 Hi everyone. We're just going to wait a couple of minutes to let people join and then we're going to get started. Okay, so I think we can start now and people can still trickle in. Welcome everyone to the Health Law Institute seminar series. We have an amazing lineup for this year that our speakers are convening around the theme of health equity and beyond recovery. My name is Adelina Iftene. I am the associate director of the Health Law Institute here at the House. And it is my great pleasure to introduce our first speaker today and to moderate discussion. Before I do that, there are just a couple of housekeeping rules that I would like to share with you. First of all, this seminar is recorded. There won't be the attendees are not going to appear on the video. It's just going to be our guest and myself, but you are going to be able to rewatch this on the Schulich School of Laws YouTube channel. Now, the other thing is that we do have a closed captioning. So if you are not seeing that automatically on your screen, you have a button at the bottom of your screen. That you can change to turn closed captioning on. The other thing is that we are using the Q&A box for the discussion today. So feel free to add your questions in the Q&A box at any time during our guest presentation. And we are going to, I'm going to come at the end and then put the questions to our guest. So without further ado, I'm going to introduce our guest today, Dr. FIFA Rahman, who has over 12 years experience working in global health. She is a presently a permanent NGO representative on the access to COVID-19 tools accelerator. Representing global NGOs in meeting with heads of global health agencies in the global COVID-19 response, and in various working groups on COVID-19 country support. She was also formerly a board member for NGOs at Unitate, working on equitable access to HIV, TB, malaria and cervical cancer tools. She has been on numerous missions to HIV facilities globally, including to early infant diagnosis programs in Mozambique, HIV self testing programs in rural areas of Zimbabwe, dissuasion commission programs in Lisbon, and needle and syringe programs in Scott County, Indiana, at the height of the HIV pandemic epidemic. As founder and principal consultant of the global health consultancy Matahari Global Solutions, she is currently working on strategy development for TB organizations on mapping access to COVID-19 tools in low and middle income countries and in mapping opportunities in the right to health for Amnesty International. We are very lucky to have Dr. Rahman here today with us, and she's going to talk about the lessons in inequity that COVID-19 has globally created. Thanks very much for that introduction, Edelina, and I'm looking forward to engaging with you all. I'm just going to share my screen and then we can just get right into it. So, first of all, I'm going to sort of introduce you to the ACT accelerator and let you know a little bit about what my role is and what I do. So this is the structure of the ACT accelerator. And the ACT accelerator obviously stands for the access to COVID tools accelerator, which, you know, hosts also the COVAX underneath it. You probably know COVAX a lot better than the other pillars just because it's been such a focus. The COVAX is was designed to deliver vaccines to countries in particular 20% of their population should be vaccinated. And that was the initial target set. But there are other parts of the ACT accelerator that you should know about. There's a diagnostics pillar which I sit on the therapeutics pillar and the health systems connector. And there are several other bodies within the ACT accelerator, which are important discussion forums. The Facilitation Council is one and I also sit there. The Facilitation Council is hosted at the WHO. It is chaired by South Africa and Norway and that's usually their Ministers of Health, and it's where the Member States sit. And this happens every few months. And the Member States usually represented by the Minister and if not officials close to the Minister of the countries in question present on their priorities, their concerns and what they need. And then there's the Principles Group, which happens every Thursday. I also sit there. The Principles Group is where the heads of the agencies are. So that is where Peter Sands from the Global Fund sits. That's where Dr. Tedros sits. That's where whoever who's the head of an agency associated with the ACT accelerator sits there. And of course there are organizations outside the global health like the IMF, the World Bank, and other folks that sit there. So what's my role in the three places that I sit? The Facilitation Council, the Diagnostics Pillar, and the Principles Group. My role is to basically consult with civil society on all the technologies. So I deal with diagnostic therapeutics, vaccines, and health systems. And basically hold people accountable. So, you know, for example, yesterday the US government was presenting on Biden's proposed vaccine summit coming up. And they said something about this new Biden initiative as needing to bolster collective accountability. What I did was I basically said, yeah, bolstering collective accountability is important, but one of the things that civil society will be needing and thinking about as we come to the summit that is occurring in the next two weeks, is about USG accountability. And that would be as regards deployment of vaccines to the global south. So, so there are things that I call out and at the Facilitation Council, a member state might say something that I would call out or I would compliment, and an example of this is when the government of India said we are completely self sufficient on diagnostics. And that was important for me to call out because we know for a fact that people in India don't have enough access to diagnostics, unlike us in the global north where we have these covert self tests at home. Like in Canada, but at least