we can provide a platform to share them. Let us know if there are interesting case studies that we can support, or if you have ideas for joint work with EQUINET. Send feedback to us by email or on the feedback form on the EQUINET website and we will follow up with you.
The pandemic is a threat. It must also be an opportunity in our region to confront conditions and mantras that have generated the worsening inequality, rights violations, precarious labour, capital outflows, underfunded and commercialised systems and ecological decline that make us vulnerable to epidemics and that undermine capacities to respond in our collective interest.
We welcome your feedback on the issues and invitation in this oped – please send them to the EQUINET secretariat: admin@equinetafrica.org. Please visit our website for information sheets produced by EQUINET.
In the past two months, drawing on a diversity of inputs, EQUINET has produced a series of information sheets on different aspects of COVID-19 in ESA countries. For 1st June we take a pause on these information briefs to send out our regular quarterly newsletter, with thanks to the newsletter team for meeting the challenges of co-production from various corners of a lockdown. Given the context, there are many articles and resources in the newsletter relating to COVID-19, but there are also those relating to other health challenges and health system developments that continue to be present, to offer learning and to demand attention in our region.
Yet we are in a crisis, not understood as an event to recover from, but in the way the Chinese word for crisis brings together two characters – “wei ji”, with wei standing for danger and ji standing for opportunity. A crisis to learn and change from.
Different dangers and risks in the COVID-19 pandemic are emerging and are the subject of an explosion of information and exchanges across countries, institutions and disciplines. The information exchanges range from stories of lived experience, responses and ideas to evidence from trials, information systems, global case tracking, reviews and analyses. Constrained by size, the newsletter only points to some of these in the region and many many more are reported daily in different platforms.
The pandemic tells us a lot about the status of our societies. COVID-19 has shown us how globalisation has opened up multiple digital channels for information to flow, how scientific collaboration can rapidly advance and share knowledge and how communities show solidarity, initiative and empathy.
It also shows where there are gaps. We talk about the poorest but the voices of the poorest communities and poorest countries are often overshadowed or absent, sometimes even silenced by the very responses to COVID-19. We see the limits in global solidarity as many African countries struggle with the diversion of critical resources to debt repayment and fail to access key diagnostics and medicines. We talk about causes, but treat each outbreak, including COVID-19, as disconnected emergencies, delinked from their deeper, sustained and common drivers in the nature of production and commercial systems, in the destruction of habitats and biodiversity and in the lack of investment in basic standards of water, sanitation, housing, clean energy and other public health inputs, drivers that converge to expose significant concentrations of people to new and old pathogens and to repeated pandemics. The 2008 Commission on the Social Determinants of Health used to say of the health sector “we cannot keep treating people to send them back to the same conditions that made them ill”. It seems we need to expand this to “we cannot keep responding to public health and climate emergencies and sending ourselves as a global community back to the same conditions that led to them.”
There are also signs of opportunities for recalibrating this pathway that is externalising and distributing pollution, climate change, precarious employment, different forms of malnutrition, pandemics, violence and other harms that threaten us as a society and as a species. The online conversations often flag responses to COVID-19 that work with and support communities and local health workers as more successful, especially when built on prior investments in distributed primary health care and socio-economic well-being. There are items in the newsletter that raise similar themes around responses to HIV, health workforce management or gender based violence.
But recalibration also needs to take place at global level. The recent World Health Assembly (WHA) resolution on COVID-19 (included in the newsletter) refers to vaccines as a global public good (implying free from intellectual property protection). There is also a link to a call from leaderships from across all regions that COVID-19 vaccines, diagnostics, tests and treatments be provided free of charge to everyone, everywhere. At the opening of the WHA, the UN Secretary General Antonio Guterres stated that “the recovery from the COVID-19 crisis must lead to more equal, inclusive and sustainable economies and societies” , as “an opportunity to address the climate crisis and inequality of all kinds”… and “to rebuild differently and better”.
The pandemic has provoked a sense that it cannot be ‘business as usual’ . For example, the Africa Group, Zambia and other country inputs to the WHA, and an ECSA HC and EQUINET brief included in this issue, raise some immediate, practical issues, including debt relief or cancellation for African countries to invest in the response and rebuild, and the removal of barriers to innovation and technology transfer for local manufacturing of diagnostics, medicines, vaccines for COVID-19 in Africa. How such issues are now treated in global forums, such as the forthcoming World Trade Organisation Ministerial and beyond, and how far our international, national and local responses reflect ‘more equal, inclusive and sustainable economies and societies’ will signal how far and for whom this crisis has been an opportunity for change, or a continuity of danger.
