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.

.

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…

.

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%)…

::::::

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…

::::::
::::::

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.

::::::

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…

::::::
::::::

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

::::::

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

::::::

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

::::::
::::::

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

::::::

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

::::::
::::::

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.

::::::

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…

::::::

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.

Featured Journal Content

Proceedings of the Royal Society B – Biological Sciences
11 December 2019 Volume 286 Issue 1917
Research articles
Articulating ‘free, prior and informed consent’ (FPIC) for engineered gene drives
Dalton R. George, Todd Kuiken and Jason A. Delborne
Published:18 December 2019 https://doi.org/10.1098/rspb.2019.1484
Abstract
Recent statements by United Nations bodies point to free, prior and informed consent (FPIC) as a potential requirement in the development of engineered gene drive applications. As a concept developed in the context of protecting Indigenous rights to self-determination in land development scenarios, FPIC would need to be extended to apply to the context of ecological editing. Without an explicit framework of application, FPIC could be interpreted as a narrowly framed process of community consultation focused on the social implications of technology, and award little formal or advisory power in decision-making to Indigenous peoples and local communities. In this paper, we argue for an articulation of FPIC that attends to issues of transparency, iterative community-scale consent, and shared power through co-development among Indigenous peoples, local communities, researchers and technology developers. In realizing a comprehensive FPIC process, researchers and developers have an opportunity to incorporate enhanced participation and social guidance mechanisms into the design, development and implementation of engineered gene drive applications.

Featured Journal Content

Nature
Volume 576 Issue 7787, 19 December 2019
http://www.nature.com/nature/current_issue.html
Article | 11 December 2019
Earliest hunting scene in prehistoric art
A rock art panel from Sulawesi—dated to at least 43.9 thousand years ago—represents the oldest currently known figurative art in the world, and provides evidence of early storytelling through narrative hunting scenes.
Maxime Aubert, Rustan Lebe[…] & Adam Brumm
Abstract
Humans seem to have an adaptive predisposition for inventing, telling and consuming stories1. Prehistoric cave art provides the most direct insight that we have into the earliest storytelling2,3,4,5, in the form of narrative compositions or ‘scenes’2,5 that feature clear figurative depictions of sets of figures in spatial proximity to each other, and from which one can infer actions taking place among the figures5. The Upper Palaeolithic cave art of Europe hosts the oldest previously known images of humans and animals interacting in recognizable scenes2,5, and of therianthropes6,7—abstract beings that combine qualities of both people and animals, and which arguably communicated narrative fiction of some kind (folklore, religious myths, spiritual beliefs and so on). In this record of creative expression (spanning from about 40 thousand years ago (ka) until the beginning of the Holocene epoch at around 10 ka), scenes in cave art are generally rare and chronologically late (dating to about 21–14 ka)7, and clear representations of therianthropes are uncommon6—the oldest such image is a carved figurine from Germany of a human with a feline head (dated to about 40–39 ka)8. Here we describe an elaborate rock art panel from the limestone cave of Leang Bulu’ Sipong 4 (Sulawesi, Indonesia) that portrays several figures that appear to represent therianthropes hunting wild pigs and dwarf bovids; this painting has been dated to at least 43.9 ka on the basis of uranium-series analysis of overlying speleothems. This hunting scene is—to our knowledge—currently the oldest pictorial record of storytelling and the earliest figurative artwork in the world.

Emergencies

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

Ebola Outbreak in DRC 72: 17 December 2019
Situation Update
In the week of 9 to 15 December 2019, 24 new confirmed Ebola virus disease (EVD) cases were reported from three health zones in two affected provinces in the Democratic Republic of the Congo. The majority of these new confirmed cases are from Mabalako (22/24; 92%), and the other cases were reported from Biena (1/24; 4%) and Mandima (1/24; 4%) health zones.

The new cases from Mabalako and Biena, are linked to a single chain of transmission, in which one individual was a potential source of infection for 24 people. This was the second documentation of EVD illness in this individual within a 6-month period. Based on the preliminary sequencing of samples from the case, this is being classified as a relapse of EVD. Rare cases of relapse have been documented, in which a person who has recovered from EVD gets disease symptoms again, but this is the first documented relapse in this outbreak.

