Evidence Informed Development – Fragile States

Data Collection in Fragile States : Innovations from Africa and Beyond
World Bank January 09, 2020 Publication
PDF: https://openknowledge.worldbank.org/bitstream/handle/10986/32576/9783030251208.pdf?sequence=1&isAllowed=y
Fragile countries face a triple data challenge. Up-to-date information is needed to deal with rapidly changing circumstances and to design adequate responses. Yet, fragile countries are among the most data deprived, while collecting new information in such circumstances is very challenging. This open access book presents innovations in data collection developed with decision makers in fragile countries in mind. Looking at innovations in Africa from mobile phone surveys monitoring the Ebola crisis, to tracking displaced people in Mali, this collection highlights the challenges in data collection researchers face and how they can be overcome.

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Media Release
Data Collection in Fragile States
Highlights
:: Decision makers in fragile countries need quality data; obtaining such data is challenging.
:: This book presents innovations, methodological as well as in data collection, to meet this challenge. The innovations presented in this book are relevant beyond fragile situations.
:: With effort, quality data can be produced for many fragile situations, effectively eliminating the notion that data cannot be collected in certain difficult circumstances.

Quality statistics are critical for development interventions to be effective. However, they are hard to obtain in fragile situations as fragility affects the ability to collect data in many ways. From exposure to violence or to other dangers, such as disease, collecting information isn’t possible using traditional means without putting enumerators at risk. There is also the association of conflict with poor-quality roads, inadequate telecommunication infrastructure and, at times, populations that are hostile to representatives of the central government.

Fragile situations can also complicate data collection in other ways such as people being displaced or the lack of sampling frames. A new report, Data Collection in Fragile States, presents innovations developed to deal with common challenges. The report presents innovations, both methodological as well in data collection, to address the data gaps in fragile situations. Through examples, the book shows that it is possible to collect high-quality data in fragile settings and such data collection need not be expensive but also warns that technology is not a panacea for all data collection issues.

Additional Findings
:: The proliferation of mobile phone networks and inexpensive handsets has opened new possibilities for data collection. Although they cannot replace face-to-face household surveys in all contexts, mobile phone surveys offer substantial benefits in specific circumstances and for specific data collection needs. For locations where mobile phone surveys are not an option, locally recruited, resident enumerators who live in the community can be used. Mobile phone surveys were used to collect information during the Ebola crisis in Sierra Leone, the drought in Nigeria, Somalia, South Sudan and Yemen, and were used to track the welfare of people displaced by the crisis in northern Mali.

:: Technological advances in geospatial data have the potential to change how survey data are collected. As geospatial technology has improved and become more widespread, costs have come down and the number of available tools has increased, making Geographic Information Systems (GIS)-based sampling approaches accessible to more users. To deal with the absence of sampling frames in the Democratic Republic of Congo and Somalia, satellite images and sophisticated machine learning algorithms were used to estimate population density and demarcate enumeration areas.

:: Sampling in chaotic and fluid locations, where people are displaced or live In Internally Displaced Peoples (IDP) settlements requires a rethinking of traditional sampling approaches. Attention should also be paid to elicit truthful information from respondents. Approaches such as endorsement experiments, list experiments, and behavioral approaches can be used to ask questions about sensitive issues such as loyalty to controversial groups along with how to avoid strategic responses when respondents might expect benefits to be associated with certain answers. For instance, in South Sudan, different sampling approaches were tested in an IDP camp to shed light on their precision.

:: Video testimonials provide a cost-effective way to give outside audiences a perspective on the lives of survey respondents. The collection of household data is usually a passive process where respondents are asked pre-formulated questions. This constrains the respondents in sharing their own narratives and emphasizing what they feel is important. The video testimonials give a voice to the poor and help better understand the concerns of the poor as well as empower them to create a narrative that they own. In South Sudan, in addition to estimating the poverty data, video testimonials revealed what it was like to live in poverty.

:: A light-touch approach to generating periodic feedback can help provide information about the performance of donor projects. A new approach called Iterative Beneficiary Monitoring (IBM) provides a feedback system that focuses on a select set of issues to measure outcomes of projects. By keeping data collection focused, IBM facilitates timely data analysis and the rapid preparation of reports. The approach was introduced in Mali to provide feedback on projects about feeding in schools to distribution of e-vouchers and cash transfers.

Governance – Biotechnology

New Report Proposes Global DNA Synthesis Screening System to Counter Biotech Terror
News 08 Jan 2020
:: Advances in biotechnology, including DNA synthesis (the creation of DNA sequences and genomes), are driving improvements in the energy, food, agriculture, health and manufacturing industries

:: But accidental or deliberate misuse of DNA synthesis could result in the spread of dangerous agents, potentially resulting in risks to public health or global health security

:: Widespread access to DNA synthesis and new synthesis methods, in the absence of global biotechnology norms and screening practices, enhances the threat

:: The World Economic Forum and Nuclear Threat Initiative propose a new mechanism to develop, standardize and strengthen screening practices
:: Read the full report here

Geneva, Switzerland, 7 January 2020 – Rapid advancements in commercially available DNA synthesis technologies – used for example to artificially create gene sequences for clinical diagnosis and treatment – pose growing risks, with the potential to cause a catastrophic biological security threat if accidentally or deliberately misused.

A new World Economic Forum and Nuclear Threat Initiative report, “Biosecurity Innovation and Risk Reduction: A global Framework for Accessible, Safe and Secure DNA Synthesis,” gathers opinion from a group of global public- and private-sector experts who propose standardized screening practices to counter the threat.

Since scientists demonstrated the means to create a full viral genome in 2002, DNA synthesis technologies have become increasingly available and frequently used by scientists and engineers around the world. These technologies support myriad advancements in synthetic biology, enhancing the efficiency and sustainability of industries including energy, food, agriculture, health and manufacturing. Further advances in technology hold great promise for sustainable development and a safer and more secure society.

At the same time, new approaches to DNA editing and synthesis have made it easier to manipulate biological agents and systems, increasing the risk of a catastrophic accidental or deliberate biological event. These technologies make it possible to create pathogen or toxin DNA that could be misused. For example, in 2018 researchers published work detailing the synthesis of horsepox virus, an extinct virus related to smallpox, using synthetic DNA fragments purchased from a commercial provider. This demonstrated the potential for creating other viruses via commercially available technologies.

Although many DNA providers practice screening procedures, this approach is voluntary and is becoming increasingly expensive. As access expands and the cost of DNA synthesis declines, more DNA is likely to reach the market via additional providers, significantly expanding the user base. In the next two to three years, a new generation of benchtop DNA synthesis machines, enabled by enzymatic DNA synthesis methods, could become available without guidance or norms to prevent misuse.

This report, endorsed by an international expert Working Group, recommends a global system for synthetic DNA screening practices by developing an international, cost-effective, and sustainable mechanism to prevent illicit practices and misuse. The new framework improves the existing voluntary guidelines because it standardizes screening processes, is accessible to new players in the market, and provides valuable feedback data to evaluate the screening – all at lower cost.

“Biotechnology is at the centre of the Fourth Industrial Revolution. To deliver on the promise of the biotechnology revolution, we must seize opportunities to develop and deliver life-advancing innovations while simultaneously and urgently addressing potential risks associated with a growing and democratized bio-economy,” said Arnaud Bernaert, Head of Shaping the Future of Health and Health Care at the World Economic Forum.

The report also proposes that companies, international organizations and governments should explore options for the sustainable oversight and the maintenance of this proposed DNA sequence screening mechanism. DNA synthesis capabilities, in addition to other emerging technologies, can benefit from a larger system of common global life-science norms overseen by a globally recognized entity.

“Global DNA synthesis screening can be a critical tool to reduce the risk that life-science technologies could be deliberately misused to carry out biological attacks or accidentally result in a high-consequence or catastrophic biological event. The time is now,” said Ernest J. Moniz, Co-Chair and Chief Executive Officer of the Nuclear Threat Initiative.

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Biosecurity Innovation and Risk Reduction: A global Framework for Accessible, Safe and Secure DNA Synthesis
World Economic Forum – Insight Report – In collaboration with the Nuclear Threat Initiative (NTI)
January 2020 :: 18 pages
PDF: http://www3.weforum.org/docs/WEF_Biosecurity_Innovation_Risk_Reduction.pdf
[Excerpt]
Recommendations
Developing a Common DNA Sequence Screening Mechanism
1) By early 2020, establish a global, standing, multi-stakeholder, technical consortium (“the Consortium”) to develop a common DNA sequence screening mechanism that is accessible at low cost,
secure and easy to use by all providers of DNA and providers of benchtop DNA synthesis machines.
This mechanism would include an internationally recognized set of sequences of pathogen and toxin
DNA (see Appendix B for additional details) and algorithms to screen ordered DNA sequences against
that set of sequences. The Consortium should work to develop a version of the screening mechanism that is fully automated for ease of use and integration as a built-in feature of benchtop DNA synthesis machines.

2) As the common DNA sequence screening mechanism is developed, the Consortium should consider security precautions and built-in technical safeguards to prevent its misuse.

3) By 2021, the common DNA sequence screening mechanism should be supplied to all DNA providers
to incorporate into their operations. Regular updates should be established thereafter.

4) By 2021, the common DNA sequence screening mechanism and its updates should be supplied to all
developers and providers of benchtop DNA synthesis machines to incorporate into their machines and/or operations.
a. The Consortium should work with providers of benchtop machines to implement procedures to
screen each DNA sequence before it is synthesized.
b. The Consortium should consider the potential to prohibit some sequences from being created by benchtop machines. In this case, benchtop machines could have a built-in version of the common mechanism and would be unable to synthesize DNA sequences that are a hit.

Oversight, policies and partnerships for establishing synthetic DNA screening as a global norm
1) The Consortium should be funded as an independent technical entity for at least two years so that it can immediately start work to meet the goal of developing the common DNA sequence screening mechanism and providing it to DNA providers and providers of benchtop DNA synthesis machines by 2021.

2) In early-to-mid 2020, NTI and the World Economic Forum should convene senior leaders from
governments, companies and international organizations to explore options for the sustainable oversight of the Consortium and maintenance of the proposed DNA sequence screening mechanism.
These options may include developing synthetic DNA screening as a new mandate for an existing
international entity or the creation of a new organization to take on this mandate.

