'No country wants to depend on another for its health and safety': Nikolaj Gilbert

During the COVID pandemic, Nikolaj Gilbert, the President and CEO of PATH, was one of the most vocal advocates for vaccine equity and a multilateral, coordinated approach to pandemic response.

For example, at the height of COVID in October 2020, Gilbert, whose organization works to accelerate health equity through innovation and partnerships, urged governments to shun nationalist policies that were undermining the global strategy and cooperation required to end the pandemic. “No country will reap the full benefits of a COVID-19 vaccine by only considering the needs of its own population,” he warned in an op-ed in Devex.

Building strong systems and preparing for health threats has been a theme for Gilbert, who came to PATH from the United Nations. He has also shared his concerns that climate-related health risks will reflect — and exacerbate — existing inequities within and among nations, especially those with vulnerable public health infrastructure.

“Those least responsible for climate change are already paying the highest price of global carbon emissions. And those who already lack access to lifesaving water and sanitation will see the largest increases in climate-linked waterborne disease,” he wrote in an article co-authored by Nanthalile Mugala, PATH’s chief of the Africa region, adding pointedly that “unfortunately, women and girls stand to suffer most.

We spoke with Gilbert about these and other issues related to health equity – and potential ways forward.

COVID has demonstrated the importance of vaccine equity and exposed significant flaws in our global response. Broadly, what steps need to be taken to strengthen health systems and preparedness ahead of the next pandemic, and how can they be achieved?

Gilbert: That is a broad question and I’d like to answer it on different levels. First, I’d like to acknowledge the successes as well as the failures. There were a lot of good efforts to set up global coordination mechanisms for response, and I think there was modest success, with COVAX, for instance. The development of COVID vaccines was also a huge success – the collaboration that occurred to make sure those were available at record speed is a public health achievement of incredible proportions.

But, despite those successes, our systems failed in other ways and highlighted some of the major public health gaps that still need to be closed. Most of the inequities came down to weak supply chains and reliance on wealthy countries for medical supplies and vaccines. When those countries hoarded vaccines, stalling access in the global south, the limits of multilateral coordination were on full display. And even when supply was finally able to meet demand, many of the left behind countries still had significant challenges importing, transporting, and distributing these essential goods. The mRNA vaccines, for example, were not developed with a global journey in mind. No country wants to depend on another for its health and safety, and when facing a truly global threat, this vulnerability compounds.

COVID also illustrated the need for stronger, more integrated health systems everywhere—including in high-income countries. When facilities and human resources were unable to shift to support the response, when surveillance and laboratories were not connected, when sick leave policy didn’t reflect reality, communities suffered.

More specifically, we've seen gaps in vaccine supply, financing, and capacity – how can we address each of these?

Gilbert: Let’s start with the supply issue. A novel virus like COVID will require development and manufacturing of a new vaccine. There are no stockpiles, so immediately, demand will outpace supply. We are fortunate that development was able to move so quickly, building on previous mRNA research as well as other vaccine technologies, notably with the AstraZeneca vaccine, which was produced at a huge volume in existing facilities and was able to supply most of the world.

Then there were the coordination mechanisms with COVAX, which was well-intentioned and a tremendous effort in terms of multilateral collaboration. But those mechanisms could not fully stand up to the inevitable scarcity, hoarding, and the more favorable market dynamics in high-income countries.

Scarce resources create inequality. When the second wave hit India, a big supplier to the rest of the world, vaccines (especially in low and middle-income countries) were unable to meet the needs of their communities. A solution to this challenge will require a different model, one in which distribution of essential medical commodities is agnostic to national interests and favorable to the people who need it most.

On the financing piece, many countries stepped up and provided financing for global purchasing of vaccines. Financing was, at least in the beginning, a little less of an issue than supply. But, when you examine the broader aspects of financing for the healthcare workforce, for systems, for rolling out the vaccines, and not just purchasing them, there were – and still are – significant gaps.

How do we address these challenges in the future? Integrated financing is key. Health is multi-faceted and can’t be siloed. Supply, purchasing, and distribution are all equally important pieces of the puzzle and must be resourced from the beginning. Buying all the vaccines in the world won’t guarantee shots in arms.

Another key question regarding vaccine equity is national distribution and delivery capabilities – how could we assist governments around the world with these issues, especially LMICs?

Gilbert: Vaccine inequity was evident at the global level, but gaps in access existed within country lines too. National governments and their leaders are responsible for their communities and charged with making difficult decisions about how to allocate vaccines and other commodities. In addition to political pressure, they may have to navigate weak infrastructure or other logistical challenges. For instance, many rural communities in LMICs didn’t get vaccines because there was no way to transport them. As governments develop national plans for vaccine distribution, they must invest in stronger infrastructure and find other ways to ensure equitable distribution, regardless of tribe, social class, position, or power.

