I’m always surprised that the LSHTM gives me the privilege of returning to talk about the shifting landscape of funding and how to help assure that it is spent well and to benefit Africa’s future. As I met the Zoom room full of bright, engaged students (many of whom are living the challenges of adequate funding daily in countries such as Uganda, Nigeria, Kenya, and Cameroon) I was struck by how fast the familiar old world of advocacy died, and how urgent it is that we build a new one.

My perspective is shaped by 35 years as a policy and communications consultant working across the continent. I have seen the era of the “Great Man” advocacy, where we simply tried to bend the ear of a US President or a billionaire philanthropist. We look back at those days with rose-tinted glasses: the billionaires and rich-country leaders were fickle and their focus was often on getting recognition or a seat at the top table, not on the real need. Even when they did try to assess the real needs, it was usually through the uninformed eyes of over-priced management consultants whose only knowledge of Africa came from airport VIP lounges. The billionaires were also shockingly bad at effective advocacy for something as obviously cost effective as health spending.

In any case, those days are over. If we want to secure the future of health in Africa, our work to influence policy must evolve to meet a much harsher, more complex fiscal reality.

The Shifting Foundation of Global Health Funding

We have seen a fundamental failure in advocacy around health funding. The data released by the OECD reveals a stark trend: the era of expanding bilateral aid is ending. Total Official Development Assistance (ODA) is contracting, and 96% of that decline is driven by just five donors: Germany, the UK, Japan, France, and most significantly, the USA.

The US alone is responsible for three-quarters of the global decline in health funding. While Germany has technically become the largest provider of ODA for the first time in history, even it is cutting budgets, albeit in an attempt to become more efficient. Meanwhile, traditional multilateral ODA, money flowing to the WHO or the World Food Programme for example, is shrinking less than bilateral grants, but the overall pie is getting smaller.

The good news is that the World Bank and regional development banks such as the African Development Bank (AfDB) are stepping in to fund some health projects. There are questions over “additionality”: are these institutions really funding things that private equity or other lenders to states would not? And there are frequent criticisms that the banks have failed to create funding buckets for innovative models such as low-cost private-sector primary care. However, there are real successes. The AfDB in particular has said loudly and clearly that economic growth depends in large measure on better health and has encouraged governments and funding agencies to invest accordingly.

The Rise of the America First Bilateral Accords

US funding has not disappeared: it has shrunk and mutated into the America First health policy. This administration is moving away from broad global initiatives toward strict bilateral health accords between the US and individual African countries. These are not just funding agreements; they are ideological and strategic contracts that come with significant strings attached.

Under these accords, the US makes a five-year commitment with a clear “exit strategy”: funding is front-loaded but tapers off to zero, forcing national governments to take on “ownership.” While national ownership sounds positive, the requirements are often demanding.

The focus is what you would expect from an administration with an ideological focus derived from Project 2030. It is on maternal and child health (and, yes. The State Department often says that it is the health of children “born and unborn”) and infectious disease.

These accords also require African countries to share pathogen data and specimens with the US within five days of an outbreak. This creates a parallel data mechanism to the WHO and, more importantly, seeks to capture what one of the post-graduate students called, “the new oil.” Africa holds 80% of humanity’s genetic diversity. In an era of genetic medicine, this data is a massive national asset. Several students at LSHTM rightly pointed out that countries like South Africa and Kenya see this as a key resource to be traded for R&D investment, not just given away for a few years of HIV funding. Africa is also developing national health databases that can be used to assess and model the impact of interventions and, as when the continent pioneered payments from mobile phones, it is less encumbered with antiquated existing systems and threatened vested interests.

Most alarmingly to me, these accords are sometimes tied to non-health issues. We’ve seen Zambia refuse to sign because the US tied HIV funding to access to critical minerals and mining data.

One Path Forward: the Accra Reset

The Accra Reset sets out to be a roadmap for this new era. It aims for 55% of health spending to be domestic by 2030, funded in part through “sin taxes” on sugar-sweetened beverages and tobacco. Other means of national funding include surcharges on profitable data transactions and health solidarity funds. Its organisers say that these taxes will raise £750 million in 2026 in six countries alone. I think that’s a high estimate, but there is real money there.

