Alice Atieno relies on sack farming outside her shanty in the sprawling Kibera Slums in Nairobi, Kenya. COVID-19 reversed gains made in poverty reduction, and the unequal access to vaccines has deepened global inequality. Credit: Joyce Chimbi/IPS

By Joyce Chimbi
Nairobi, Kenya, Mar 29 2022 (IPS)

Even as COVID-19 brought Africa’s already fragile health care and economic systems to the brink, wealthy states colluded with corporate giants to dupe people with empty slogans and false promises of a fair recovery from the ongoing health pandemic, a newly released report by Amnesty International report finds.

The global human rights organization says at the heart of the report are revelations of how “global leaders peddled false promises of a fair recovery from COVID-19 to address deep-seated inequalities, despite only 8 % of Africa’s 1.2 billion people being fully vaccinated by the end of 2021.”

Amnesty International Report 2021/22: The State of the World’s Human Rights finds that wealthy nations, alongside corporate titans, have driven deeper global inequality. As a result, African countries are worse off and left struggling to recover from the pandemic against a backdrop of significant levels of inequality.

Grace Gakii, a Nairobi-based gender and development expert, says fall-out from COVID-19 includes “poverty and unemployment, severe food insecurities, increased sexual and gender-based violence as well as a strained and struggling health system.”

According to the World Bank, as early as August 2020, COVID-19 induced economic downturn had already pushed an estimated 88 to 115 million people in the world’s most vulnerable communities into extreme poverty. For the first time in a generation, gains made in global poverty reduction were reversed. For instance, an UN-backed report indicated that extreme poverty in West Africa rose by almost 3 % in 2020 due to COVID-19.

World Bank’s Kenya Economic Update showed that the East African nation gained an additional two million ‘new poor’ as of November 2020 due to the ongoing health pandemic. Many like Alice Atieno in the sprawling informal settlements practice sack farming outside their shanties to put food on the table.

According to Amnesty International, many countries in Africa and the Sub-Saharan Africa region face multiple socio-economic challenges because of the unequal distribution of vaccines in the year 2021.

“COVID-19 should have been a decisive wake-up call to deal with inequality and poverty. Instead, we have seen deeper inequality and greater instability in Africa exacerbated by global powers, especially rich countries who failed to ensure that big pharma distributed vaccines equally between states to ensure the same levels of recovery from the COVID-19 pandemic,” says Deprose Muchena, Amnesty International’s director for East and Southern Africa.

“As things stand now, most African countries will take longer to recover from COVID-19 due to high levels of inequality and poverty. The after-effects of COVID-19 have been most damaging to the most marginalized communities, including those on the frontlines of the endemic poverty from Angola to Zambia, Ethiopia to Somalia, and the Central Africa Republic to Sierra Leone.”

Dr Githinji Gitahi, a medical doctor, currently serving as the Global CEO of Amref Health Africa, tells IPS Africa was first let down when it desperately wanted COVID-19 vaccines. But they were hoarded despite high demand and urgency.

He tells IPS the trajectory has changed because the COVID-19 vaccine supply has significantly improved after rich countries satisfied their need and greed. With this sudden increment, more than 50% of doses in the continent were supplied from November 2021. However, other cracks have appeared and will continue to widen if urgent responsive measures are not taken.

“Africa has major inequalities with regard to COVID-19 vaccine distribution and delivery between urban and rural areas and between rich and poor communities. Whereas the urban centers may have reached up to 50 percent COVID-19 vaccination coverage rate, some rural areas are at below 10 percent absorption rate even in Kenya,” he observes.

He explains that vaccine distribution inequalities exist between countries and within countries because initially, countries in Africa, including Low-Income Countries, were required to buy their vaccines.

This was before COVAX – the COVID-19 Vaccines Global Access, which is co-led by GAVI, the Coalition for Epidemic Preparedness Innovations, and the World Health Organization – was able to supply vaccine doses for Low-Income Countries as earlier planned.

“African countries in a position to buy were able to access these vaccines ahead of others. Kenya, for example, bought COVID-19 vaccines with a loan from World Bank. Other African countries could not afford it.”

Gitahi further speaks about the different capacities that countries have to deliver these vaccines once they arrive in African countries, as countries have better health system infrastructures than others.

“Health systems capacities in terms of clinical health workers and the vaccine cold chain that ensures proper storage and distribution of vaccines in a country such as Morocco is not the same as those in South Sudan or even Chad. This creates inequality because of a lack of capacity to deliver the vaccines to the people and more so, in far-flung areas in a manner convenient to them,” he cautions.

“Today, they are sending vaccines in Africa, and it is almost as if they are being dumped, and some of them are short expiry vaccines forcing countries to hold back shipments and demand all arriving vaccines must have at least three months of shelf life. The supply is high, but distribution and convenient delivery are low in communities doing informal work and facilities that open only on weekdays when people are at work.”

Just because a country can and has received millions of doses of vaccines does not mean that people are receiving these vaccines in a manner that fits their daily lives. He says millions of doses arrive three months or six weeks before the expiry date.

Africa, he stresses, needs an ongoing increased supply of vaccines to match delivery capacities so that vaccines are available and easily accessible to all who need them on time – further emphasizing the need to match shipments to absorption to avoid wastage while at the same time working to improve delivery capacity.

In the absence of increased delivery and distribution capacities in African countries, health experts such as Gitahi are raising alarm that Africa will remain ill-equipped to overcome and recover from existing COVID-19 induced challenges and that socio-economic inequality will only widen.

IPS UN Bureau Report

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The private sector and some government agencies have demanded that staff vaccinate, especially in the tourism industry that drives many regional economies. Credit: Zadie Neufville/IPS

By Zadie Neufville
KINGSTON, Nov 22 2021 (IPS)

When face-to-face Cabinet meetings resumed in Jamaica following more than a year of virtual meetings due to COVID-19, Ministers lined up to have their immunisation cards inspected.

Prime Minister Andrew Holness said the Government “has to lead the country towards normality”.

“The way to do it is for every Jamaican to comply with the infection, prevention and control measures that have been established, which will eventually be relaxed the higher the level of vaccination,” he said after the October 12 meeting.

In the current atmosphere, outbreaks, no-movement days that shut down commerce and vaccine hesitancy send ripples through the economy. So, while Jamaica has no national vaccine mandate, private sector companies and some government agencies are already demanding that staff vaccinate.

In addition to several vaccination drives that target employees, Jamaica Private Sector Organisation joined the Jamaica Chamber of Commerce and the Jamaica Manufacturers and Exporters Association to put their support solidly behind a campaign for a national mandate.

The groups say that with the low vaccination rates almost two years into the pandemic, Jamaica is being left behind in achieving population immunity, putting the country’s recovery at risk. The groups contend that the social and economic impact will be devastating, and “the ripple effects will continue for years to come”. But even with growing support for a mandate, opposition leader Mark Golding opposes one. Only about 17 percent of the Jamaican population is vaccinated.

Across the region, governments have already implemented mandates. In Guyana, nationals who want to enter any public buildings, including banks, restaurants, supermarkets and schools, must show proof of vaccination. In the twin-island state of Antigua Barbuda, opposition legislators accused House Speaker Sir Gerald Watt of acting beyond his powers after he prevented them from participating in the sitting of the Senate because they did not show proof of vaccination.

With each outbreak, concern for the tourism industry that drives many regional economies grows. Many countries now have vaccination policies for incoming adult travellers. These include Anguilla, Grenada, St. Barts, St. Kitts and Nevis, Trinidad and Tobago, Turks and Caicos, and the Cayman Islands.

And even as governments ponder mandates, they are also bracing for civil unrest and legal challenges from workers. In a recent opinion, the Jamaican Bar Association said nothing was preventing the Government or employers from implementing mandates. The Organisation of Eastern Caribbean States outlined its position in a 16-page document titled: “The Legal Dimensions of Mandatory/Compulsory Requirements for COVID-19 Vaccinations, August 2021”.

According to the report, that countries could legally pursue mandatory vaccination laws.
“Having demonstrated … that mandatory vaccination is constitutionally appropriate given the leeway granted in favour of public health imperatives, it is submitted that employers could justify a requirement in a pandemic context, at minimum where the workplace is a high-risk environment, such as health-care, or essential services, or for workers more at risk at the workplace, such as frontline workers interacting with the public,” the document said.

But while public health legislation specifically addresses restrictions in times of pandemic, those who oppose mandates argue that they are a breach of human rights.

President of the Jamaica Confederation of Trade Unions, Helene Davis-Whyte, is expecting a national mandate if efforts to boost vaccination numbers fail. She argued for a comprehensive public awareness programme with consultations before such a step is taken and cautioned that a “draconian approach” could discourage some people.

“We are not necessarily opposed, but what we are saying is that you have to do more work because we don’t think that enough work has been done,” she told journalists recently.

And so, armed with their individual legal opinions, governments have been implementing the rules they say will protect their countries. By October 2021, at least seven governments across the region had instituted COVID-19 mandates for government workers.

In August, in Guyana, police were called to evict staff members in the education ministry’s head office who had entered the building without proof of vaccination. Earlier that month, there were mass protests in St. Vincent and Barbados. And in July, Prime Minister Ralph Gonsalves was hit on the head and injured by an angry protestor during anti-mandate demonstrations in St Vincent.

Barbados, like Jamaica, has not officially backed a vaccine mandate, but Holness acknowledges he may have to make the decision soon. But even with no national mandate in Jamaica increasingly, civil servants find they must be vaccinated to work.