The ongoing extraction of minerals and biodiversity from Africa is not only a contributor to climate change. It leaves us less able to respond to climate change and is generating a social, health and natural resource debt burden for current and future generations.
That is why in the recent 2020 Alternative Mining Indaba (AMI), delegates from trade unions, ex-mineworkers, civil society and technical institutions who came together in Extractives and Health Group claimed that any framing of a just transition to address climate change must at the same time address the legacy of past health burdens and prevent such burdens now and into the future.
What are these ‘debts’? They don’t appear in the balance sheets of banks, ministries of finance or international finance institutions. They appear in the form of lead poisoning in children living in the shadow of mines, undermining their development; as mercury poisoning in communities living near mine dumps; or as chronic silicosis in thousands of ex- mineworkers across the region. They appear in the displacement of people away from fertile land, in contamination of drinking water, land and air and in the cancers, respiratory and other diseases this causes. The debt grows as an opportunity cost when mining companies do not contribute to local infrastructures, economies and services, or to skills and capacities for technological innovation, or when taxes collected do not return to develop local communities. The debt is there in the absence of information and voice given to communities in decisions and claims that affect their lives.
Sometimes part of the debt is translated into a number. In July 2019, the South Gauteng High Court approved a class action settlement worth at least 5 billion Rand (approximately USd350 million), to be paid as compensation for injury and illness for eligible ex-mineworkers and their dependents in Southern Africa. However, the Southern African Miners Association (SAMA), who organise ex-mineworkers, told the AMI that this figure is only the tip of the still buried level of occupational illness in ex-mineworkers.
At a regional workshop held before the AMI, convened by EQUINET with the regional trade union body, SATUCC and with SAMA and Benchmarks Foundation, delegates from organisations representing or working with mineworker, ex-mineworker, community, health and economic justice constituencies identified a shared concern over the way mining is affecting our current and future environments for health. It was perceived that we are not getting the current or future economic and social benefit we should get from mining and that rights are not being protected and claims ignored.
From the work that different organisations are already doing on these issues and from work in the region on HIV, TB and occupational health, it was evident that we have a platform to build on to address this. The meeting identified the building blocks of what needs to be done, not as isolated pockets of activity, but in a more integrated way across all countries of the region.
We must prevent the harms. The information, tools and capacities to map, assess and report on the conditions affecting health should be in the hands of communities, workers and ex-mine workers across the region, to be able to bring conditions affecting health to wider attention. While environment impact assessments are done in many countries, this is not enough. There should be a legal duty to carry out health impact assessments before licensing and during mine operations in all countries. These assessments should ensure, implement and monitor plans to prevent risks to health from mining. They should also assess the living conditions, the potential impacts on displaced communities and post closure and set plans to prevent negative impacts. They should be done jointly with workers and communities and publicly reported.
The rights of current and future generations should be protected. In many of our countries the laws are outdated, have gaps, or are not well enforced. As the AMI declaration stated, the right to life and to health for current and future generations must be central in whatever laws, policies and practices we design and implement. Health cannot be left to voluntary corporate social responsibility. There are over 25 international standards from United Nations and other institutions on the social obligations of the sector. SADC itself said in 2006 that it should set harmonised health standards in mining and that ‘member States should develop, adopt and enforce appropriate and uniform health, safety and environmental guidelines for the sector as an immediate milestone area’. It is time we implemented this commitment, not just for TB, HIV and occupational diseases, but for all the public health issues being faced in the sector.
The regional meeting shared information on efforts underway to inform and organise affected communities in the region. They included health literacy activities and the Tunatazama action voices alert where community activists share their knowledge and experiences on mining on a website at http://communitymonitors.net/. There are efforts underway to identify clean energy and green technologies that can limit health damage at source and measures to promote recycling and reuse of metal products. Accessing such information, building capacities for healthy innovation and having a voice in decisions is a right and an investment, especially for the young people whose futures depend on the choices we make today. The trickle of resources that goes to this in comparison to the flow of investment funds that go to the extraction of materials suggest that we have an imbalance that needs to be addressed in the value we are placing on the relative contribution of economic, social and natural resource inputs to our future wellbeing.
The regional meeting and the AMI highlighted many practical things we can do to meet the health and natural resource debt and to rebalance future policies and practices. We know that the right to life and health supersedes all other claims and that the natural resources of the region are ours to guard for future generations. We also know, as stated in the 2020 AMI declaration, that these rights “have been won through social struggle and are a source of social power and organization”. The formation of an Extractives and Health Group that crosscuts different constituencies and disciplines recognises the need to work collectively if we are to advance alternatives that meet past debts and that prevent the current and future liabilities of extraction.