in the UK we can order them free over the NHS and it comes to your house. But of course they don't have this in India so it's important to call out. And those are just two examples of my role in keeping any countries and agencies accountable. And let's go into the detail, right. So the next slide is talking about how inequity is perpetuated. And this is an important slide to set the tone for this whole presentation. I think as you remember there, there are four pillars of the Act Accelerator. And, unfortunately, in the working group meetings so under, under each pillar under diagnostics there are working groups, and therapeutics working groups vaccines working groups health systems working groups. And that's where we work on the nitty gritty stuff right we work on. So what particular diagnostics are being deployed, we work on strategy on these diagnostics we work on. And of course there are there are manufacturing working groups in in the vaccines anyways let's spare the detail. But the important point is there's almost no low and middle income country involvement in those working groups. And this is this perpetuate inequity. It's because you have the distortion of priorities and I'll give you a couple of examples on why this needs to be improved. And the first example is probably on the DRC and South Sudan vaccine return to covax. I don't know how many of you know about what happened was vaccines were deployed to Democratic Republic of Congo and South Sudan. And, unfortunately, they were unable to deploy this despite vaccine readiness tools completed in France. Those vaccines were sent back to the covax, which of course takes time, effort money to return. My intention is this and my, my, my theory and my belief is this is that if we had African experts frequently consulted as frequently consulted as we consult experts in the global north. In these discussions. This wouldn't have happened, right because you have that expertise you could you have that contact in DRC we go. We give you five days notice to send you these vaccines will you be ready to deploy will your community health workers be ready to deploy, will your provincial leadership be aware that the vaccines are coming. You know, do you have the information systems to register people, you know, all that kind of stuff can be asked to the person if they were included in the working groups, right. We have issues with insufficient lead time to arrival of vaccines in country. And this was illustrated by a presentation we had from WHO Somalia is brilliant doctor and he, he said that that there were five days notice between the deployment and the arrival in country. Now, if you know anything about health systems worldwide is that they vary. And one thing that the COVID pandemic has taught us is that even the most developed countries in the world, like the United States and the United Kingdom might mess up on health systems they might mess up on the response and resulting in lots of deaths. Five days is not enough time for any country. You know, especially a country like Somalia, but despite this, they successfully deployed and consumed 90% of their vaccines and I actually have a slide on this, but I'm telling you now. I'll show you the slide in a second so we can talk about that in more detail. Another thing is about this new requirement that Gavi or the vaccine Alliance is using was using that's a July 15 slide in their next deployment of vaccines after July, which is assessing country absorptive capacity. So if your country is assessed to have less absorptive capacity, you would get less vaccines. And I remember the conversations on on the call where this slide was presented. And there was a lot of concern from major global health agencies and major global health thinkers that this would be inequitable, because just because your absorptive capacity is less does not mean you deserve less vaccines. If your absorptive capacity is less, there should be efforts integrated immediately to improve that absorptive capacity to reach a certain level. And what was promised in the covax was that 20% of populations would be vaccinated. So there's obviously real concerns about that. And of course the inequity today exists for diagnostics as well and I'm sure therapeutics even though I engage less on therapeutics just because we're still waiting for the therapeutics to come in and come in at affordable prices. So obviously I just showed you my, my antigen self rapid tests which I have in my home and at my work table and I can do them. You know, every time I decide I want to go out to a bar or restaurant. And the situation in the global south is very different, right, we don't, you know, there's a real inequity in testing because I can do it twice a week if I want. And, you know, some people are not being tested at all. So there's clear problems with with how that works. There's an article there that I've put right at the bottom that sort of illustrates the lack of LMIC involvement. So Pascal Andoa is a diagnostics expert, she's from the African society of lab medicine. She said in this Lancet article and the DOI is there I'm not sure if slides will be shared but look up the article it's by a by a journalist called and Anaya Asha in the Lancet. And she said the current format of consultations could be improved to provide the right enabling environment for LMICs to bring their priorities forward and shape the agenda. So it's important that pandemic responses going forward, because this won't be our last pandemic invest in the equal intellectual partnership of LMICs. And this is really, really important, and I'll speak about this further. So this is a slide from last week on the Kovac supply forecast. And I circled there that we're expecting a further 1.1 billion doses to become available for delivery between September and the end of 2021. So I did a rough calculation, September to the end of 2021. That is 120 days approximately, and 1.1 billion doses divided by 120 