Uncovering the root causes of the mpox outbreak with Boghuma Titanji

This week's conversation focuses on the current spread of M-Pox (formerly Monkeypox) in Africa and the response to the outbreak. Dr. Boghuma Titanji, an infectious disease expert at Emory University, discusses the history of M-Pox outbreaks in Africa and the factors contributing to its spread. The conversation also explores the role of African governments, the Africa CDC, and the international community in addressing the outbreak. The need for increased investment in healthcare, research, and development in Africa is highlighted, as well as the importance of holding governments accountable and promoting grassroots education on healthcare funding. The conversation explores the challenges and potential solutions for Africa to produce its own vaccines and medications, emphasizing the untapped potential of the continent. It highlights the low percentage of vaccines and basic drugs manufactured in Africa and the competition with established manufacturing hubs in other countries. Trust in locally produced vaccines is also discussed, with the need to shift the mindset of consumers. The conversation emphasizes addressing infrastructure and resource limitations before focusing on vaccine production. Considering the different transmission patterns and populations affected, the need for a tailored vaccination approach for M-POX outbreaks is highlighted. Exciting developments in infectious disease research and vaccine trials in Africa are also mentioned.

00:00 The Current Spread of M-pox in Africa

14:20 The Response to the M-pox Outbreak

19:00 Underlying Issues: Lack of Investment and Prioritization

23:21 The Role of Global Solidarity in Public Health

25:45 Accountability and Self-Reliance in Healthcare

29:35 Accountability and Local Ownership

37:47 The Role of the Private Sector in Vaccine Production

50:26 Tailoring Vaccination Strategies

55:20 Promising Developments in Infectious Disease Research

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Transcript

Global Health Unfiltered (00:41.23)
Hello friends and welcome to the Global Health Unfiltered podcast. Podcast about the unspoken realities of global health in Africa and the world. I'm your host Desmond Jumbam and I'm here with my co -host Yao Bediaco. So mParks, previously known as monkeypox, is currently spreading at an alarming rate across the continent. On August 13, the African CDC declared mParks a public health emergency of

and the World Health Organization declared it a public health emergency of international concern. Yet, seems not much is being done to address the spread of empox. At least not enough. So joining us today is Dr. Bogumar Titangi, an assistant professor of medicine and an infectious disease expert at Emory University.

And we'll be discussing with how the current situation of -pox, what is being done to address it, as well as some trends in infectious disease across the continent and the implications for public health. Hello, Volgoma. Welcome to Global Health on FieldTip. Hi, Desmond. Thanks for having me. So perhaps we could start with you giving us an overview of the current spread of -pox. I understand that there was

an MPOX outbreak back in 2022. But so it's not this is the second outbreak in about two years. So can you give us what is currently happening with MPOX across the continent? Yeah, before I come to the current outbreak, I think it's very important to remember that the issue of MPOX, particularly in the African continent, is an issue that has been progressively growing.

over the last five decades from the time it was first identified in humans as a human pathogen in 1970 in the DRC, we have seen through the years more frequent outbreaks of EMPOCs happening in countries within the African continent where the virus circulates in an endemic fashion. And through the years, we've seen larger outbreaks, more consequential outbreaks.

Global Health Unfiltered (03:02.222)
And some of this is due to population growth. Some of this is due to the waning of vaccine immunity from smallpox vaccination because we know that smallpox vaccination ended in 1980 for most countries. And some of this is due to enhanced movements of populations and population growth within the African continent. So we know that this has been a problem that has been trending upwards throughout the decades going all the way back from 1970.

In 2017, Nigeria experienced its first major outbreak of MPOX from 2017 to 2018. And that was the first time Nigeria was reporting hundreds of cases of MPOX throughout its history. So that again was a signal that this was a problem that was continuing to grow in the African continent. The Nigeria CDC and public health officials in Nigeria at the time

had a concerted effort that led to containment of that outbreak. But again, this barely made a blip in sort of the international discourse when you think about emerging infections and the global health scene. Now, fast forward to 2022, that's when we saw really an explosion of MPOCs internationally outside of countries where this virus has circulated within the African continent endemically.

we saw cases in North America and across Europe and even extending to Latin America as well as Asia. And that led to the first declaration by the WHO in 2022 of a public health emergency of international concern. And this was finally the time when the world was absorbing the fact that this problem that had been ignored for five decades within the African continent could really impact

countries in the Northern Hemisphere, notably in Europe and in North America. That public health emergency declaration led to a robust response in those countries that didn't really trickle down again to the endemic countries in Africa that have been experiencing outbreaks of this infection through the years. So we had a situation where

Global Health Unfiltered (05:25.39)
While we were addressing Mpox in North America and addressing it in Europe, we weren't really thinking about addressing it in the countries where this virus circulates in an endemic fashion. Now, coming back to the context of the Democratic Republic of Congo and what's happening within the African continent, throughout that time from 2022, they had been dealing with an outbreak, albeit with much lower numbers than we're currently seeing.