Please send feedback or queries on the issues raised in this oped to the EQUINET secretariat: admin@equinetafrica.org. You can read the meeting report and further information on this work on the EQUINET website. Please also find further information on the websites of the partner institutions named in the oped and of the Alternative Mining Indaba.
Industry marketing aimed at children presents a major challenge to efforts to control the global crisis of non-communicable diseases (NCDs). Advertising and promotion of tobacco, alcohol, sugar-sweetened drinks and other unhealthy processed foods are common in all countries. They are a particular threat in countries with weak laws, poor enforcement and political cultures that are beholden to foreign investment. Africa is particularly vulnerable to unhealthy marketing by corporates.
Internationally, attention is growing on what works best to reduce the risk of NCDs, and to the role that human rights-based approaches have in this. In particular, the Convention on the Rights of the Child (CRC) can act as a strategic lever against health risks from corporate practice. Under the CRC, governments have obligations to protect children from economic exploitation and harm generated by the activities and products of tobacco, food and beverages industries. Governments are also obliged to protect children from information harmful to their health and development. This includes the marketing of unhealthy goods. However few governments in low-income countries implement measures to meet these particular obligations to protect the best interest of the child.
The European Scientific Network on Law and Tobacco (ESNLT) hosted a roundtable in mid-2019 to generate a better understanding of the successes and potential constraints of a child rights-based approach to address the global NCD epidemic. (See https://www.rug.nl/rechten/onderzoek/expertisecentra/ghlg/outcome_document_25_june_geneva.pdf). Participants were researchers, mainly from high-income countries, with some from low- and middle-income countries. The meeting also involved personnel from World Health Organisation and UNICEF staff working on NCDs and human rights. In the meeting, participants shared experiences of using a child-rights approach in domestic and international responses to NCDs and identified new opportunities to use a child-rights approach and to advocate for these approaches to be applied in addressing industry behaviours relevant to the risk factors for NCD.
Participants in the meeting explored how to apply a child rights-based approach to support regulation of NCD-related risks, particularly in low-income countries, vulnerable settings and trade policies, and how best to disseminate this knowledge more widely. Various recommendations were made in the meeting. Participants proposed networking with academics and civil society working with broader child rights and health equity issues to advance awareness, advocacy and implementation of these approaches, working also with public health networks like EQUINET in low- and middle-income countries, especially where civil society space is constrained. It was proposed that regional blocs such as the East Africa Community and Southern African Development Community be engaged to promote effective regulation of NCD risks related to marketing practices, including in relation to online and cross-border marketing and trading. Participants observed that evidence needed to be generated and shared on effective strategies and that this knowledge be brought into online and distance training courses to strengthen regulatory capacities and into postgraduate training linking human rights, law and public health. One suggestion was for a test case to be brought in one country that has constitutional provisions protecting these rights, such as South Africa. These actions could tap into existing resources. For example, the World Federation of Public Health Nutritionists has set up a mechanism for reporting conflicts of interest. The learning from this could be consolidated and shared.
It was significant that the ESNLT engaged beyond high-income countries and is addressing wider risk factors for NCDs. Bringing together a diverse set of actors in the meeting helped to build links across different disciplines and opened avenues for future collaboration. Linking with existing networks can help to identify capacity gaps and to stimulate and support research and advocacy. Education of both public health and law professionals can expose each to the respective field of the other to promote collaboration and team approaches. This interaction has already been stimulated by the meeting. For example, soon after it, one of the participants was invited to give a keynote address at the Association of Schools of Public Health Conference in Africa to highlight the role of law in public health.
The meeting also proposed that international organizations, such as WHO, UNICEF, the Office of the United Nations High Commissioner for Human Rights, the UN Human Rights Committee and the UN Committee on the Rights of the Child, link to reduce capacity gaps and overlaps in their work and outputs. A child rights-based approach and qualitative assessment of country performance could be included in WHO assessments of how far regulations targeting the main risk factors are implemented. Evidence on NCD-related issues could be included in country reporting to the Committee on the Rights of the Child and shadow reporting by civil society promoted.
This is not simply a technical matter. Industry actors are well-resourced, powerful and able to thwart regulation of NCD risk factors. This power imbalance calls for co-operation across international and national organizations, civil society organizations, academia and public officials. For regional networks such as EQUINET, the fact that every country in Africa has ratified the CRC and all but 6 have ratified the African Charter on the Rights and Welfare of the Child offers an opportunity and policy space to use human and child rights-based approaches to tackle health equity challenges, including the prevention of corporate and market-induced risks for NCDs.