The Ministry of Tourism has raced ahead to vaccinate the 170,000 people who work in the sector. Already workers who come in contact with cruise ship visitors must be fully inoculated.

And as the country eyes a return to full-time school, it’s the turn of teachers and school staff. Medical workers have already been issued a mandate. In the private sector, more than 80 per cent of staff are vaccinated.

In the Business Process Outsourcing (BPO) sector, where several companies became hotspots during the height of the first wave, vaccination is compulsory. In Jamaica, COVID-19 restrictions and 14-days of lockdown cost the sector US$42 million (J$5.88 billion) in revenue.

But it is in the region’s tourism industry that mandates have become the norm. Hoteliers and other service providers seek to prevent lawsuits and shutdowns by demanding that staff be fully vaccinated. In the Bahamas, workers and visitors must be fully vaccinated. Unvaccinated visitors face a 14-day quarantine. Jamaica is aiming for a 100 per cent vaccinated workforce.

A growing number of countries have instituted vaccination policies for incoming adult travellers. These include Anguilla, Grenada, St. Barts, St. Kitts and Nevis, Trinidad and Tobago, Turks and Caicos, and the Cayman Islands.

Meanwhile, the private sector’s desire for a return to normalcy and increased economic activity could push many toward a vaccine faster than any government mandate could.

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Zimbabweans readily join the COVID-19 vaccine queues, but the rollout hasn’t been smooth. Credit: Jeffrey Moyo/IPS

By Jeffrey Moyo
HARARE, Zimbabwe , Oct 8 2021 (IPS)

More than a month ago, she lost her parents, brother, and wife, to the coronavirus. Then her fiancé battled COVID-19, but 27-year-old Melinda Gavi said she had not contracted the disease.

Gavi joined crowds scrambling to get vaccinated at Parirenyatwa hospital in the Zimbabwean capital Harare even though she was previously sceptical about getting vaccinated against the dreaded disease.

Her parents, brother, and wife were equally sceptical of the COVID-19 vaccines before they were visited by the disease, which eventually claimed their lives.

In a country of about 15 million people, nearly 5.5 million have had at least had one dose of the vaccine the Reuters COVID-19 tracker, which assuming that each person needs two doses, represents 18.8% of the population.

The World Health Organisation (WHO) confirmed in October that Zimbabwe had received 943 200 COVID-19 vaccine doses from the global COVAX Facility in September and October for its ongoing vaccination campaign.

IPS has been following the rollout of the vaccines in various centres over the past few months, recording people’s personal experiences in the queues.

Gavi says it has taken her days to get vaccinated.

“This is my third day coming here at Parirenyatwa to try and get vaccinated,” Gavi told IPS as she stood in a long and meandering queue at Zimbabwe’s biggest hospital.

About 200 people gathered at the back of the hospital, some looking tired as they lingered in the queue. Some sat on the pavements and or flower beds, waiting for their turn to get vaccinated in the slow-moving queue.

“We have limited vaccines, and often on a day we are vaccinating just 80 people and everybody else often just goes back home without getting vaccinated,” a nurse who refused to be named as she was unauthorised to speak to the media, told IPS.

In February this year, Zimbabwe began vaccinating its citizens against coronavirus after receiving a donation of 200 000 doses of China’s Sinopharm vaccine.

But when the vaccine first arrived, it was met with growing scepticism from social media platforms like WhatsApp, Twitter, and Facebook, which fuelled the vaccine hesitancy.

This is no longer the case. Now healthcare workers have to battle hordes of people scrambling for the vaccine.

“With time, as more and more people got vaccinated without severe safety fears, the public became more assured, and demand for vaccines gradually started to rise,” said epidemiologist Dr Grant Murewanhema in Harare.

In Bulawayo, on July 8, in the presence of IPS, at the United Bulawayo Hospital, a nurse moved along the queue of people waiting to get vaccinated, counting up to 60 recipients. She told the rest to return the next day.

She told them she only had enough vaccines for 60 people.

At number 60 was 47-year-old Jimmy Dzingai, who said he was a truck driver.

“Oh, better, at least I am going to get vaccinated,” said Dzingai then as he heaved a sigh of relief, folding his hands across his chest.

Meanwhile, as they were told to leave, others did so but grumbled as they filed outside the hospital, some waving their face masks in anger, shouting at hospital authorities for turning them away.

“This is not the first time I am coming here to try and get vaccinated. I have been here four times, and this is my fifth day starting mid-June – only to get excuses,” 54-year-old Limukani Dlela, a man who said he lived in Matsheumhlope, a low-density suburb in Bulawayo, told IPS saying that at times the excuse was that there not enough vaccines available and at other times there were a limited number of vaccines.

Corruption and nepotism have characterised this Southern African country’s bitter war against COVID-19, and many people like Dzingai, the truck driver, have not been spared by the rot.

As Dzingai stood at the end of the queue, four middle-aged women strode past him and all others, going straight to the head of the queue and quickly got vaccinated and left.

According to one of the nurses who manned the queue, “the four were staff members and couldn’t wait in the queue like everybody else.”

The nurse said this even though the four women, after receiving doses, immediately left the premises just like any other ordinary person.

“I was talking to my bosses right now, and my truck has been loaded for me to take the delivery to Zambia. I have told my bosses I was getting my vaccine. Instead, you are telling me I’m not going to be vaccinated. You should get water to inject me and give me the vaccine certificate. I will not leave this place without the vaccine,” swore the truck driver.

But the nurse would have none of it.

“You won’t be vaccinated today. That won’t happen, unfortunately,” she said.

Dzingai vowed to stay put at the hospital until he was vaccinated, but because the four women who jumped the queue and got vaccinated before him, it meant he (Dzingai) and three others who had waited at the end of the queue had to leave without the jab.

With many Zimbabweans like Dzingai now eager to get vaccinated, the government has so far authorised the use of China’s Sinovac and Sinopharm, Russia’s Sputnik V, and India’s Covaxin and the U.S. Johnson and Johnson vaccines.

It has not, however, been easy for people to get the doses. Now bribery has become the order of the day at Zimbabwe’s hospitals like Sally Mugabe Referral hospital in the capital Harare.

Lydia Gono (24), from Southertorn middle-income suburb in Harare, said she had to ‘switch to her purse’, which is local parlance for a bribe, to get quickly vaccinated at Sally Mugabe hospital, the closest medical facility to her home.

“I spent close to a week trying to get vaccinated here without success, but today I just rolled a US 10 dollar note in my hand and shook the hand of a nurse who manned the queue, leaving the note in her hand. I was taken to the front and vaccinated without any delay,” Gono told IPS.

Tired of the corruption and nepotism and the delaying tactics characterising the vaccination process at public healthcare centres, many middle-income earners like 35-year-old Daiton Sununguro have opted for the private medical centres to get their vaccines parting with US 40 dollars for a single dose.

“Paying is better than having to wait for many hours before getting the vaccine at public healthcare facilities. I will still come back and pay the other US 40 dollars for my second dose,” Sununguro told IPS at a posh private medical facility in Harare’s Mount Pleasant low-density suburb.

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There are calls to include migrants and other vulnerable groups in the vaccine rollout programmes in the Southern Africa region. Credit: UNICEF/Nahom Tesfaye

By Kevin Humphrey
Johannesburg, South Africa, Aug 23 2021 (IPS)

Migrants across the Southern Africa region are massively disadvantaged as they find themselves excluded from vaccine programmes – even when the global vaccine initiative COVAX often funds these programmes.

This is the latest in a long list of struggles migrants have experienced since the start of the COVID-19 pandemic. Migrant is a catch-all word that includes a diverse set of people, including non-citizens, asylum seekers, refugees and those who have acquired permission to dwell in the country they have settled.

However, vaccines are just one of the issues faced by migrants. Border shutdowns, travel restrictions and lockdowns have severely restricted large swathes of the region’s economic activities. Relationships between friends, family and social, religious, and other groups have also suffered.

Experts believe that ending the pandemic can only be achieved if vaccines are available in all countries – to all populations, including refugees and displaced people fleeing conflict and other crises – but this regional cooperation is not yet on the region’s agenda.

“In terms of the Southern African region, we are currently not seeing a conversation in place around a regional response,” Public health researcher and Associate Professor and Director of the African Centre for Migration & Society at the University of the Witwatersrand, South Africa, Jo Vearey told IPS.

“In a region of such high levels of population mobility, we need to ensure that our response to COVID-19, in access to vaccinations and testing and other related issues, can reflect the forms of movement that people undertake in the region.”

The Southern African Nationality Network (“SANN”) has called on governments in the South African Development Community (SADC) region to ensure all have access to vaccines. The group advocates for equitable treatment for vulnerable groups such as refugees, asylum seekers, internally displaces persons, undocumented persons, and stateless persons. They also asked authorities to “enable irregular migrants, undocumented persons and stateless persons to access health care without fear and risk of arrest or detention”.

Vearey agrees, saying that “if a person is in a location other than their normal place of residence, we need to ensure that they can access vaccines easily and safely regardless of documentation status. We need firewalls to be in place – where the firewall acts as a legal provision so that undocumented people have no fear of penalty should they be accessing COVID services”.

She says extraordinary measures were needed. National departments of health, home affairs, foreign affairs, and the Southern African Development Community (SADC) should ensure a smooth and inclusive rollout.

“There are, however, questions about the capacity of the SADC structures,” Vearey says.