days. That's about at least 9.5 million doses a day that need to be deployed, which is monumental. The question is, how exactly is the Kovacs going to deploy this. You know there are real logistical concerns with the idea that we're going to be able to deploy these 1.1 billion doses by the end of the year. So that's some of the critical questions that we're asking. And, and, you know, in my meeting yesterday and yesterday was Thursday so it was the principles group. And, you know, the, you know, it's it's clear that these things are probably going to stretch into 2022. Another interesting thing that is coming out of the supply forecast is that Gavi is is changing its tone a little bit. And we've of course been demanding sort of transparency increased transparency on delivery schedules, because it hasn't been clear to us when we can say, you know, pick any country, when is Haiti going to get their next transfer vaccines, when is Somalia going to get the next charge, when is Mozambique going to get the next charge. That's not clear to us at all. And it's not clear to Gavi, because what's been happening in the recent meetings with Gavi is that they said that they are demanding increased transparency from industry because industry is not being transparent about when the vaccines are coming. So, overall, there's a lot of opacity in in in how people are doing things and this is this doesn't bode well for timely a timely pandemic response. And this does not bode well for in for equity. And we're working every day to try and change this and try and be a voice of accountability. So I wanted to address hesitancy because some people have tried to make it an issue. For LMICs. And by some people, I want to call out the Pfizer CEO, right, who said that even if we made the vaccines available and I'm paraphrasing. There'd be too much hesitancy and they would be no consumption. So, this is so problematic on so many levels. And of course there's plenty of hesitancy in the United States and in France. But there's something underneath that is underlying people's comments about Africa and about the developing world on hesitancy. And this article by Tian Johnson is really worth reading, because there is no doubt that there is racism ingrained in what people are saying. There is racism ingrained in systems, right, and to the act accelerators credit. So this is really the diagnostics pillar, I think, and the foundation for innovative diagnostics which has been more engaging with CSOs, and we've been able to shape their agenda more there. I actually introduced country roundtables where countries are speaking, and they can exchange their views, and more can be learned from them there. There's also more being done on the principles group by the chair of the principles group which is Carl Bilt, he's a former finance minister of Sweden. And, you know, there's been invitations to LMIC experts and things like that to try and improve engagement. But it's curious that these things were only done so one year into the pandemic and happened only this year and that has been running for one and a half years now. So, so there are real concerns, right. So, so we've been talking about hesitancy a little bit and, you know, the fact is, it's not so much an issue of hesitancy, but more of an issue that supplies and there. There is inequity in supply, and you, I'm sure you've heard the term that people are throwing around around its vaccine apartheid, right. There's a real problem with the global health architecture as is on COVID, and not taking advantage of community health workers and their role. Now, of course we could unpack this a lot more but community health workers are largely unsalaried. The only global health agency that I know of, and people can correct me if they know of any others but is probably the only global health agency that salaries community health workers. And, you know, every other agency provides them sort of a travel per DM for the work that they do. And community health workers are very important. They were very important in the Ebola response when they tackled hesitancy there, right. And I feel like the ACT accelerator hasn't adequately invested in community health workers. Now, why hasn't this been so what's also needed is sort of a shift in funding, right, because everyone, vaccines is a sexy thing right is the sexy thing donors are putting all their money into the investment of deployment of vaccines. And unfortunately the health systems connector on the ACT accelerator hasn't sat for weeks. Months now I think. And community health workers come under them. And it's incredibly important that community health workers are funded and of course health systems isn't just about community health workers. It's about my apologies I have a parcel. I'll keep talking. So, and it hasn't sat for weeks and help the health systems connector is really about. It's about electricity. It's about wash. It's about wash meaning water and sanitation, and all of that. It isn't just community health workers and all of these things need to be tackled. You've got situations like in Iraq, where the they had a major fire in the hospitals and including in the COVID wards and a lot of people died. And that was caused by an explosive exploding oxygen implement that's a health systems issue. Right. So, these are issues that are incredibly important and the fact that the health systems connector isn't funded is a problem. And of course, why isn't it funded. And there are governments in the EU who have given as much as 50 million euros to the health systems connector, but we don't know whether money necessarily is has it been rerouted to vaccines. There's a little bit of lack of transparency that we would like to see further in terms of budgets and things like that, to make sure that all the pillars are adequately funded, and technologies can be deployed. Another question that's important. And, you know, obviously, I remember the days when I was doing a master