The Accra framework is, though, delusional in thinking that out-of-pocket health can be reduced over the next five years. The AfDB projection is that the private health market in Africa will explode. This is not necessarily bad news for health equity: much of the growth will come in highly efficient fixed-cost private primary care models targeted to working people (although, admittedly, rarely to the bottom of the pyramid or the working poor). These models can be valuable ways to give fast access to innovation and convenient, timely provision of sexual and reproductive health services.

Recommendations for the New Advocate

Given this backdrop, I suggested that these elite advocates do the following.

1. Make Health Explicitly Political

We often hear that health should be non-political. This is a mistake. Non-political subjects are boring and ignored. We need health to be the subject of election campaigns, impassioned debates and social media memes. When health becomes a political must-have, politicians make promises they can be held to. We want people shouting about health in the streets of Accra, Nairobi, and Lagos.

2. Frame Health as a Capital Asset, Not a Cost Centre

We must stop arguing for funding based solely on morality. We need to speak the language of Finance Ministers. According to the World Bank and the AfDB, health is a growth engine.

• ROI Data: For every $1 spent on malaria treatment, the economy gets $35 back. For paediatric immunisation, it’s $20. For SRHR, the returns are less often quantified rigorously but similarly massive because they enable women to enter the workforce and stay productive.
• Preventative Care as Infrastructure: Just as investing in robotics improves productivity, investing in the health of a citizen from birth to age 65 creates a stock of human capital that belongs on a national balance sheet, as the World Bank has now recognised.

3. Build Alliances with FBOs

Faith-Based Organisations (FBOs) provide roughly 30% of healthcare in Africa. The America First plan prioritises them, in part because it plays well to US domestic audiences and, in part, because they are efficient and embedded in communities. While we may disagree with some FBOs on abortion or family planning for unmarried youth, they have incredible national reach. As one student noted, a Pentecostal church in Nigeria aiming for a branch every 15 minutes of walking distance is a more powerful delivery network than any government programme. We must engage them to improve quality and advocate for rights within their frameworks.

4. Harness the Power of Media and Social Media

We can’t forget about media, especially in Africa where so many people are still dependent entirely on TV and local radio and where online and offline newspapers are declining less slowly.

Increasingly, though, we must go where the people are — which is social media. During the lecture, students raised concerns about medical influencers spreading misinformation or misogyny. My response: then we must flood the zone. We need to train responsible influencers. When Joe Fazer, a bodybuilding influencer with about 30 million followers produces content about health equity, he can mobilise a generation we will never reach through traditional policy papers.

Overall, we are in a time of great opportunity and serious danger. The transition from aid to co-investment is the only way to escape the whims of Washington or Berlin. We must be like the “trained revolutionaries” Lenin spoke of — professionals who know how to stir up movements and demand that our governments prioritise health not because a donor asked them to, but because their own citizens demand it.

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Conflicts compound these inequities. Fragile and conflict-afflicted countries account for just a quarter of the world’s infants, yet they harbour half of all zero-dose children, whose numbers have increased from 3.6 million in 2019 to 5.4 million in 2024. In Sudan, vaccination coverage collapsed — from 85% pre-war to as low as 8% in conflict zones — while Yemen’s zero-dose figures climbed significantly, driven by instability, health service disruptions, and misinformation.

Conversely, Gavi-supported, low-income countries saw marked improvements, reducing un- and under-vaccinated cohorts by around 650,000 in 2024. Yet even high- and upper-middle-income economies are experiencing slippage, with measles coverage hovering at 84% (first dose) and 76% (second), below the 95% threshold needed for herd immunity. Consequently, measles outbreaks surged, with 60 countries reporting significant incidents in 2024, doubling since 2022.

