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Gavin: Hello, welcome to another episode of the Lancet Voice. I'm Gavin Cleaver. 

Jessamy: And I'm Jessamyn Bagonal. As vaccine rollout in high income countries accelerates, much has been said about the relatively slow progress on mainland Europe compared to the US and UK. Professor Martin McKee is the former chair of the WHO's European Advisory Committee on Health Research.

Gavin spoke with him to get the full story of COVID 19 vaccination in Europe. 

Gavin: Martin, thank you so much for joining me today to talk about the European, COVID over the last 12 months, talk a little bit about the vaccination program. When we're thinking about the vaccination program, there's been so much written about it in the news over the last few months.

What are some of the unique challenges that this mass scale vaccination poses across Europe and the EU region? 

Martin: Yeah, quite a few. This is being done on an unprecedented scale. Everything is really unprecedented. The development of a portfolio of vaccines in such a short time is unprecedented. And then the challenge of trying to roll them out to the entire population is also unprecedented.

It's really difficult to know where to start with all of this, except that we probably should have started sometime previously to make sure that every country had a really good plan in place so that it could roll it out whenever the vaccines did become available. And that's, I think, where the challenge is, because Every country is dealing with the infrastructure that it has in place, which may or may not be well suited to this particular challenge.

And there lies the difficulty. We've seen, I think, a remarkable achievement in the United Kingdom. It has clearly been in the forefront along with Israel and some other countries like Chile who have done very well as well. And it's been able to do so I think because it's taken advantage of the National Health Service.

You've got a single national body, or in fact four national bodies in the constituent nations. And actually not to forget Gibraltar, which actually has done even better. But of course it is somewhat smaller. So you have a clear structure in place that can deliver something like this and it has done that very well, but not every country has.

And in particular countries, particularly those with social insurance systems are more fragmented. You have a contractual relationship, a stronger contractual relationship between the physician's chambers and other groups. You may not have the flexibility in terms of the ability to shift tasks. So for example, in a number of countries like in Germany there has always been a a restriction by which only physicians can give vaccines, and that clearly makes it more difficult when you're scaling up things.

So there are a whole series of problems there, but perhaps I could step back and say that I think the biggest challenge that all countries face is recognizing that the organization and delivery of a vaccination program involves putting in place a complex adaptive system, by which I mean a system that has a whole range of elements and components within it, population registers, organizations for developing and disseminating and implementing guidelines, mechanisms for following up if there are any problems, and in particular, some sort of a surveillance system so you can identify groups that are not being vaccinated and take appropriate measures, for example, by translating the material into other languages or addressing culturally specific concerns that lead into vaccine hesitancy.

All of these things need to be joined up and somebody needs to be in charge. And I think that is the problem, because as we go forward with this vaccination program, we need to make sure that we leave nobody behind. We need to get up to a level which will achieve population immunity, which, with the newer variants of the virus, with their R numbers in excess of 3, to achieve population immunity, you're going to get to levels of 85 90%.

coverage. And there lies the difficulty because at the minute we're not even scheduling the vaccination of children, which take about 20 percent of the population in most countries. So we're going to have to move to them and we're going to have to get a high level of coverage in everybody else. And in particular, the groups that are at risk of being left behind.

So we need a whole systems approach and we need to make sure that it is an inclusive whole systems approach. Do 

Gavin: Europe moving towards this? Obviously it's a case of working it out as you go along, and like you said, this is completely unprecedented. But do you think Europe is moving towards this more coherent vaccination approach across, across the countries?

Yes 

Martin: and no. On the one hand, the EU procurement exercise for the vaccinations, for the vaccines has been problematic. I think that's very evident. There is a strong argument for having joint procurement. Not for the large countries because Germany and France would be able to procure vaccines anyway. But if everybody was going their own way, then the smaller countries, Malta, Estonia, Latvia, Slovenia, would be left behind.

So as a matter of European solidarity, I can see the argument for doing it. That said, the whole procedure needs to be much slicker than it was. It needs to be much faster, much more agile. And the reality of it is, when you're dealing with 27 member states, that is Go bound to be problematic. However, we also have to recognize that AstraZeneca in particular have been rather problematic in terms of the timeliness of putting forward their documentation for approval at the European Medicines Agency, their ability to honor contracts that they signed.