“There are also issues around how we respond appropriately to the myths and assumptions around the movement of people. We know foreign nationals tend to be scapegoated and blamed for various issues. There is also the issue of giving out numbers of foreign nationals in a given country, particularly South Africa, often inflated. We know that immigration, in particular, is a heavily politicised issue. Some political leaders make use of rhetoric to blame foreign nationals for failures in delivery by the state.”

It was time to set aside differences, and there was no place in this pandemic for xenophobia.

“This is a pandemic, it affects everyone, and obviously, a pandemic by definition doesn’t respect borders, doesn’t care who someone is. It works by moving from person to person. Unless we effectively break that train of transmission, we won’t get a grip on the pandemic and will probably see more variants emerge, which will lead to more ill-health and fatalities,” Vearey says.

“It will also mean a further impact on people’s livelihoods because of more lockdowns and restrictions. Migrant labour is so important in the region through various forms of employment, both formal and informal. Particularly in the sectors of mining, agriculture and construction work. The sooner we can get everyone vaccinated, the sooner we will return to some semblance of normality.”

Traditional forms of migrant labour in the region were established during the minerals super boom in South Africa during the colonial era. Kicked off by the discovery of diamonds (1867), a handful of mining magnates accumulated enough capital to develop deep level gold mining on the Witwatersrand (1886) which is now part of modern-day Gauteng province. This history still exerts massive influence and attracts people with expectations of jobs and business opportunities.

Covid 19 has interfered significantly with these economic crosscurrents.

Senior economist at Trade and Industrial Policy Strategies (TIPS), Dr Neva Makgetla, former lead economist for the Development Planning and Implementation Division at the Development Bank of Southern Africa, among many other roles, told IPS significant impacts of the pandemic were on tourism and mining.

“International and regional tourism has collapsed, and mining has seen a run-up in prices. According to the World Bank, tourism accounted for 9% of South African export revenues in 2018, which is a real blow.

Mira Gaspar outside her studio in Kempton Park, South Africa talks about the devastating impact of COVID-19 on her and her business. Credit: Kevin Humphrey

“The recovery will depend above all on the rollout of vaccinations, which has made good progress but is expected to reach the majority of adults only toward the end of 2021,” Makgetla said.

“The loss of tourism revenues has, however, to date been offset by mining prices, which rose to 2011 levels this year. The question, of course, is how long they will remain so high; the answer depends in part on monetary policy in the global North, and in part on Chinese growth prospects.”

Down at street level, Mira Gaspar, a single mother (originally from Mozambique but now, after many years of struggle, has a South African permanent resident status), tells of her earth-shattering experiences since the COVID-19 Tsunami hit the world and her neck of the woods.

“I had managed to open up a hair salon in a part of Kempton Park where I did not have too much competition. I basically had a reasonably sized area where I was the nearest salon. It was not easy to establish the business, but I did manage to build a steady clientele of women and girls and even went into men’s hair. I added to my income by working with a close friend to import and export items between Johannesburg and Maputo,” Gaspar said.

She sold hair extensions – and even prawns from Mozambique to make a living.

“It was hard, but it worked. COVID wrecked it. The big lockdown took my salon. The border closures took my import-export business. Now I am slowly trying to pick up the pieces, but I have used any money I had for my daughter and me to survive during this time. It is hard, but God will help us through this time.”

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Logistic and communication challenges to rolling out the COVID-19 vaccine are immense in the rural and remote highlands region of Papua New Guinea. Credit: Catherine Wilson

By Catherine Wilson
CANBERRA, Australia , Jul 13 2021 (IPS)

Papua New Guinea (PNG), like many other Pacific Island countries, successfully held COVID-19 at bay last year, aided by early shutting of national borders. However, by March this year, the pandemic was surging in the most populous Pacific Island nation, and by July, it had reported 17,282 cases of the virus and 175 fatalities.

PNG has a steep battle against the virus ahead, made more problematic by a high rate of refusal by health workers to take the vaccine. PNG’s Health Minister, Jelta Wong, stressed in an interview with Australia’s Lowy Institute for International Policy in April that “the vaccine will be the key to containing COVID-19 in our country.”

But in Eastern Highlands Province in the country’s rural interior, Dr Max Manape, the province’s Director of Public Health, told IPS that “in our province, there is a huge COVID-19 hesitancy due to so much negativity of COVID-19 vaccinations in social media and we are finding it very hard to convince our fellow frontline workers, including health workers.” By early July, only 23.3 percent of all health and essential workers in the province were vaccinated, including 329 health workers.

The situation is causing wider community concern. “Health workers are the frontline and first responders in this pandemic, and their refusal places them at a greater risk to contract the virus. This will lead to the feared collapse of our struggling health system, and the roll-on effect of other deaths from preventable diseases and maternal health issues created by a lack of manpower,” a spokesperson for the PNG National Council of Women told IPS.

In April, the country was supplied with 132,000 doses of the AstraZeneca vaccine, the first batch of a total supply of 588,000 doses by COVAX, the global alliance of organizations, including the World Health Organization (WHO), working to achieve equitable vaccine access. The Australian Government also supplied eight thousand doses. The national vaccination rollout began in early May, with priority given to frontline responders.

Yet progress has been very slow. By this month, only 59,125 people in a national population of about 9 million had been vaccinated, including 7,844 health workers. The largest group of healthcare recipients, about 1,150, were located in the capital, Port Moresby.

PNG’s Health Minister says there are numerous challenges to achieving widespread inoculation. “In this country, we’ve never had an adult vaccine go out, we’ve always had the children’s ones, and that has worked really well. It is going to be a real challenge for us to do this vaccination rollout…The biggest thing will be education. Our people need to be educated enough to know that this vaccine will help them in the future,” Wong said.

More than 80 percent of people in PNG live in rural and remote areas where logistic and communication challenges are the greatest. Here scepticism of the vaccine is high. Only 12 percent of all health and essential workers in remote Enga Province in the northwestern highlands region have been vaccinated. “The uptake of the vaccine is very poor in Enga Province. Frontline health workers at the hospital have mostly refused the vaccine,” Dr David Mills, Director of Rural Health and Training at Kompiam District Hospital in the province, told IPS.

However, it’s a nationwide issue. PNG’s newspaper, The National, conducted a public online survey last month, reporting that 77 percent of respondents did not want the vaccine. In May, a survey of students at the University of Papua New Guinea by the Crawford School of Public Policy at the Australian National University, Canberra, revealed a high level of indecision among respondents. Only 6 percent said they would accept the vaccine, 46 percent had not decided either way, while 48 percent planned to refuse it.

Doctors and health care leaders claim that major reasons for the low uptake are cultural and religious opposition, misinformation and conspiracy theories being touted on social media. And lack of public trust in the country’s health system, which, for decades, has struggled with an insufficient workforce, very poor infrastructure, and resources.

However, Dr Mills said that the government was very active in responding to conspiracy theories with facts and authoritative health information. “There is plenty of information, too much information. It’s a blizzard of information but sorting it out is the hard part. Keep in mind that there is a high level of mistrust and scepticism generally in this society. People don’t take anything at face value. It’s fertile soil for believing alternative hypotheses,” he said.

Confusion was one of the biggest reasons for indecision among respondents to the Australian National University’s survey. And they were more likely to trust the information provided by local Christian leaders (32 percent), followed by family and friends (31 percent) and the WHO (29 percent). In contrast, faith in the government as a source of information was negative (-8) percent, leading to the study’s conclusion that ‘distrust of institutions of authority and vaccine hesitance goes together.’

Despite having an economy based on natural and mineral resource wealth, PNG has a relatively low human development ranking of 155 out of 189 countries and territories, and basic service delivery beyond urban centres, hindered by lack of investment and corruption, has been deficient for decades. There are 0.5 physicians and 5.3 nurses per 10,000 people in the country, according to the WHO.

Distrust of the vaccine by healthcare staff has consequences. “High vaccine refusal amongst health workers, particularly nurses, confuses the general public and fosters vaccine scepticism. And unvaccinated health workers can be a danger to the very vulnerable patients that we have as inpatients in hospitals,” Professor Glen Mola, Head of Reproductive Health, Obstetrics and Gynaecology at the School of Medicine and Health Services, University of Papua New Guinea in Port Moresby, told IPS.

Although uptake by health staff in the capital could change following a new ruling at the Port Moresby General Hospital. “Recently, the hospital board approved a policy of the hospital management that any new health workers, contract renewals and trainees, like interns and medical students, must be vaccinated before they can enter the clinical care areas of the hospital,” Professor Mola said.

However, in the highlands, Dr Mills said the challenges were too great for vaccinating everyone. “For the broader population, vaccination was never going to be the way out (of the pandemic). The uptake is too small, the delivery too small, and delivery mechanisms too weak. We will get to herd immunity the hard way, which is by getting most people infected,” he claimed.

Nevertheless, in June, further funding of US$30 million was approved by the World Bank to boost PNG’s COVID-19 inoculation program, where it is now being offered to all citizens aged 18 years and over.

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Ahead of the United Nations General Assembly (UNGA), the U.N. Secretary-General António Guterres warned against the rapid rise in misinformation campaigns about vaccines, leading to “vaccine hesitancy and igniting wild conspiracy theories”. Credit: Jorge Luis Baños/IPS

By Samira Sadeque
UNITED NATIONS, Sep 17 2020 (IPS)

Key focuses of the upcoming 75th session of the United Nations General Assembly (UNGA) High Level Week will be the accessibility of vaccines and a renewed plea for a global ceasefire. “I will make a strong appeal to the international community to mobilise all efforts for the global ceasefire to become a reality by the end of the year,” U.N. Secretary-General António Guterres said on Wednesday. 