Country case snapshots powerfully illustrate these trends. In Bosnia and Herzegovina, measles vaccination rates are at just 55%, compared to Croatia’s 90%, contributing to over 7,000 cases and two adolescent deaths, prompting WHO and UNICEF to urge intensified immunisation campaigns. In Pakistan, polio resurgence has occurred amid militant threats and disrupted campaigns, with over one million children missing doses in 2024. The government’s response includes large-scale vaccination drives and policy enforcement, such as arrest warrants, signalling both the challenge and political recognition of routine immunisation’s fragility. Meanwhile, Bangladesh has steadily expanded its vaccine schedule — adding Hib, rubella, PCV, IPV and MR2 — achieving DTP3 coverage around 93% and fully vaccinated rates near 84% by 2019.

These illustrations reveal both progress and vulnerability. Countries with strong political will, robust systems, and community trust — like Bangladesh — are managing gains. Others, like Pakistan and Bosnia, highlight how instability, mistrust, and misinformation can swiftly unravel public health gains.

The 2024 immunisation data reiterates an urgent message. Global coverage has stabilised and broadened, but millions of children remain vulnerable in conflict zones and complacent high-income settings. Measles outbreaks, polio flare-ups, diphtheria spikes, and new threats like RSV underscore that the progress we’ve made is neither permanent nor evenly shared. Unless we decisively fill funding gaps, fortify health delivery in emergencies, ensure vaccine equity, and strengthen trust, these vulnerabilities will deepen — and outbreaks will follow.

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Imagine it’s the mid-1990s and the U.S. has decided to pursue policies that would restrict trade and investment to Asia instead of promoting it. Would those markets still prosper? Would the U.S. have grown as strongly or had the same counterweight to China if the American government had abandoned Indonesia, Vietnam, Thailand, Malaysia, Singapore or other regional markets?

At the time, these countries represented the next frontier of economic opportunity for American companies seeking to establish manufacturing and financial hubs, sell to millions of new consumers and tap an emerging talent base. Much of the economic data from the past thirty years underscores the mutual economic benefits that came from favorable policies that promoted deeper diplomatic cooperation and corporate investment in Asia.

I had a front row seat on this economic rocket ride early in my career, spending more than four years right after college working in international marketing throughout Southeast Asia. We have seen a tectonic shift in global trade since then, mostly resulting in incalculable benefits to global trading partners, including the U.S., as market access has opened for an array of goods and services. In combination with health systems investments, countries like Indonesia, which were once leading recipients of development assistance, have seen their GDPs increase to the point where they are now considered middle-income countries and are providing economic assistance to other countries in public health programs like the ones supported by Gavi, the Vaccine Alliance.

This sort of massive transformation came about because the U.S. and other countries played the long game. It’s crucial to keep this in mind – and the hypothetical scenario of where we would be today if we had lopped off trade opportunities with Asia 30 years ago – because we are about to retreat from the next great frontier market of the 21st century: Africa.

The implications of such a move are reflected in economic and demographic data. Eleven out of the top 30 fastest-growing economies in the world last year were in Africa. A staggering 70 percent of the population is under 30 years old, a tsunami of innovators, entrepreneurs, researchers and everyday workers hungry to supercharge their futures. In health, education, financial services, technology, manufacturing and many other sectors, African markets are showcasing new models that can help emerging economies leapfrog in their economic development.

It’s a big reason why China, India, the Gulf States and many other countries are racing to establish economic partnerships with key African markets so they have an established presence as the region becomes more prosperous. But the United States is opting out.

Currently, plans developed by the Trump Administration to reorganize the State Department indicate an intention to scale back the American diplomatic presence substantially in Africa. This follows the dismantlement of USAID, de-funding of PEPFAR and other key public health programs, and the anticipated scuttling of the Africa Growth and Opportunity Act (AGOA), a vital trade agreement that allows for duty-free access to the U.S. for many African exports.

The result of these cuts could leave the U.S. government and companies sidelined from any meaningful diplomatic engagement and commercial gains as African markets race ahead with support from our greatest geopolitical rivals. Without robust engagement from American embassies, U.S. companies may be hobbled as they seek to create commercial partnerships, understand the competitive landscape of key African markets, negotiate regulatory barriers and navigate legal and operational threats that arise in any market.

Such a shutout may be felt acutely by American biopharmaceutical companies and health start-ups that include African markets in their clinical trials, partner with national governments and civil service organizations on early-market initiatives, attract talented scientists and build brand loyalty with more than a billion new health consumers. Policy and regulatory issues in Africa are routine problems that healthcare companies work with American embassies to solve, along with risk management.