So there are difficulties. everywhere. And unfortunately, that has meant that the process of European joint procurement has rather got a bad name and all of this, which is unfortunate. There are lessons to be learned. But I think the fundamentals of the system were essentially right. It was the execution was problematic.

Out of the pandemic, we are now seeing the discussions on the European Health Union. Member States have long guarded very jealously their competence in health and in fact the progress that has been made getting health into the Maastricht Treaty, cross border care directive, really came about as a side effect of other measures.

It became clear that you could not have an internal market without some provision for health. And after a series of judgments in the European Court of Justice. It was necessary to legislate. It was necessary to have an increased competence, but it was always very reluctant. The member states were unwilling to give up their their jurisdiction.

The importance of shared action coming together now is very clear. So we now have this very active debate on a European Health Union to work on cross border health threats. Still a lot of things to be decided, but it is at least on the agenda now and it's likely to move forward in, in some way.

But always we will have a situation where individual member states are responsible for the detail of the delivery of their health care because that's part of their broader social system and is linked to so many other things. 

Gavin: Now you mentioned the AstraZeneca which has become something of a kind of political football over the last few weeks and of course we're recording this interview just a week after the pause and then the reinstatement of the AstraZeneca vaccination programs across many countries in Europe.

What did you make of this pause? 

Martin: In a way I could understand, if not support, the decisions that were being made. The regulators were in an invidious situation. Once concerns had been raised, they had to decide whether the most appropriate approach was to pause and demonstrate they were taking them exceedingly seriously.

Or to say, actually, even in the worst case scenario, the risk is very little and the benefits clearly outweigh the risks, so we will continue. But given that these regulators are under sustained attack from social media and from some politicians and others, I can understand why they were very defensive.

But I think they made the wrong decision, because given what we, the evidence we had from the clinical trials, given, the evidence, all of the evidence that was available from a population health point of view, then there was a strong case for continuing to vaccinate while these, the cases were investigated.

However, from the perspective of the chief executive of a national regulator, It would look differently because they would always have the fear that if they got something wrong, that could seriously undermine confidence in the future, even if they were reasonably confident it was not a problem. Looked at from the UK, there is another issue, and tragically, this is a reminder when we look at the very nationalist media coverage that Too many journalists, despite four years of speaking of little else than the European Union and the Brexit discussions.

But many of our leading newspapers employ journalists who simply do not understand how the European Union works. And we're attributing the decisions of the national regulators in the member states to the European Union, even though the European Medicines Agency, the European institution, had consistently come out to say that the benefits outweigh any risks.

But that is a domestic problem that unfortunately we still have to confront in this country. 

Gavin: Of course, yes, the conversation around Europe in the UK is still sadly underdeveloped, shall we say, despite, as you said, four years of ceaseless conversation about it in the media. When we're looking at Europe, and you'd mentioned, of course, in the answer to your first question about herd immunity and herd immunity levels and the high level of uptake we're going to need, what sort of timescales do you think we're looking at to the point where Europe gets such a high percentage of its population vaccinated?

Of course, and that's completely discounting, the global situation. 

Martin: As I said, we do need to make sure that we have children vaccinated as well, and we're only now doing the clinical trials, so that's going to be sometime yet. I heard Thierry Breton, who is the European Commissioner for the Internal Market, say that he hoped that they would be able to achieve population immunity by July.

He is, of course, the French Commissioner, so he chose the 14th of July, which is as he said, a symbolic day, the Bastille Day, but I think that is really quite optimistic at this point particularly because some of the countries are still they're probably six to eight weeks behind the UK. They are making progress, but there is still some way to go.

And I'm not sure that we will, that any country, I'm not even sure that the UK will be in a position to get herd population immunity by that point. We are seeing some very encouraging signs coming out from Israel, but again I think it, it will be certainly even for Israel. In fact, maybe the summer might work for them, but I think for most of us, it's going to be late in 2021.

Gavin: Yeah. I would tend to agree. You were talking as well about the kind of. Patchwork of, when we're thinking about Western European, Central European, Eastern European countries, there's so many different considerations to take into account there. The kind of smaller countries, the later accession countries in the European Union, what kind of different challenges do they present compared with the countries that when the Western media discusses it tend to think of as the EU, like Germany and France?