And then fast forward to 2024, 2023, 2024, we saw a real explosion in the numbers of cases of -pox that the DRC was experiencing. And it's estimated that in the context of the current outbreak, there are about 20 ,000 recorded cases with over 600 deaths reported in African countries. And we've also seen exportation

of MPOX cases and introduction of MPOX into countries within the African continent where it wasn't known to circulate in an endemic fashion. So notably Kenya, Uganda, Burundi, Rwanda and South Africa are currently reporting cases. So it is this explosion in cases as well as the regional spread of MPOX to countries that have not encountered this infection before

that really triggered the current emergency declarations that we're seeing. But in reality, it's been a crisis for a much longer time than one would have you imagine or realize if you're just focusing on the snapshot of what is happening now. In regard to what you said, it's been simmering for a long time. It blew up in the US and Europe. They did something about it, but they didn't really do anything about where.

It's quote unquote. I hate to use originate because then we begin to blame Africa for everything. But, you know, they didn't deal with the endemic countries. But then could we say it's not their problem to deal with? Right. I mean, when it showed up in America and Europe, it was dealt with by their public health officials. Where do you see the problem? Why? Why is it that with all the issues we've had at the DRC and before that in Nigeria, you had all these warning signs?

Global Health Unfiltered (07:47.66)
Why was not more done? Because there is a vaccine as far as I'm aware. It's not like COVID where we had to do all the R &D from scratch. There are effective vaccines. So why do you think we've allowed this to happen? you know, where does, I don't know, maybe not use the word blame, but why has this happened? You may not use the word blame, but I would say there's enough blame to go around, right?

I think that you're absolutely right in saying that, you know, this is a problem that we know has been endemic in African countries and asking the question why it's not been robust, more robustly dealt with by the African countries that have been experiencing this issue, whereas European countries and countries in North America did what was required to address the outbreak when it got to their shores.

layer this response and start on the Africa side. think that looking at who has historically been most impacted by EMPOCs when it has happened in outbreaks in the African continent, remember that when it first emerged back in 1970, this is really a zoonosis. So meaning it is an infection or a virus that circulates in an animal host reservoir and people

frequently came in contact with it when they came in contact with an animal that was carrying the virus. So it tended to affect communities in very rural and remote parts of countries that had been experiencing an pox in an endemic fashion. And when you think about rural communities, you're again thinking about communities that are vulnerable communities, that are communities that don't always have their voices represented at the decision -making

table and that are not always prioritized, be it by local governments or by the powers that be that are charged with tackling this issue. So it is what usually happens when you have a neglected disease. And -pox was essentially a neglected tropical disease, a term that I hate because again, it turns to point blame based on geography, which shouldn't be what should be done.

Global Health Unfiltered (10:09.102)
So those are some of the local factors within the African continent that led to a lack of prioritization of resources directed at tackling this issue. The second problem is that although the African continent has made significant progress following the 2014 to 2016 Ebola outbreak in terms of viral surveillance and emerging disease surveillance, there's still a lot of room for improvement.

And unfortunately, a lot of countries where -pox has circulated in an endemic fashion do not have the surveillance resources to allow them to really define the magnitude of the problem. If you're not tracking a virus and you don't understand how it spreads, you can't really define a strategy with which to address it. Like when you look at the current outbreak of the 20 ,000 cases that have been

reported in the DRC and in the other countries reporting cases, only about a third or a quarter of these cases have actually had confirmatory testing. Again, showing you the gap that exists between the problem and the resources that we have to address them. Now, coming back to the shared blame, per se, and thinking about what countries in the West could

have done or whether they had any responsibility towards African countries to help these countries support them in responding to the outbreaks. We live in an interconnected world. We can no longer think about emerging pathogens and emerging threats from a perspective of they versus us or we have to only take care of our own because if you have an outbreak of an emerging virus that

can threaten human populations, even if it's occurring in Kinshasa, it's less than a 24 -hour flight time total for that virus to be introduced into the heart of New York City and in the United States. So there is still a powerful argument for global solidarity when it comes to dealing with serious public health threats that have.