Then there is the potential cost to domestic U.S. healthcare from cutting global health programs and diplomatic presence in Africa. USAID offices were often attached to American embassies and have been among the first to respond to the early detection of disease outbreaks. The U.S. spent $900 million in 2023 to fund laboratories and emergency preparedness and response in more than 30 countries, many in Africa. Those programs are now on hold, which increases the danger that outbreaks of polio, Ebola, Marburg, and mpox, as well as bird flu, could erupt. Without that frontline defense, the risks grow dramatically higher for existing and new diseases to reach Americans at home and overwhelm our health systems.

It’s become cliché to say “health there affects health everywhere,” but when more than 77 million people travel to the U.S. from foreign destinations in 2024, it’s obvious that humans are the greatest vector known to disease. America’s massive biomedical research capacity and our biopharma companies are at the vanguard of protecting our health. Abandoning our political and commercial connection to key countries in Africa reverses years of important progress.

We depend on access and cooperation with Africa’s emerging markets to help maintain our health defenses and build a next generation drug pipeline, but also to create a pathway to future economic growth. Without the vital support our companies receive through U.S. diplomatic assistance, that pathway could be closed off. Are we prepared to risk that?

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The migration of healthcare workers from low and middle-income countries (LMICs) to high-income countries (HICs) — the so-called “medical brain drain” — is not a new phenomenon. But its scale and impact have reached a point where we can no longer turn a blind eye.

Consider this: some HICs draw as much as one-fifth of their physician workforce from LMICs. This exodus is happening against a backdrop of a global shortage of 2.8 million physicians, with LMICs bearing the brunt of this deficit. It’s akin to siphoning water from a drought-stricken village to fill swimming pools in wealthy neighbourhoods.

The drivers of this migration are complex. Healthcare workers often cite poor working conditions, limited career advancement opportunities, and socioeconomic challenges in their home countries as push factors. As one study notes, “the top five reasons for respondents choosing to emigrate from their home country were: socioeconomic or political situations in their home countries; better education for children; concerns about where to raise children; quality of facilities and equipment; and opportunities for professional advancement.”.

But the consequences are far from complex — they are devastatingly clear. Beyond the immediate loss of skilled professionals, there are significant economic costs to LMICs. A study by Saluja et al. estimated that “LMICs lose nearly US$16 billion annually (95% CI $3.4 to $38.2) due to the cost of excess mortality that results from physician migration to HICs.” This figure represents the direct financial investment in training these professionals and the potential lives lost due to their absence.

The impact on healthcare systems in source countries is equally severe. As Misau et al. point out, “The health care system in the developing countries faces many problems, human resource being one of the majors. The system is structurally and systemically fragile and weak to provide effective service where it most needs. Brain drain appears to have complicated the situation and made matters worse.”

It’s easy to point fingers at HICs for “stealing” healthcare workers from LMICs. But this oversimplifies a complex issue. Many argue that individuals can seek better opportunities and living conditions for themselves and their families. One commentary notes, “when health-workers leave, they exercise their autonomy in pursuing their life plans; the freedom to leave one’s country and free choice of profession are codified as human rights in the UDHR.”.

So, what’s to be done? The World Health Organization has developed a global code of practice for the international recruitment of health personnel. But as Brugha and Crowe point out, “the code is ultimately voluntary. Recent research has suggested a lack of awareness of the code among relevant stakeholders and that the code has not affected policies, practices, or regulations in Canada or other developed countries.”

LMICs need to implement strategies to retain their healthcare workers. Kamarulzaman et al. suggest, “Investing in and strengthening domestic health care, providing career opportunities and attractive remuneration, and investment in research and development in a context of political stability are necessary to attract and retain health workers.”

But HICs cannot absolve themselves of responsibility. Ethical recruitment practices, support for health system strengthening in LMICs, and partnerships for medical education and training can help mitigate the negative impacts of healthcare worker migration.

The current situation is unsustainable and detrimental to global health equity. As Eaton et al. argue, addressing this issue requires “a comprehensive approach that considers the rights and aspirations of individual healthcare workers, the needs of source countries, and the ethical responsibilities of destination countries.”