At the briefing, where he discussed the issues the UNGA will address, he also announced the launch of a report on how the U.N. has responded to the current pandemic. It details three approaches the U.N. has taken to address the crisis: a health response, a focus on safeguarding lives and livelihoods, and a transformative recovery process that aims to address the “underlying fragilities and identifying opportunities for transformative change towards more just, equal and resilient societies and economies”.

In an interview with U.N. News on Sept. 15 Guterres called for a COVID-19 vaccine to be made available to everyone. 

“To think that we can preserve the rich people, and let the poor people suffer, is a stupid mistake,” he said.

The report calls for the “most massive public health effort in history” — a move that is made possible by a global collaboration between countries putting together the Access to COVID-19 Tools (ACT) Accelerator. 

The ACT-Accelerator, which the Secretary-General also mentioned in his speech, has been designed to accelerate the development, production and proper access to tests, treatments as well as vaccines, according to the report. The ACT-Accelerator employs different stakeholders such as governments, those in the field of science and health, and civil society members among others. 

Guterres further reiterated that while it’s important to keep driving towards a vaccine, it’s crucial to keep other factors in mind when discussing a vaccine. 

“A vaccine alone cannot solve this crisis; certainly not in the near term,” he said. 

“We need a vaccine to be affordable and available to all – a people’s vaccine,” Guterres added later. “That means a quantum leap in funding for the ACT-Accelerator and its COVAX Facility.”  

“For any vaccine to work, people across the globe need to be willing to take it.”

He warned against the rapid rise in misinformation campaigns about vaccines, leading to “vaccine hesitancy and igniting wild conspiracy theories”. 

This concern is also highlighted in the report, which introduces the U.N.’s “Verified” project, an initiative to “share clear, compelling content, and fight lies with fact-based advice and solutions”. With the work of more than 18,000 people battling misinformation, the initiative has reached 400 million people, according to the report.  

The report also showed a glaring difference in the budget required to address the current crisis against the resources raised. 

For a “Strategic Preparedness and Response Plan”, which prioritises addressing immediate health needs, there is a need for $1.74 billion, but so far $1.44 billion has been raised. 

For the Global Humanitarian Response Plan, which focuses on 63 highly vulnerable countries, the requirement is $10.31 billion, but only $2.48 billion has been raised. 

For responses to the socio-economic response and recovery in middle- and lower-income countries, the “U.N. COVID-19 Response and Recovery Fund”, the required amount is $1 billion, and the amount raised is $58 million. 

Meanwhile, Guterres also highlighted other issues the world is reeling from at the moment and put a light on how these issues are all interlinked in different ways: such as climate change, gender inequality. He added that the world’s recovery from this crisis should address all of these issues. 

“Recovery must be green. Subsidising fossil fuels and bailing out polluting industries means locking in bad patterns for decades to come,” he said. “Recovery must advance gender equality. And recovery requires effective multilateralism.”

A young boy in Pakistan receives an oral polio vaccine (OPV). Over the last 30 years huge progress has been made against polio and it is now only endemic in 2 countries, Afghanistan and Pakistan, with only 33 cases confirmed cases last year. Credit: Ashfaq Yusufzai/IPS

By Tharanga Yakupitiyage
UNITED NATIONS, May 1 2019 (IPS)

Since the introduction of vaccines, diseases such as measles and polio were quickly becoming a thing of the past. However, the world’s progress on immunisation is now being threatened.

According to the World Health Organisation (WHO), 85 percent of the world’s children received basic vaccines, including the measles and diptheria-tetanus-pertussis (DTP) vaccines, which can protect them from infectious diseases that cause serious illness and even death.

In fact, measles immunisation resulted in an 80 percent drop in measles-related deaths between 2000 and 2017 worldwide.

Still, access to vaccines remain elusive for many out-of-reach communities.

In 2017, an estimated 20 million infants did not receive the DTP vaccine, 60 percent of whom live in just 10 countries, including Afghanistan, the Democratic Republic of the Congo, Iraq, and Nigeria.

A rising anti-vaccination movement is also threatening to dismantle progress.

In the United States, there are now more than 700 cases of measles across 22 states making it the highest figures the country has seen since 2000.

The phenomenon has prompted some states to not only make immunisation mandatory, but also to ban unvaccinated children from public spaces.

To mark World Immunisation Week, held during the last week of April, IPS spoke to WHO’s Coordinator of the Expanded Programme on Immunisation Dr. Ann Lindstrand on the challenges of immunisation and the way forward. Excerpts of the interview follow:

World Health Organisation’s Coordinator of the Expanded Programme on Immunisation Dr. Ann Lindstrand.

Inter Press Service (IPS): How is the overall global picture regarding immunisation, and why does immunisation matter? 

AL: Immunisation matters because it is one of the most effective health interventions that we have, and it has saved millions of lives. I don’t think there is any other health intervention that works that well, with such high coverage, worldwide.

Just looking back at what we have gained from immunisation—back in 1963 when we didn’t have any vaccine for measles, there were about 2.6 million deaths every year due to measles. Now, that figure has reduced by 95 percent. The last figures we have are from 2017 with an estimated 110,000 deaths—so there has been a tremendous health gain.

Same with polio—30 years ago, we had widespread polio crippling people but now its only endemic in two countries Afghanistan and Pakistan with only 33 cases confirmed cases last year.

Now the newer vaccines like HPV [human papillomavirus] will help us reduce numbers of cervical cancers and new vaccines on the horizon like the Ebola vaccine which is used in outbreaks in Africa right now has really played a critical role in stopping the spread of the current outbreak in the DRC.

Just this month, the first ever malaria vaccine is being piloted in routine immunisation programs in three countries.

We still need to reach more. We still need to reach the last 15 percent and we need to close equity gaps to reach those furthest away.

IPS: WHO and others have pointed to the anti-vaccination movement as one of the biggest health threats in the world. How concerning is the move away from vaccinations, and what does this mean for people around the world? Is this a new challenge for WHO? 

AL: It is an area of concern, yes.

But it is not the global picture. We do not have the data to say that hesitancy has increased but we have seen that with social media and the internet, misinformation is spread more widely and easily.

That’s something we are really worried about. In some areas, there is a resurgence of disease because of unacceptably low coverage rates or that people are refusing vaccines.

We need to see this in a historic perspective. Anti-vaccine messages have been around for just as long as vaccines have been around—these things come and they go.

But it worries us and we need to be right there to tackle to spread of vaccine misinformation. It is really important to put out the right messages.

I work as a paediatrician and I have talked to a lot of parents who have had these concerns and it takes a lot of effort.

At the heart of it, it is really the health worker who is sitting there with the [parent] who have concerns or have heard something on the internet or media, and they need to be able to respond to their questions and to listen and respect the concerns of parents.

And that those health workers actually have the capacity and time to respond, both with the social ability to listen to the parents’ real concerns and also provide the scientific evidence.

There is a lot of work in training healthcare workers which is ongoing and we need to keep doing that. We need to equip healthcare workers with the right methods, words, scientific evidence to reassure parents.

The bigger picture for us to improve health is for children everywhere to get vaccinated on time and every time. We need to increase access so that vaccine services are made convenient and welcoming so people want to go there, that we are good at putting out credible information from the beginning including what are the facts, what is the evidence.

IPS: Some U.S. states are enacting mandatory immunisation laws or even barring those who have not received vaccines from certain public spaces. Do you agree with these steps, or does more need to be done? 

AL: The only disease where WHO actually recommends mandatory proof of vaccination applies to yellow fever and for international travellers in certain countries.

Beyond that, it is up to every country to make decisions based on existing disease epidemiology, their laws and regulations, and if it is the best way to go.

Many countries have achieved high immunisation coverage without mandatory immunisation.

It is a complex area—how do you sanction parents? How far do you go to enforce laws when they are in place?

That is a conversation that every country needs to have before even considering any of the mandatory vaccinations.

I think it is important to encourage countries to invest in and protect their individuals and communities from vaccine-preventable diseases and then remove barriers—have few access barriers when it comes to cost and convenience.

Make it simple and easy. Make the choice of vaccines the social norm.

IPS: In light of World Immunisation Week, what is your message for people around the world regarding the importance of immunisation?  

AL: Immunisation is a fantastic health intervention. It is a right for all children, and it is also a shared responsibility.

As we have seen with the recent outbreaks, no country and no individual can afford to be complacent about vaccines. It is important that we look at not just putting out fires or responding to outbreaks after they have happened—that’s expensive, ineffective and it costs lives.

What is more important is to have sustainable prevention, thinking and ensuring that everyone everywhere is vaccinated at the right time with the right vaccines and throughout their life course.

It also important to see that vaccines is not just for saving lives, it helps children to learn, grow, keep them in school instead of sick, avert disabilities and long-term consequences. It reduces the health care costs for a country, and protects families and communities from sliding into poverty.

There is no debate to have on the benefit or the risk between vaccines and the vaccine-preventable diseases.

We need to continue to protect people also in the future, and we really need to invest in trust in vaccines and in our healthcare system.

Excerpt:

An infant in intensive care at the Holy Family Hospital in New Delhi. Indian hospitals prefer traditional DPT vaccines. Credit: Holy Family Hospital.

By Ranjit Devraj
NEW DELHI, Feb 8 2014 (IPS)

A spate of sudden infant deaths following vaccination in India has prompted leading paediatricians to call for stronger regulatory mechanisms to evaluate new vaccines for safety and efficacy before their acceptance into the national immunisation programme.