3) In partnership with the new or existing organization focusing on this work, the technical Consortium
should work with states, international organizations, industry groups, universities and others to pursue
opportunities to strengthen synthetic DNA screening as a global norm and standard among governments, researchers, institutions, and providers of DNA and benchtop DNA synthesis machines.

Featured Journal Content

PNAS – Proceedings of the National Academy of Sciences of the United States
of America
http://www.pnas.org/content/early/
[Accessed 11 Jan 2020]

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What music makes us feel: At least 13 dimensions organize subjective experiences associated with music across different cultures
Alan S. Cowen, Xia Fang, Disa Sauter, and Dacher Keltner
PNAS first published January 6, 2020. https://doi.org/10.1073/pnas.1910704117
Significance
Do our subjective experiences when listening to music show evidence of universality? And if so, what is the nature of these experiences? With data-driven methodological and statistical approaches, we examined the feelings evoked by 2,168 music excerpts in the United States and China. We uncovered 13 distinct types of experiences that people across 2 different cultures report in listening to music of different kinds. Categories such as “awe” drive the experience of music more so than broad affective features like valence. However, emotions that scientists have long treated as discrete can be blended together. Our results provide answers to long-standing questions about the nature of the subjective experiences associated with music.
Abstract
What is the nature of the feelings evoked by music? We investigated how people represent the subjective experiences associated with Western and Chinese music and the form in which these representational processes are preserved across different cultural groups. US (n=1,591) and Chinese (n=1,258) participants listened to 2,168 music samples and reported on the specific feelings (e.g., “angry,” “dreamy”) or broad affective features (e.g., valence, arousal) that they made individuals feel. Using large-scale statistical tools, we uncovered 13 distinct types of subjective experience associated with music in both cultures. Specific feelings such as “triumphant” were better preserved across the 2 cultures than levels of valence and arousal, contrasting with theoretical claims that valence and arousal are building blocks of subjective experience. This held true even for music selected on the basis of its valence and arousal levels and for traditional Chinese music. Furthermore, the feelings associated with music were found to occupy continuous gradients, contradicting discrete emotion theories. Our findings, visualized within an interactive map (https://www.ocf.berkeley.edu/∼acowen/music.html) reveal a complex, high-dimensional space of subjective experience associated with music in multiple cultures. These findings can inform inquiries ranging from the etiology of affective disorders to the neurological basis of emotion.

Featured Journal Content

Journal of Adolescent Health
December 2019 Volume 65, Issue 6, Supplement, S1-S62
https://www.jahonline.org/issue/S1054-139X(19)X0005-1
Adolescent Sexual and Reproductive Health and Rights: Progress in the 25 Years Since the International Conference on Population and Development and Prospects for the Next 25 years
Edited by Caroline W. Kabiru
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Review Articles
The State of Adolescent Sexual and Reproductive Health
Mengjia Liang, Sandile Simelane, Guillem Fortuny Fillo, Satvika Chalasani, Katherine Weny, Pablo Salazar Canelos, Lorna Jenkins, Ann-Beth Moller, Venkatraman Chandra-Mouli, Lale Say, Kristien Michielsen, Danielle Marie Claire Engel, Rachel Snow
S3–S15
Published in issue: December 2019
Abstract
In the 25 years since the 1994 International Conference on Population and Development, significant progress has been made in adolescent sexual and reproductive health and rights (ASRHR). Trend analysis of key ASRHR indicators at global, national, and subnational levels indicates that adolescent girls today are more likely to marry later, delay their first sexual experience, and delay their first childbirth, compared with 25 years ago; they are also more likely to use contraceptives. Despite overall progress, however, unequal progress in many ASRHR outcomes is evident both within and between countries, and in some locations, the state of adolescents’ lives has worsened. Population growth in countries with some of the worst shortfalls in ASRHR mean that declining rates, of child marriage, for example, coexist with higher absolute numbers of girls affected, compared with 25 years ago. Emerging trends that warrant closer attention include increasing rates of ovarian and breast cancer among adolescent girls and sharp increases in the proportion of adolescents who are overweight or obese, which has long-term health implications.

The Political, Research, Programmatic, and Social Responses to Adolescent Sexual and Reproductive Health and Rights in the 25 Years Since the International Conference on Population and Development
Venkatraman Chandra-Mouli, B. Jane Ferguson, Marina Plesons, Mandira Paul, Satvika Chalasani, Avni Amin, Christina Pallitto, Marni Sommers, Ruben Avila, Kalisito Va Eceéce Biaukula, Scheherazade Husain, Eglé Janušonytė, Aditi Mukherji, Ali Ihsan Nergiz, Gogontlejang Phaladi, Chelsey Porter, Josephine Sauvarin, Alma Virginia Camacho-Huber, Sunil Mehra, Sonja Caffe, Kristien Michielsen, David Anthony Ross, Ilya Zhukov, Linda Gail Bekker, Connie L. Celum, Robyn Dayton, Annabel Erulkar, Ellen Travers, Joar Svanemyr, Nankali Maksud, Lina Digolo-Nyagah, Nafissatou J. Diop, Pema Lhaki, Kamal Adhikari, Teresa Mahon, Maja Manzenski Hansen, Meghan Greeley, Joanna Herat, Danielle Marie Claire Engel
S16–S40
Published in issue: December 2019
Abstract
Among the ground-breaking achievements of the International Conference on Population and Development (ICPD) was its call to place adolescent sexual and reproductive health (ASRH) on global health and development agendas. This article reviews progress made in low- and middle-income countries in the 25 years since the ICPD in six areas central to ASRH—adolescent pregnancy, HIV, child marriage, violence against women and girls, female genital mutilation, and menstrual hygiene and health. It also examines the ICPD’s contribution to the progress made. The article presents epidemiologic levels and trends; political, research, programmatic and social responses; and factors that helped or hindered progress. To do so, it draws on research evidence and programmatic experience and the expertise and experiences of a wide number of individuals, including youth leaders, in numerous countries and organizations. Overall, looking across the six health topics over a 25-year trajectory, there has been great progress at the global and regional levels in putting adolescent health, and especially adolescent sexual and reproductive health and rights, higher on the agenda, raising investment in this area, building the epidemiologic and evidence-base, and setting norms to guide investment and action. At the national level, too, there has been progress in formulating laws and policies, developing strategies and programs and executing them, and engaging communities and societies in moving the agenda forward. Still, progress has been uneven across issues and geography. Furthermore, it has raced ahead sometimes and has stalled at others. The ICPD’s Plan of Action contributed to the progress made in ASRH not just because of its bold call in 1994 but also because it provided a springboard for advocacy, investment, action, and research that remains important to this day.

Forward, Together: A Collaborative Path to Comprehensive Adolescent Sexual and Reproductive Health and Rights in Our Time
Marina Plesons, Claire B. Cole, Gwyn Hainsworth, Ruben Avila, Kalisito Va Eceéce Biaukula, Scheherazade Husain, Eglė Janušonytė, Aditi Mukherji, Ali Ihsan Nergiz, Gogontlejang Phaladi, B. Jane Ferguson, Anandita Philipose, Bruce Dick, Cate Lane, Joanna Herat, Danielle Marie Claire Engel, Sally Beadle, Brendan Hayes, Venkatraman Chandra-Mouli
S51–S62
Abstract
The 1994 International Conference on Population and Development established a basis for the advancement of adolescent sexual and reproductive health and rights (ASRHR) that endures today. Twenty-five years later, our vision for the future warrants reflection based on a clear understanding of the opportunities and challenges before us. Inclusion of adolescents on global, regional, and national agendas; increased investment in ASRHR policies and programs; renewed commitments to universal health coverage; increased school enrollment; and advances in technology are all critical opportunities we can and must leverage to catalyze progress for adolescents. At the same time, a range of significant challenges remain, have newly emerged, or can be seen on the horizon, including persistent denial of adolescent sexuality; entrenched gender inequality; resistance to meaningfully engaging adolescents and young people in political and programmatic processes; weak systems, integration, and multisectoral coordination; changes in population dynamics; humanitarian and climate crises; and changes in family and community structures. To achieve as much progress toward our vision for ASRHR as possible, the global ASRHR community must take strategic and specific steps in the next 10 years within five areas for action: (1) mobilize and make full use of political and social support for ASRHR policies and programs; (2) increase and make effective use of external and domestic funding for ASRHR; (3) develop, communicate, apply, and monitor enabling and protective laws and policies for ASRHR; (4) use and improve available ASRHR data and evidence to strengthen advocacy, policies, and programs; and (5) manage the implementation of ASRHR strategies at scale with quality and equity.

Emergencies

Ebola – DRC+
Public Health Emergency of International Concern (PHEIC)

Ebola Outbreak in DRC 74: 07 January 2020
Situation Update
Since the last Situation Report 73 issued on 24 December 2019, 28 new confirmed Ebola virus disease (EVD) cases were reported from five health zones in two affected provinces in the Democratic Republic of the Congo between 23 December 2019 to 5 January 2020. The new confirmed cases in the past 14 days are from Butembo, Katwa, Kalunguta, Mabalako and Mambasa. The source of exposure for the four new cases reported from Mambasa Health Zone, Ituri Province is currently under investigation. Mambasa Health Zone had previously not had a confirmed case for 66 days. Similarly, the source of exposure of the initial case reported in Kalunguta at the end of December is still under investigation…

…As of 5 January 2020, a total of 3390 EVD cases, including 3272 confirmed and 118 probable cases have been reported, of which 2233 cases died (overall case fatality ratio 66%). Of the total confirmed and probable cases, 56% (1903) were female, 28% (956) were children aged less than 18 years, and 5% (168) were healthcare workers.

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POLIO
Public Health Emergency of International Concern (PHEIC)
http://polioeradication.org/polio-today/polio-now/this-week/

Summary of new viruses this week (AFP cases and ES positives):
:: Afghanistan — two WPV1 cases and two WPV1 positive environmental samples;
:: Pakistan — 11 WPV1 cases, 13 WPV1 positive environmental samples and two cVDPV2 positive environmental samples;
:: Malaysia — one cVDPV2 and one positive environmental samples;
:: Zambia — one cVDPV2 case.

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Editor’s Note:
WHO has posted a refreshed emergencies page which presents an updated listing of Grade 3,2,1 emergencies as below.