of health law and I was, I was thinking very much about these difficult questions and one of the difficult questions that should be thought about. And this issue of who decided that the covax would only vaccinate 20% of populations of these countries 20, 20% how, you know, was it a practical decision in terms of what they thinking. Okay, and rich countries are going to monopolize the market for vaccines so we can only reach 20% of LMC's populations. Well, you know, what was the bar for that. And I guess I get, I get that you don't want to go. Okay, will vaccinate 100% of populations. Like, you know, just announce it like that I'm sure there's some rationale behind it, but 20% isn't enough. And 20% is going to create whole populations in the global south that are at risk for creating new variants, which are of danger to the north right so how does this make sense. These are important questions that need to be asked. This is a slide that I already spoke about in advance, but that I wanted to show you this is the slide on the deployment in Somalia. And 90% of the doses were administered, despite having only five days notice. But you would think, you know, if they had more days how much more could be deployed. And Somalia is of course a country with a large mobile population. So, you know, there are concerns also around, you know, what if people don't have a home, what if people are moving to different areas you know how, how are you going to make sure that you administer two doses. One of the things that was quite clear from this presentation by WHO Somalia was that the role of the community health workers in reaching out for the communities and bring elderly people to the vaccination center, bringing mobile populations, migrant populations to the vaccination center. And the role of the community health workers is incredibly important. And this is where health systems overlaps with vaccines. The next slide is going to show something quite stark as well. So, the number of people who received the vaccine in a particular age group of 550 years and above, only 23%. Yeah, I'm, it's only 23%. The female were only 18% out of that group, right. So, you know, there's a clear disparity in terms of gender. So, why are females being less vaccinated and this is, this is why it's sort of so important to take an intersectional approach when we're analyzing any global health issue really, especially in vaccine deployment. Women often don't, they have limited decision making power on their health. They might not own the transport that is necessary to get there. They also are primary caretakers of families and may not have the place to put their children for while they get the vaccine. So many things that affect access to vaccines and gender is quite clearly one of them. So, this is, this is switching to diagnostics. And I wanted to show you this because the inequity isn't isn't just related to vaccines and I know people are probably raging at this point about about vaccines. If you rage even further. There've been a number of bottlenecks right in, in deployment of rapid tests in particular, and rapid tests are important, especially when you have vaccine inequity because it helps people control their own risk, right. And it helps economies stay open. So if you are you're a truck driver and delivering supplies over borders. It would be important for you to have a test done. It's important for care home workers as you probably heard like in the UK. And care homes had so many COVID tests. And my husband works in a care home and he gets him. He had we have so many rapid tests just in our home. It's, it's, it's probably a lesson in inequity in in itself. He gets tested once a week with PCR and, you know, he can test many times a week with rapid tests. So it basically keeps the economies open. And it helps people manage risk while, while they still is vaccine inequity. So, what happened in the act accelerator is there was a diagnostics capacity reservation, which sounds fancy, but all it means is that the accelerator reserved manufacturing capacity volumes of the rapid test for two companies for supply under that accelerator so they booked the manufacturing space basically. As time progressed, it became quite clear that countries weren't taking up the diagnostics as quickly as they should, right. There was quite low demand for the rapid tests and everybody was like why. So, what happened was they commissioned a study to look at bottlenecks. You know, what are the key bottlenecks what, what, what are the issues why why a country is not asking the act accelerator for rapid tests. So there were a number of reasons that countries gave which are listed there on your screen. One of the things that I kept hearing because my job is outreach to people in country and ask what's going on. And one of the things we kept hearing is that WHO guidelines are too restrictive. It doesn't allow us to use the tests for what we want to use them. This is interesting because this was WHO being about bottleneck right. So, what we did was, we had a look at the guidelines and I'll tell you that about that in a minute. But what was clear was that we needed decentralize decentralization of testing and these are some of the things that countries said, right. So, a Kenyan guide interim guide for antigen rapid diagnostic tests that only qualified registered and licensed medical laboratory officers can carry out the tests. So, community health workers would be able to, to, to use these tests right I mean these are really easy to use the image folder the instructions you can do it yourself. You can report it, at least in the UK to the NHS whether it's negative or positive through your, through your phone. And of course there are questions about the digital divide and what about people living in poverty and not being able to report it, but anyone can do these tests and not very hard to do. The fact that some countries had quite conservative interpretations of who