Martin: First of all, we should recognize the star performer, Malta, which is doing very well and is up there. Denmark is also doing quite well, but I think we do need to recognize that the country, the so called A8 the Central and Eastern European countries that joined in 2004 and afterwards, do face a number of challenges, in particular, their health workforce.

They've had large scale medical and nursing migration. And also there's a particular problem in getting getting vaccines to isolated rural areas, for example, in Romania, in the Carpathians and elsewhere. The other groups that we need, the other things we need to recognize are that we have, for many years, had an issue of low uptake of vaccination among the Roma population, who number about 10 million in the region, and they have a well founded fear of the authorities in a number of countries.

They have suffered from powerful discrimination in countries like Hungary, Slovakia, in particular, in recent years. So it's going to be very important to work with Roma mediators and community leaders and so on. I think I've also got some concerns about some of the other minorities, including the more recent minorities.

the migrant migrants from the Middle East who've been coming to that region and who unfortunately have not been welcomed. And here I'm thinking in particular of the Hungarian 

Gavin: government. So we're talking, of course, and of course, much of the conversation in Europe has been based around looking at different European countries and their progress.

But where do you see Europe's role? in the kind of wider global vaccine distribution. 

Martin: First of all, European member states have already contributed to COVAX. Germany is the second largest contributor after the United States. UK comes third and then we have the European Union and individual member states have also made contributions.

So that's one thing, but one of the things that we would like to see, and in fact we have written a letter coming out in the Lancet, would be that the that Europe could actually use the fact that it has contributed substantially to the research and development that was required, particularly to bring the Pfizer BioNTech vaccine to market, and should be saying that perhaps as a quid pro quo for that.

then the vaccines should be licensed for production in other parts of the world freely. Now that, of course, is easier said than done, and you also need to make sure you have the expertise and the capacity to actually manufacture them, but I think that would be a good start to do something like that.

Gavin: You mentioned as well, we were talking about disparities there in the Roma populations. The UK's been seeing some striking disparities in vaccine uptake in socially and economically disadvantaged populations. What's the data like that for the rest of Europe? Do we have 

Martin: similar data?

Sadly not. One of the problems that we face in much of Europe is a lack of data on ethnicity in particular. Now there are historical reasons for this, because in Germany in particular there was a clearly an abuse of data on religion in the 1930s and that legacy has continued in terms of memories of how the data were abused in France, for example, there is again a great reluctance to collect data on ethnicity because everyone is considered on city on the France citizen of France, and therefore they are equal under the law.

That is, of course, not the reality as we see from the disadvantaged communities in the Banyo, around some of the larger cities. But it is a problem that many of us have been saying we really need to get a concerted effort to make sure that the challenges of inequality can no longer remain invisible. We cannot simply assume that everybody is treated equally, and in fact in those in studies that have been done, and there have been some excellent studies done by Oliver Ratzum in Bielefeld and others in Germany, for example, looking at the families the now often third or fourth generation students.

from the Turkish Gasdarbeytin to show that there are significant challenges being faced by many minorities. But we still have a long way to go. Do you know of any approaches that are being taken along those lines in Europe? There's a lot of reluctance politically to even go near it or even to discuss it.

And each time I and others raise it we don't get very far. There are people who are working very hard in many of the countries to get this on the agenda, but it is difficult. The countries where we, I've mentioned Norway already. some data from the other Nordic countries, from the Netherlands, some excellent work has been done on minorities in in the Netherlands, kind of Strontz and others, but it is still far too little.

So just finally 

Gavin: then, what have been some of your kind of abiding thoughts about European politics over the last 12 months? What are your hopes 

Martin: for the near future? Oh, it's so difficult, isn't it? This has been a test for Europe and I think we have to be honest, it could have done better. Now, this is not an argument against Europe.

We desperately need Europe to succeed because it's for everybody's benefit. We've seen what has happened when a member, when a country leaves the European Union and let's face it, we now have a massive problem in the United Kingdom. I was just looking at headlines a few minutes ago. Our exports of food have, and drink, have virtually collapsed and we can say some of that's due to COVID.