WHO Grade 3 Emergencies [to 11 Jan 2020]

Democratic Republic of the Congo
:: Ebola Outbreak in DRC 74: 07 January 2020
[See Ebola above for detail]

Mozambique floods – No new digest announcements identified
Nigeria – No new digest announcements identified
Somalia – No new digest announcements identified
South Sudan – No new digest announcements identified
Syrian Arab Republic – No new digest announcements identified
Yemen – No new digest announcements identified

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WHO Grade 2 Emergencies [to 11 Jan 2020]
Measles in Europe
:: Strengthening national laboratories’ oversight capacity to support measles and rubella elimination 08-01-2020
[See Milestones above for detail]

Afghanistan – No new digest announcements identified
Angola – No new digest announcements identified
Burkina Faso [in French] – No new digest announcements identified
Burundi – No new digest announcements identified
Cameroon – No new digest announcements identified
Central African Republic – No new digest announcements identified
Ethiopia – No new digest announcements identified
HIV in Pakistan – No new digest announcements identified
Iran floods 2019 – No new digest announcements identified
Iraq – No new digest announcements identified
Libya – No new digest announcements identified
Malawi floods – No new digest announcements identified
MERS-CoV – No new digest announcements identified
Myanmar – No new digest announcements identified
Niger – No new digest announcements identified
occupied Palestinian territory – No new digest announcements identified
Sudan – No new digest announcements identified
Ukraine – No new digest announcements identified
Zimbabwe – No new digest announcements identified

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WHO Grade 1 Emergencies [to 11 Jan 2020]

Chad – No new digest announcements identified
Djibouti – No new digest announcements identified
Kenya – No new digest announcements identified
Mali – No new digest announcements identified
Namibia – viral hepatitis – No new digest announcements identified
Tanzania – No new digest announcements identified

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UN OCHA – L3 Emergencies
The UN and its humanitarian partners are currently responding to three ‘L3’ emergencies. This is the global humanitarian system’s classification for the response to the most severe, large-scale humanitarian crises. 
Syrian Arab Republic
:: Syrian Arab Republic: Recent Developments in Northwestern Syria Situation Report No. 5 – As of 8 January 2020

Yemen – No new digest announcements identified

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UN OCHA – Corporate Emergencies
When the USG/ERC declares a Corporate Emergency Response, all OCHA offices, branches and sections provide their full support to response activities both at HQ and in the field.
Editor’s Note:
Ebola in the DRC has bene added as a OCHA “Corporate Emergency” this week:
CYCLONE IDAI and Kenneth – No new digest announcements identified
EBOLA OUTBREAK IN THE DRC – No new digest announcements identified

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The Sentinel

Human Rights Action :: Humanitarian Response :: Health :: Education :: Heritage Stewardship ::
Sustainable Development
__________________________________________________
Week ending 4 January 2020

This weekly digest is intended to aggregate and distill key content from a broad spectrum of practice domains and organization types including key agencies/IGOs, NGOs, governments, academic and research institutions, consortia and collaborations, foundations, and commercial organizations. We also monitor a spectrum of peer-reviewed journals and general media channels. The Sentinel’s geographic scope is global/regional but selected country-level content is included. We recognize that this spectrum/scope yields an indicative and not an exhaustive product. Comments and suggestions should be directed to:

David R. Curry
Editor
GE2P2 Global Foundation – Governance, Evidence, Ethics, Policy, Practice
david.r.curry@ge2p2center.net

PDF: The Sentinel_ period ending 4 Jan 2020

Contents
:: Week in Review  [See selected posts just below]
:: Key Agency/IGO/Governments Watch – Selected Updates from 30+ entities   [see PDF]
:: INGO/Consortia/Joint Initiatives Watch – Media Releases, Major Initiatives, Research:: Foundation/Major Donor Watch -Selected Updates
:: Journal Watch – Key articles and abstracts from 100+ peer-reviewed journals  [see PDF]

The Sentinel resumes publication after an end-of-year holidays break.
This edition of 4 January 2020 begins the seventh year of weekly publication.

Happy 75th Birthday, United Nations!
United Nations Department of Economic and Social Affairs
2 January 2020, New York
The United Nations makes a difference in the lives of everyone, everywhere. From providing food and assistance to 91.4 million people in 83 countries, supplying vaccines to 45 per cent of the world’s children, to working with 196 countries to keep global temperature rise well below 2 degrees Celsius. The examples are many of how this 193-Member-State strong global organization makes an impact on the ground. This year, we will commemorate and reflect on the organization’s first 75 years of existence by inviting YOU to join the largest-ever global conversation.

The United Nations saw the light of day in 1945, when it was created in the wake of the devastating World War II, with pledges to save future generations from the atrocities of war and reiterate faith in fundamental human rights. Since then, the organization has played a vital role on the world stage, bringing countries together in addressing problems that transcend national boundaries and which no country can solve on their own…

Through this UN75 initiative, the United Nations is embarking on the largest, most inclusive conversation on the role of global cooperation in building the future we want. The organization is calling on people from all walks of life to join dialogues hosted both online and offline, throughout the year. By bringing together people’s voices and views in this way, the organization seeks to find out how enhanced international cooperation can help realize a better world by 2045, when the UN will celebrate its 100th birthday…
Through this worldwide listening exercise, the UN75 initiative aims to foster a greater sense of global citizenship and to empower a critical mass of international actors to address global issues. The views and ideas generated, will be presented by the Secretary-General to world leaders and senior UN officials on 21 September 2020 at a high-level event to mark the anniversary…

For more information: UN75 – Shaping our future together

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In First Annual Budget Since 1973, Fifth Committee Approves $3.07 Billion for 2020, Concluding Main Part of Seventy-Fourth Session
Delegates Clash over Funding for Mechanism Investigating Serious Crimes in Syria
General Assembly Fifth Committee
GA/AB/4350 27 December 2019
21st Meeting (AM)
The Fifth Committee (Administrative and Budgetary) concluded the main part of its seventy fourth session on Friday, approving resources totalling $3.07 billion for 2020, its first annual budget since 1973 and $200 million more than the $2.87 billion outlay proposed by Secretary General António Guterres in early October.

With the new one year fiscal cycle for its regular budget, the Organization temporarily leaves behind more than four decades of biennium budgets and a year in which it grappled with a severe liquidity crunch. The cash crisis has forced the Organization to limit staff hiring and travel, the hours of operation at the New York Headquarters and carry out other cost saving emergency measures.

At the close of the day long and at times contentious meeting, Fifth Committee Chairman Andreas D. Mavroyiannis (Cyprus) thanked the delegates and the Secretariat staff for their dedication and hard work. The Secretariat handled more than 1,300 questions submitted in writing by Fifth Committee members scrutinizing an initial proposed programme budget resolution with more than 500 paragraphs…

Featured Journal Content

Lancet Infectious Diseases
Volume 20, ISSUE 1, P1, January 01, 2020
http://www.thelancet.com/journals/laninf/issue/current
Personal View
The public health crisis of underimmunisation: a global plan of action
Lawrence O Gostin, James G Hodge Jr, Barry R Bloom, Ayman El-Mohandes, Jonathan Fielding,
Peter Hotez, Ann Kurth, Heidi J Larson, Walter A Orenstein, Kenneth Rabin, Scott C Ratzan, Daniel Salmon
[Excerpts]
Summary
Vaccination is one of public health’s greatest achievements, responsible for saving billions of lives. Yet, 20% of children worldwide are not fully protected, leading to 1·5 million child deaths annually from vaccine-preventable diseases. Millions more people have severe disabling illnesses, cancers, and disabilities stemming from underimmunisation. Reasons for falling vaccination rates globally include low public trust in vaccines, constraints on affordability or access, and insufficient governmental vaccine investments. Consequently, an emerging crisis in vaccine hesitancy ranges from hyperlocal to national and worldwide. Outbreaks often originate in small, insular communities with low immunisation rates. Local outbreaks can spread rapidly, however, transcending borders. Following an assessment of underlying determinants of low vaccination rates, we offer an action based on scientific evidence, ethics, and human rights that spans multiple governments, organisations, disciplines, and sectors.

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Introduction
Vaccination is among public health’s greatest achievements, saving billions of lives. Global scourges such as smallpox have been eradicated, with polio nearing eradication. Childhood diseases (such as measles, mumps, and pertussis) have substantially diminished through modern vaccination practices. Yet, one in five children worldwide are not fully protected, resulting in 1·5 million child deaths annually from diseases that are preventable by vaccination, including diarrhoea and pneumonia, equating to one death every 20 s.1 Millions more people have severe disabling illnesses, cancers, and disabilities from infections caused by underimmunisation. Ten highly populous countries with suboptimal immunisation systems account for over 70% of the world’s unvaccinated children.1

Despite vast benefits, immunisation levels are falling among specific populations in countries at all wealth levels. Reasons vary, ranging from low public trust in vaccines to constraints on affordability or access. The WHO rates vaccine hesitancy—reluctance or refusal to vaccinate despite vaccine availability—as among the top ten global health threats for 2019.2 Overall, both WHO and UNICEF report in 2019 that global immunisation rates for common childhood vaccines have flat-lined at 86% over the past decade.2, 3 Country rates vary widely, from 25% in Equatorial Guinea to 96% in Norway.3 Vaccinations in many countries are falling below levels needed for so-called herd immunity, or community protection, resulting in outbreaks. The global incidence of measles increased by 30% over the previous year in 2017 alone, with major diphtheria outbreaks in multiple regions.4

The vaccination crisis ranges from hyperlocal to national and worldwide. Outbreaks often originate in small, insular communities with low vaccination rates. Yet, local outbreaks can spread rapidly, transcending borders. Mass migration and international travel propel infectious diseases across the globe. Anti-vaccine messaging targets local communities, but is also disseminated widely on internet platforms and social media. Multiple forces driving the resurgence of childhood diseases also threaten immunisation campaigns, such as for polio and malaria.

The remarkable promise of immunisation has stubbornly stalled, with losses measured in deaths and human suffering.5 In 2018, 20 million children missed out on lifesaving measles, diphtheria, and tetanus vaccines.3 Underlying this public health crisis is a striking paradox—vaccines are victims of their own success. Immunisations are remarkably effective, closely monitored, and very safe. Consequently, many clinicians and parents have not seen the consequences of vaccine-preventable diseases and underestimate their harms. Governments also fail to adequately invest in vaccines, from research to cold storage and delivery.