could and still can be in a lot of countries still have conservative approaches to antigen rapid tests is a real impediment for making sure there is empowerment on testing in the So there's COVID-19 testing in South Africa and that should be conducted in authorized labs only samples to be collected by trained health care workers now this languages is a little bit better, just because there's some room for interpretation right. If you're trained to deploy it and if you're a community health worker you could potentially do it right. But it has to be conducted on site rather than at home, which is, you know, you know what we want is for tests to be able to be done in communities, especially for marginalized communities people use drugs internally displaced people, all, all these kind of people. So they need it's better for these tests to come to them in their communities, and a key challenge there is that the community health workers aren't empowered to do this. So, that's obviously a real problem. This is the letter that I signed and wrote to the WHO about my concerns with the testing guidelines that they were too restricted to certain use cases and use cases is just the word to say, you know, where they're being used right. And we were concerned about the inequity resulting from this. And this of course went to Dr. Tedros Maria van Kerkhove and Dr. Sumia was the chief scientist of the World Health Organization. And of course this letter went to them after a principles group call where I was, I was raging about it really I was just like this is really problematic, WHO guidelines are a bottleneck. And we've, we were of course really quite concerned. And one of the things that was said to us was like if you interpret the guidelines, you can, you can use these tests in communities. And my problem with that is that if you need creative interpretation to do something in your country, the guidelines are not good enough. Right. So that was the concern. And this was quite a long letter you can read it if you like, or use it for your essays and dissertations or lectures. So you can see the date on that is 9th June, but this resulted in a lot of discussion on 16th June, and I'm my cat out on 16th June, the WHO issued these infographics. So, the infographics are important because we've been making so much noise on communities, living. We wanted the test to get communities. These infographics and we also in the letter we demanded. We wanted to see visual tools. Right. Sorry. This is, this is I expected this and I told that Lena that this might happen. And so, as you can see, it says there that they are looking at communities where there's ongoing transmission. So, our letter was on 9th June. This happened on 16th June. So it's quite clear that our work is is resulting in something right. I don't think this language is clear enough, but it's a step in the right direction. So, and it's really quite important to keep going on this work and to make sure we have testing everywhere. And the next thing I want to talk about is oxygen. We all know about the oxygen crisis that happened in India and the deaths that occurred from that, but there are oxygen crises happening every day in multiple countries. Now, this is a very busy graphic, obviously. But as you can see the countries where which are displayed in red and have high and rising oxygen need. So you've got India and Iran. They've got Serbia and Mongolia, you've got Costa Rica, Palestine, Ukraine. There are lots and lots of countries that are struggling with with with high oxygen needs. So, there's a lot of oxygen inequity as well. And where are lessons from this? Because I am supposed to talk about lessons and not just be a series of complaints or concerns. The top oxygen companies in the world, they're all based in the global north. So there's six of them that includes air lender and a number of other oxygen producers. And there are real opportunities for building more facilities in the global south because there are gas companies in the global south who are producing nitrogen and things like that for industrial use. And oxygen is really a byproduct. So the question is how do we decolonize and decentralize and make sure that countries in the global south have manufacturing capacity. There's a lot that needs to be done on supply chain and health systems issues and to make sure that this improves for the next pandemic. But as you can see, it continues to be a major problem across the world. I wanted to go to therapeutics as well. And there's a lot of buzz around how, how brilliant it is. And sometimes this buzz didn't turn out. There's a lot of buzz earlier about Gilead's Remdesivir, but that turned out to be just incorrect. And we don't use Remdesivir today for COVID. There's a lot of buzz around Molnokiravir because it can be used as an outpatient treatment. And what does that mean? That means someone gets diagnosed with COVID potentially at home, right? If they have rapid self tests, they can do that at home. And they could, I don't know, in a health system have a doctor come to their home and deliver the Molnokiravir to them, reducing the risk of them spreading COVID to others and infecting others. And they could be treated within the home. So it's exciting, right? And this is where health law comes in and the intersection of intellectual property. So there were voluntary licensing agreements with five generics, Indian generics manufacturers to accelerate that access to Molnokiravir. And it's, you know, there's a lot, there was a lot of critique coming out of this because, and now I can't remember how many countries allowed it to supply it to, but it was I think 105 countries or something like that. Who would get access to the generic Molnokiravir? But there are more than 105 countries in the world. Who chooses these countries? Countries like Russia included, probably not. Countries like China included where there's a massive poverty problem included. Countries