Maybe some of it is, we know exactly what, we really know what the big problems are. So we do need Europe to succeed. And that does mean that member states have got to recognise that in health, as in the other areas where Europe has been so much of a success, they have to pool their sovereignty for the greater good.

I think there will be a lot of discussion over the next year or so to make a reality of a European Health Union. Going forward, I think we will see greater collaboration in health, but we also need to recognize that everybody, and particularly the European institutions, need to be much more ambitious.

They need to be more agile. And that means that member states need to allow them to act in a way that they don't have to be constantly checking and constantly be on the defensive, and if they do that, then I think hopefully we will be in a better place. 

Gavin: It's interesting, isn't it, how this crisis has refocused governments towards this kind of fundamental tenet of public health rather than, something that was tertiary, but actually now it would seem across so many governments that really it's refocused their efforts and the ways that they think about population health at the forefront.

Martin: It hasn't it? I think the old argument that it was that money spent on health was wasted in somewhere or money down the drain. I think that's gone because we've seen the cost of not investing in health and in particular not investing in a healthy population. We've seen the situation in the United Kingdom where one of the reasons why we have done so badly and we have done very badly in terms of cases and deaths has been our failure to invest in our people, having large numbers of people living precarious existences dependent on food banks and living from day to day, high levels of background ill health, which has made life much worse.

I've made the situation much worse. And so I think hopefully that lesson will be learned. very much. I'm a member, a commissioner on a pan European commission on health and sustainable development chaired by Mario Monti, the former Italian prime minister. I'm one of the very few medics on that. Most of the, and I chair the scientific advisory board as well on it, most of the members are former politicians.

We've got two prime ministers, a couple of former presidents, central bank governors, people like that. And where I, what I've been struck by is that these people who are coming from. the larger world of politics and from the, from finance, absolutely get the need to invest in health. So they're talking about how we can get the international financial institutions to prioritise investment in health in the same way that they, since the financial crisis, have been prioritising an investment in environmental, social and governance indicators.

They have been talking about the need to look at how we support health in a very much more positive way going forward. So I think we're very much pushing at an open door and I think we in the health community need to recognize that, but that means that we need to engage. We need to be in the room where it happens and unfortunately that is often not the case.

Well, Professor Martin McKee, thank 

Gavin: you so much for taking the time to speak with me. We really appreciate it. Thank you 

Martin: very much indeed, Gavin.

Gavin: So Jasmina, our editorial actually in the Lancet this week is on Central and Eastern Europe, and it really strikes me there's so many different stories to tell about mainland Europe. Such a kind of interesting patchwork of different stories and experiences of Covid 

Jessamy: 19. Yeah, it's so interesting because I suppose you've got this group of countries, countries both within the EU and outside of the EU, who share very close borders, very close economic ties, a complex history.

This sort of very, just different geopolitical background. But there is a sort of sense of some, neighborhood, obviously within the EU, but outside of the EU. And then that sort of relates to how the health of these individual countries. is potentially impacting the health security of the overall region and what that means in the future.

Gavin: Yeah, there's this kind of concept of solidarity and health that Martin and I talked about and of course that the editorial talks about too. It's a really interesting one, isn't it? Because of course it's not what centrally this idea of kind of solidarity in Europe was founded on, but it's really something that's come to the fore.

Jessamy: Yes, because it's so difficult at the moment. We're in this awful crisis. People are losing their lives. Infection rates are very high and often it's hard to look beyond that. But I do think it's important to look beyond that because actually health shouldn't be politicized. It should be a tool to for health diplomacy to strengthen the ties between these countries.

And so I suppose You know, you can sometimes feel that disconnect between we're in this immediate crisis, which is very difficult, people losing their lives. Is it really appropriate for us to even be thinking about the long term implications for how countries are going to deal with each other? And I think that it is, because otherwise we can allow health and the crises that's going on at the moment to be very divisive.

And it shouldn't be divisive. It should be unifying.

Gavin: If you're listening to this on the day it goes live. Then it's March 24th, 2021, and that makes it World Tuberculosis Day. TB is sadly still a major killer, and about 1. 4 million deaths per year, despite being treatable. The effects of the COVID 19 pandemic threaten worldwide progress made on eradicating TB.