The volume of alerts reported has returned to levels seen before the security incidents in the past weeks. In general, the overall average proportion of contacts under surveillance in the last seven days has returned to previously observed levels. However, Mabalako, the health zone with the highest volume of contacts, has the lowest performance with 73% of contacts under surveillance…

::::::

First FDA-approved vaccine for the prevention of Ebola virus disease, marking a critical milestone in public health preparedness and response
December 19, 2019
The U.S. Food and Drug Administration announced today the approval of Ervebo, the first FDA-approved vaccine for the prevention of Ebola virus disease (EVD), caused by Zaire ebolavirus in individuals 18 years of age and older. Cases of EVD are very rare in the U.S., and those that have occurred have been the result of infections acquired by individuals in other countries who then traveled to the U.S., or health care workers who became ill after treating patients with EVD.

“While the risk of Ebola virus disease in the U.S. remains low, the U.S. government remains deeply committed to fighting devastating Ebola outbreaks in Africa, including the current outbreak in the Democratic Republic of the Congo,” said Anna Abram, FDA Deputy Commissioner for Policy, Legislation, and International Affairs. “Today’s approval is an important step in our continuing efforts to fight Ebola in close coordination with our partners across the U.S. Department of Health and Human Services, as well as our international partners, such as the World Health Organization. These efforts, including today’s landmark approval, reflect the FDA’s unwavering dedication to leveraging our expertise to facilitate the development and availability of safe and effective medical products to address urgent public health needs and fight infectious diseases, as part of our vital public health mission.”…

… “Ebola virus disease is a rare but severe and often deadly disease that knows no borders. Vaccination is essential to help prevent outbreaks and to stop the Ebola virus from spreading when outbreaks do occur,” said Peter Marks, M.D., Ph.D., director of the FDA’s Center for Biologics Evaluation and Research. “The FDA’s approval of Ervebo is a major advance in helping to protect against the Zaire ebolavirus as well as advancing U.S. government preparedness efforts. The research approach used to study the effectiveness and safety of this vaccine was precedent-setting during a public health emergency and may help create a model for future studies under similar circumstances. The FDA is committed to continuing our work across the U.S. government and with our international partners to prevent future Ebola outbreaks and mitigate the current outbreak in the DRC, reflecting our nation’s commitment to preparing for and responding to biological threats, like Ebola.”’’’

…The FDA granted this application Priority Review and a Tropical Disease Priority Review Voucher under a program intended to encourage development of new drugs and biologics for the prevention and treatment of certain tropical diseases. The FDA also granted Breakthrough Therapy designation for Ervebo to facilitate the development and scientific evaluation of the vaccine. Because of the public health importance of a vaccine to prevent EVD, the FDA worked closely with the company and completed its evaluation of the safety and effectiveness of Ervebo in less than six months. The approval was granted to Merck & Co., Inc.

::::::

::::::
::::::

POLIO
Public Health Emergency of International Concern (PHEIC)

Polio this week as of 18 December 2019

Summary of new viruses this week (AFP cases and ES positives):
:: Afghanistan – two WPV1 cases and two WPV1-positive environmental samples.
:: Pakistan – seven WPV1 cases, one cVDPV2 case and 12 WPV1-positive environmental samples.
:: DR Congo – Eight cVDPV2 cases.
:: Somalia – two cVDPV2-positive environmental sample.
:: Angola – 11 cVDPV2 cases and two cVDPV2-positive environmental samples.
:: Chad – one cVDPV2 case.
:: Ethiopia – one cVDPV2-positive environmental sample.
:: Ghana – three cVDPV2 cases.