There are no simple solutions to this problem, but innovative policies and programmes working in concert would substantially increase vaccination rates. We offer an action plan based on scientific evidence, ethics, and human rights. Crucially, an effective response must be multidisciplinary and multisectoral, spanning governments, international organisations, the private sector, and civil society. Our plan begins with an examination of underlying determinants of low vaccination rates…

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Generating sustainable solutions
Underimmunisation is a global crisis requiring sustainable solutions. We offer a three-pronged strategy: innovative financing for vaccine affordability, accessibility, and availability; evidence-based health communication campaigns at local, national, and global levels; and law reform that has public acceptance and is fairly implemented.

:: Vaccine affordability, accessibility, and availability
Projected global funding shortfalls of $7·2 billion (between 2016 and 2020) undermine immunisation goals.36
WHO’s 2013 Global Vaccine Action Plan estimated $60 billion needed for 94 LMICs from 2011 to 2020,37 nearly half of which is unsecured through government or philanthropic sources. WHO also seeks an additional $10 billion for its own operations by 2023, including $667 million to “strengthen routine vaccination and health systems” and $1·6 billion for polio eradication.38
Most costs focus on immunisation services, including management, training, social mobilisation, and surveillance. Rapid deployment of vaccines in response to emerging threats is also essential to save lives and reduce costs.

WHO’s Action Plan partners focus on the entire vaccine pipeline—from research, price, storage, and delivery to robust health systems. Dedicated funding for national immunisation programmes is an essential driver for national and global initiatives. Gavi, for example, generates long-term resources through the international finance facility for immunisation and advanced market commitments to support pneumococcal vaccines. A global campaign to raise financing to scale should be a major priority, especially for low-income countries that are unable to pay for or administer vaccines across their populations. Solidarity for universal vaccine availability is warranted because deficiencies in any country threaten populations worldwide. Each government must assure robust national immunisation systems, but the international community also shares responsibility to fill gaps in capacity through enhanced coordination, forecasting, and manufacturer incentives. Global partnerships like the Coalition for Epidemic Preparedness Innovations (CEPI) align public and private actors to fund, develop, and equitably distribute vaccines.

:: Trustworthy information environment
Resources alone, of course, cannot ensure high immunisation rates if the public distrusts the quality, safety, or effectiveness of vaccines. Gaining trust has become difficult with the rise of nationalist populism, which often questions science and casts doubt on expert opinions. The public cannot rely on the media to provide unbiased or accurate messages. Although some parents remain vehemently opposed to vaccinations, most are open to non-judgmental messages and want the best for their children. Altering the informational environment to afford greater salience to accurate, science-based messages could assuage parental concerns. WHO, governments, and partners (eg, philanthropists, industry, and civil society) should sustainably fund evidence-based engagement and health communication strategies that are proactive, timely, and credible, and tailored to specific audiences. WHO is generating a hub for vaccination acceptance and demand to provide reliable information and tools. Governments should similarly develop national and regional campaigns, including an emphasis on behavioural changes. Key components of effective communication campaigns include objective messaging in traditional and social media designed to assuage fears and promote accurate health information and immunisation outcomes. Campaigns should recruit well trusted spokespeople such as leaders in sport, entertainment, and religion. Health engagement is often the most effective at the community level through local leaders, teachers, and religious figures.

Governments should also adopt transparent, lawful, and measured regulations to correct or remove disinformation from the internet and social media. In the same way that states limit malicious hate speech and violent images, they can sensibly regulate patently false or misleading vaccine information. Social media enterprises should be held accountable for rooting out irresponsible vaccine rumours pervading their platforms. For example, searches for vaccine-related terms on Pinterest are automatically diverted to trustworthy vaccine sources like WHO and CDC.39 Furthermore, internet search engines should prioritise reliable scientific sources over anti-vaccine websites.

Traditional and social media play a special role in open and free societies, and their independence is highly valued. Encouraging self-regulation and ethical corporate responsibility could avoid formal regulation. Governments at the 2019 G20 Summit, for example, asked social media companies to remove violent, terrorism-related messages and images. Facebook agreed to assess its policies governing anti-vaccination information and advertising on its site. YouTube has begun taking down misleading videos and images. Moreover, Amazon is removing anti-vaccination videos, books, and documentaries.

:: National or regional law reform
Governments can use legal tools successfully to increase vaccination rates. Efficacious vaccination laws can lead to higher immunisation coverage.30 Vaccination mandates passed in France and Italy are associated with increased vaccine rates.40 A meta-analysis of European laws, however, did not find a strong link between vaccination laws and coverage.24 These disparate findings might suggest that legal approaches tailored to local cultures work best.

Vaccination laws must exempt people for legitimate medical reasons, such as infants and immunosuppressed individuals. Yet, overzealous reliance on non-medical exemptions can result in preventable outbreaks.27 Multiple US studies conclude that school vaccination laws with fewer exemptions lowered the incidence of childhood diseases. Governments should consider repealing or restricting permissive religious and philosophical exceptions. Such reforms are consistent with freedoms of religion and conscience because they do not target particular religious or other communities, but are applied fairly and equally throughout society. Parents are responsible for not placing their own, and other, children at risk of serious infections. Well tailored laws can also help reduce the number of people objecting to vaccinations due to misinformation.

,

Conclusion
The global crises of underimmunisation risks hard-won gains in preventing infectious diseases. Resurging childhood diseases and fragile global vaccination campaigns necessitate concerted action. Our action plan focuses on the prime causes of underimmunisation: vaccine availability, public distrust, and lax immunisation laws. Immunisation is a potent public health tool. Finding the political will and holding governments accountable are essential. Countless lives can be saved if the international community sustainably funds vaccination systems, assures reliable information, and safeguards the common good through meaningful law reform.

Featured Journal Content

The Lancet Child & Adolescent Health
Volume 4, ISSUE 1, P1, January 01, 2020
https://www.thelancet.com/journals/lanchi/issue/current
Editorial
Youth without freedom
The 30th anniversary of the UN Convention on the Rights of the Child (UNCRC) on Nov 20, 2019, is a chance to reflect on the global status of children’s rights. A report by UNICEF addresses the progress made in the past three decades, including reduced child mortality rates and increased global access to education, but notes many outstanding challenges such as increasing poverty, dangers posed by climate change, and declining vaccination rates. A Viewpoint by Jeff Goldhagen and colleagues discusses these threats to children’s health through a rights, justice, and equity lens.

One focus of the convention is a child’s right to an appropriate justice system, protection from danger and conflict, and provision of humane detention when necessary. It stresses that deprivation of a child’s liberty should only be used as a measure of last resort, and for the shortest appropriate period of time. The UN Global Study on Children Deprived of Liberty, published on Nov 20, 2019, is therefore timely because it provides the first comprehensive data determining the magnitude of the issue of children deprived of liberty, its possible justifications and root causes, as well as conditions of detention and their harmful effect on the health and development of children.

The UN study indicates that at least 1·3 million children are globally deprived of liberty per year; an estimated 410 000 in the administration of justice, 330 000 in migration-related detention, 35 000 in armed conflict situations, and 1500 for national security reasons. An additional 19 000 children are living with their primary caregivers in prisons and a further 1 million children are in temporary police custody. Lesbian, gay, bisexual, transgender, and intersex children and adolescents, boys, and those with a disability are at increased risk, and constitute a disproportionate share of institutionalised youth. External risk factors also contribute—eg, ineffective child welfare systems, insufficient support for family environments, low minimum age of criminal responsibility, harsh sentencing, discrimination, socioeconomic hardships, and a lack of resources for the administration of justice.

The UNCRC specifies that when children cannot live with their families, “the State should endeavour to provide a family-like environment where they can develop their personality, their emotional relationships with others, their social and educational skills and their talents”. Due to the formative nature of childhood, deprivation of liberty during development can have highly detrimental effects on a child’s physical and mental health. Although there is little evidence that detention alone is a primary cause of health problems, living in overcrowded conditions increases the risk of communicable diseases, unnecessary restrictions on movement and physical activity negatively affect development, and abuse or neglect while in detention often cause or compound mental and cognitive health problems, such as anxiety, depression, or regression of language. Often, health problems in children deprived of liberty are further exacerbated by limited accessibility to and low quality of health care.

On Nov 21, WHO released a status report on prison health in Europe detailing the health status of those incarcerated in the region. The data present a dire situation, showing enormous health disparities between people detained in prison and those living in the community, and highlighting the increased risk of suicide and self-harm. The report suggests that prisons and other institutions should be considered as public health opportunities, where existing health conditions can be treated and improved, and interventions to promote healthy lifestyles and positive behavioural changes can be administered. Such approaches are particularly appealing in the context of youth detention. While adolescence is a period of unique vulnerability, it also offers great potential because many children and young people are receptive to behavioural change and interventions are applied early enough for any lifestyle modifications to make enormous gains in future health outcomes.

The UN study shows that sentencing children to custodial prison sentences remains widespread, despite recommendations that even when a child has committed a crime, alternative solutions such as probation, foster care, or education and vocational training programmes should be considered. Where alternatives to custodial prison sentences cannot be found, it is imperative that detained youth are able to access the same standard of health care as available in the community. The UNCRC declares that all children and adolescents have a right to the highest attainable standard of health. We must not accept anything less for those young people deprived of their liberty.

Emergencies

Ebola – DRC+
Public Health Emergency of International Concern (PHEIC)

Ebola Outbreak in DRC 73: 24 December 2019
Situation Update
In the week of 16 to 22 December 2019, 14 new confirmed Ebola virus disease (EVD) cases were reported from four health areas within two health zones in North Kivu province in the Democratic Republic of the Congo. The new confirmed cases in the past week are from Mabalako Health Zone (12/14; 86%) and Butembo Health Zone (2/14; 14%)…

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DRC Ebola outbreaks
Military presence leads MSF to stop activities in Ebola-affected Biakato
Press Release 24 Dec 2019
Following security incidents in Biakato, Democratic Republic of Congo, an increase in security – including armed military forces – have been deployed around and within health structures. The presence of arms and weapons in hospitals and clinics has resulted in Médecins Sans Frontières (MSF) taking the difficult decision to stop medical activities – including those related to Ebola – in Biakato.
“We are no longer able to work in accordance with our principles of neutrality and impartiality,” said Ewenn Chenard, Emergency Coordinator for MSF. “We regret this decision, but the presence of armed forces around and within the health structures of Biakato goes against our principles.”
MSF has been working with the people of Biakato, located in DRC’s northeastern Ituri province, since 2016, supporting the Ministry of Health. Initially, our activities were dedicated to assisting victims of sexual violence…

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POLIO
Public Health Emergency of International Concern (PHEIC)

Statement of the Twenty-Third IHR Emergency Committee Regarding the International Spread of Poliovirus
20 December 2019
[Excerpts; Editor’s text bolding]
The twenty-third meeting of the Emergency Committee under the International Health Regulations (2005) (IHR) regarding the international spread of poliovirus was convened by the Director General on 11 December 2019 at WHO headquarters with members, advisers and invited Member States attending via teleconference, supported by the WHO secretariat.