According to data obtained from the Union Ministry of Health and Family Welfare, over the last one year 54 babies are recorded to have died soon after receiving the newly introduced “pentavalent” vaccine that is designed to prevent infection by five disease-causing microbes.“If the birth cohort in India of 25 million is vaccinated with pentavalents, 6,250 babies will die each year from adverse effects following immunisation." -- Dr. Jacob Puliyel

Rolled out gradually in different Indian states since December 2012, the pentavalent vaccine is a combination which seeks to confer immunity against Haemophilius influenzae type B and Hepatitis B, in addition to the protection afforded by the traditional trivalent vaccine against Diphtheria, Pertussis and Tetanus (DPT).

“Going by the ministry’s figures, an average of one death has occurred for every 4,000 babies vaccinated with pentavalents,” says Dr. Jacob Puliyel, who heads paediatrics at the St. Stephen’s Hospital here. “If the birth cohort in India of 25 million is vaccinated with pentavalents, 6,250 babies will die each year from adverse effects following immunisation (AEFI).

“The huge cost in terms of lives lost from AEFI on being given the combined pentavalent vaccine is difficult to justify,” Puliyel tells IPS, adding that the time-honoured DPT vaccine had a far better record for safety.

Given that the reporting of AEFI in many Indian states is unreliable, paediatricians believe that many more deaths may have occurred than recorded, and recommend a ban on the use of pentavalent vaccines until there is a thorough investigation of the policy change that allowed their entry into India.

In September 2013 Dr. Yogesh Jain, former assistant professor of paediatrics at the All India Institute of Medical Sciences and currently expert at India’s Planning Commission on developing universal health, filed a public interest litigation in the Supreme Court seeking a ban on pentavalent vaccines.

Jain’s lawyers argued at preliminary hearings that the “five-in-one” vaccine is banned in Canada, the United States, Europe, Australia, the United Kingdom, and Japan as also in the developing countries Pakistan, Bhutan, Sri Lanka, and Vietnam, following infant deaths.

Puliyel says that pentavalents gained entry into India as the government chose to bypass the National Technical Advisory Group on Immunisation (NTAGI) that was set up in 2001 to advise on the introduction of new vaccines. “NTAGI instructions for evaluation were not done after the first year.”

In most countries vaccines are introduced into the national programme after an expert committee has studied the burden of the disease, the safety and efficacy of the vaccine and affordability. If these are satisfactory the vaccine may be considered for inclusion in the routine immunisation schedule.

“Of late, the World Health Organisation has been recommending vaccines that are accepted without regard to local cost effectiveness,” says Puliyel. “Organisations like the Global Alliance for Vaccines and Immunisation (GAVI) have also been pushing new vaccines into India and other developing countries by providing substantial donor grants at the introductory stage.”

Typically, according to Puliyel, once a vaccine gains entry into the Universal Immunisation Programme (UIP), funding is withdrawn and the government finds itself saddled with the full costs of supporting a vaccine of doubtful value and, in some cases, dangerous.

In India, until recently, when a vaccine was proposed to be introduced into the UIP, a subcommittee of the NTAGI would review the available literature and consult experts to make an informed decision. In the interests of transparency the minutes of the meetings and recommendations would be uploaded onto the ministry’s website.

In 2013, an Immunisation Technical Support Unit funded by the Bill & Melinda Gates Foundation was set up to “help” NTAGI in its work, but a new confidentiality clause was inserted to protect the “proprietary” interests of commercial, academic and research institutions.

“In fact, the confidentiality clause is not limited to proprietary matters and NTAGI members are barred from divulging discussions, opinions or decisions for 10 years after leaving the committee that decides on the new vaccine,” Puliyel says.

“Vaccines being introduced in the UIP must be cost effective and look at the disease pattern and load in the country, rather than ape models from other countries,” says Sumbul Warsi, leading city paediatrician and medical director of the well-known Holy Family Hospital.

“The NTAGI must be a totally independent body which is capable of resisting pressures from outside and be transparent,” she tells IPS. “It seems that of late there has been a lot of interference in the process leading up to the introduction of vaccines.”

Puliyel says the government must publish information about a vaccine under consideration for inclusion in vaccination schedules. Stakeholders, including patient groups, health professionals, academic institutions, vaccine companies and organisations like the WHO and GAVI can then register their interest.

Transparent processes would gain the confidence of the public, which is vital in any mass immunisation programme, Puliyel says.

Families and health workers defy the Taliban's ban on oral polio vaccines (OPV). Credit: Ashfaq Yusufzai/IPS

By Ashfaq Yusufzai
PESHAWAR, Pakistan , Jul 11 2013 (IPS)

Four-year-old Muhammad Jihad is handicapped, and his parents know who to blame: the Taliban.

Jihad’s father, Muhammad Rishad, says the boy tested positive for polio on May 6 at the National Institute of Health in Islamabad.

The family had travelled from their home in North Waziristan, a mountainous region that comprises part of Pakistan’s Federally Administered Tribal Areas (FATA), to ensure their son had the best possible care, only to be told that the virus had spread too far, and little Muhammad would likely never walk again.

"The Taliban are enemies of children. They are against education and vaccination, both of which are necessary for a child’s development.” -- Noor Gul, a schoolteacher in northern Pakistan
A distraught Rishad told IPS, “The Taliban militants are responsible for my son’s (paralysis) – they placed a ban on the oral polio vaccine, so my son could never get immunised.”

Rishad is a daily wage-labourer, who had few dreams beyond securing a decent life for his only son. Now, he says, the Taliban have robbed him of his little hope for the future.

“When he grows up, my son will condemn the militants,” Rishad added, even though such thoughts bring him little solace.

Experts here say children are the future of this troubled country of 170 million, and should be protected at all costs.

Sadly, such advice has fallen on deaf ears in the militancy-ridden northern regions, where the Taliban have imposed a complete ban on all vaccines against preventable childhood diseases, including polio – sometimes referred to simply as “infantile paralysis” due to its crippling effects on a child’s nervous system – measles, diphtheria, hepatitis, meningitis, pertussis, influenza and pneumonia.

Children in all seven agencies of FATA have been the worst affected by the ban on the oral polio vaccination (OPV), which the Taliban have described as a ploy by the United States to render the Muslim population infertile. Over 160,000 children in North Waziristan and 157,000 children in South Waziristan are now at risk of contracting deadly ailments.

The Taliban have used violence and terror to implement the ban – since December 2012 at least 20 volunteer health workers and policemen have been assassinated for daring to defy the militants’ orders by participating in immunisation drives in the Khyber Pakhtunkhwa (KP) and Sindh provinces.

Two years ago, polio had been wiped out in all but three countries worldwide: Afghanistan, Nigeria and Pakistan. In Pakistan, the recent recurrence of the disease marks several steps back from successful attempts at eradication: from just 28 cases in 2005, the country saw a rapid increase of up to 117 cases in 2008, and 198 cases in 2011.

Eighteen cases have already been reported in 2013, and experts fear that number could rise very quickly.

Dr. Farman Ali, based at the Agency Headquarters Hospital in the town of Miranshah in North Waziristan, told IPS “an outbreak of polio” is never far off when large numbers of children remain unimmunised while the virus is in circulation.

According to the Health Department, medical workers have recorded over 50,000 incidents of families refusing the vaccination in FATA and the KP.

“The Taliban have strictly warned us to stay away from vaccination. They have broken the iceboxes of health workers and threatened to kill them if they (continue their work),” Ali said.

Taliban Spokesman Ihsanullah Ihsan told IPS last year that his “leadership decided to ban the vaccine because it was an excuse for the U.S. to send in its spies and expose Taliban leaders to drone strikes…we will allow vaccination when the U.S. stops its drone strikes.”

But rather than the U.S. government, it is poor families who are paying the price for this ban.

Gul Daraz, a resident of North Waziristan Agency, has a three-year-old son who had already received his first dose of the OPV when the ban was announced. Because he was never allowed to complete the full course of three doses, as required by the World Health Organisation, he is now handicapped.

“Every time my wife sees our crippled son, it reduces her to tears,” Daraz, a poor shopkeeper, told IPS.

Sadly they are not alone in their plight. According to FATA Health Director Dr. Fawad Khan, “We have only been able to vaccinate 400,000 of the 900,000 target children under five years in FATA.”

He told IPS 58 cases were reported across the country last year, including 27 in KP and 20 in FATA, of which 12 of the victims had been prevented from receiving the OPV.

Zareen Taja, a housewife in FATA’s Bajaur Agency, told IPS over the phone, “My son is very beautiful, but he will not be able to walk like normal people. I have no one to blame but the Taliban.”

At this rate, she added, Pakistan will never achieve its goal of eradicating this preventable disease that has been stamped out in all but two other countries in the world.

Noor Gul, a schoolteacher in the Frontier Region Bannu, whose son is one of the two affected children in the province, labeled the Taliban “enemies of children”.

“They are against education and vaccination, both of which are necessary for a child’s development.”

An international conference of Islamic scholars held on Jun. 6 in the capital, Islamabad, condemned Taliban militants for killing Pakistani polio workers, and held them responsible for the resurgence of the disease.

Dr. Muhammad Wesam, chief scholar of Al-Azhar University in Cairo, told conference participants that the Taliban’s campaign “contravenes Islam”.

Thirty-four scholars from Pakistan, Yemen, Egypt and Saudi Arabia issued a decree saying that those impeding vaccination efforts were committing a crime, for which God would hold them accountable.