The medical brain drain is not just a problem for LMICs — it’s a global health emergency. And like all emergencies, it demands immediate, concerted action. The health of millions depends on it.

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The scale of our collective progress can be measured against a timeline of vaccine milestones. The polio vaccine brought hope to millions of families from America to Zambia. Up until the mid-Twentieth Century, few could imagine the eradication of smallpox, but a global vaccination campaign against the disease starting in the 1960s ushered in an era of new possibilities for billions. And the roll-out over the past week of the first-ever approved malaria vaccine may mark another landmark: the moment when children across Africa have been given hope in the form of a tool that can help them escape a plague that kills 500,000 of them each year.

A future where malaria is eliminated as a public health threat in the African continent may remain out of reach for the immediate future, but that shouldn’t stop us from working to fulfil our dreams of a malaria-free Africa. As it has with other diseases, the introduction of a new vaccine has the potential to catalyze innovation and create new opportunities for economic growth.

If the malaria vaccines enter the immunization schedule of most African countries over the next year, as planned, the steady stride of the region’s economic power may accelerate. When more children survive past their 5^th birthday and the strain on health systems is reduced, that’s not only intrinsically valuable, it’s a good thing for economic growth.

Healthy children fuel healthy economies

With the coming decades expected to see the ascendance of several African markets as global economic players, malaria vaccination could be a catalyst to sustained development in the region. This serves as a benefit for nations around the world, including the U.S.

Yet, one of the most immediate ways to derail Africa’s economic potential is to hamper the very immunization programs that have delivered the most impressive returns on health investments, both in Africa and globally. That’s what is on the line later this year when Gavi, the alliance responsible for financing the delivery of more than 19 different vaccines to low-and-middle-income countries, is set to have its funding reauthorized by the U.S. and several other governments.

Gavi has written the playbook for creating an investment-driven approach to providing emerging markets with the immunization infrastructure they need to thrive. In the 24 years since its founding, the alliance has vaccinated half of the world’s children. That alone is a remarkable achievement, but the alliance has matched humanitarian outcomes with powerful financial results: Its model has proven so successful that $1 of investment in Gavi yields $54 in health savings among its beneficiary countries. Peer-reviewed research has shown a strong link between child survival rates from vaccine-preventable diseases and GDP growth.

As investments of U.S. taxpayer funds go, few if any can rival the return that Gavi brings for the roughly $300 million committed to it by the American government each year. Looking beyond the direct impact on lives saved – nearly 18 million children and counting – global immunization programs supported by Gavi have strengthened health systems in many of the most vulnerable countries of the world. These are the very places where deadly disease outbreaks have the greatest chance of growing undetected until they are uncontainable.

Continuing support for routine immunization is essential

Gavi funding helps protect Americans by blunting the relentless pace of viruses and bacteria to evolve beyond our control. Better immunization against known threats, more sophisticated early-detection systems in disease hot zones, new vaccine manufacturing capacity closer to the likely sources of outbreaks, and hospital systems that are less burdened by increasingly preventable maladies like malaria – these are the building blocks that Gavi has helped put in place to foster a healthier future for all of us.

At a time when disinformation further erodes trust in the institutions tasked with protecting public health and the spread of disease is supercharged by climate change, the value of Gavi’s time-tested model deserves to be acknowledged through funding replenishment later this year. This would send an unmistakable message to the world that we can still fulfill the hopes and dreams of billions of people by providing the lifesaving vaccines they need to have a shot at a more prosperous, peaceful future.

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Advocacy for Africa’s potential as a global vaccine production hub has gained significant momentum. The Africa Centres for Disease Control and Prevention (Africa CDC), through its Partnership for African Vaccine Manufacturing (PAVM), aspires to achieve 60% self-sufficiency in local vaccine use by 2040. This ambitious yet attainable goal underscores the vital steps necessary for realisation.