The Emergency Committee reviewed the data on wild poliovirus (WPV1) and circulating vaccine derived polioviruses (cVDPV).  The Secretariat presented a report of progress for affected IHR States Parties subject to Temporary Recommendations.  The following IHR States Parties provided an update on the current situation and the implementation of the WHO Temporary Recommendations since the Committee last met on 16 September 2019: Afghanistan, Angola, Benin, Central African Republic (CAR), Chad, Cote d’Ivoire, Democratic Republic of Congo (DR Congo), Ethiopia, Ghana, Nigeria, Pakistan, Philippines, Togo and Zambia…

Wild poliovirus
The Committee remains gravely concerned by the significant increase in WPV1 cases globally to 113 as at 11 December 2019, compared to 28 for the same period in 2018, with no significant success yet in reversing this trend. 

In Pakistan transmission continues to be widespread, as indicated by both AFP (acute flaccid paralysis) surveillance and environmental sampling. Khyber Pakhtunkhwa province continues to be of particular concern.  The issues noted previously by the committee, including refusal by individuals and communities to accept vaccination, and problems with politicization of the national polio program are still being addressed.  Added pressure is now on the program due to confirmation of detection of cVDPV2 in several provinces (see below).
In Afghanistan, the security situation remains very challenging.  Inaccessible and missed children particularly in the Southern Region represent a large cohort of susceptible children in this part of Afghanistan.  The risk of a major upsurge of cases is growing, with other parts of the country that have been free of WPV1 for some time now at risk of outbreaks. This would again increase the risk of international spread.  Major efforts must be made to improve access if eradication efforts are going to progress.

The committee noted that based on sequencing of viruses, there were recent instances of international spread of viruses from Pakistan to Afghanistan and also from Afghanistan to Pakistan.  The recent increased frequency of WPV1 international spread between the two countries suggests that rising transmission in Pakistan and Afghanistan correlates with increasing risk of WPV1 exportation beyond the single epidemiological block formed by the two countries…

Vaccine derived poliovirus
The multiple cVDPV outbreaks in four WHO regions (African, Eastern Mediterranean, South-east Asian and Western Pacific Regions) are very concerning, with seven new countries reporting outbreaks since the last meeting (Chad, Cote d’Ivoire, Malaysia, Pakistan, Philippines, Togo and Zambia).  Since the last meeting, cVDPV2 has spread through West Africa and the Lake Chad area, reaching Cote d’Ivoire, Togo and Chad, and cVDPV1 has spread from the Philippines to Malaysia.

The rapid emergence of multiple cVDPV2 strains in several countries is unprecedented and very concerning, and not yet fully understood. 

The committee noted that the GPEI was developing a strategy to address cVDPV2 outbreaks but was extremely concerned that the monovalent OPV2 stockpile was becoming depleted.  The committee strongly supports the development and proposed Emergency Use Listing of the novel OPV2 vaccine which should become available mid-2020, and which it is hoped will result in no or very little seeding of further outbreaks.

Conclusion
The Committee unanimously agreed that the risk of international spread of poliovirus remains a Public Health Emergency of International Concern (PHEIC) and recommended the extension of Temporary Recommendations for a further three months.  The committee recognizes the concerns regarding the lengthy duration of the polio PHEIC, but concludes that the current situation is extraordinary, with clear ongoing risk of international spread and ongoing need for coordinated international response…

Additional considerations  
Preparedness – The committee urged all countries, particularly those in Africa, be on high alert for the possibility of cVDPV2 importation and respond to such importations as a national public health emergency.  This means countries should ensure polio surveillance can rapidly detect cVDPV2, and plans are in place to respond rapidly with well planned and executed mOPV2 campaigns, and with strict procedures to ensure unused vials are returned and managed so that inappropriate or accidental use is avoided.

International Coordination – Unprecedented levels of international spread of cVDPV require urgent coordinated control measures at regional and sub-regional levels.  The committee strongly encourages countries to do more in support of cross border actions, such as sharing of surveillance and other data, synchronizing campaigns and where possible ensure vaccination of international travelers.

Emergency Response – The committee noted the endorsement of SAGE for the accelerated clinical development of novel OPV2 and its assessment under the WHO Emergency Use and Listing (EUL) procedure, which can be used in a public health emergency of international concern (PHEIC), and added its support to ensure the supply of monovalent OPV2.

Financing – The number of outbreaks is proving to be costly to manage, and the committee urged affected countries to prioritize polio control as a public health emergency and ensure adequate domestic funding is available for an effective response.  The committee urged affected countries to mobilize domestic funding to complement the GPEI resources which are being stretched by the large number of outbreaks being fought globally.

Communication – Vaccine hesitancy is a significant factor in the spread of these outbreaks particularly certain countries including Pakistan and Angola.  The committee urged countries to invest time and resources into pro-actively circumventing and countering myths and misinformation regarding vaccination is general, and rumors that arise during the course of campaigns in particular.  Campaign communications need to address issues around avoiding spreading excreted Sabin-like viruses through good hygiene.

Based on the current situation regarding WPV1 and cVDPV, and the reports provided by affected countries, the Director-General accepted the Committee’s assessment and on 19 December 2019 determined that the situation relating to poliovirus continues to constitute a PHEIC, with respect to WPV1 and cVDPV.  The Director-General endorsed the Committee’s recommendations for countries meeting the definition for ‘States infected with WPV1, cVDPV1 or cVDPV3 with potential risk for international spread’, ‘States infected with cVDPV2 with potential risk for international spread’ and for ‘States no longer infected by WPV1 or cVDPV, but which remain vulnerable to re-infection by WPV or cVDPV’ and extended the Temporary Recommendations under the IHR to reduce the risk of the international spread of poliovirus, effective 19 December 2019.

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Three African countries halt polio outbreaks
Kenya, Mozambique and Niger have curbed polio outbreaks that erupted in different episodes over the past 24 months, allowing them to regain their polio-free status, World Health Organization (WHO) announced
Brazzaville, 19 December 2019 – Kenya, Mozambique and Niger have curbed polio outbreaks that erupted in different episodes over the past 24 months, allowing them to regain their polio-free status, World Health Organization (WHO) announced.
Transmission of vaccine-derived poliovirus was detected in the three countries in 2018, affecting 12 children. No other cases have since been detected.
“Ending outbreaks in the three countries is proof that the implementation of response activities and ensuring that three rounds of high-quality immunization campaigns are conducted can stop the remaining outbreaks in the region,” said Dr Modjirom Ndoutabe, Coordinator of the WHO-led polio outbreaks Rapid Response Team for the African Region.
“We are strongly encouraged by this achievement and determined in our efforts to see polio eradicated from the continent. It is a demonstration of the commitment by Governments, WHO and our partners to ensure that future generations live free of this debilitating virus,” added Dr Ndoutabe…

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Editor’s Note:
WHO has posted a refreshed emergencies page which presents an updated listing of Grade 3,2,1 emergencies as below.

WHO Grade 3 Emergencies [to 4 Jan 2020]

Democratic Republic of the Congo
:: Ebola Outbreak in DRC 73: 24 December 2019

Syrian Arab Republic
:: WHO deeply concerned about deteriorating health conditions in northwest Syria
25 December 2019, Geneva-Cairo-Copenhagen –  The World Health Organization today expressed its deepening concern about the situation in northwest Syria and the impact hostilities are having on the health of a population that has endured sustained hardships, in what is now harsh weather conditions.
“The recent military escalation in this area has resulted in loss of lives, injuries and exacerbated suffering of civilians, displacing more than 130,000, including women, children and elderly,” said Dr Richard Brennan, Director of Health Emergencies for WHO’s Eastern Mediterranean Region. “Some have been displaced three times during the nine years of the Syrian conflict,” he added.
Among the 12 million people in need of health services in Syria, over 2.7 million are in the northwest and half 0.5 million live in the areas south of Idleb, where disruption of fragile health services continues…

Mozambique floods – No new digest announcements identified
Nigeria – No new digest announcements identified
Somalia – No new digest announcements identified
South Sudan – No new digest announcements identified
Yemen – No new digest announcements identified

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WHO Grade 2 Emergencies [to 4 Jan 2020]
Myanmar
:: Bi‐weekly Situation Report 25 – 19 December 2019
HIGHLIGHTS
:: Tuberculosis(TB) performance for the third quarter for Cox’s Bazar District was reviewed at a meeting held with a view to strengthening TB programme activities in the district.
:: Oral Cholera Vaccine (OCV)campaign in Rohingya camps has ended on 14 December. However, the campaign for the host community will continue for the period of 8 to 31 December 2019.
:: A total of 127 Community Health Worker(CHW) supervisors have received a two-day training on risk factors of Non-Communicable Diseases (NCD) and behavioral interventionsin Cox’s Bazar.
:: The government of Bangladesh through National Expanded Program on Immunization(EPI), is going to conduct a month-long Measles Outbreak Response Immunization (ORI) activity from 12 January to 12 February 2020 in the Rohingya camps.
SITUATION OVERVIEW
As per Inter-Sector Coordination Group (ISCG)report of September 2019, there are 914,998 Rohingya refugees in Cox’s Bazar. This includes 34,172 refugees from Myanmar who registered before 31st August 2017. All refugees, including new arrivals, face compounding vulnerabilities, including in health. WHO has been responding to this crisis since September 2017. A summary of response actions from epidemiological weeks 49 and 50 of 2019 is presented below…

Niger
:: L’OMS offre un important lot de médicaments et matériels médicaux au Gouvernement du…
27 décembre 2019
Le Niger fait régulièrement face à des urgences de plus en plus complexes avec un impact négatif sur la santé des populations. Parmi ces urgences « les maladies à potentiel épidémique », telles que le choléra, la méningite, entre autres, mais aussi « les conséquences sanitaires liées à l’activisme de groupes armées non étatiques (GANE) » le long du périmètre des quatre frontières Mali-Burkina Faso-Nigéria-Niger impliquant dix (10) districts sanitaires (DS) dans la région de Tillabéry, 2 dans celle de Tahoua, cinq (5) dans celle de Diffa et 2 dans celle de Maradi, engendrant de grands mouvements de populations.