Global Health Unfiltered (12:28.622)
a significant consequences for the international community. And it's important for countries and the leaders of countries that have more resources to recognize that, that a key component of protecting their own populations is also ensuring that the problem is dealt with on a more broad and global scale. The case for solidarity has been made before many times in the past.

for other diseases, including COVID -19, right? When the vaccines became available, African countries were really scrambling, even though there were all these alliances that had been made, but a lot of Western countries broke and were hoarding vaccines. And so I'm curious to know, so it seems like even though the case of solidarity is made and the Western countries make those, they don't really...

believe that because in the end they end up being primarily more concerned about their own constituents before anybody in the Congo in the remote parts of the world. And so it seems to me that countries first and foremost need to take the responsibilities for addressing

infectious disease outbreaks in their communities, even though it may have kind of a global outbreak. So my question is, can you tell us what the African governments, the ministries of health, and then expanding to the Africa CDC have been doing to manage this current outbreak? What are they doing well and what have they not been doing so well? I think that, you know,

For the case of -Pox, I think I've been especially impressed with the speed with which the Africa CDC has really tried to move with to react and respond to this outbreak of note. They declared this a continental emergency even before the WHO made that decision. And additionally, they have also been very vocal in spelling out quite clearly.

Global Health Unfiltered (14:49.582)
what is needed to respond to the outbreak, but also lobbying leaders of African governments to actually invest in the response. And for the first time, we've seen the Africa Union put out a huge amount of funding towards supporting the response to this outbreak. We saw the government of the DRC pledge $10 million to its own local response, which are really encouraging signs that we've not

always seen kind of in previous responses. Additionally, in seeing the way in which they have framed the conversation around vaccines, they have also made it very clear that there are African countries that want to purchase vaccines, but the pricing point is such that it is prohibitively expensive for a local government to absorb that cost and really advocating for a lowering in vaccine.

costs so that these countries can purchase vaccines. Again, underlying the fact that we are not just begging for donations, but we are actually telling you we have resources to buy these vaccines if you put them at a pricing point that is affordable to these countries. I think that these have been very positive signals, which are quite different from some of the things that we've seen in previous outbreaks. If you think about Ebola that happened in an era

before the existence of the Africa CDC, you think about other outbreaks, dotted outbreaks, the previous Ebola outbreaks that have happened in the DRC and in other African countries prior to the existence of this public health agency. So I think that that has really been a very positive aspect of the response, again, highlighting the importance of African countries to really lead in responding.

to an outbreak that is affecting countries within the African continent. Now, when you go back on the flip side and you think about what hasn't been done right, instead of saying what hasn't been done right, I would rather frame it as what has taken too much time to be accomplished. We think about, as Yael mentioned, we know that there are

Global Health Unfiltered (17:15.662)
smallpox vaccines that exist that have effectiveness against Mpox and have been used in Mpox outbreaks in North America and Europe when those outbreaks happened in 2022. But when those outbreaks happened in 2022, up until now, we still do not have emergency use listing for these vaccines for countries within the African continent, which means that

For a lot of countries that rely on large public health agencies to help them evaluate the effectiveness and the safety of vaccines so that they can accelerate their use on the emergency use licensing within their own countries, even if those vaccines arrive today, they may not be able to use them because of the lag, of the delay in the processes that should have led to this emergency use listing.

These are areas in which I think the Africa CDC could have worked in tandem with the WHO to make sure that that process was more streamlined so that when the vaccines arrived, they would have been able to be in a situation to plug and play. So currently only Nigeria and the DRC have finally...

got an emergency use listing or emergency use authorization for these vaccines within their countries, right? But the other country, Burundi, that's experiencing a pretty significant outbreak is still working on this. So these are all kinds of things that I think knowing that this virus existed and was circulating and was causing large outbreaks, at least within the African continent, we know large outbreaks happening from Nigeria in 2017 up until now.

When we look at that timeframe, you're talking about almost six years and it's unimaginable that we're still having conversations around how do we get these vaccines licensed so that we can get them into arms. Yeah, I mean, I think that raises a point I've been grappling with recently about organizations like the African Union, African CDC. Africa is the most culturally, linguistically

Global Health Unfiltered (19:29.656)
genetically diverse continent on the planet. And yet, I mean, I guess Pan -Africanism makes sense to me. I consider myself a Pan -Africanist, but Africa seems to be being pushed towards greater and greater integration at a scale that the world has really never achieved. I mean, even the EU is not as integrated perhaps as the way Africa is being asked to do it. And if I look at the EU,

The EU success is largely predicated on the strength of a few strong economies. mean, many countries in the EU are really not that wealthy, but you have France, Germany before Brexit, you had the UK. The success of the EU is because you have strong individual countries and that through those strong countries, it then sort of bleeds over into the weaker countries. But Africa is predominantly poor. And so we are being asked to integrate

in such a way without really having individually, maybe besides South Africa, really strong economies. And so the question is, while I agree that organizations like the Africa CDC are very useful for certain things, would it be also safe to say that if we don't strike a balance between strong continental agencies and then strong national bodies, we end up in a situation like we have now? You said, so yourself, that Nigeria handled MPOC pretty well.

because Nigeria has a pretty I mean, I think by African standards, probably has the best CDC that we have. So of course, like even Ebola, look how they handled it, you know, know, remarkably well. I feel like post COVID, I sometimes feel as though Africa CDC sucks sucks up all the oxygen and all the investments in public health. The idea is they will then distribute. But of course, it gets caught up in others and caught up in political wrangling.