Without transparent plans for equitable distribution and response, trust in these essential systems deteriorates. We know that trust in public health systems is essential, and that this trust can’t be won overnight. These systems that are in place to support everyday public health – the infrastructure, healthcare workers, etc – are the same ones tasked to respond to a pandemic. In LMICs, these systems were already under-resourced and depleted, unable to scale in emergency or earn the confidence of their constituents. Then, when a pandemic puts incredible, additional pressure on those systems and the workers, we see devastating consequences: more illness and more death.

When the systems can’t support the community, trust declines and misinformation spreads. Meanwhile, health care workers are overworked and under-protected. During the pandemic, this vicious cycle cost many lives on the front line. When health care workers don’t have the support or resources they need to stay safe—vaccines and PPE for instance—everyone is at risk. Prioritizing health care workers in a pandemic seems obvious, but it didn’t happen this time.

It's a web of challenges that overlap and reinforce each other, which is why we need to make sure countries are able to build strong systems now so they can effectively and equitably respond in the future.

You’ve spoken about how climate change poses particular risks to global water supply and sanitation systems. What must be done – and by whom – to reverse these trends?

Gilbert: You don’t have to look far to see the relationship between climate change and health. Recently, here in Washington state, drought caused wildfires, which led to heavy air pollution and smoke in Seattle—some of the worst in the world and a serious hazard to human health.

And that’s just one example. Deforestation and shifting temperatures disrupt ecosystems and create new vectors of infectious disease. Zoonotic diseases—like malaria and Ebola—could become even more threatening, and waterborne disease will rise too.

Too much rain and flooding stresses sanitation systems, and creates an even greater opportunity for waterborne diseases such as cholera and typhoid to spread in communities that use the water for drinking, cooking, and cleaning. Equally bad is too little water, which forces some families to choose between hydration and hygiene and damages crops and food production. Poor nutrition and ongoing infection weaken immune systems, resulting in lower quality of life and even death.

Investments in sanitation and strengthening and creating resilient water and sanitation infrastructure are one of the best investments countries can make. They are an essential part of health systems – long-term investments that are going to prevent not only those diseases we know today– but future ones too.

You’ve also said the only thing standing in the way of universal access to sanitation is the political will – why is political will for sanitation so difficult to muster and how can we encourage governments to take it seriously?

Gilbert: Right now, governments must make some important and difficult decisions. They need to recover from the pandemic. They need to prepare for pandemics. And they need to meet the needs of their communities now. Water and sanitation just isn’t rising to the top, and I think this is due, in part, because it’s not viewed as an emergency. But it is an emergency.

I would love to see this raised more at the multilateral level by the development banks. There are a lot of opportunities to broaden the scope of this conversation, such as how it is affecting women and girls in particular with access to facilities and sanitation and so on. Hopefully, this will mean it won’t be pushed off the list of priorities of local ministers of infrastructure, ministers of finance, and ministers of health.

Women and girls suffer most from lack of sanitation – what steps can be taken to improve that situation right now?

Gilbert: What I see and what the data tells us is that if you look at the people that are collecting water today and walking a lot of miles or kilometers to do that, it's often the women and the children. The loss of productivity alone, when water has to be transported this way, is a big problem.

We also know that lack of access to water and toilet facilities at schools means that girls will sometimes stay at home when they should be in school simply because they lack access to facilities. This perpetuates gender inequity and creates disparities at the macro level. You cannot think about access to sanitation and water facilities without also discussing equal opportunity.

Lastly, you’ve also highlighted the need to re-imagine the global development financing system, including in global health. What needs to be done and how can we get there?

Gilbert: There's always a lack of money and there is even more lack of money now. Even when funds are available, what it takes to access those funds is a lot, as with lending and grants.

There were lots of aspirations during COVID to make funds available for countries faster and quicker, for example, through the World Bank. It proved very difficult to actually allocate the sums of money to countries when they needed it, especially in the beginning. Countries weren’t able to prepare their health systems, to scale their workforce, to have the ability to purchase supplies from the vaccine manufacturers. There was a huge gap there, which was not filled.

It’s an equity issue. There is some hope with the pandemic financing facility that has now been established at the World Bank, but I don't know if that’s going to be enough. Ultimately, I think what we would need to see in financing is sustained national investments in health systems, workforce, and infrastructure. This is going to be the best investment for dealing with non-communicable diseases, infectious diseases, as well as emerging pathogens and conditions. If countries build strong systems that prevent illness and disease, and if they are financed to do so, they will be much better off than if we have to respond to a pandemic or some other kind of emergency.

We also need to think more creatively about how we can use existing financing systems now. No grant funded project or initiative should exist in a silo. Pandemic preparedness primary healthcare can and should be built into everything. It is all connected and must connect for long-term sustainability.