Such interventions by clerics are crucial to correcting the misconception that OPV is “anti-Islamic”. Dr. Jan Baz Afridi, head of the KP immunisation programme, told IPS his office is working with religious scholars and volunteer health workers to continue vaccination drives.

“We are under tremendous pressure to immunise all 5.2 million children in the KP in order to effectively wipe out the disease,” he added.

The Ukraine is facing a “real threat” of a return of polio as well as outbreaks of other serious diseases such as mumps, rubella and measles because of a combination of state inefficiency and public mistrust of vaccinations, health experts have said.

The country has one of the lowest vaccine coverage rates in Europe, especially among children, and cases of some preventable diseases have soared in recent years.

International health officials say they are working with the Ukrainian authorities to improve immunisation rates, but fear that there could be major disease outbreaks in the future and lives endangered unless progress is made on raising vaccination rates.

“There is a very real risk that polio could return and that there could be outbreaks of other disease, such as mumps and rubella. Unless coverage, which is now at a 20-year low in the Ukraine, is improved we can only expect further outbreaks in the future,” Dr Dorit Nitzan, World Health Organisation representative in the Ukraine, told IPS.

Vaccination rates in the Ukraine have plunged since 2008 following an incident in which a teenage boy died after he received a jab for measles and rubella.“There is a very real risk that polio could return and that there could be outbreaks of other disease, such as mumps and rubella."

The boy’s death was wrongly reported as being caused by the vaccine and an initial confused government response and the arrest of the country’s chief medical officer in what critics say was a purely political move left many people fearful over the safety of vaccinations.

This fear remains ingrained in many today. A recent survey by UNICEF showed that a third of Ukrainian parents are against immunisations.

Vaccination rates among children are particularly low. Although national health guidelines state that children should be vaccinated against 10 infectious diseases, including polio, rubella, whooping cough and measles, only 50 percent are fully immunised. This is down from 80 percent in 2008, according to UNICEF.

Olga Denisova, a 33-year-old sales assistant from Kiev, told IPS that she had had her adolescent daughter vaccinated, but was very worried about the safety of vaccinations.

“As a mother of course I am worried. I hear so many stories about vaccines not being safe that it is hard not to be concerned. People don’t have enough information about vaccination and the government should be telling them more about it,” she said.

“I know that because of the low vaccination rates there might be cases of polio here. That scares me. I think it is obvious that if myself and other mothers are worried about vaccines that there is something wrong with the whole vaccination process.”

Child vaccinations are not enforced by law but children are not allowed to start school without certificates showing that they have been vaccinated. Parents get round this by obtaining fake documents.

These fears are also, perhaps surprisingly, being reinforced by local healthcare workers.

Many of them take an at best apathetic, and at worst dismissive, approach to vaccines.

“We are working to try and get medical staff to actively promote vaccinations,” Dr Nitzan told IPS.

She said that many remained worried that, as happened to doctors in the case of the death of the immunised boy in 2008, they could find themselves punished or arrested if someone had an adverse reaction to a vaccine.

While the World Health Organisation (WHO) and the United Nations Children’s Fund (UNICEF) and some prominent Ukrainian physicians have been keen to make the public aware of the safety and importance of immunisation, it is not uncommon to find doctors claiming that vaccinations are harmful.

Even when people do want to be vaccinated, they are not always able to have it.

Immunisation is free under state health care but hospitals often run out of stocks for months at a time.

Some mothers have told local media of facing a ten-month wait at their local clinics for the vaccine their child needs. While some resolve the situation by paying out of their own pocket at a pharmacy, not all parents in a country where the average monthly wage is 300 euros can afford to do so.

The shortages at hospitals are put down to a mix of underfinancing, inefficient vaccine procurement procedures and corruption.

The state budget is under pressure, with the economy having struggled desperately since the 2008 financial crisis. The government says it has funding for around 65 percent of the nation’s vaccine needs.

Procurement processes for vaccines have also been widely criticised as inefficient with poor forecasting leading to problems with supplies.

Meanwhile, allegations of corruption in vaccine tender processes – leading to inflated prices being paid for vaccines by the health ministry and subsequently less vaccines available – are made frequently. UNDP officials have previously told Ukrainian media that “private interest in vaccine tenders” was behind vaccine shortages.

All these problems combined have left the Ukraine facing a serious health challenge, the WHO says.

An outbreak of polio – a disease almost completely eradicated from Europe – is of particular concern. Only 74 percent of the population is immunised against it compared to average rates in Europe and the U.S. of more than 90 percent. Because of the threat of an outbreak, the WHO last month led a polio simulation exercise in the Ukraine.

The WHO is hopeful that the situation can be improved.

“What’s needed is better procurement mechanisms, improved capacities, better reporting, for example proper investigations after adverse events, and of course an information campaign to build trust with the public,” Nitzan told IPS.

“We are hopeful though. The new Ukrainian health minister, Raisa Bogatyrova, is committed to not just public health in general but to vaccines specifically. We can only hope that there is cross-sector support from the other ministries involved in health in the Ukraine, such as the finance ministry, and progress (on improving vaccination coverage) can be made.”

Argentina is one of the countries in Latin America with the highest levels of vaccination coverage. But experts are concerned about the growing campaign by vaccine critics against immunisation.

“Vaccines have saved as many lives as clean water. Risking not giving shots is like playing Russian roulette,” Dr. Carlota Russ, secretary of the Argentine Paediatric Society’s Committee on Infectious Diseases, told IPS.

Russ said that in industrialised countries, immunisation coverage is in decline as the culture of vaccination weakens, creating a risk of re-emergence of diseases that have already been controlled, like measles.

“Fortunately, in Argentina, the anti-vaccine movement is not strong,” she said.

Vaccines are obligatory in Argentina. Credit: Alviseni/CC BY 2.0

However, when a case of refusal to vaccinate reaches the courts, the story has a great impact in the media and produces a wave of uncertainty that reaches even clinics and doctors’ offices, she said.

Well-informed, well-educated parents with small children are drawn in by theories alleging adverse effects from the inoculation of viruses, bacteria or toxic substances.

In 2012, the case of a couple who refused to vaccinate their child reached the Supreme Court, which ordered that the mandatory state immunisation plan be administered, “by force” if necessary, “for the greater good of the child and of public health.”

In an interview with IPS, paediatrician Eduardo Yahbes, of the Argentine Homeopathic Medical Association, said the family “had a poor legal defence,” and endorsed their right to refuse to have their child immunised.

Yahbes is one of the health professionals who contribute to the web site “Libre Vacunación” (Vaccination Freedom), which says that the idea that immunisation is safe and effective, or that it is the only means of preventing diseases, is a myth.

“Vaccines are not effective; the idea that infectious diseases have disappeared thanks to vaccines is a fraud,” said the paediatrician, a practitioner of alternative medicine.

Yahbes quoted a number of research studies that purportedly show the adverse effects of vaccines, and blamed “the hegemony of the dominant medical system that violates people’s human rights” by forcing them to receive medical treatments they do not want.

In Argentina the mandatory vaccination schedule included four vaccines in 1970, and now includes 16. According to the Pan American Health Organisation (PAHO), it is one of the most comprehensive protocols on the continent.

In addition to traditional vaccines like BCG (against tuberculosis) or the Sabin anti-polio vaccine, new ones, for example for preventing infection with human papilloma virus, which can cause cervical cancer, have been added in recent years.

Russ said vaccines are “essential to reduce the chances of contracting illnesses and their complications; they are mandatory because the burden of the illness justifies protection.”

She pointed to the re-emergence in Europe and the United States of cases of measles, while in Latin America there are only a few cases imported from other regions of the world.

“We are covered, but we must not lower our guard,” she said.

Russ acknowledged that “there are occasional adverse side effects, as with any medication. But they are so minimal that the use of vaccines is amply justified.”

She referred to the alleged link between autism and vaccines, reported by Yahbes in a 2011 article in the publication Homeopatía para Todos, of the Argentine Homeopathic Medical Association. Yahbes wrote that “vaccinations are regarded as a major factor in the development of this pathology (autism).”

Russ said the theory, which created a scare that was “disastrously harmful,” “was later shown to be untrue.” In 2010, the British scientific journal The Lancet, at the request of the General Medical Council (GMC) of the United Kingdom, retracted a paper by researcher Andrew Wakefield on the presumed link between the two, published in 1998.

Wakefield had postulated a link between the triple viral vaccine against measles, mumps and rubella (MMR), autism and gastrointestinal symptoms. After investigating, the GMC ruled that the scientist had acted “dishonestly and irresponsibly” in his research and banned him from practising medicine.

However, the rumours and scares proliferated, and won new converts in the field of alternative medicine. As a result, measles vaccination coverage in developed countries has fallen, leading to the re-emergence of diseases like measles and whooping cough.
In Argentina, the official schedule of vaccinations is legally binding and free of charge. Since 2009 immunisations have been a requirement for receiving the universal child allowance, a direct cash transfer to families with children.

The allowance is paid to families with parents who are unemployed or who work in the informal economy, with children under 18, or disabled dependants of any age, in exchange for regular school attendance, health checks and certified vaccinations.

A new vaccine will immunise five million Pakistani children annually against pneumonia. Credit: Adil Siddiqi

By Zofeen Ebrahim
KARACHI, Nov 22 2012 (IPS)

Medical practitioners at the National Institute of Child Health (NICH), a leading government-run children’s hospital in Karachi, hope that this will be the last winter they have to treat a stream of children suffering from pneumonia.

The disease is one of the leading killers of under-five children in the country, accounting for about 19 percent of child mortality.