::::::
::::::

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 21 Dec 2019]

Democratic Republic of the Congo
:: Ebola Outbreak in DRC 72: 17 December 2019

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

::::::

WHO Grade 2 Emergencies [to 21 Dec 2019]
Measles in Europe
:: Nordic countries working together to sustain measles and rubella elimination 20-12-2019
:: 2019: the WHO European Region’s year in review 19-12-2019

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…

Immunization
Oral Cholera Vaccine and Measles Outbreak Response Immunization campaigns
:: The Civil Surgeon, with support from WHO and UNICEF, established an immunization core group. The first meeting took place at the Ministry of Health and Family Welfare (MoHFW) Coordination Cell offices. Details of the upcoming Oral Cholera Vaccine (OCV) campaign were discussed.
:: A total of 1 270 170 doses of OCV was approved for the OCV campaign targeting around 635 000 individuals. The campaign will take place from 8 to 14 December in the Rohingya camps and 8 to 31 December in the host communities.
:: Several preparatory meetings have taken place. This includes District planning and Coordination meeting on 27 November, Upazila planning and microplanning meetings on 28 November and several advocacy meetings involving different target leaders including political leaders, Imams, Ministry of Education officials, among others.
:: Training has taken place for 34 OCV Camp Coordinators, 34 OCV Associate Camp Coordinators on 23 and 24 November 2019. These trainings were cascaded to over 2750 Community Health Workers and Communication for Development volunteers and 240 team supervisors between 28 and 30 November 2019, with support from partners.
:: For the host community, 300 vaccinators and mobilizers have been trained alongside 50 supervisors. Training for 1 050 and 900 volunteers commenced and will be completed by 4 December 2019, for Teknaf and Ukhia respectively.
:: The Rohingya Camp Wide Measles Rubella Outbreak Response Immunization (MR ORI) is planned in response to the measles outbreak that is currently confirmed in 16 of 34 camps in the Ukhia and Teknaf Upazila. Discussions on MR ORI took place 28 November 2019 during Scientific and Technical Sub- Committee (STSC) of the National Committee for Immunization Practices (NCIP) meeting held in Dhaka. There is need for timely ORI while ensuring quality, good coverage and proper capacity and management plan for any Adverse Events Following Immunization (AEFI).
:: MR ORI implementation planned for first week of January 2020 subject to Government approvals and favorable preparedness assessment. The target age group for this ORI is all children 6 months to less than 10 years of age in the Rohingya camps of Ukhia and Teknaf in Cox’s Bazar district.

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
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

::::::

WHO Grade 1 Emergencies [to 21 Dec 2019]

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

::::::
::::::

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 Flash Update No. 1 – As of 20 December 2019
HIGHLIGHTS
:: Following the intensification of airstrikes and shelling since 16 December in southern Idleb, tens of thousands of civilians are reportedly fleeing from Ma’arrat An-Nu’man area in southern Idleb governorate to north. Thousands of others are reportedly waiting for the bombardment to ease allowing them to move. The shortage of fuel in Idleb area is also limiting the movement of civilians fleeing from hostilities.
:: As of 20 December, ground fighting also resumed along the frontlines in southern Idleb governorate, amplifying displacement from southern Idleb as civilians are fleeing in anticipation of fighting directly affecting their communities.
:: Displacement happening in winter months is exacerbating the vulnerability of people in need. Many of those who fled are in urgent need of humanitarian support, particularly shelter, food, health, non-food and winterization assistance.

Yemen – No new digest announcements identified

::::::

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

::::::
::::::

The Sentinel

Human Rights Action :: Humanitarian Response :: Health :: Education :: Heritage Stewardship ::
Sustainable Development
__________________________________________________
Week ending 14 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 14 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]

Human Development Report 2019 – Beyond income, beyond averages, beyond today: Inequalities in human development in the 21st century
UNDP 2019 :: 366 pages
PDF: http://hdr.undp.org/sites/default/files/hdr2019.pdf

Press Release
To answer global protests, tackle new inequalities — UN report
2019 Human Development Report says business as usual will not solve new generation of inequalities
Bogota, December 9, 2019 – The demonstrations sweeping across the world today signal that, despite unprecedented progress against poverty, hunger and disease, many societies are not working as they should. The connecting thread, argues a new report from the United Nations Development Programme (UNDP), is inequality.