Jessamy spoke with the director of the WHO's global TB program, Dr. Tereza Karieva, to find out more. 

Jessamy: So I think we'll start off, if you don't mind, by asking you to tell us a little bit about your background and your expertise and, what your role is within the WHO. 

Tereza: I started my career as a practitioner, worked in the province in the Russian Federation for several years, then continued my education and I completed my PhD on TB.

Worked for the last 10 years for the Ministry of Health of Russian Federation. And I was coordinating national TB, HIV, oncological, and cardiovascular disease programs. They were so called social dependent diseases, and they've been managed by me and my team. And for Almost four years already I'm working for WHO as Director of the Global Tuberculosis Program.

Jessamy: Wow, what an incredible career and breadth of experience you have. I know that so much has happened with TB and it's such a sort of global problem, but Perhaps you might be able to just summarize some of the major progress that we've made over the last 10 years with TB. 

Tereza: First first of all, I would like to acknowledge all the enormous joint efforts of the member states, different stakeholders WHO partners, and civil society really to drive TB agenda towards ending.

And we've managed to achieve quite a lot jointly, and I will just give you a few numbers over 63 million lives have been saved since the year 2000. Due to the TB prevention diagnosis and care. There has been an 18 percent global decline in TB incidence rate. The number of TB deaths was reduced by 29 percent and this happened these last two numbers since the year of 2010.

However, despite this TB. Remains one of the top infectious disease killers in the world. And now with the COVID, the situation is becoming even worse. And in the same time, we all remember that TB is a preventable and curable disease. Since the adoption of the NTB strategy we could see further progress.

For the progress and especially it was faster and accelerated after first ever high level meeting in TBI at the UN General Assembly in two thousand eighteen. We have our milestones for twenty twenty. But unfortunately, even before the pandemic, these milestones globally were not reached. I will remind you, these milestones are 20 percent of the reduction in TB incidence compared with 2015, and 35 percent of the reduction in TB mortality.

And, We've managed altogether to only reduce by 9 percent of the incidents and by 14 percent number of TB death. And still about 50 percent of people affected with TB and their families are facing catastrophic costs. We have also since high level meeting on TB, other ambitious targets aligned with the NTB strategy and plus and they are 40 million target it means that.

40 million should be treated for five years till 2022. Globally, 30 million, this is new target, should be provided by preventive treatment the second very ambitious target. And of course, the very important significant increase in financing for TB programs and research. Related to TB, and this target is 13 billion annually by 2022.

And if to summarize, we are moving forward. The progress was made 14. 1 million treated for the last two years, 6. 3 million provided by preventive treatment, and some additional funds raised globally, but still F the gap is huge. We have only 6.5 billion as a global financing for TB programs.

This including not only domestic, but also international funding. This all happened before covid and of course now we are pushed back. And this is of our great concern that's why it's extremely important that, and we're urging countries to undertake measures and to safeguard essential TB services, prioritize at least in the highest TB burden countries, and to come back on track as soon as possible.

Jessamy: Thanks, Teresa. That's a very comprehensive overview. Perhaps you might just be able to talk briefly about What the sort of real concerns are for the impact COVID 19 is going to have on TB now and how we might be able to prevent some of those impacts or the work that's going on to try and prevent them?

Tereza: Since early 2020 when the novel coronavirus outbreak was declared a public health emergency of international concern, WHO global TB program has been undertaking a lot of additional measures like realtime monitoring of the COVID-19 pandemic including ONB notifications and service delivery.

We also provided guidance and technical support to the countries supported with procurement of drugs and diagnostics, modeling and analysis of the impact of COVID-19 was undertaken. To drive further actions. So what we can see from the data we are collecting over a year monthly data, as I told from now from 84 countries.

These countries account for 85 percent of estimated global TB incidence. In 2020, These countries reported 4.9 million cases compared with 6.3 million reported in 2019. The relative shortfall in TB case notifications was 21% in the group of the 10 highest burden countries with the largest shortfalls.

The overall shortfall was. Even more severe at 28 percent delays, as in case detection translate into increased number of cases, increased transmission and greater mortality and estimated half a million excess to be death could result setting the world back. a decade to the level of TB mortality in 2010.