BioNTech aims to start mRNA vaccine output in Rwanda

Simultaneously, the African Vaccine Manufacturing Initiative (AVMI), a network of manufacturers, has broadened its role, engaging more deeply with multilateral partners and championing the industry’s interests. For example, BioNTech aims to start mRNA vaccine output in Rwanda in 2025. Additionally, the recent surge in bilateral technology transfer agreements and infrastructural investments with local African producers marks a notable shift in the landscape.

The International Monetary Fund (IMF) is playing a role in supporting vaccine manufacturing in Africa by providing financial assistance to governments and businesses involved in the effort. For example, the IMF provided $100 million to Ghana to support the establishment of a vaccine manufacturing facility in the country. The IMF has already worked with African governments to develop harmonised standards and regulations for vaccine manufacturing and provides technical assistance to African governments and businesses on vaccine manufacturing.

Moderna, BioNTech, and the Serum Institute of India (SII) plan to establish vaccine manufacturing facilities in various African countries in 2024. These facilities will initially produce COVID-19 vaccines, but they also have the potential to produce other essential vaccines, such as the measles, mumps, and rubella (MMR) vaccine and the polio vaccine specifically for African populations.

Sustaining Growth

However, sustaining this growth trajectory beyond 2023 necessitates immediate action in three critical areas.

First, ensuring predictable vaccine demand and procurement from African governments is essential. This certainty enables manufacturers to plan effectively and achieve economies of scale. A continental pooled purchasing agreement could guarantee the requisite offtake, providing much-needed stability.

Secondly, a significant increase in financing is crucial. This funding could come from donors, lenders, and public budgets, which are essential to spur ongoing projects and innovation. Initiatives proposed by entities like the Gavi, the Vaccine Alliance and the African Union are critical starting points that must be actualised. The plans from the combined efforts of SII, Moderna and BioNTech must be maintained and not left to be a ‘health-washing’ exercise.

Lastly, a streamlined and efficient regulatory framework is vital for expediting vaccine development and approval processes. Strengthening national regulatory agencies and fostering an integrated system are underway, with the imminent launch of the African Medicines Agency poised to enhance coordination across the continent.

Thus, 2024 emerges as a pivotal year, a unique opportunity for tangible progress if all parties commit to a shared vision of long-term, sustainable success. The groundwork laid by pioneers has brought the dream of African vaccine independence closer to reality. The key to unlocking this potential lies in decisive actions and implementing mechanisms ready for utilisation by Africa’s emerging vaccine enterprises.

The Stakes are High

The stakes are high, with continental health security and economic growth hanging in the balance. The COVID-19 pandemic exposed the risks of dependency on external supply chains. At the same time, a burgeoning pool of local talent in pharmaceutical sciences and biotechnology is eager to address regional health challenges. Decisions made in the next year will determine the pace at which these health and economic benefits can be integrated into the broader economy.

As we face a steady rise in infectious diseases, Africa stands at a crossroads in 2024. It has the opportunity to establish a world-class, integrated vaccine industry that serves its needs and those of the global community. This pivotal moment calls for bold leadership and unwavering commitment. We are at the threshold of a unique opportunity and must mobilise our collective resolve to leverage it effectively. The dawn of Africa’s era of health autonomy and leadership is within grasp, contingent on the essential roles played by key actors.

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Now, Amanda leads a global team working to make the world safer from the next epidemic while also urgently responding to COVID-19. Medika Life Editor-in-Chief Gil Bashe spoke with Amanda on the challenges facing public health efforts around the world.

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Gil Bashe:  Amanda, I would like to talk about the core problems that you and Resolve to Save Lives work to address. Let’s talk about why these problems are critical to public health globally, why we have to be much more aware of them, and what’s at stake for the world if we neglect to address the challenges that Resolve to Save Lives has decided to shoulder?

To start, what brought you to global public health? I know you’ve worked with very established organizations like the International Red Cross in the past. Can you talk a little bit about the mindset and transition for a moment?

Amanda McClelland: It’s a good question. Like many people who worked in West Africa during the Ebola epidemic, it raised several issues centered around how to make sure something like that didn’t happen again.

As part of the International Federation of the Red Cross, our work needed to scale across 90 – 100 countries with 17 million volunteers. The work is at the community level, which is so critical. Yet, it was missing a connection point into government systems and structures. We’ve led a lot of advocacy and tried to put communities at the center of our efforts, but it didn’t move beyond the kind of rhetoric of “communities are important.”  There was nowhere for communities to engage inside the existing architecture, whether that be at a domestic or global level.