“Different triggers are bringing people onto the streets — the cost of a train ticket, the price of petrol, demands for political freedoms, the pursuit of fairness and justice. This is the new face of inequality, and as this Human Development Report sets out, inequality is not beyond solutions,” says UNDP Administrator, Achim Steiner.

The 2019 Human Development Report (HDR), entitled “Beyond income, beyond averages, beyond today: inequalities in human development in the 21st Century,” says that just as the gap in basic living standards is narrowing for millions of people, the necessities to thrive have evolved.

A new generation of inequalities is opening up, around education, and around technology and climate change — two seismic shifts that, unchecked, could trigger a ‘new great divergence’ in society of the kind not seen since the Industrial Revolution, according to the report.

In countries with very high human development, for example, subscriptions to fixed broadband are growing 15 times faster and the proportion of adults with tertiary education is growing more than six times faster than in countries with low human development…

…The 2019 Human Development Index (HDI) and its sister index, the 2019 Inequality-Adjusted Human Development Index, set out that the unequal distribution of education, health and living standards stymied countries’ progress. By these measures, 20 per cent of human development progress was lost through inequalities in 2018…

Planning beyond today
Looking beyond today, the report asks how inequality may change in future, looking particularly at two seismic shifts that will shape life up to the 22nd century:

• The climate crisis: As a range of global protests demonstrate, policies crucial to tackling the climate crisis like putting a price on carbon can be mis-managed, increasing perceived and actual inequalities for the less well-off, who spend more of their income on energy-intensive goods and services than their richer neighbours. If revenues from carbon pricing are ‘recycled’ to benefit taxpayers as part of a broader social policy package, the authors argue, then such policies could reduce rather than increase inequality.

• Technological transformation: Technology, including in the form of renewables and energy efficiency, digital finance and digital health solutions, offers a glimpse of how the future of inequality may break from the past, if opportunities can be seized quickly and shared broadly. There is historical precedent for technological revolutions to carve deep, persistent inequalities – the Industrial Revolution not only opened up the great divergence between industrialized countries and those who depended on primary commodities; it also launched production pathways that culminated in the climate crisis.

The change that is coming goes beyond climate, says the report, but a ‘new great divergence’, driven by artificial intelligence and digital technologies, is not inevitable. The HDR recommends social protection policies that would, for example, ensure fair compensation for ‘crowdwork’, investment in lifelong learning to help workers adjust or change to new occupations, and international consensus on how to tax digital activities – all part of building a new, secure and stable digital economy as a force for convergence, not divergence, in human development.

Development Finance – World Bank Replenishment

Global Community Renews Commitment to the World’s Poorest Countries with $82 Billion
Focus on jobs, gender, fragility, climate, and good governance
STOCKHOLM, December 13, 2019 — A global coalition of development partners announced today their commitment to maintain momentum in the fight against extreme poverty, with $82 billion for the International Development Association (IDA), the World Bank’s fund for the poorest. The financing, which includes more than $53 billion for Africa, will help countries invest in the needs of their people, boost economic growth, and bolster resilience to climate shocks and natural disasters…

Two thirds of the world’s poor—almost 500 million people—now live in countries supported by IDA. The funding will allow IDA to reinforce its support to job creation and economic transformation, good governance, and accountable institutions. It will also help countries deal with the challenges posed by climate change, gender inequality, and situations of fragility, conflict, and violence, including in the Sahel, the Lake Chad region, and the Horn of Africa.

IDA will renew its support to facilitate growth and regional integration, including investments in quality infrastructure. The IDA Private Sector Window will continue enabling the International Finance Corporation (IFC) and the Multilateral Investment Guarantee Agency (MIGA) to mobilize private sector investment in challenging environments, a critical component to meet the scale of financing needed in developing countries.

IDA’s resources are replenished every three years; this 19th replenishment will cover the period from July 1, 2020, to June 30, 2023. The new funding will support projects that deliver life-changing results, including:
:: Essential health, nutrition, and population services for up to 370 million people;
:: Safe childbirth for up to 80 million women through provision of skilled health personnel;
:: Enhanced access to broadband internet for 50 to 60 million people;
:: Immunizations for up to 140 million children;
:: Better governance in up to 60 countries through improved statistical capacity;
:: An additional 10 GW of renewable energy generation capacity.