Afghanistan – No new digest announcements identified
Angola – No new digest announcements identified
Burkina Faso [in French] – No new digest announcements identified
Burundi – No new digest announcements identified
Cameroon – No new digest announcements identified
Central African Republic – No new digest announcements identified
Ethiopia – No new digest announcements identified
HIV in Pakistan – No new digest announcements identified
Iran floods 2019 – No new digest announcements identified
Iraq – No new digest announcements identified
Libya – No new digest announcements identified
Malawi floods – No new digest announcements identified
Measles in Europe – No new digest announcements identified
MERS-CoV – No new digest announcements identified
occupied Palestinian territory – No new digest announcements identified
Sudan – No new digest announcements identified
Ukraine – No new digest announcements identified
Zimbabwe – No new digest announcements identified

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WHO Grade 1 Emergencies [to 4 Jan 2020]

Chad – No new digest announcements identified
Djibouti – No new digest announcements identified
Kenya – No new digest announcements identified
Mali – No new digest announcements identified
Namibia – viral hepatitis – No new digest announcements identified
Tanzania – No new digest announcements identified

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UN OCHA – L3 Emergencies
The UN and its humanitarian partners are currently responding to three ‘L3’ emergencies. This is the global humanitarian system’s classification for the response to the most severe, large-scale humanitarian crises. 
Syrian Arab Republic
:: Syrian Arab Republic: Recent Developments in Northwestern Syria Situation Report No. 4 – As of 2 January 2020

Yemen – No new digest announcements identified

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UN OCHA – Corporate Emergencies
When the USG/ERC declares a Corporate Emergency Response, all OCHA offices, branches and sections provide their full support to response activities both at HQ and in the field.
Editor’s Note:
Ebola in the DRC has bene added as a OCHA “Corporate Emergency” this week:
CYCLONE IDAI and Kenneth – No new digest announcements identified
EBOLA OUTBREAK IN THE DRC – No new digest announcements identified

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Editor’s Note:
We rarely include editorials/opinions in our coverage each week, but thought to share this as we close the year.

Financial Times
The editorial board
Opinion
The spirit of endeavour has not dimmed in 2019
Power of the human mind, body and creativity was on display this year
December 23 2019

These can seem unsettling times. Populism is on the rise; liberal democracy is under pressure. Protectionism is threatening to stifle free trade. China and the US are locked in what seems ever more like a new cold war. Leaders are struggling to agree on how to cut carbon emissions. Extreme weather events are increasing. Yet amid the uncertainty, stories of extraordinary people have been the bright spot.

Countless citizens across the world have shown the power of the human body, mind and spirit to achieve remarkable things in 2019. The Financial Times chose Satya Nadella as its person of the year for reviving Microsoft while instilling a new purpose and sense of humility. Many others deserve to be honoured.

In April, a team of scientists developed the first picture of a black hole, an astronomical phenomenon from which no light can escape. Katie Bouman, a young computer scientist, became the symbol of the achievement for using her knowhow to craft an algorithm that could stitch together the images from a network of telescopes. Outer space witnessed other new human firsts. Fifty years after the moon landing, astronauts Christina Koch and Jessica Meir took part in the first all-female spacewalk while China’s Chang’e 4 mission completed the first successful “soft” landing on the far side of the moon.

Many of the greatest individual achievements this year have been internal: victories over our own limits. Eliud Kipchoge was the first human to run a marathon in under two hours. He achieved the milestone in a time trial in Vienna in October, helped by a laser routemarker, a team of support staff and 41 pacemakers. Jasmin Paris became the first woman to win the 268-mile Montane Spine Race, breastfeeding her 14-month old daughter on the way. Nepalese mountain climber Nirmal “Nims” Purja, a former Gurkha, scaled the 14 highest peaks in the world in six months, beating the existing speed record by more than seven years.

Others have depended on teamwork: Siya Kolisi, captain of the world cup winning rugby team, became the first black South African to lift the trophy. Megan Rapinoe, captain of the US team that won the women’s football world cup, used her platform to call for equal pay. Ben Stokes, the English cricketer, secured the world cup for his nation in highly dramatic style.

This was the year when humans began to harness the power of quantum computers: a team at Alphabet, Google’s parent, declared they had achieved “quantum supremacy”, as their device beat a traditional computer. Others focused on making sure that technological advances did not mean abandoning morality: Meredith Whittaker, an artificial intelligence worker who had led protests about her employer Google’s policies in 2018, resigned from her job this year.

Others have demonstrated the human power for creativity. Bernadine Evaristo became the first black woman to win the Booker prize this year. She shared it with Margaret Atwood, who first won the prestigious prize close to two decades ago. Stormzy, a British rapper, not only crafted stunning imagery in his headline set at Glastonbury, but a scholarship he funds was credited with an increase in the number of black students applying to the elite University of Cambridge.

Those listed here are just the tip of the iceberg. Many of the most extraordinary people go unsung in unglamorous jobs, doing the work of caring for others day in, day out. They are a reminder that no matter how dark the news appears to be, the spirit of human endeavour remains undimmed. The FT salutes them.

The Sentinel

Human Rights Action :: Humanitarian Response :: Health :: Education :: Heritage Stewardship ::
Sustainable Development
__________________________________________________
Week ending 21 December 2019

This weekly digest is intended to aggregate and distill key content from a broad spectrum of practice domains and organization types including key agencies/IGOs, NGOs, governments, academic and research institutions, consortia and collaborations, foundations, and commercial organizations. We also monitor a spectrum of peer-reviewed journals and general media channels. The Sentinel’s geographic scope is global/regional but selected country-level content is included. We recognize that this spectrum/scope yields an indicative and not an exhaustive product. Comments and suggestions should be directed to:

David R. Curry
Editor
GE2P2 Global Foundation – Governance, Evidence, Ethics, Policy, Practice
david.r.curry@ge2p2center.net

PDF: The Sentinel_ period ending 21 Dec 2019

Contents
:: Week in Review  [See selected posts just below]
:: Key Agency/IGO/Governments Watch – Selected Updates from 30+ entities   [see PDF]
:: INGO/Consortia/Joint Initiatives Watch – Media Releases, Major Initiatives, Research:: Foundation/Major Donor Watch -Selected Updates
:: Journal Watch – Key articles and abstracts from 100+ peer-reviewed journals  [see PDF]

The Sentinel will resume publication on 4 January 2020 after an end-of-year holidays break.

COP25 :: UN Climate Change Conference – December 2019

UN Climate Statement / 19 Dec, 2019
Statement by the Executive Secretary of UN Climate Change, Patricia Espinosa, on the Outcome of COP25
Several days have passed since the closing of the UN Climate Change Conference COP25 in Madrid, and it is important to conduct an honest and realistic assessment of what happened so that appropriate measures can be taken by the international community in guiding the next crucial steps in the multilateral climate process next year.

We need to be clear that the conference did not result in agreement on the guidelines for a much-needed carbon market – an essential part of the toolkit to raise ambition that can harness the potential of the private sector and generate finance for adaptation. Developed countries have yet to fully address the calls from developing countries for enhanced support in finance, technology and capacity building, without which they cannot green their economies and build adequate resilience to climate change. High-emitting countries did not send a clear enough signal that they are ready to improve their climate strategies and ramp up ambition through the Nationally Determined Contributions they will submit next year.

At the same time, in the final decision texts, governments did express the need for more ambition by Parties and non-State actors alike, and they agreed to improve the ability of the most vulnerable to adapt to climate change. Many decisions that emerged from the conference in Madrid at least acknowledge the role of climate finance, essential for concrete action. And decisions were taken in areas including technology, oceans and agriculture, gender and capacity building. A large group of countries, regions, cities, businesses and investors signaled their intention to achieve net-zero CO2 emissions by 2050, as part of the Climate Ambition Alliance led by Chile. Also rallying under the Climate Ambition Alliance, 114 nations have meanwhile signaled their intention to submit an enhanced climate action plan next year. The caveat here is that not enough major economies have signaled that they are ready to shift the needle on climate ambition through improved plans.

Commitments from many sectors of society showed an overwhelming agreement on the only way forward: that we need to follow what science is telling us, with the sense of urgency and seriousness that this requires. What we need now is to focus our undivided attention on the next steps to further strengthen the trust in the multilateral process. As we head towards the UN Climate Change Conference COP26 in Glasgow, we must be united and work in a true spirit of inclusive multilateralism in order to realize the promises of the Paris Agreement and the UN Framework Convention on Climate Change. I thank the governments of Chile and Spain for their enormous efforts to organize COP25, and I thank all observer organizations, including the private sector, youth and scientists, for reminding us every day of the need to raise ambition. I look forward to working with the governments of Chile, the UK and Italy to achieve the best possible results at COP26 in Glasgow. Together, with all sectors of the economy and societies at large, we must work tirelessly to address the greatest challenge of our generation.

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Global Community Must Not Give Up Tackling Climate Crisis, Secretary-General Says, Expressing Disappointment with Results of Twenty-Fifth Conference
SG/SM/19914-ENV/DEV/2034
15 December 2019
The following statement by UN Secretary General António Guterres was issued today:

I am disappointed with the results of [the twenty fifth Conference of the Parties (COP25) to the United Nations Framework Convention on Climate Change (UNFCC)].

The international community lost an important opportunity to show increased ambition on mitigation, adaptation and finance to tackle the climate crisis.

We must not give up and I will not give up. I am more determined than ever to work for 2020 to be the year in which all countries commit to do what science tells us is necessary to reach carbon neutrality in 2050 and a no more than 1.5°C temperature rise.