So could an argument be made that as much as we need continental bodies to help promote collaboration, Africa needs to also build strong, maybe subregional and national capacity and not simply try to integrate under one big African flag, which is what I feel we are pushed to do by the West. And I think it's, my argument is that is becoming counterproductive because we can never agree. If Burundi is taking six years to approve something,

Global Health Unfiltered (21:54.958)
you know, perhaps if we had better structures within Burundi, within Congo, within Nigeria, within Ghana, then they would be able to do some of these things at a national level. And then Africa CDC can kind of provide guidelines as opposed to implementing. absolutely. 1000 % agree with you on this point. You know, the Africa, the role of the Africa CDC really needs to be more clearly defined instead of being as this body that represents

you know, the 50 plus countries that exist within the continent. And as you've rightly said, it's just so diverse that you can't have this one body be the end all and be all of dictating public health policy within individual countries. I think that there is one of the key things about the root of the problem is that still too many African countries and African governments are not investing enough in healthcare.

in research, in development. A majority of African countries, in fact, almost all African countries, to the exception of South Africa, invest less than 1 % of their GDP towards research and development and health. And so far as those numbers don't move, you can't have the structures in terms of having robust public health structures within a country

that allow it to be able to be nimble and adapt and respond to a public health crisis. And I think the conversation that we really need to be having is how do we get countries to recognize that the importance of raising that investment in research and development and in health, and also how do we pitch it to governments of countries so that they recognize that this in fact is an economic investment.

that would yield dividends downstream. And that is a policy question that again, a policy conversation that should be happening at the level of the African Union, which can be facilitated by the Africa CDC because they know the importance of having these local investments in public health and in research and development to make sure that we raise the level.

Global Health Unfiltered (24:17.526)
of individual countries to at least a minimum requirement that will make their job of integration a lot easier. And I think that it's important for us as public health professionals to continue to call this out. I call it out all the time. Going back to the MPOC's outbreak in the DRC, listening to some of the frontline reporting within the DRC, there were talks about people starving or not having enough food in hospitals.

within the DRC where patients with MPOCs were being treated. Now, is it the responsibility of the international community to come provide food and substance to your own populations? You know, I think it's very, very important to be able in having the conversation about global solidarity to also be able to call out where it's not a global solidarity issue, but it's rather

a local government neglect issue towards its own people. Because if you don't hold governments accountable, they would keep getting away with repeating the same errors. And I think that the over -reliance and the over -dependence on foreign aid to fund health care in individual countries within Africa is really the Achilles tendon that leaves us vulnerable.

to continue witnessing these types of outbreaks and relying on others to come and stop the bleeding when it's happening. Yaw and I, we've had this conversation with our co -hosts about the under investment into research in Africa quite a bit. And you mentioned over reliance on foreign aid. know, some people have advocated for needs cut down on

foreign aid as a way to really get our governments to put more money into research, more of their own money into research. I'm curious what you think about this approach, because in order to address the issue, we really need to understand what is causing this underinvestment in R &D on the continent, right? So what would you suggest, based off of your own thoughts and conversations as to...

Global Health Unfiltered (26:44.022)
how we address this issue of under investments? Yeah, I think that, you know, that is a very important sort of question and discussion to have. And one of the examples that I think I would draw from to answer and give my thoughts on this particular issue is looking at a program like the PEPFAR program, which is the federally funded US program that funds

antiretroviral therapy and HIV treatment in over 25 countries in Africa. And that has been around for over a decade with tremendous impact. Now, with the changes in the political climate within the US, in the last two years, there had been questions as to whether PEPFAR was going to be renewed. Right? And that caused a lot of tension in

the global health space and there were a bazillion think pieces written about how Africa cannot survive without PEPFAR and how it would be a humanitarian crisis if PEPFAR was not funded. I wanted to look at the conversation through a different lens. Granted, PEPFAR is a great program and has saved literally millions of African lives.

But from the time it was initiated 20 years ago up until now, what was the plan by countries within the African continent who are beneficiaries of PEPFAR in terms of contingency planning for a time where PEPFAR may not be there to provide antiretroviral therapies to its own population? I think if you have a program like PEPFAR that has funded ART within

your country for 20 years and you still do not have a plan on how to fill that gap if all of a sudden PEPFAR is no longer there, then there is a significant failure somewhere. 70 % of the people living with HIV across the world are within the African continent. I think it's absolutely unconscionable that we have countries within our continent that still cannot

Global Health Unfiltered (29:06.102)
fully absorb the cost of antiretroviral therapy for their own citizens. So coming back to your question, I think that the co -dependence in terms of funding works as a two -way street. I think at the time when the funder or the U .S. government is coming in with a program that's meant to support countries to fund, say for instance, HIV treatment,

there has to be a discussion at the initiation phase of how this program will be phased out to make sure that local systems that are in place can take it over. Essentially, if that conversation is not had at the origin, then the governments don't have any incentive to actually do better towards its own people in terms of ensuring that, okay, we have assistance now.

