Cristina Azevedo and Javier Abi-Saab (Fiocruz News Agency)
Still in the heat of the World Health Assembly and the G20 Global Health Summit, held at the end of May, the Advanced Seminar of the Fiocruz's Global Health Center (CRIS/Fiocruz) brought, last Wednesday (6/10), the main conclusions and challenges for this biennium, in a challenging conjuncture during the COVID-19 pandemic. To account for such a broad issue, the webinar Global Health Agenda 2021 brought together eight debaters and was held in two parts: one in the morning and one in the afternoon, in what Paulo Buss, coordinator of CRIS/Fiocruz, defined as "a double journey".
The 74th Assembly "was different from last year, because it was not just looking at the crisis, but already thinking about the future, how to get out better", explained Luiz Augusto Galvão, a senior researcher at CRIS and representative of the Fiocruz Presidency in Washington, before agencies such as the World Health Organization (WHO). Among more than 30 resolutions of the meeting is the one that establishes a meeting in November to discuss a new global health treaty in the pandemic, a topic that occupied much of the webinar discussions. The assembly also adopted a central resolution to strengthen the organization, which was considered historic by its participants, and created a working group for the sustainable financing of WHO. "The Pandemic Treaty is the great novelty. It will try to promote sharing, trust and accountability. The idea of strengthening national capacities is one of the challenges for the new treaty", Galvão said.
The results of the meeting, however, are not without controversy. In addressing the relations between the G20, the Rome Declaration and the Global Health Agenda, Ilona Kickbusch highlighted the distance between rhetoric and practice. "At the end of the day has all these statements, but then member states are not willing to increase the WHO budget. I think this is a scandal”, said the professor at the Graduate Institute for International Studies and Development in Geneva. "And one problem with the reform proposals seen over the years is that, instead of thinking about how to strengthen this fantastic multilateral organization, they let it dry while suggesting new organizations. They want to give billions to an organization, but they don't want to give millions to WHO."
She also pointed out that today's recommendations for the COVID-19 pandemic are similar to those made at the Ebola outbreak time. For her, this demonstrates the lack of action by states in these 16 years since the International Health Regulations (IHR) creation. For Ilona, the treaty's own proposal is controversial, seeing it more focused on the pandemic than on global health and in shock with the IHR.
Speaking about the Global Civil Society Vision on the Health Agenda, Geneva Global Health Hub (G2H2) co-chair Nicoletta Dentico criticized "zoom multilateralism", with predominantly online assemblies that have further reduced society's participation and undermined negotiations that take place between meetings. Nicoletta also questioned the treaty proposal, when there is already a document "validated by 196 countries and which during the pandemic was violated by most member states".
Lawrence Gostin, a professor at Georgetown University School of Law, believes that a treatise on the pandemic can help fill gaps in the document. For him, WHO needs, in addition to greater funding, a change in its governance. "The organization is in the middle of the 20th century, when it should be in the 21st century. This means that civil society is a key voice. If WHO wants to be strong in a country and internationally, it needs civil society."
The event second part was moderated by Ambassador Santiago Alcázar, diplomat and researcher at CRIS/Fiocruz and brought as main themes access to vaccine production and social health determinants.
Access to vaccine production
In addition to social, political and economic problems, the COVID-19 pandemic " reveals the high dependence on strategic health insums for vaccination when the vaccine is everyone's hope", said Akira Homma, emeritus researcher and senior advisor at the Immunobiological Technology Institute (Bio-Manguinhos/Fiocruz). For the Fiocruz former president, while immunization is progressing in more than 180 countries, vaccine production is concentrated in a few developed countries. In addition, vaccine nationalism was imposed prohibiting the export of ingredients needed for production.
Seventy-five percent of immunizations have occurred in developed countries because, "due to the high cost and risk, few developing countries have been able to make the vaccines early purchase”, Homma said. That is why local production has become a relevant strategy for these countries. "Local or regional production is important for rapid access to vaccines and in an equitable manner. However, there are a number of challenges that must be considered, among them: the government policies definition, the obtaining of third-generation technology, the long-term investment guarantee, and the operation sustainability", said the researcher. Homma also explained that vaccine production activity is very complex with several steps, requires experts; good practices standards; high quality ingredients, mostly imported; industrial production scale; functional regulatory system; training program; and technological competitiveness. In short, "the relevance of producing vaccines locally and/or regionally is unquestionable, but countries should be able to measure the efforts this means in the short, medium and long term to create successful strategies," he said.
However, access to vaccination not only faces production challenges, it must also address the challenges in the intellectual property area. This theme, of extreme relevance in the Global Health Agenda, was brought to the table by Claudia Chamas, a researcher at the Center for Technological Development in Health (CDTS/Fiocruz), who sought to answer where we are in the patents flexibilization. Two relevant events were highlighted by Chamas. The first would be the proposal brought to the WTO by India and South Africa in October 2020 so that intellectual property rights do not interfere with access to medicines. The second would be the United States' support for the patent suspension for COVID-19 vaccines, which has also caused Russia and China to speak out in favour. Chamas pointed out that, despite these advances, "the vaccine as a global public good with equitable access is still a distant reality. It is necessary a realignment of knowledge governance for the common good because, in addition to legal barriers, there are important technical barriers", explained the researcher, emphasizing that the intervention scope should include strategies for the knowledge passage, treatments and equipment, and that the suspension should be for a minimum period of 3 years.
The fundamental problem of access to health and medicines lies in the so-called social health determinants. For Kumanam Rasanathan, head of the WHO Equity and Health Unit, iniquity is consuming us all today. "We live in a world where only 4% of vaccines were aimed at low-income countries. This is a symptom of the broader inequities that we face in the world and that are becoming increasingly evident." For Rasanathan, it is not enough to act on vaccine iniquity, we need to work more deeply for COVID-19, but also for other diseases and problems. "The virus sees the weakest parts of society, sees our flaws, and with the increase in vulnerabilities, we are all at risk", he said.
In this sense, Luis Eugênio Souza, World Federation of Public Health Associations (WFPHA) president-elect, considers that the first step is "to recognize that it is not a pandemic, but a syndemic", that is, a set of diseases that interact in a social and environmental context characterized by profound inequality. According to Souza, the fragility in social protection systems and the wrong political choices have worsened inequalities, and "by focusing only on medical issues, our chances of overcoming this crisis are very few." We must then, as governments and civil society, strengthen actions that consider the social and environmental factors that influence health.
The event is part of the Advanced Seminars of the Global Health Center (CRIS/Fiocruz) and was co-sponsored by the Latin American Alliance for Global Health (Alasag), the Brazilian Association of Collective Health (Abrasco), Sustainable Health Equity, the Brazilian Academy of Sciences (ABC) and the National Academy of Medicine.