Syria

20 December 2019
SC/14066
Security Council Rejects 2 Draft Resolutions Authorizing Cross-Border, Cross-Line Humanitarian Access in Syria
The Security Council today failed to adopt two draft resolutions on extending the authorization for the mechanism that allows cross border delivery of humanitarian aid in Syria today — one tabled by Belgium, Germany and Kuwait; the other by the Russian Federation.

The draft proposed by co sponsors Belgium, Germany and Kuwait was rejected by a vote of 13 in favour and 2 against (China, Russian Federation). By its terms, the Council would have decided to renew the mechanism created by resolution 2165 (2014), excluding the border crossing of Al Ramtha, for a further six month period, to be followed by an additional six months unless the Council decided otherwise.

That draft would have demanded that all parties allow safe, unimpeded and sustained access for humanitarian convoys, including medical and surgical supplies, to all requested areas and populations, according to the United Nations’ assessment of need in all parts of Syria. It would have called on United Nations humanitarian agencies to improve monitoring of the distribution of relief consignments and their delivery inside Syria. It also would have requested the Secretary General to conduct an independent written review of United Nations humanitarian cross-line and cross-border operations, including recommendations on the need to reauthorize use of the Al Ramtha border crossing.

The draft proposed the Russian Federation was likewise defeated by 5 votes in favour (China, Côte d’Ivoire, Equatorial Guinea, Russian Federation, South Africa), to 6 opposed (Dominican Republic, France, Peru, Poland, United Kingdom, United States), with 4 abstentions (Belgium, Germany, Indonesia, Kuwait).

By its terms, the Council would have decided to renew the decisions in paragraphs 2 and 3 of Security Council resolution 2165 (2014), excluding border crossings at Al Yarubiyah and Al-Ramtha until 10 July 2020. It would have also called on all United Nations humanitarian agencies and their implementing partners to ensure appropriate identification for vehicles delivering assistance through cross border operations authorized by the resolution…

Rohingya

Myanmar :: Bi‐weekly Situation Report 24 – 5 December 2019
HIGHLIGHTS
:: A total of 1,270,70 doses of oral cholera vaccine (OCV) was approved for the OCV campaign, targeting around 635,000 individuals, which will take place from 8 to 14 December in the Rohingya camps and 8 to 31 December in the host communities.
:: Since 5 September 2019, a total of 213 cases of Acute Watery Diarrhea (AWD) have tested positive by cholera Rapid Diagnostic Tests (RDTs), or culture.
:: An assessment undertaken for the operational risks associated with Fecal Sludge management (FSM) and water sources has concluded that, urgent actions are required to improve the water safety situation in these camps.

SITUATION OVERVIEW
As per Inter-Sector Coordination Group (ISCG) report of September 2019, there are 914,998 Rohingya refugees in Cox’s Bazar. This includes 34,172 refugees from Myanmar who registered before 31st August 2017. All refugees, including new arrivals, face compounding vulnerabilities, including in health. WHO has been responding to this crisis since September 2017…

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The Lancet
Dec 21, 2019 Volume 394 Number 10216 p2201-2284
https://www.thelancet.com/journals/lancet/issue/current
Editorial
The Rohingya people: past, present, and future
The Lancet
Aung San Suu Kyi’s fall from grace is complete. Last week she gave an inhumane defence of Myanmar, a nation being tried for genocide, in a hearing at the International Court of Justice. But while events in The Hague monopolise the world’s attention, the appalling situation for the Rohingya refugees in Bangladesh is being neglected.

The Rohingya people have long been disenfranchised, including with respect to health, but since a mass flight from killing, rape, and arson in 2017, almost 1 million now live in refugee camps in Cox’s Bazar. Sanitation is poor, food is scarce, and shelters are basic and overcrowded. Humanitarian agencies have brought some stability, but the health situation is precarious.

The risk of infectious disease outbreaks is high: measles and diphtheria have already struck. And now a huge cholera vaccination campaign, with 635 000 doses, has begun after a series of cases of acute watery diarrhoea, some positive for cholera. Sexual abuse and intimate partner violence have been widely reported. The trauma of sexual violence and displacement from Myanmar, combined with a lack of prospects and unemployment in Bangladesh, is harming mental health, ranging from anxiety to depression to suicidal thoughts; 80 000 children are estimated to have severe mental distress. Fewer than half of births take place in health facilities. Only 46% of health centres have insulin. Disability care, eye care, oral care, and the care of older people are severely lacking. To describe the humanitarian situation in Cox’s Bazar is to list shortcomings in practically every facet of health.

Efforts at repatriation have failed, naturally, without major change in Myanmar and guarantees of safety. The Bangladeshi Government has blocked communications and intends to build a barbed wire fence around the area, as tensions with the local population grow. Plans to give the Rohingya a more permanent home elsewhere in Bangladesh have been mooted. Meanwhile, a new generation is being born in the camps of Cox’s Bazar, a generation whose health and prospects are in jeopardy. Their future is uncertain. For the present, the very least we can give them is our attention.

Waves of protests around the world are reminder that voices of children and adolescents must be heard and their rights protected
Statement by UNICEF Executive Director Henrietta Fore
NEW YORK, 18 December 2019 – “Children and young people from around the world have taken to the streets in recent months to demand their rights.

“Although every context is unique, from the Middle East to Latin America to the Caribbean, and in Europe, Africa and Asia, young people are calling for action on the climate crisis, for an end to corruption and inequality, for better education and employment opportunities – and for a fairer world for everyone, everywhere.

“It is therefore a heartbreaking irony that, in standing up for their fundamental rights, many children and adolescents are simultaneously having their rights taken away.

“Many of these protests have left young protesters behind bars, injured and at times killed. Schools have been shuttered and public services interrupted.

“Children’s rights to peaceful assembly and freedom of expression, including in peaceful protest, are enshrined in the Convention on the Rights of the Child, the most widely ratified human rights treaty in the world. It is incumbent on Member States to ensure that children can exercise this right in a safe and peaceful manner.

“All actors must refrain from violence, and fundamental guarantees for the protection of children must remain applicable everywhere, at all times, including where there is civil unrest or armed conflict.

“My plea is to please protect children from violence and respect their right to speak up and be heard. Give them opportunities to meaningfully voice their concerns and participate in matters that affect their futures. Listen to them and respond in a principled, constructive and supportive way.”

Refugees – Multilateral Development Banks (MDBs)

Global Refugee Forum – Joint Commitments by the MDB Coordination Platform on Economic Migration and Forced Displacement
On the occasion of the Global Refugee Forum on 17-18 December 2019 in Geneva (Switzerland), we, a group of Multilateral Development Banks (MDBs) including the African Development Bank, Asian Development Bank, European Bank for Reconstruction and Development, European Investment Bank, Inter-American Development Bank, Islamic Development Bank and the World Bank Group, affirm our commitment to work in support of the operationalization of the Global Compact on Refugees by the UNHCR, United Nations Member States, and other relevant stakeholders.

We acknowledge the Global Compact on Refugees as a key enabler and accelerator towards the achievement of the Sustainable Development Goals, and the importance of the protection mandate of UNHCR.

We recognize the imperative for MDBs to scale up financing for programs and projects that benefit the forcibly displaced and host communities alike.

In line with our different mandates and countries of operation, we wish to highlight MDBs’ ongoing support to countries of origin, transit areas, host communities, and refugees and migrants in refugee-like situations, through targeted financing and policy instruments.

In this context, we work together through a dedicated MDB Coordination Platform on Economic Migration and Forced Displacement, which seeks to foster strategic alignment among MDBs, strengthen operational coordination and knowledge sharing to leverage our synergies and complementarities.

We also work with strategic partners, including UNHCR, on issues of common interest. This includes data monitoring and sharing where possible, as well as across a number of the focus areas identified as critical by the 2019 Global Refugee Forum.

On the occasion of the Forum, we take the opportunity to commit to expanding and deepening cooperation amongst each other, and with member countries, and relevant specialized organizations, notably the UNHCR, as well as civil society and the private sector, to maximize our collective development impact.

In this context, MDBs reaffirm their commitment to:
:: Step up their work together and individually through a range of financing and policy instruments in accordance with each organization’s investment and financing criteria and requirements.

:: Coordinate with each other and with core stakeholders on key issues on the ground in order to build on existing initiatives, better enable shorter lead times, and deliver better outcomes for host communities and vulnerable populations.

:: In large-scale and rapidly evolving contexts, provide rapid financing through dedicated financial instruments or sources that can help alleviate the strain on public services in host countries, and support livelihoods, inclusiveness and resilience for all. Examples of these financing instruments and sources include AfDB’s Transition Support Facility, the AsDB’s Emergency Assistance Loan Instrument, the EBRD’s Refugee Response Plan, the EIB’s Economic Resilience Initiative, IDB’s Grant Facility to support countries with large and sudden intraregional migration inflows, IsDB through matching funds mechanisms and other channels, the World Bank IDA18 Sub-window for Refugees and Host Communities and the World Bank-administered Global Concessional Financing Facility, among others.

:: Promote and support the essential contribution of the private sector – inter alia through MDBs playing a facilitating role – in enhancing private sector participation in sustainable skills development and employment opportunities, SME and entrepreneurship support, as well as economic and social infrastructure and provision of essential services for host communities and target groups, including women and youth.

As part of these commitments, MDBs will follow principles of good practice that recognize the specific needs of vulnerable populations:
:: Tailor interventions to the specific country situations and regional dimensions in which MDBs are working.
:: Leverage and adapt existing programming and expertise to enable shorter lead times in deploying effective responses.
:: Align with good international practice, including on refugee protection, when developing programming that supports access to essential services and decent employment.
:: Foster inclusive approaches that benefit both host communities and target groups alike, with particular emphasis on interventions that strengthen resilience and social cohesion.
:: Consider the capacity and capabilities of partners at the regional, national and local level, and, where needed, provide targeted technical assistance to boost capacity.
:: Refine and strengthen incentives for private sector participation, including through risk mitigation, blended instruments and political risk insurance.
:: Measure and share information where possible on the impact of interventions to scale up and replicate the most effective programs in other areas of need, while ensuring that further interventions remain responsive to the new circumstances.
:: Continuously review and strengthen MDB staff expertise and capacity to ensure that programming appropriately considers the specific needs of host communities and vulnerable populations.