But we've got a 10 year plan during which we need to make sure we are able to absorb and take full charge of these people that PEPFAR is taking care of. And without those conversations, you essentially create a system where governments are not being held accountable to doing more because they can always rely on the fact that a program that is funded to the tune of four

billion annually by the US government is going to continue to funnel resources to allow funding for things that they should be funding within their own population. So it's a two -way street. And I think that the co -dependence benefits corrupt governments, but it also benefits the people that are funding it. Because if you're funding a program, there's a power dynamic that's created there.

PEPFAR dollars can only be used for projects that are designated and decided by PEPFAR, which is a US -based program. So you cannot divert that funding to anything else, even if you consider within your own country that certain things may be of higher priority than whatever the priority has been set by PEPFAR. So we are in an impasse, I would say. And I don't know how we break it.

Global Health Unfiltered (31:33.326)
Yeah, I was gonna I was gonna ask, mean, who should hold who accountable? You know, I agree 100 % with what you're saying. But I don't think it's PEPFAR's job to hold our governments accountable. Because like you said, the US doesn't know countries don't do anything for free. The $4 billion is US taxpayer money that has to be justified and is justified through providing political leverage. They can count on African votes.

in the UN and other places and other, you know, in other situations through this support that they provide. And I think, you know, that has to be very clear to African people that we're not helped out of charity. We're helped out of, you know, it's global geopolitics. And it's at a heightened state now between the US and China. And we see in Russia these days with BRICS and everything else that's happening. So the question is, how do we hold

Who should, I think, mean, my feeling is the African people need to hold their governments accountable. But then, I mean, for instance, I'm thinking Ghana, we're coming up with elections soon. We have a choice between an incumbent government that many people are very unhappy with. And then also a former president who in his time, probably people were also not necessarily that happy. So then it's like, you know, who is holding, I mean,

I agree, it's an impasse because I feel it is not the external donor's job to police our governments. They need to strike the best deal for their external, their countries. So the question is who holds the African leadership's feet to the fire and how do we get better leaders? I mean, think that's, at the end of the day, we need better leadership. I think that's the frustration of most young, young old, anybody thinking African people is.

our countries are struggling and it's largely because we have poor leadership and we don't quite know how to find the good leaders. I don't know. mean, maybe it's not for Global Health Unfiltered to figure out. Yeah, it's something, I don't know. I fully agree with you and yet we keep shirking the responsibility onto external sources. And I think maybe as people, maybe it starts with us African citizens to look at ourselves and say,

Global Health Unfiltered (33:50.53)
You know, we can complain all we want, but are we holding our leaders accountable? Yeah. And I will just add that I think that just the conversations we're having play an important role because when you talk about African people holding their governments accountable, a lot of that also, you need education about the issues. You need education about what we are talking about to be able to have

the conversations that need to be had to hold your governments accountable and ask the questions that matter. And I think that oftentimes, you know, the narrative is lost, like people on the ground, people who are beneficiaries of say a PEPFAR program. If you went, for instance, to Cameroon and you went to an HIV treatment center and there was someone who was there to pick up their antiretroviral therapy and you asked them,

how these drugs are funded, they wouldn't be able to tell you. And I think it starts there, right? It starts even when you think about the malaria vaccines that are currently being rolled out across the African continent, oftentimes a lot of these vaccines and countries were getting the vaccines rolled out, they're being funded by Gavi. It's not the local government that is funding these vaccines, but the young mother who is bringing her child in to get vaccinated doesn't know who is funding.

the vaccination and that if that funding goes away, that she may be able to come in to the center in a month or in a year and there will be no vaccines for her to give her child. that is really, there has to be a grassroots movement that really educates people on how healthcare funding works within the African continent, the importance of funding research.

and how that impacts their day -to -day lives. Because if people don't see the direct impact of a problem on their day -to -day lives, it's very hard for them to see it as a problem to begin with. And that's really where I think this conversation should start.

Global Health Unfiltered (36:01.55)
Hi there, Desmond here. I hope you're enjoying the episode. We're gearing up for season four of the Global Health Unfiltered podcast, and we can't wait to bring you more insightful, unfiltered conversations like this one. To help us make this season even better, we're reaching out to potential sponsors. If you're a company or organization passionate about global health and want to support our mission of bringing unfiltered conversations to the world, we'd love to hear from you.