included. You know, there's a lot of questions about equity, which is really what this presentation is about. And there's a lot of questions on whether compulsory licensing would be better. So what is the difference, right? A voluntary licensing is basically where the company voluntarily does it, right? And compulsory licensing is where usually the country who wants the cheaper generic medicines has to negotiate with the company to say, okay, are you able to give us a cheaper price, right? And if the country, the company goes, no, we can't give you a cheaper price, then the country can override the patent. And they can issue a compulsory license and it depends on which country, whichever ministry does it. In Malaysia, for example, it's a trade ministry that issues compulsory license. And what happens is, you know, it overrides the patent, which allows the generic manufacturer to manufacture them at a cheaper price. So a lot of people were saying our compulsory license is better for this kind of situation. And it depends. I mean, I'm all for compulsory licensing. I think a lot of these things are publicly funded with our tax dollars and pounds and whatever currency it is. And, you know, should there be a reckoning and a return on investment to the people, right? Because people are putting the tax dollars into this. Should these be so that the prices, they're so that. So that's one of the things that is obviously of concern. And I wanted to go to health systems. Now, and obviously I've talked about health systems throughout because health systems is so linked to every one of the issues that we've discussed so far. Now I told you earlier that the health systems connector, which is one of the pillars in that accelerator. Those are not set for weeks or months, right? And health systems connector in the start of the act of starator last year when we had the pandemic, the start of the pandemic. If you look at what this article says, and the act of starator focused on medical oxygen and PPE, which are components of clinical care they're not really health systems. And this year we saw oxygen move to the therapeutics pillar, which is, you know, it is a treatment it's it's one of the most effective treatments for COVID. And it belongs in this in the therapeutics pillar that left PPE within health systems, but health systems isn't just that. I told you this before, health systems is making sure community health workers are out there in the communities, bringing people to get vaccinated, and you know participating in health education, telling people about the risks of certain things bringing people to be addressed to people right so community health workers is a major thing that wasn't addressed. Then but we know that the health systems connectors today, while it hasn't sat for some time is doing rapid assessments on what countries need. This is a start. But it needs to be I know they're rapid assessments but it needs to be quicker because health systems are falling apart, and it's really important that they're sorted or strengthened. It's a big task, but it needs to be done. So, one of the things that we're asking for is more transparency in the health systems connector. And you know it's, it's incredibly important because what whatever you've got on the screen right now is a matrix from July 2020. And I told you about the working groups that happen in the health systems connector and I know there's a lot of technicality in it, but this was the community led responses. And there's several priorities in there. There's the need to improve basic infrastructure at public health facilities, including wash which is water and sanitation and hygiene electricity connectivity scale up of training for frontline services, availability of PPE so this is just some I only took a tiny snapshot of what the priorities were in July 2020. We're at September 2021, and I don't know. And I, my job is to know a little bit about everything. Right. To this day, I don't know the progress on any of these deliverables. There are conversations with these people all the time. So what happened to this matrix. Why have we not strengthened health systems in a way where they're supposed to. You know it's, it's a real problem. And I get the whole argument that this is our first rodeo right this is our first rodeo we're going to mess up. We're going to ask questions and keep people accountable and this is one of the key questions right. What happened in health systems. Now there's some. And I keep emphasizing community health workers because it's so essential and this is such a good article to read because Madeline Ballard did this time series analysis. She found that community health workers who equipped and prepared for the pandemic were able to maintain speed and coverage of community delivered care during pandemic period. She also points out that community health workers globally remain unpaid and unsupported, which I mentioned before. And the paper that suggests that the opportunity costs of not professionalizing community health workers, maybe larger than previously estimated. And this is a fact in the fact that we don't invest in community health workers. And this is one of my final slides I think, and I'm not sure where I am on time. That's an hour. But but important to end here. This is a slide from yesterday. It shows that to deploy the amount of doses we need to deploy by the end of 2021 health systems have to be four times stronger, right. And how can that be done. I mean it says on the right field there health systems must be must be ready to deploy more doses than accustomed to in the past, which is nice to say, right. It's a it's a nice aspiration. It's an important aspiration. But how do we do that when health systems are adequately funded. It's important and there's no kind of roadmap on health systems in the code response and it's concerning. And one of the things that I was concerned about, and the question that I got by the consultants