To support the above work, the MDB Coordination Platform on Economic Migration and Forced Displacement is working towards establishing streamlined mechanisms to facilitate cross-MDB knowledge sharing and operational exchanges including via an online community of practice, a series of papers on good practices, and focused workshops.

We look forward to taking stock of progress and sharing lessons learned at the next gathering of all stakeholders devoted to bringing the Global Compact on Refugees to life.

Development – Inequality

G7 Paris Summit
Reducing inequalities for sustainable development
Paris Joint Statement of the French Minister of Labour, the Managing Director of the International Monetary Fund (IMF), the Director-General of the International Labour Organization (ILO), and the Secretary General of the Organisation for Economic Cooperation and Development (OECD).

Statement | Paris, France | 19 December 2019
Throughout the world, increased inequalities within countries pose risks to inclusive growth, economic stability and social cohesion, both in advanced economies and in developing countries. In the absence of strong and effective policy responses to citizens’ call for social justice and shared prosperity, high inequalities contribute to the erosion of trust in democratic institutions and may ultimately challenge the foundation of our rules-based international cooperation system.

At a time of weak growth, the world of work is also undergoing profound and rapid global changes, driven by technological innovations, demographic shifts as well as environmental and climate change. These are defining global challenges requiring effective and coordinated responses through international cooperation and sustained social dialogue, to develop a human-centered approach which puts the needs, aspirations and rights of all people at the heart of economic, social and environmental policies.

The evidence from the work of our respective organizations has demonstrated that well-managed, digital transformations and transitions to environmentally and socially sustainable economies can become a strong driver of job creation, job upgrading, social justice and inclusion. Economies must be robust and productive to meet the needs of the world’s growing population. Societies must be inclusive, providing opportunities for decent work for all and must generate a fairer and more equitable distribution of income from work, reducing absolute poverty and inequalities.

Enhanced social spending can be a key policy lever for addressing emerging challenges from demographic shifts, technological developments, and climate change. Investment in education, health and social protection plays an essential role in generating equal opportunity, supporting social and political stability, addressing inequalities of income, protecting vulnerable groups and stabilizing economies in the face of shocks.

Adapting, reinforcing and expanding adequate, efficient, and fiscally sustainable social protection systems and investing in education, skills upgrading and health can help reduce inequality in income and opportunities, including in its gender dimension, address the persistence of poverty across generations, enhance social mobility, and ultimately promote sustained inclusive growth. Sound and effective redistributive fiscal policies adapted to national contexts are therefore needed to help governments address high levels of inequality. This requires fostering the adequacy, efficiency and equity, including risk sharing and solidarity, of social spending.

In this regard, and in light of the respective mandates of the International Labour Organization (ILO), the Organisation for Economic Cooperation and Development (OECD) and the International Monetary Fund (IMF), we believe that stronger cooperation and coordination among the international organizations constitutes an opportunity to increase the efficiency and impact in delivering the outcomes identified by our stakeholders and to foster the realization of the 2030 sustainable development goals, as agreed at the G7 Leaders Summit in Biarritz in August 2019.

In line with the G7 Social members’ call for a multilateral dialogue and coordination for the reduction of inequalities, we will strengthen our joint efforts at the institutional and country level, within our respective mandates, to identify areas for collaboration to reduce inequalities and to promote access to education, health and social protection.

Development – Debt in Emerging/Developing Economies

Global Wave of Debt Is Largest, Fastest in 50 Years
WASHINGTON, December 19, 2019—Debt in emerging and developing economies (EMDEs) climbed to a record US$55 trillion in 2018, marking an eight-year surge that has been the largest, fastest, and most broad-based in nearly five decades, according to a new World Bank Group study that urges policymakers to act promptly to strengthen their economic policies and make them less vulnerable to financial shocks.

The analysis is contained in Global Waves of Debt, a comprehensive study of the four major episodes of debt accumulation that have occurred in more than 100 countries since 1970. It found that the debt-to-GDP ratio of developing countries has climbed 54 percentage points to 168 percent since the debt buildup began in 2010. On average, that ratio has risen by about seven percentage points a year—nearly three times as fast it did during the Latin America debt crisis of the 1970s. The increase, moreover, has been exceptionally broad-based—involving government as well as private debt, and observable in virtually all regions across the world.

“The size, speed, and breadth of the latest debt wave should concern us all,” said World Bank Group President David Malpass. “It underscores why debt management and transparency need to be top priorities for policymakers—so they can increase growth and investment and ensure that the debt they take on contributes to better development outcomes for the people.”

According to the report, the prevalence of historically low global interest rates mitigates the risk of a crisis for now. But the record of the past 50 years highlights the dangers: Since 1970, about half of the 521 national episodes of rapid debt growth in developing countries have been accompanied by financial crises that significantly weakened per-capita income and investment.

“History shows that large debt surges often coincide with financial crises in developing countries, at great cost to the population,” said Ceyla Pazarbasioglu, the World Bank Group’s Vice President for Equitable Growth, Finance, and Institutions. “Policymakers should act promptly to enhance debt sustainability and reduce exposure to economic shocks.”

The analysis found that this latest wave is different from the previous three in several ways—it involves a simultaneous buildup in both public and private debt; it involves new types of creditors; and it is not limited to one or two regions. Some of the increase in debt has been driven by China, whose debt-to-GDP ratio has risen 72 points to 255 percent since 2010. But debt is substantially higher in developing countries even if China is excluded from the analysis—among EMDEs, it is twice the nominal level reached in 2007.

Those characteristics pose challenges that policymakers haven’t had to tackle before. For example, nonresident investors today account for 50 percent of the government debt of EMDEs, considerably more than in 2010. For low-income countries, much of this debt has been on non-concessional terms, and outside the debt-resolution framework of the Paris Club.

Under the circumstances, policymakers should develop mechanisms to facilitate debt resolution when it becomes necessary, according to the report. Greater debt transparency would also help.

Featured Journal Content

PLoS Medicine
http://www.plosmedicine.org/
(Accessed 21 Dec 2019)
Research Article
Estimating the global impact of poor quality of care on maternal and neonatal outcomes in 81 low- and middle-income countries: A modeling study
Victoria B. Chou, Neff Walker, Mufaro Kanyangarara
Research Article | published 18 Dec 2019 PLOS Medicine
https://doi.org/10.1371/journal.pmed.1002990
Abstract
Background
In low-resource settings where disease burdens remain high and many health facilities lack essentials such as drugs or commodities, functional equipment, and trained personnel, poor quality of care often results and the impact can be profound. In this paper, we systematically quantify the potential gain of addressing quality of care globally using country-level data about antenatal, childbirth, and postnatal care interventions.
Methods and findings
In this study, we created deterministic models to project health outcomes if quality of care was addressed in a representative sample of 81 low- and middle-income countries (LMICs). First, available data from health facility surveys (e.g., Service Provision Assessment [SPA] and Service Availability and Readiness Assessment [SARA]) conducted 2007–2016 were linked to household surveys (e.g., Demographic and Health Surveys [DHS] and Multiple Indicator Cluster Surveys [MICS]) to estimate baseline coverage for a core subset of 19 maternal and newborn health interventions. Next, models were constructed with the Lives Saved Tool (LiST) using country-specific baseline levels in countries with a linked dataset (n = 17) and sample medians applied as a proxy in countries without linked data. Lastly, these 2016 starting baseline levels were raised to reach targets in 2020 as endline based upon country-specific utilization (e.g., proportion of women who attended 4+ antenatal visits, percentage of births delivered in a health facility) from the latest DHS or MICS population-based reports. Our findings indicate that if high-quality health systems could effectively deliver this subset of evidence-based interventions to mothers and their newborns who are already seeking care, there would be an estimated 28% decrease in maternal deaths, 28% decrease in neonatal deaths, and 22% fewer stillbirths compared to a scenario without any change or improvement in quality of care. Totals of 86,000 (range, 77,800–92,400) maternal and 0.67 million (range, 0.59 million–0.75 million) neonatal lives could be saved, and 0.52 million (range, 0.48 million–0.55 million) stillbirths could be prevented across the 81 countries in the calendar year 2020 when adequate quality care is provided at current levels of utilization. Limitations include the paucity of data to individually assess quality of care for each intervention in all LMICs and the necessary assumption that quality of care being provided among the subset of countries with linked datasets is comparable or representative of LMICs overall.
Conclusions
Our findings suggest that efforts to close the quality gap would still produce substantial benefits at current levels of access or utilization. With estimated mortality rate declines of 21%–32% on average, gains from this first step would be significant if quality was improved for selected antenatal, intrapartum, and postnatal interventions to benefit pregnant women and newborns seeking care. Interventions provided at or around the time of childbirth are most critical and accounted for 64% of the impact overall estimated in this quality improvement analysis.

Author summary
Why was this study done?
:: In low- and middle-income countries, health systems struggle to provide high-quality medical care to pregnant women and their newborns in need.
:: Delivery of key health interventions is critical to save lives and prevent morbidity and mortality in high-burden settings.
:: The impact of extant or poor quality of care at a population level is poorly understood, and quantifying the benefits of improving quality among those already seeking or accessing care would be a critical first step for prioritization.

What did the researchers do and find?
:: To examine the global impact of improvement in the quality of care, we used a linking approach, which combines health facility and population-level survey data to estimate baseline for a subset of important evidence-based interventions.
:: Intervention coverage trends were modeled in 81 countries by setting current levels of reported utilization as the final country-specific targets for 2020.
:: If those seeking medical attention arrived at facilities reimagined with adequate resources and receive high-quality care, our systematic tally indicates that almost one quarter of the maternal deaths, neonatal deaths, and stillbirths would be preventable during the period 2016–2020 if the gaps in quality of care were eliminated.

What do these findings mean?
:: Countries and current health systems are far from ensuring that skilled providers with adequate supplies are providing timely and appropriate healthcare to existing populations in need. Our analysis of potential gains quantifies the consequences of these missed opportunities, ranging from the prenatal to postnatal periods.
:: Bolstering the quality of care is an essential checkpoint because efforts to increase utilization will rely on the same health systems where vulnerable populations are presently accessing care.
:: With greater attention focused on tracking country-level progress, more data will hopefully become available to effectively monitor changes in coverage for key maternal and neonatal interventions. As these parameters or inputs are better defined, modeling can contribute to the body of knowledge by offering an informed approach to examine quality of care gaps so that better strategies can be developed to improve health among mothers and their children seeking care in this context.