Drop us a line at podcast at global help on filter .com to explore partnership opportunities. And you are wonderful listeners. Did you know you can become a paid subscriber? Your support helps us to keep the show going and allows us to dive deeper into topics that matter most to you. You can do that by visiting global help on filter .com.

You'll have access to exclusive content and behind the scenes goodies. It's a win -win. Thank you for being part of the Global Health Unfiltered community. And now let's get back to our fascinating conversation with Bogumah Tichanji.

Global Health Unfiltered (37:20.622)
So speaking of vaccines, know we've heard a bit off script, but this is global heart and filter than that is to be expected. So speaking of vaccines, I think there's a big incentive, especially in the West, for the private sector to develop new drugs and vaccines. And that seems that in Africa we...

produce about 1 % of vaccines that we consume. Moderna had this contract with the Africa CDC to provide COVID -19 vaccines and they ended up pulling out because in their statements they said the demand was not there, there was no longer a demand. And then the Africa CDC came out and condemned Moderna for chasing profits over equity.

And so, know, Yao and I talked about this and we, you know, I'm in business school and a lot of my thinking came to mind. like, well, if I was an African business, to be honest, developing vaccines and the demand was not there and I see that the revenue would fall below a certain line, it would be a smart business decision to also pull out, right? So it seems like they're not,

business incentives for a lot of African pharmaceutical companies, even global companies to get invested in developing vaccines on the continent. So what are your thoughts around the role of the private sector in addressing these shortage of vaccines and making sure that there are vaccines produced in Africa for the African people? Yeah, I think that, you know, it's

That's a problem or question that has so many different facets to it. Remember, there is an absolute important need for Africa to be able to produce its own vaccines and not only vaccines, even medication. know, vaccines is the more glaring one because, you know, less than 1%, as you say, of the vaccines that are administered in the African continent are actually made in the African continent. But if you start going down to...

Global Health Unfiltered (39:44.856)
just basic drugs, think about antibiotics, think about antihypertensive medication, think about anti -malarial drugs, the percentage of countries that are manufacturing these drugs is also incredibly low. And there are many forces at play here, right? When you think about being able to establish manufacturing,

of vaccines, just focusing on the vaccine question within the African continent, you rightly highlighted the importance of ensuring that the demand will be there. If you establish a vaccine manufacturing hub in Africa right now, you will be competing against hubs that have been established, quite robust hubs that have been established and are able to produce those vaccines at very subsidized pricing from India, from South Korea, from Japan.

and from Europe and North America. A new company that is just starting out, I doubt will be able to compete in pricing point, even with a large vaccine manufacturer in India, because they're making these vaccines in their numbers and they have figured out a way to make them at relatively low cost for African countries. So remember that an African manufacturing

facility will still be in competition with companies in the global landscape. And when you're in competition with other manufacturing companies, business forces are at play in terms of a country has the right to purchase from the person that has the best pricing point for them. I struggle to see how

a new company that's manufacturing vaccines in Africa right now will be able to compete with the Serum Institute of India in terms of the pricing point. They make high quality vaccines. They make them dirt cheap. So coming back to how we figure out that problem, I think that it's a problem that has been established over so many years that it's not going to be resolved overnight. And I think that it would have to be a very focused

Global Health Unfiltered (42:07.022)
sort of approach, like if a company were to come in and start manufacturing vaccines within the African continent, you would have to think about starting with a very focused vaccine production, not going for 10 vaccines initially, and really building a niche where you could produce in quantity reliably and at competitive pricing that could establish you as a force. So that's one of the first things that I think about when we have conversations around this issue.

The second thing that I think about is there are issues around trust and where the vaccine is coming from, right? And I have had conversations with fellow Africans from across the spectrum, not only Cameroonians, Nigerians, Ghanaians, South Africans. Would you trust the vaccine that was made in your country? Shocker, the answer is no, right? Because again, time builds reputation.

And time kind of also builds sort of like that reliability factor. And unfortunately, the forces of neocolonialism still has us in the mindset of what's coming from outside is better than what is produced internally. So there's that internal work that needs to be done to shift the mindset of the average person who is the consumer to

educate them on the importance of supporting these local businesses when they do ultimately get established and trusting what is produced by these companies if and when we ultimately get them. And when you're dealing with vaccines and human health, you're even in a more precarious situation because these are biologic agents, there's misinformation and disinformation in that context. Oftentimes you're giving them to children. So the bar

for safety and reliability is even a lot higher, right? So these are kind of things that would need to be addressed even before we get to a point where we are thinking about, okay, how do we scale it up to a point where every country in Africa is buying its vaccines from a continental producer of vaccines? I just think that it's not going to happen overnight. It would have to start small.