After 15 years of responding to outbreaks, I’ve been going back to the same countries for different reasons. I worked in Sierra Leone from 2012–to 2013 during a very large cholera outbreak. I was back there in 2014–2015 for Ebola. And despite this, the recovery that we talked about didn’t fit sustainably.

Dr. Thomas Frieden approached me about joining Resolve to Save Lives with a focus on strengthening community systems and targeting preparedness as a full-time position, tapping into my real-world experiences. This was an opportunity to try to make sure that we weren’t going back to the same countries over and over again, and that we were building systems that could detect diseases and respond sustainably.

Bashe:  You and Resolve to Save Lives recently launched an important campaign.  You’ve just taken on non-communicable disease and specifically cardiovascular disease. That is rare when people are frightened about the next pandemic.  Too often we forget to recognize that 70 to 80% of people around the world perish from non-communicable diseases such as heart disease, diabetes, respiratory disease, and mental health illnesses.  Now you are elevating the conversation around cardiovascular disease, why?

McClelland: So often people think it’s a bit strange that we work in two areas, preventing epidemics and cardiovascular illnesses. You’re right, we picked two problems where we think we can save the most lives. COVID-19 has shown us the absolute relationship between infectious diseases and the health of a population.

The impact of COVID’s abilities or mortality from COVID is a stark reminder that a healthy community is critical. Social cohesion and community engagement are at the center of all public health problems. And that comes through in cardiovascular disease and epidemics.

Bashe: I find this to be fascinating because when talking about people most at risk for COVID severity or death, tragically often we talk about people with chronic illnesses, it could be obesity, it could be cardiovascular disease, it could be diabetes. Together these comorbidities are tipping points leading to COVID-related death.

McClelland:  I’m a primary health care nurse by training, so I go one step further and look at those individuals who have chronic conditions—those people who get asked to come back in six months.

What’s the root cause of that? Many of these people, don’t have access to care promptly. They don’t necessarily have good health literacy, good nutrition advice, or access to nutritious food. We know that COVID is disease oriented. But we need to understand that there is a relationship in many countries between low socio-economic indicators, access to care and the increasing amounts of chronic diseases that can easily become acute—like they did during COVID-19—and overwhelm the health system.

We must provide clinical care along with public health interventions for those diseases and start collaborating more effectively. And we think about this as a spectrum, from prevention to early detection and early treatment, all the way through to chronic care and palliative disease. If we don’t start working together, we’re going to lose people through the cracks and that’s where it becomes acute.

Bashe: Great answer. I know you recently had a campaign in Africa and as a global organization, could you talk a little bit about the work you’re doing in Africa?

You know I’m a very big believer that when we look at health, we tend to look at the health of the developed world. There are many problems in ensuring health in the developed world, and among developing nations. They are working to put together infrastructure. I would appreciate your perspective about developing and developed but also why Africa specifically?

McClelland: So, my opinion on this is changing quite a lot and I’ll give you one example. When COVID started, I was working in lower-middle-income developing countries.

For the last 15 years, even in Australia, I worked with indigenous communities that you could say were sometimes worse. I lived in an Aboriginal community, which had massive health challenges and an inexcusable disparity between aboriginal health and the white population in Australia. But when we started the COVID-19 response, Dr. Frieden came to me and said we were going to start responding in the U.S. because New York was getting hit extremely hard.

I said I can’t. I haven’t worked in a high-income country for many years, I don’t understand the American health system. We don’t have anything to add in this context. But we did it. We mobilized a team of 45 people and supported numerous activities at the local level across partner jurisdictions. We ran two different teams—a U.S. team and a global team. We wrote two different sets of guidance—guidance for high-income countries and guidance for low-income countries.

After the first eight weeks, we realized the challenges were similar. High-income countries don’t necessarily have highly resourced public health departments. The public health departments here in the United States are completely underfunded and understaffed. The challenges that we face in Uganda, Liberia and Nigeria were actually to manage because there was a lack of bureaucracy. Teams knew how to collaborate with partners and how to accept outside help. They were able to accelerate through the challenges, trying to supplement like high-income countries.

