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Vol 61 No 8

Published 16th April 2020

The war for the cure

International rivalries and empire-building are shaping the response to the pandemic in Africa

Serial financial crises and political meddling have weakened the operations of the World Health Organisation for decades but the rivalries between the United States and China over the coronavirus pandemic have taken it to new depths. Those rivalries may also undermine the Atlanta-based Centers for Disease Control's (CDC) operations in Africa, with Washington threatening to withdraw funding and personnel if it accepts finance from Beijing.

Although the WHO is caught in this row, independent health professionals reckon that its director-general, Tedros Adhanom Ghebreyesus, Ethiopia's former health minister, has managed the competing interests effectively. He is the first head of WHO from a developing country since Brazil's Marcolino Candau in 1953.

Tedros hired David Nabarro, his British rival for the post in a bad-tempered election in 2017, and has won the respect of many US health professionals. But relations with the US government nosedived after Donald Trump's election in 2016, and on 14 April he announced the US would cut its contribution to WHO immediately while its handling of the pandemic was investigated. Until now, the US Congress has pushed back against Trump's calls for cuts.

In 2018/19, the US was the largest contributor to the approved budget of US$4.42 billion, providing 14.6% of the total. Bill Gates, who immediately condemned Trump's decision to pull funding from the WHO, contributes 9.76% through the Bill and Melinda Gates Foundation.

The US's voluntary contributions, which have fluctuated widely in recent years, are entirely of the 'specified type' which ties the money to projects and programmes that its government favours.

Long-run impacts
In the short term, the effect of the US finance withdrawal may not be that damaging, but the longer term effects and political fall-out will be critical, if Trump prevents US state agencies from collaborating with WHO on key programmes, slowing life-saving operations and research.

So, WHO has had to scrap many programmes it used to support, mostly covering healthcare for the poorest. It also retreated from work on drug pricing.

Now, it puts a bigger emphasis on the International Health Regulations. This is the mechanism by which all countries report specifically nominated health threats, and WHO issues alerts according to information received. In effect, it means that WHO becomes the watchman for rich countries, who are paranoid about threats like the coronavirus, although they at first expected any pandemic to come from Africa, not China.

Although this is an important role for the WHO, it means the organisation's function has changed dramatically. It has also fostered disillusion in many African countries who see the WHO is becoming less relevant.

US institutions like the National Institutes of Health, the CDC, and outward-looking universities such as Harvard, Columbia and South Carolina have a strong relationship with the WHO, a frequent political sticking point has been the WHO's attempts to make medicines more affordable for the poor. That has clouded many annual World Health Assembly meetings, with the US government sending an army of lawyers to represent its interests. This usually meant stopping initiatives rather than finding solutions.

In recent years US drug companies have doubled down in defence of their corporate intellectual property. They couch it as protecting the free market against 'insurgent' drug manufacturers in India and China.

On the WHO's response to the coronavirus pandemic, many African doctors have praised the WHO secretariat in Geneva for its clear leadership. Yet there is some frustration about the role of the African Regional Office (ARO) in Brazzaville which has been hobbled by financing shortfalls and political constraints. Botswana's Dr Matshidiso Moeti, the WHO Regional Director in Brazzaville, is a very capable and transparent administrator but lack the funds to fulfil her mission (AC Vol 61 No 7, Third wave threatens the continent).

Much of the Personal Protective Equipment (PPE) and testing kits being distributed in WHO's name is being coordinated via a Geneva-based task force. All the epidemic modelling for African countries is being done by a team in Geneva.

At the ARO's weekly press conference in the early stages of the crisis, Moeti was pressed on how many ventilators there are in Africa. After three weeks ARO revealed that there were fewer than 5,000 ICU beds in all of Africa, less than 5 per million. In Europe it is around 4,000 ICU beds per million. She then reported that there are 'less than 2,000 functional ventilators' in Africa.

Faced with such scant resources, and with US and European countries fighting over stocks of ventilators, Africa's front-line health workers have shifted their attention to improving the supply of oxygen to hospitals in Africa. If 80% of patients are reckoned to be asymptomatic or self-treating, then the 15% who need oxygen to survive are getting the attention. That's means little help for the 5% who need ventilating.

Brazzaville bypass
The WHO-ARO office in Brazzaville is run semi-autonomously from Geneva. Any country wanting to fund a programme against trachoma, for example, has to channel the work and money through Brazzaville, not Geneva.

Before the Ebola crisis in Guinea, Liberia and Sierra Leone, the Brazzaville office failed almost every test of transparency. As a result, donors were reluctant to finance regional initiatives and instead backed country programmes, by-passing the ARO.

In fact, UNAIDS, the UN body dedicated to fighting HIV and AIDS, was set up as a separate organisation mainly to avoid sending money Brazzaville, our sources say. Today, the Brazzaville office under Moeti ticks all the boxes for transparency and accountability. It's now getting direct funding from the donors.

This, however, is at the cost of being a more outward-looking organisation. Many see it responding first to donor demands, and only second to its African constituents. On that score, some of the strongest criticism has come from East, Central and Southern Africa.

It was significant that the donations from China's Jack Ma, who runs the Alibaba empire, went to the African Centre for Disease Control and Prevention headquarters in Addis Ababa, instead of being sent to WHO-ARO in Brazzaville.  The Africa CDC is part-funded by the African Union contributions from the World Bank China, Japan, and the US.

There is tension over the emergence of Africa CDC (and its regional offices), with some UN and African officials seeing it as a rival to WHO. It is well-financed, largely by the CDC in Atlanta, well led, and generally unhampered by bureaucracy.

It has played a central role in Africa's response to the pandemic. On communications and multilateral coordination, it has been quicker off the mark than the under-funded WHO office in Brazzaville.

That's partly down to the media-savvy of its Director, John Nkengasong, a virologist and CDC employee for over 25 years. He's backed up by Dr Ahmed Ogwell, a Kenyan physician who worked for the Ministry of Health in Kenya before a stint with WHO in Geneva.

Africa CDC is hoping to launch its own epidemic modelling unit in Addis in the coming days 'because things are different in Africa and we need to adjust the modelling accordingly'. And the decision has been taken that the African HQ of CDC in Addis, under Nkengasong, will be the coordinating agency for strategy and also for dealing with the multilateral agencies.

Africa CDC has a much closer day-to-day relationship with the African Union, with coordinated briefings from their senior staff at both health minister and head of state level.

But even here, the China-US rivalries are being played out. China's offer to build a $80m centre for the Africa CDC in Addis Ababa is seen by the US as meddling. Here too, Washington is threatening to cut funding to Africa CDC if the offer from China is accepted. It's also threatened to recall the senior staff it has seconded to the organisation from Atlanta.

Senior African health officials shake their heads in disbelief at such nationalist brinkmanship. They sense that part of the reason for the rivalry is the scientific and commercial demand for the vast amounts of African genomic data that have not been systematically collected and analysed so far. It may prove vital in the quest for future vaccines and therapeutics.

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