Last month Pakistan became the first country in South Asia to introduce a free pneumonia vaccine, to immunise five million children against the deadly disease annually.

According to Dr. Mohsina Ibrahim at the NICH, the move will also help lower the incidence of other related diseases like meningitis, but only if “the vaccine is given the same importance as polio and taken door-to-door”, she told IPS.

The government was under considerable pressure to introduce the vaccine: with infant and under-five mortality rates of 78 and 94 per 1,000 children respectively, the country is unlikely to meet the target of reducing under-five mortality by two-thirds by 2015, as stipulated by the Millennium Development Goals (MDGs).

Considered to be the largest rollout of the vaccine after Africa and Central America, the new initiative will form part of the state’s routine child immunisation programme, a set of scheduled inoculations provided free of cost from birth to 15 months to protect against diseases like diphtheria, pertussis (whooping cough), measles, tetanus, meningitis, polio, tuberculosis, and hepatitis B.

The vaccine is being delivered through a partnership between the Pakistan government, the Global Alliance for Vaccines and Immunisation (GAVI), which supports and finances vaccines in the world’s poorest countries, the United Nations Children’s Fund (UNICEF) and the World Health Organisation (WHO).

GAVI plans to contribute 680 million dollars, and the government has donated 17 million rupees (175,000 dollars) to provide the vaccine until 2015.

“GAVI provides funds for countries to jump-start the introduction of newer vaccines, which they would otherwise never have the fiscal (capacity) to do,” Dr. Zulfiqar Bhutta, a leading paediatrician heading the women and child health unit at the Karachi-based Aga Khan University, told IPS.

This is done by procuring highly subsidised vaccines in bulk directly from manufacturers. “After a negotiated period, countries (are expected) to pick up the vaccine tab,” he said.

Efficacy not guaranteed 

According to Bhutta, the “critical task remains” of increasing routine vaccine coverage from 60 percent to 90 percent of all children, if the country hopes to stay on track for achieving the fourth MDG.

In addition, Bhutta said, there remains the challenge of “ensuring that these vaccines reach the poor and are not leaked or sold in the open market”.

Dr. Ifra Sameen, another paediatrician at the NICH, is also sceptical about the vaccine “reaching those in need”.

Acknowledging that it is a “step in the right direction”, she told IPS that she fears “good intentions may be marred by the low coverage of immunisation in the state’s health system.

“We have not been able to eliminate polio, which has received enormous political commitment and was (taken) door-to-door. In addition, we already have a vaccine for measles, yet the disease still persists. Given this scenario, what are the chances of eliminating pneumonia, which requires the child to be brought to the health centre and given three doses at three different times?”

Huma Khawar, coordinator of GAVI CSO Support, believes awareness is vital. Unless all caregivers, whether mother, father or grandparent, are fully convinced of the importance and benefits of the vaccine and ensure their children are immunised against all nine childhood diseases, efforts made by the government, GAVI and other U.N. partners to reduce under-five mortality will not go far.

In addition to being cut off from children in conflict-riddled areas and those controlled by militants, the programme must also overcome the hurdles of poverty, uneducated mothers and poor governance within the state-run health systems to ensure widespread inoculation, according to Ibrahim.

And while she is happy that an otherwise cost-prohibitive vaccine – costing a little over 13,000 rupees (roughly 133 dollars) for the entire course of three injections – will be available to everyone, she believes “it would have been better to have strengthened the coverage of existing vaccines, instead of introducing new ones”.

“The government should have focused on diphtheria, pertussis (whooping cough), measles and tetanus. The measles vaccine, which boasts an efficacy of 95 percent, would reduce the incidence of not just measles… but also pneumonia, meningitis and diarrhoea.”

The government should also tackle issues like “malnutrition, low birth weight, and non-exclusive breastfeeding, which put children at greater risk of pneumococcal disease,” said Ibrahim, adding that babies who live in overcrowded places, where indoor pollution levels are high and sanitation is poor, are particularly susceptible.

Malnutrition is perhaps the leading cause of pneumonia, said Sameen. According to the last Pakistan Demographic and Health Survey (PDHS) for 2006-7 38 percent of children under five years are underweight.

Sameen, who specialises in child nutrition, carried out a study on severely malnourished children admitted to NICH between January and June this year and found some 20 percent suffered from pneumonia.

The Global Action Plan for Prevention and Control of Pneumonia (GAPP), issued by the WHO and UNICEF, recommends a three-pronged approach to fighting child pneumonia that includes protection (exclusive breastfeeding and improved nutrition), prevention (including the routine use of measles, DTP3, Hib, and pneumococcal vaccines), and treatment (with appropriate antibiotics and oxygen).

After four years, tens of thousands of children in Pakistan’s Federally Administered Tribal Areas (FATA) are receiving the polio vaccination. Credit: Ashfaq Yusufzai/IPS

By Ashfaq Yusufzai
PESHAWAR, Pakistan, Sep 26 2012 (IPS)

Over thirty thousand children in the remote Tirah area of the Khyber Agency, part of the Federally Administered Tribal Areas (FATA) in Northern Pakistan, have waited four years for protection from polio, a viral disease that is sometimes referred to as ‘infantile paralysis’ due to its crippling effects on children.

A massive government and civil society effort through the month of September finally began to reverse the trend that had kept the children of Tirah, along with hundreds of thousands in the greater FATA area, under the shadow of polio.

Up until this year, children in all seven FATA agencies have been the worst victims of the Taliban’s ban on the oral polio vaccination (OPV), which the organisation claims was a ploy by the United States to render the recipients impotent and infertile, thus strangling the growth of the Muslim population.

On Jun. 20 the outlawed Tehreek Taliban Pakistan (TTP) banned vaccinations in North Waziristan, putting 161,000 at risk of contracting the preventable childhood disease.

A week later, the TTP in the adjacent South Waziristan province imposed a ban on numerous vaccinations that rendered 157,000 children vulnerable to eight preventable childhood ailments – polio, measles, diphtheria, hepatitis, meningitis, pertussis, influenza and pneumonia.

“Anyone found involved in vaccination-related activities was dealt with sternly,” TTP Spokesman Ihsanullah Ihsan said a statement, adding that the responsibility rested with those who advocated for any kind of vaccination.

Not even professional health workers were spared if they were found to be in violation of the ban.

“Due to the Taliban’s barbarism, such as beheading soldiers and local residents on charge of spying, stoning alleged ‘sinners’ (such as adulterers) to death and targeted assassinations, the Taliban have spread their message about the vaccinations loud and clear,” explained FATA Director of Health, Dr Fawad Khan.

Khan said that more than 6000 FATA health workers had been directed to stay away from vaccine-related work.

Earlier this month officials mounted an offensive against the ban. The government enlisted a local NGO, the National Research and Development Foundation, and religious scholars to hold talks with the outlawed jihadist outfit Ansar ul Islam (AI) to negotiate the terms of a vaccination programme.

The NGO began facilitating the vaccination on Sept. 4, an upbeat Dr. Aftab Akbar Durrani, social sector secretary of the FATA, told IPS.

He added that AI’s cooperation had enabled 95 percent of the children in the Tirah area to receive the vaccination.

“It is a major breakthrough, as many (previous) efforts to vaccinate children in the Taliban-controlled areas had failed,” officials told the English-language Dawn newspaper, crediting the organisation with protecting 32,641 children from polio.

Officials added that 11,626 children also received the vaccine against measles, while another 3,889 newborns and month-old infants were vaccinated against five other ailments between Sept. 4 and 6.

“Ansar ul Islam and religious leaders attached to the group understand that the poliovirus can cause lifelong disability so they are ready to support the initiative,” according to officials. Only four families refused to vaccinate their children, but efforts are currently underway to convince them otherwise.

“Ansar ul Islam played a vital role in countering community refusals,” officials told IPS

Fifty percent of children In Bara, a town in Khyber Agency, had not received the oral polio vaccine (OPV) since October 2009, owing to an ongoing operation against militants in the area.

Officials developed a new strategy to reach the inaccessible children in FATA, which included working in “collaboration with scouts (who) carried out door-to-door visit with the help of local vaccinators”.

Durrani told Dawn that aggressive efforts were underway to ensure immunisation of all 900,000 target children in FATA.

“We are administering OPV to the displaced children of Waziristan in the adjacent districts of Bannu, Tank and Dera Ismail Khan where they live in rented houses or with their relatives,” he said.

He said that more than 25,000 displaced children from Orakzai Agency had been vaccinated in the nearby Hangu district, while 50,000 children In Jalozai had also received the OPV.

“Displacement has been proving a blessing in disguise for the displaced children, who are getting protection against eight vaccine-preventable ailments through immunisation,” Durrani said.

A three-part campaign throughout September saw the immunisation of 600,000 children in FATA while 300,000 were still inaccessible.

(END)

Dengue patients at Cambodia's National Paediatric hospital. Credit: Erika Pineros/IPS

By Vincent MacIsaac
PHNOM PENH, Sep 13 2012 (IPS)

Public health experts in Cambodia are unenthused by reports of trials for a dengue vaccine conducted in neighbouring Thailand, saying it will be too costly for those who need it most – children in the least developed and developing countries.

“Of course, they cannot come out with a vaccine that costs 20 cents,” Dr. Philip Buchy, head of the virology unit at the Pasteur Institute of Cambodia, told IPS.

Buchy was referring to the Paris-based pharmaceutical company Sanofi SA’s dengue vaccine efficacy trials, the results of which were published in the British medical journal Lancet, this month.