Global Health Unfiltered (44:32.5)
And the work will need to happen not only at the level of ensuring business deregulation that supports a small budding company, but also at the level of the population in educating people on the importance of locally manufactured medical products and ensuring that those are of the same quality and can compete with what's out there in the open market.

You know, my frustration, I mean, I'm a proud African, I'm an immunologist, I believe in vaccinations. My frustration post -COVID is we're making emotional responses to what is a very scientific and it needs a very pragmatic solution. know, Africa Now, based on the reports of how many factories have sprung up or the plans for factories, Africa Now has excess vaccine production capacity, at least for fill and finish. If all the factories that are in blueprint and have started are completed.

Africa can make three billion, I think it's something like over two and a half or three billion vaccine doses, but it's all fill and finish. So it's all dependent on someone else producing the actual drug substance. But it's also just even fill and finish is not trivial. To do fill and finish well, you need certain highly sterile conditions. You need highly trained people. You don't just do that over a two year course. Doing this well takes time.

And the worst thing you can do is do it half -cocked, make a mistake, you give the vaccines, people get sick and then it's over, right? So we need a much more, my frustration is we have enough scientists and I think, know, Woguma, you've actually given one of the first times I've heard someone besides maybe me or other people I know, making such a sort of a dispassionate response saying that, hey, hold on a minute. Yes, we need vaccines.

but it's not just automatic. Everybody's jumping on the bandwagon that Africa needs to produce. As if Africa can just, we can overnight build factories. And we don't have good water, we don't have good power, all of the things that we struggle with, the infrastructural stuff that we struggle with. But all of that is not being solved. Instead, they're building a factory in the midst of all the other structural problems. And I feel we need to take a step back and be realistic. I think...

Global Health Unfiltered (46:47.626)
It's fine to be proudly African, but we have to be realistic and call out where we are. We don't even buy vaccines. So why are we manufacturing them? Like we just said, we don't, Gavi provides all the vaccines. COVID was a peculiar case where there was an outbreak, there was a new disease, new vaccines were made and the West hoarded them. Under normal circumstances, we don't have problems with access to vaccines typically because Gavi gives them to us, UNICEF gives them to us, Serum Institute can manufacture.

all the vaccines Africa needs. So COVID was a weird situation where you had this global pandemic and now people are hoarding. But for the past several, you know, probably decades, Africa has been receiving vaccines manufactured elsewhere, but we don't pay for them. So before you start building a local factory, I want my government to pay for vaccine. If I'm a business person and I'm building a factory in Accra, till the Ghana government puts dollars down or CDs down to buy vaccines from Serum Institute.

I don't see why I should build a factory because when I build my factory, who is going to buy your vaccine? Gaby is not going to buy it, right? Gaby is going to go to the place that can get the best deal, which will not be me for the reasons you described. So it's like, I mean, it's almost like we're, you know, we're in this weird Afrocentric bubble where yes, we need the vaccine. But I think that that's because we keep insisting on having these conversations in a vacuum and having emotional responses around them.

You know, I didn't have that emotional response to Moderna reversing its plans to start because again, if there's no demand, does it make sense to start cranking out a hundred million vaccines a year? No, it doesn't. You know, so it's again taking a step back and thinking about addressing those problems that lie in front of us that we can effectively address. You know, I...

found something out shocking a couple of years ago, like that in dialysis units, in some dialysis units in Cameroon, the sterile water that's used for the dialysis machines is important.

Global Health Unfiltered (49:02.912)
sterile water used in dialysis is imported. It's water. We've got water in Cameroon and we have processes to sterilize water. But if you're at the level where for dialysis, you need to import the sterile water, maybe you should focus on taking that one challenge that for the

X thousands of Cameroonians who need dialysis, the Cameroon government will set up a factory that would produce sterile water for dialysis and do that well. Before we ever get to the level of having conversations about building a factory to start cranking out vaccines. Just bringing it back to public health solutions. Should we go out? mean, should the approach?

Surveillance is important, but we know where -Pox is right now. Should the approach right now be to get vaccines in as many people as possible? I mean, should we be advocating for mass vaccine administration across central East Africa, maybe? mean, is that, because now what he's saying, we need vaccines, but I'm not seeing that campaign to say, look, we need to vaccinate a million, two, three, four million people.

to stop this in its tracks because we have a vaccine. It's what we did for COVID. We went out and vaccinated everybody. Why aren't we doing that? I think that the vaccine strategy question is a delicate one, particularly when it comes to MPOCs, because there are a couple of things that we don't yet fully understand about how this outbreak is spreading. And we know that it's not spreading in the same way in all the countries that are being affected. Taking, for example, the case of the DRC,

There are outbreaks of clade 1A, there are outbreaks of clade 1B that are spreading quite differently. There's zoonotic transmissions that are setting off some of the outbreaks. There are also human to human transmissions, primarily through heterosexual networks that are responsible for some of the other transmissions. And there's also the question of why are more children getting infected, et cetera. One of the key things that needs to happen even before you sort of

Global Health Unfiltered (51:24.174)
design what is the right vaccination approach for a country that's facing an outbreak is you have to have an understanding of how the virus is spreading. Who is getting infected? Who is getting exposed? Again, at the beginning of the podcast, I highlighted that only a quarter of the estimated 20 ,000 cases have actually had confirmation of through testing to demonstrate that these are cases of MPA.