Across the board, the fundamental challenges remain the same—poorly paid and under-staffed public health systems. Core data infrastructure, the ability to manage data and the ability to make good decisions on that data are commonalities that we all face. We have more in common than we think. There are different challenges in terms of access and cost of care, but not from an epidemic prevention perspective, and also from a chronic disease perspective. Moreover, the under-resourcing of public health is common across many, many developed and developing countries.

Bashe: Could you talk a little bit about what you’ve been doing in Africa, specifically?

McClelland: When we were first starting Resolve to Save Lives, we looked across the globe at where we, as a small but nimble non-governmental organization (NGO), could add the most value. Through an initial assessment, we realized the burden of infectious diseases in Africa, so that was a logical place to start.

When the COVID-19 pandemic began, it became clear that the missions and social measures that developed countries were going to put in place to control COVID would have a significant secondary impact in low-income countries that would make it extremely difficult to maintain.

And so very early on in our work in the pandemic, as early as 2020, we joined up with Africa CDC, WHO Africa, World Economic Forum and several product companies, including IPSOS, as part of the Partnership for Evidence-Based Response to COVID-19 (PERC) to collect data on how public health and social measures would be implemented on the continent.

We wanted to measure both the epidemiology and the secondary impacts such as food insecurity and education disruptions. So, we started our work in Africa with regular large-scale surveys during the pandemic, which we did in four waves across 20 countries. We were able to provide decision-makers with enough data to make balanced decisions. Balancing risk and corporate control against the secondary impacts that those measures caused, strengthened our understanding that the pandemic was not just a health issue. It was also a political and social issue that required data and information from all sides to be able to make informed decisions.

Bashe: And what have been some of the results, I mean that’s the program but how do you see the impact of your efforts?

McClelland: We spoke to the World Bank on global funding and others in terms of where we were seeing change on the ground. We noticed that countries that did very well at the beginning of the pandemic were those that leveraged their public health to enforce social measures. They quickly had political support.

There was a large amount of public trust in most of the countries with the initial government response. But we also saw economic impacts in those countries along with security incidents. While strong trust in the public health system improves outcomes, people’s behavior was also impacted by their ability to meet their daily needs. You can only protect yourself from COVID if you still have enough food and enough fuel, etc.

We have to make decisions based on risk, and we saw the risk perception of the community go up and down with the various waves of the COVID Delta wave. We also see political disruption move up and down with the epidemic curve, along with secondary impacts, as governments turned on and off safety measures. It reinforced the idea that we cannot make these types of decisions just based on cases or deaths.

Every country must find a balance for what works for them in terms of balancing out access to economic opportunities and food and security against what they will accept as a level of COVID. And we’ve seen examples of that. New Zealand versus the United States varies in terms of how they managed COVID and the economic impacts, but also the absolute mortality that caused them.

There are varying thresholds of what is acceptable in different communities. Some communities accepted zero deaths and, in some places, 1,500 deaths a week is still the norm and things are getting back to normal. It is important to understand that pandemic control is a choice that’s driven by politics and communities. And that was a difficult realization for many, that the dependency wasn’t wholly and solely within the health domain, that we were one actor of many trying to influence how this was controlled.

Bashe: When you look at the next six months to a year, what do you hope to achieve?

McClelland: We hope to have this recognized as a once-in-a-generation opportunity to build forward better and to make sure that we recognize the threat that biology still has to us—that we haven’t outsmarted the germs, so to speak.

There are things that you can do to control the risk to make sure that we’re better prepared, to make sure that individuals and systems are more resilient. We have this opportunity in the next six months. We must harness the political will, the financial resources required and the lessons that we’ve learned during COVID to make sure that we build a more protected and healthier world. There is a significant risk that we don’t learn any of these lessons and then we go back into this cycle of panic and neglect. The next six months are so critical for us.

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The next six months may be critical for us.  Keep watching the work of Resolve to Save Lives and their in-the-trenches team to see the progress that they are making to sustain and save lives around the world.

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