Dr. Stephen Bjorges, leader of the vector-borne disease team at the World Health Organisation (WHO) in Cambodia, agrees. Even if Sanofi succeeds “funds would need to be mobilised” to cover the cost of inoculating children in Cambodia, he said.

A dengue epidemic that raged through Cambodia during the first eight months of the year landed more than 30,000 people in hospital, the majority of them children.

According to the Lancet report, Sanofi’s vaccine offers some protection against three of the four serotypes of the dengue virus – about 30 percent against serotype one and from 80 to 90 percent against serotypes three and four.

However, Sanofi’s vaccine does not protect against serotype two, which was circulating in the study area during the trial, giving the vaccine an overall efficacy rate of 30.2 percent, the report said.

Large-scale phase-3 trials are underway on 31,000 children and adolescents in Latin America and Southeast Asia, Sanofi said in a press statement timed with the release of the Lancet report.

According to the Reuters news agency, the company has already invested more than 430 million dollars in a new factory in France to produce the vaccine.

WHO’s Bjorges said that if the phase 3 trials proved the vaccine was effective, its initial market likley would be tourists from wealthy nations and the military, a view Buchy agrees with.

Buchy doubted, however, that an effective vaccine was around the corner. “The vaccine is not for tomorrow,” he said. “Dengue epidemics still have good days ahead of them.”

Still, both doctors expect increasing investment in vaccines and vaccine-related research as global warming expands the range of the mosquito that transmits dengue into southern Europe and the United States.

Developed countries are beginning to factor the costs of dengue treatment into their long-range healthcare budgets, while pharmaceutical companies have identified a potentially lucrative, emerging market, Buchy said. “Global warming is providing a shortcut for vaccine research.”

“Interest in vaccines is going to grow exponentially now that there is some success with a vaccine,” Bjorges said.

The European Union provided more than 10 million dollars for three dengue-related research projects in Southeast Asia earlier this year, including one in Cambodia to investigate the role that asymptomatic carriers play in transmission, Buchy said.

“If we can identify a gene that is protective this may allow us to develop drugs for treatment and vaccination,” he added.

Funding for prevention and control of epidemics in poor countries remains scant, however. The budget for Cambodia’s national dengue control programme is about 500,000 dollars, most of it provided by the Asian Development Bank.

Bjorges says one reason for the lack of funding for prevention and control is that it has shown little success. “Dengue control is 50 years old and everything that has been thought of has been tried.”

Breeding sites have to be eradicated weekly in order to prevent the mosquito that transmits the virus from emerging from its larvae, and this requires changes in human behaviour that have proven difficult to sustain on a weekly basis, Bjorges explained.

Another problem may be that those who allocate global health funds rely on short-term cost-benefit models, Bjorges said. They are under pressure to produce quick, quantifiable results for the funds they allocate, and dengue prevention and control projects do not fit these models, he explained.

Buchy was less pessimistic about the possibility of changing human behaviour. “Behaviour change is possible, but it requires more investment in education.”

Buchy’s view is echoed by Prof. Duch Moniboth of Cambodia’s National Pediatric Hospital that treated 1,673 children for dengue in the first seven months of this year. “There is not enough education about dengue – how to prevent infection and how to eradicate breeding sites.”

New research, however, suggests that dengue is far more prevalent in Cambodia than previously calculated, underscoring the need for increased investment in prevention.

The disease is underreported partly because Cambodia’s dengue surveillance system relies on data from state-run hospitals and charitable children’s hospitals. Cases treated at private hospitals and clinics are not reported to the health ministry.

Charitable hospitals treating dengue patients in Cambodia have been pleading for donations after being inundated with patients in May. The National Paediatric Hospital has been relying on nursing students to treat children who spill into the hallways and the foyer around the main stairwell.

The hospital receives a mere 20 dollars per patient, regardless of how long the child stays, Moniboth said. On average, doctors receive monthly salaries of about 125 dollars, while nurses are paid about 75 dollars, he said.

With such meager funding for healthcare what is needed is a cheap vaccine, Moniboth said.

Four-year-old Deepak Yadav, a mentally disabled boy from Indore city in the Indian state Madhya Pradesh, was being treated for stomach problems at Chacha Nehru Bal Chikitsalaya, a government hospital for children attached to the M. G. M. Medical College.

(Right to left) Clinical trial victims with medical right activist Dr. Anand Rai. Credit: CTVA, Indore.

But when repeated administration of the anti-ulcer drug Rabeprazole started to exacerbate his condition, his parents stopped treatment and sought help from the Clinical Trial Victims Association (CTVA), which discovered that the boy had been a lab rat for an untested drug.

“We should have been told an unknown drug was being tested on our innocent child and given the choice to say no,” Deepak’s father Sooraj told IPS.

Deepak is now almost entirely reliant on his mother for survival. The family is poor, yet “doctors did not take any steps to get us compensation,” his father added.

This family’s tragic story is just one example of a sinister pattern unfolding across India.

A spate of deaths over the last four years caused by illegal clinical trials of untested drugs has ignited the wrath of rights activists and prompted prominent legal institutions to consider tightening the country’s drug regulation laws.

In response to a Right to Information query filed by Indore-based medical rights activist Anand Rai, the Drug Controller General of India (DGCI) disclosed that 2,031 people have died as a result of serious adverse events (SAEs) during drug trials in the past four years.

SAE-related deaths for 2008, 2009, 2010 and 2011 were 288, 637, 668 and 438 respectively.

Rai, who is currently spearheading a campaign against unethical drug tests on human beings, has urged legal authorities and activists to raise their voices against clinical trials in which desperate people become easy prey for multinational pharmaceutical companies.

He told IPS that most of the victims were illiterate and poor people.

“Clinical trials on citizens without their consent is considered a violation of basic human rights and often results in the death of innocent persons, who were not even aware of the kind of tests being (performed) on them, since clinical research organisations use roundabout ways of acquiring the consent of patients and their relatives,” he said.

Many of the institutions involved in the drug trials fail to “provide the patients with copies of the informed consent form, patient’s information sheet or clinical trial liability insurance policy,” according to the CTVA. As a result, very few victims have access to compensation.

An intervention by the Supreme Court of India last month further exposed the unethical practices of clinical researchers and pharmaceutical companies.

A division bench headed by Supreme Court Justice R M Lodha stated in early July that it was “unfortunate” that humans are being treated as “guinea pigs” for testing of drugs and vaccines produced by multinational corporations.

Lax regulations breed impunity

Experts on medical law assert that tight regulations in Europe and the U.S. prompt many pharmaceutical companies and research organisations to look to India and other developing countries as cheaper and less restrictive sites for drug trials.

Dr. Mohan Rao, professor at the centre for social medicine and community health at Jawaharlal Nehru University in New Delhi, told IPS that India did not have a proper regulatory authority to monitor the trials of new drugs.

“We have unfortunately opened our health sector to global pharmaceutical companies for trials without the infrastructure to monitor and regulate them. It is cheaper for transnationals to locate trials in India, which has a large and captive (drug) market, in addition to doctors not constrained by ethics,” he said.

“The growth of local clinical research organisations has also contributed to this. Above all, we have a large and unregulated private medical sector with a culture of impunity. For the general public, and the elites, the lives of the poor do not matter,” Rao added.

The CTVA said that many doctors give more importance to their earnings than to the lives of their patients.

“Lured by offers (from) big pharmaceutical companies, these doctors have deliberately violated all regulations and have reduced clinical trials to a money spinning exercise,” according to a statement on the CTVA website.

According to the Financial Express daily, stiff opposition from research organisations on how clinical trial victims should be compensated has dealt a blow to the health ministry’s efforts to legislate the practice.

The ministry was on the brink of making it mandatory for pharmaceutical companies sponsoring clinical trials to pay financial compensation to volunteers in case of a proven trial-related death or injury, the Financial Express reported on Jul. 4.

Eminent drug regulatory expert C M Gulhati believes compensation rules in the Motor Vehicle Act can serve as a basis to determine the amount of compensation, while other factors such as the age of the volunteer, number of dependents and prevalent morbidity in the community should also be taken into account in an effort to standardise such payments, according to the newspaper.

Activists say many clinical trials in the country have been conducted behind a veil of secrecy and with little transparency in clinical research.

One such dubious deal was brought to light in 2001, when a group of cancer patients was subjected to drug trials under an agreement between the Thiruvananthapuram-based Regional Cancer Centre and the renowned Johns Hopkins University in Baltimore.

Compounding the issue, according to Dr. Sree Kumar, a private medical practitioner in Chennai, “is the easy availability of a large population of patients in Indian hospitals displaying a broad spectrum of conditions.”

“Collaborative ventures between Indian hospitals and foreign pharmaceutical industries and academic institutions ensure that the lab-to-market journey of a new product is achieved at a low cost and shorter duration,” he added.

Ethical testing required

The flip side of the illegal testing coin can be equally problematic. A panel of lawmakers in the Indian Parliament headed by Brajesh Pathak recently discovered that many popular medicines were being sold without having undergone clinical trials at all.

Lambasting the collusive role of the Central Drugs Standard Control Organisation, the parliamentary standing committee for health and family welfare said that 33 new medicines were found to have been approved between January 2008 and October 2010 without undergoing trials.

Medical scientists claim that drug trials conducted on animals do not produce accurate results.

Dr. A. B. Salim, an independent researcher in Bangalore, told IPS that a drug tested successfully on animals could produce harmful side effects when administered to human beings.

“Therefore it is the duty of the ethics committee and the DCGI to monitor and ensure that the trials are done honestly,” he added.

(END)