So we don't yet with that gap in information, not understanding who is getting infected, who is exposed and having granular detail of the factors mediating the outbreak in different countries. You cannot design a one size fits all vaccination approach because that again will not work. It would spook the populations. would segue or kind of give room.

to misinformation agents to exploit that as a way of reducing confidence in vaccines. We know that the vaccines work. I'll take the example of what happened in North America when we experienced the EMPOC's outbreaks here. Vaccines played an important role in interrupting the transmission, but it was a very focused vaccination approach, which was led by identifying

which populations were at highest vulnerability to contacting MPOCs. In the case of the 2022 outbreaks, was primarily 95 % of cases were happening in social and sexual networks of men who have sex with men. And that was the group that was really prioritized for vaccination. But in combination with that, the factor that carried the bigger

weight in terms of having an impact in interrupting transmission was education and information. Once it was identified the way in which the virus was spreading in these particular communities, there was a huge public health information campaign and also giving people tools and education around how to adopt behavior modification in a way that impacted transmission.

Global Health Unfiltered (53:51.948)
So it cannot be a one -pronged approach. It would have to be a combination approach that will involve vaccination as one of the prongs, but alongside vaccination, informing, educating the public and giving them tools with which to protect themselves and trying to make sure that you have the available testing so that you can identify who is affected and who is impacted.

Now, coming back to kind of what I think would be a plausible vaccination approach that would make sense. Again, ring vaccination is something that can be very effective in these sorts of outbreaks, particularly when you're dealing with a pathogen that's causing very focal and localized outbreaks. So basically, immunizing people who are the closest contacts of identified cases. And again, it brings us back to that testing as the

pivot that should really be what we should be focusing on to help us design these immunization strategies. Thank you very much, Muguma. I think we're getting to the end of the episode, but we'd love to end on the high notes. What's got you excited about the infectious disease world promising development on the continent and beyond? Yeah, I think that there are

A couple of things that I'm very excited about. This year, in March, we finally saw the launch of the first phase three trial of a TB vaccine. TB is an infectious disease that still infects almost 11 million people globally every year. And about a million people die from TB infections every year. But these are primarily people in impoverished communities in Africa and in Asia.

This vaccine trial is essentially going to be one of the first new vaccine candidates to be brought to phase three. And it's a five -year trial, it's an ambitious trial, but I'm super excited about the fact that it's finally happening and that recruitment has started and fingers crossed that we get a positive result from this trial. The second thing I'm excited about is the phase two trial that is looking at

Global Health Unfiltered (56:19.15)
vaccine for Lassa. Lassa fever vaccine. Again, that trial is ongoing, being led by CEPI in West Africa. We know that over 100 ,000 people get Lassa every year. It's a neglected tropical disease. It is a public health emergency for those countries that are impacted by it because it's an infection that has a high mortality rate. And it's really nice to finally see a push towards getting

a vaccine that could protect communities in these affected countries. So very excited to see that moving forward. It's also a trial that started recruitment in summer of this year. So looking forward to seeing those results. And then the third and final thing will be the results that recently were released regarding the long acting antiretroviral drug, Glenacapivir.

and its effectiveness for pre -exposure prophylaxis against HIV. And that trial was conducted in African communities, primarily in African women, was one of the first times that an HIV intervention has first demonstrated its effectiveness in a trial that focuses on African women, because previously it was always MSM in Europe and North America, and then subsequently African women as an afterthought.

And we see this long acting injectable, which can be administered twice a year. And that was a hundred percent effective at preventing HIV infection. So really a potent tool that, you know, gives us the hope that we can effectively protect communities and interrupt HIV transmission in Africa, in African communities with the caveat that this would become broadly available to the people who stand.

to benefit. But I was very excited about this result. you know, it gives me hope that we are moving forward in certain things. That's a very important caveat to put at the end of this is to ensure that these new exciting developments, vaccines, get to the people who need them the most. Dr. Tizandi, thank you very much for joining us today. I really enjoyed it.

Global Health Unfiltered (58:43.894)
speaking with you and hope to get you back here soon. It was a great conversation. I said some things that probably will come back to haunt me, but hey. I walked into this with my eyes open.