was, what kind of structure do we need to consult alumni sees, which I think is so loaded and problematic, because we don't really have a problem consulting white global north experts we just email them this is thing called email it's miraculous. We don't have problems going to this professor at Boston University. Hey, what you know I'm concerned about XYZ. What you know what can you tell me about this. We don't really have a problem consulting white global north experts we just email them this is thing called email it's miraculous. We don't have problems going to this professor at Boston University. Hey, what you know I'm concerned about XYZ. We need to do that for my sees. I don't know why we're not doing that. And people, you know, people think like oh to consult alumni sees you need some kind of special structure some kind of integrated structure which is great I mean if you want to do that. But you know it shouldn't be in a tokenistic kind of way, you know it shouldn't be the way I foresee it. It's as if that structure is reserved for the comments of my sees and it happens once a month or whatever, when you should, you should be consulting regularly and if there's a problem in DRC you should have that expert in DRC ready in your WhatsApp to go. Hey, I'm concerned about this, you know, I do you think community health workers are ready. Do you think, you know how many days do you need to get the vaccines. What's the situation with your rapid tests right. So, which leads to the larger question of the fact that we need to decolonize global health architecture and we need to quite clearly make some basic statements to people running things right. You know why, why didn't you consult the DRC expert why didn't you consult somebody in South Sudan. Why didn't you do that. There are problems with global health architecture that need to be tackled and, and they make their uncomfortable questions they make they make some people quite constipated, especially when we say things like racism or, you know, it but it's important to mention because it distorts priority. The response for the future needs the equal intellectual partnership of LMIC it needs that indigenous knowledge. And until we learn how to do that until we learn how to make friends in the global south and, and send those emails and not feel the need for any specific structure or those structures are important as well. We're not going to be as effective as we would like. And I'm happy to to get questions. Thank you so much FIFA for that amazing presentation. I would like to encourage people to use the Q&A box now to to ask questions. We already have a couple of questions here they are from Matt Herder who's the director of our health law Institute here so I am going to read out the question just so everybody can hear it. Dr. Raghman you can you can see the questions as well in the Q&A if you if you need a visual. So Matt says thanks for a for a wonderful thought provoking presentation. It really helped me to understand how the accelerator operates. My question is about this governance. You noted the example of the fighter CEO making problematic claims about vaccine hesitancy in Africa. The industry is represented within the accelerator. What happens when industry representative representatives make such comments which others engaged in the accelerator likely disagreed with. Did that slow the work of the accelerator. Did it fragmented. How are tensions among the different actors with conflicting interests mediated. I'm curious about your reflections on how to improve the governance of pandemic responses in the future given the division between public and private actors in the global north and the global south. So, these are such important questions. So industry has multiple times so industry is in the principles group as well. And there was actually a moment where it was brilliant and I have so much faith in the WHO DG and I know, you know, there's been some horrifying articles out there about his competence and his links to China and all sorts of crazy things. But this was about making sure manufacturing of vaccines could occur in the global south. And Thomas Cooney, who is the, from the International Federation of pharmaceutical manufacturers, said the language was not appealing to industry, something along those lines. And Dr. Chad Ross made an impassioned speech for equity. And it was, it was very important for him to say that there are things like that. But your question was on how to improve governance. It's a lot of things. Industry has its uses right I mean they are the ones producing the vaccines. But at the same time, you know, governance needs to be improved so much and for example the vaccines pillar didn't have CSOs till much later. All the other pillars had civil society much earlier. And the answer in the global south and the global north that that unfortunately requires us to engage with with questions that make us uncomfortable. And I know Michelle Bachelet she said we need to tackle systemic racism to uproot it. And that's it racism and it's it's funny how many people just recoil at this word they're okay with diversity and inclusion, but they're not okay with the word racism and it really needs to be sorted because it's endemic in global health. And governance structure wise. It's, it's, it's hard to say because in the actor there isn't just one decision making place you know it happens across multiple working groups it happens behind the scenes it happens at the facilitation council it happens at the principles group. And everywhere, and maybe some kind of specification as to where decisions are made would help. Thank you. We have another question. So thinking about the periods in between pandemics and epidemics. What are the policy levels and strategies that might help to ensure equitable access of infectious disease interventions. One question here. In asking this question I'm thinking about how universities and other public research