To promote greater equity and economic growth, IDA will also tackle broader development challenges, such as enhancing debt sustainability and transparency; harnessing and adapting to transformative digital payment technology; promoting inclusion of those living with disabilities; strengthening the rule of law; and investing in human capital, including efforts to achieve universal health coverage…

World Bank Group Strategy for Fragility, Conflict and Violence [FCV] 2020-2025
December 5, 2019 :: 69 pages
Timeframe: April 2019 – January 2020
Draft Strategy for Fragility, Conflict and Violence (.pdf)

Phase 2 consultations are open until January 16, 2019.

The World Bank Group has released its draft strategy for Fragility, Conflict and Violence (FCV). The objective of the strategy is to address the drivers of FCV in affected countries and their impact on vulnerable populations, with the ultimate goal of contributing to peace and prosperity. To ensure the strategy benefits from a wide range of inputs, the World Bank Group is undertaking global consultations to inform the strategy’s development.

Introduction
1. By 2030, around half of the world’s extreme poor will live in fragile and conflict-affected situations (FCS). Preventing and mitigating fragility, conflict, and violence (FCV) is central to achieving the Sustainable Development Goals (SDGs) and the World Bank Group’s (WBG) twin goals of ending extreme poverty and promoting shared prosperity. It will also support the international community’s broader efforts to promote peace and prosperity.

2. The global fragility landscape has worsened significantly. According to Pathways for Peace: Inclusive Approaches to Preventing Violent Conflict, there are more violent conflicts globally than at any time in the past 30 years,6 and the world is also facing the largest forced displacement crisis ever recorded. Rising inequality, lack of opportunity, and exclusion are fueling grievances and perceptions of injustice. Climate change, demographic change, migration, digital transformation, illicit financial flows, and violent extremism are often interconnected, with effects that transcend borders. These factors can increase vulnerability to shocks and crises and create regional spillovers. They can cause lasting and devastating impacts, especially on women, children, and youth, that will be felt for generations. Without swift and effective action, FCV risks could both erode gains made in the fight against poverty and undermine the prospects for progress.

3. The objective of the FCV Strategy is to enhance the WBG’s effectiveness to support countries in addressing the drivers and impacts of FCV and strengthening their resilience, especially for the most vulnerable populations. To this end, the strategy sets out a framework to support countries in addressing diverse challenges across the FCV spectrum. While FCV challenges are often more longstanding and acute in low-income and lower-middle income countries (LICs and LMICs), the strategy also addresses countries at higher levels of income that are affected by high levels of violence, forced displacement shocks, and subnational conflict. The FCV Strategy builds on successive IEG reviews of WBG engagement in FCV settings, portfolio reviews and lessons learned in FCS, to systematically address the root causes of fragility and long-term risks that can drive or exacerbate conflict and violence.

4. This strategy is among the WBG’s contributions to the collective global effort to tackle FCV. While the WBG strives to increase its direct impact on FCV, it also approaches this task with humility. It recognizes the intractable challenges of FCV, and that the full commitment of local and national actors
is imperative to achieve progress. The WBG has prioritized supporting countries’ efforts to mitigate FCV and promote peace, and is committed to deepening partnerships with a diverse set of actors, based on respective complementarities and comparative advantages.

5. This strategy has greatly benefitted from extensive global consultations held during 2019. The consultations engaged a wide range of partners, including governments, international organizations, global and local civil society, and the private sector. They captured lessons learned and best practices such as: (i) the need to tailor interventions and financing to the distinct FCV challenges faced by a country; (ii) the importance of supporting the most vulnerable and marginalized groups, and addressing the grievances underlying and driving FCV; (iii) the importance of vibrant and inclusive private sector development to support job creation and provide economic opportunities; and (iv) the recognition of the crucial role of partnerships in FCV settings to address the drivers and impacts of FCV…