And we see that the situation with the ongoing pandemic, but still, as I told to me, remains one of the top infectious disease killers worldwide. On a positive note, in line with WHO guidance countries have, taken measures to mitigate the impact of COVID 19 on essential TB services.

Including by strengthening infection control. A total 108 countries included 21 countries with a high TB burden have expanded use of digital technologies to provide remote advice, care and support to reduce the need for visits to health facilities. Many countries are encouraging home-based treatment.

All oral treatments for people with drug resistant TB provision of TB preventive treatment of course, ensuring people with adequate supplies of drugs. Impact is there and that we can predict, unfortunately, if services will not be urgently maintained further further negative impact and that's why it's extremely important today.

Again, to undertake measures and prioritize essential TB services, at least in the highest burden countries. 

Jessamy: That's great. Thank you so much, Teresa. I think that covers everything that we wanted to talk about. It's seems a dangerous place to be. Is there anything else that you'd like to highlight? Yes.

Tereza: Thank you very much. I can't miss this opportunity. And of course we can see that that this devastating impact off COVID pandemic not only on TB, but also in general on many health services on health systems and also socioeconomic impact. And frequently people are asking why TB should be prioritized, why it's so important.

It's not only because TB is one of the oldest and sometimes neglected infectious disease cures, but in the same time, It's completely preventable and curable disease. The whole reason of the neglection is unfortunately this lack of access, disparities, inequalities, and TB affects the poorest.

the most vulnerable. And we can't use new threats, coming threats as an excuses for not take actions to combat the TB. We've set very ambitious targets. We all agreed and 2030 is close despite of all the challenges is still possible. And we would like to be heard by the member states during in the midst.

of a new threat. And another reason is we can see that TB services are not only disrupted, they are contributing a lot into the COVID response. And it clearly shows that Previous investments in TB program programs were real and very impactful investments. And you see now how lab systems are used for the diagnosis, not only of TB, but also COVID.

We can see how capacity of our community health focus and health workers knowing very well about infectious control measures, about contact tracing. I used to provide support in many countries to the health system to respond to the new threat. That's why I think that we should continue investments in so called all diseases.

Programs, TB programs are already integrated. They're contributing into the strengthening health systems. And we unfortunately see that life cycle of mycobacteria is longer and it will remain with us as it's already with us for the centuries. It depends on us how we will respond. And in the same time, we can build back stronger and with the support of the TB programs.

Prepare be better prepared and prepare adequate response to the new and old threats. 

Jessamy: Thanks so much, Teresa. That's a lovely note to finish on.

It's a disease that's important to highlight because We go through this every year, there are these reports about how we're not really making progress. You can feel a little bit, they can feel that we there's frustration and exhaustion almost. And sort 

Gavin: of a deja vu, there's a lot of kind of things in public health where we see the same reports every year.

It's this is bad, this is still really bad, this is still bad. 

Jessamy: And obviously this last year is different because COVID 19 is going to impact so many different diseases. so substantially and in a really scary way as Teresa laid out for us, I think, quite comprehensively. But I think that the reason that we wanted to talk about it is that TB is so global it affects so many different sort of types of people.

Obviously there is the poverty element, but in terms of the actual progress that we've made in treatments and, vaccinations, It's not necessarily that great, especially when you compare it to the progress that we've made against COVID 19 in the last year. I think the reason that we wanted to talk about it was to really just keep shining that light on it, because actually the only way that.

Progress is going to be made is if attention is paid to it and it's sometimes difficult I think to get that sort of renewed energy and Feeling that there is movement back into a field like TV. 

Gavin: Yes interesting to hear wasn't it Teresa say that roughly about six billion pounds was being spent on TB worldwide every year and I think previously, maybe before COVID 19, we would have considered that to be a relatively large sum for an infectious disease, but now it really sounds like an extraordinarily small sum.

You hear that, you hear six billion pounds and you think how's anyone going to eradicate a major disease with that? 

Jessamy: Yeah, and also, even when you think about, the total WHO money funds that they get is three or four billion UN. similar. These are, I think our whole concept of what sort of the finances that we need to be able to really bring change has completely changed in COVID 19.

Thanks for listening to this episode of the Lancet Voice. You can subscribe to us wherever you usually get your podcasts and we'll see you again next time.