institutions have let us down the liquid delivery system that is integral to fighter and Moderna vaccines came out of the University of British Columbia. The tech transfer office has been lauded for having strong principles of global access. Yet, none of those principles seem to have been applied to ensure that the delivery system could be licensed out to entities in the global south. So if university won't follow through, at least not voluntarily, what other strategies and policy levers might be deployed instead. That's a really good question and I'm thinking immediately of the WHO transparency resolution. And how we need more discuss and how the global health architectures broken and how the voluntary system doesn't work because we had this wondrous transparency resolution will not wondrous because I know a lot of things were deleted from it. And it said that countries would commit to being more transparent about the costs of R&D, the origins of R&D into medical tools, and to relate the cost to that. But what has been the progress on the transparency resolution? What accountability mechanisms has occurred on that? We don't know which countries have been more transparent with where these tools came from. And whatever is in the transparency resolution needs to be applied to universities as well. What did you contribute to this? How much of your money is publicly funded? What's the recipe? And one of the things that we're thinking about is what there should be is a whistleblowing line either hosted by maybe human rights organizations could host a whistleblowing line for people within universities that develop these things or within companies even. So if there's a Pfizer scientist who wants to come out and call the whistleblowing line and say, I have this a bit of recipe of the vaccine or things like that, that's another thing that we need to use creative ways to get to these things just because they're just not going to happen with voluntary mechanisms. Okay, so another question. Advanced market commitments, the tool used by COVAX to get vaccines from sponsors, has been found inappropriate by some scholars mainly because it puts COVAX into competition with deep pocketed high income countries. What has been your experience or observation with the advanced market commitments? Thanks so much for this question and it's a real problematic one because one of the things that we've been concerned about is the UK, of course, dipping into the doses with COVAX. You know, I've just been really, these are, global south need the doses and the UK and I live in the UK and we have at least four or more, like some articles say seven, four, nine, we have at least four or more doses per person. The UK has completely overbought and monopolized the market. And yet they got doses from COVAX. Now Gaby's response has been to the, has been that they need to honor their agreement. It's, of course problematic, you're correct. And now we know better, but the good thing is, I suppose, is that a lot of the countries who have overbought vaccines, they have enough vaccines for their countries are now saying we don't want the allocation that was provided to us under the COVAX. That's good, but it's voluntary. There's no way to compel them to say no to their COVAX doses, you know, and there are countries like the UK who will keep saying yes. And this is obviously digging into the supply from the global south so definitely problematic. Do I have an answer to how to solve it for the next pandemic to not allow it, but for now what do we do. Welcome to your suggestions. We have time for one more question. I'm just going to, and we're going to end here because I think that's a, that's a question that a lot of people have. And it's about the boosters do folks within the accelerator worry about the impact of boosters on the global vaccine supply. Any counter strategies apart from the important statements that Dr. Tedros and other global health advocates have already made. And the strategies you know it's it's something that I'm sure my colleagues in the vaccines pillar are thinking about right now our latest update is that that, you know, folks in the WHO are not going to issue any recommendations on them at this stage there are comments that that they are beneficial for immunocompromised people. You know that could be elderly people or people and cancer survivors and things like that which is like. Okay, fine, but it's clearly going to dig into to markets when most countries haven't even been vaccinated by 1% it's so problematic. That strategy is tough question maybe maybe Matthew you and I need to sit down and strategize together on how to, how to how to solve these problems. But it's, it's a big question and question I don't actually have the answer to, but but it's an important one and we need to try to figure out but you know vaccine manufacturing in the global south is clearly clearly something that we need to think about. It's, it's a whole global global health architecture and I know it sounds like a broken record but it is heavily broken and it's so pandemic profiteering we're seeing is insane. So, more conversations to be had to get the answer the answers. Thank you so much you have some some some thank yous in the in the chat as well from people I think your talk was really well received and we're very grateful for you for taking the time to join us today for our for our seminar in this very important conversation. And as I said the the the recording will be available on the YouTube video for those who want to rewatch or share. Next, our next seminar is going to be October 8 with the Dr. Holly Northam of University of Canberra talking about restorative approaches to remove institutional and professional barriers to human flourishing also is going to be online via zoom. Thank you again so much Dr. Rachman, and thank you for sharing your knowledge and for the important work that you are doing. And thanks so much for having me. Thank you.