UHC is: Clean Air For All

The First Ever International Day of Clean Air for Blue Skies Underscores the Environmental Link to Human Health

UHC Benefits from Clean Air

For the inaugural International Day of Clean Air for Blue Skies on September 7, 2020, HGHI and the One by One: Target 2030 campaign is highlighting clean air as a necessity to achieving Universal Health Coverage (UHC). Contributing to over 7 million premature deaths every year, the burden of air pollution on healthcare systems threatens any achievement towards effective UHC. While air pollution is the largest environmental risk to public health globally, it is a solvable problem. Many affluent countries have greatly improved their air quality in recent decades. However, air pollution continues to inequitably affect populations in low-and middle-income countries, and in particular, women and children. Across the African continent, the economic costs of premature deaths from outdoor and indoor air pollution are estimated to be almost USD$450 billion annually or equal to the entire GDP of Nigeria. With air pollution’s relationship to climate change and crop yields, as well as its implications in the current COVID-19 pandemic, ensuring clean air will not only save lives but support cleaner environments, alleviate poverty and increase shared prosperity. For these reasons, UHC advocates must integrate reduction of air pollution into Universal Health Coverage initiatives, and national and sub-national plans for UHC must work in collaboration with efforts to promote clean air and energy.

Impacts on Health Outcomes and Access

Air pollution causes both acute and chronic diseases and is one of the leading contributors of preventable death in Africa, including 400,000 annual infant deaths. These deaths are mainly due to non-communicable diseases such as stroke, chronic obstructive pulmonary disease (COPD), adverse pregnancy outcomes, and lung cancer, which often require visits with specialized medical personnel, expensive drugs and treatments like chemotherapy and reliable access to a healthcare facility. These medical costs cause a formidable strain on families and health systems. By improving long-term health outcomes and reducing healthcare costs, ensuring clean air can help save lives and support a higher quality of life

Impacts on Health Systems

Air pollution is inextricably tied to energy. Barriers to access clean energy, as an alternative to fossil fuels, not only increase pollution but also make communities and health facilities more vulnerable to power outages and costs. Energy sources such as kerosene for lamps, diesel generators for energy and open fires for cooking all require the burning of fossil fuels like coal, crude oil and natural gas. Each of these fuels emits harmful pollutants and toxic chemicals, emissions that would be eliminated with the adoption of solar or wind energy. The lack of these sustainable or “clean” energy sources also contributes to a lack of quality care within health facilities. In sub-Saharan Africa, only 28% of healthcare facilities have access to reliable electricity. Lack of energy access can mean vaccine spoilage, interrupted surgeries, equipment failure, lack of access to electrically-pumped water, and unsafe birth practices, all barriers to care for patients suffering from air pollution-related illnesses. Renewable energy can provide health facilities an


efficient, low-cost, and reliable source of energy, while cutting down on harmful emissions that contribute to air pollution and climate change. Having reliable energy can also help expand and improve health care access and delivery in remote rural areas where electricity is lacking. Small photovoltaic (PV) solar power systems are already widely in use across Africa, and help health workers provide care and diagnoses, charge cell phones for communication, and safeguard vaccines and other medications in portable cooler units. Therefore, efforts to achieve sustainable energy for all is integral for reducing pollution, and is a critical investment for sustainable UHC. 

Impacts on Social Equity​

Air pollution is foremost an equity issue. Due to traditional gender roles that relegate activities such as cooking and raising children to women, women spend more time indoors, they are more likely than men to suffer from air pollution-induced diseases. Of the 7 million annual deaths due to air pollution, more than half are of women and children. In 2015, 920,000 children died of pneumonia; over 50% of these deaths occured in African countries. Air pollution is associated with roughly half of these childhood deaths from pneumonia. For women in low-and-middle-income countries, household air pollution is the single leading environmental health risk and is the main cause of non-communicable diseases like strokes, COPD, lung cancer and heart disease. In Africa, only 17% of the population has clean cooking access, meaning the majority of the population still cooks with biomass or open fires and is thus exposed to indoor air pollution. Poverty is also strongly correlated with disproportionate exposure to air pollution because of low-income populations’ reliance on unclean energy sources. The health burden associated with the use of such energy sources is further compounded by the lack of information and access to health resources. The burden from air pollution can keep populations in unending cycles of poverty.


Next Steps

To achieve sustainable and effective Universal Health Coverage in Africa, clean air is essential to protecting human health. Reducing air pollution is not only fundamental to our quality of life, but to breathe clean air is a human right. Air pollution is a solvable problem and there are many steps that governments, communities and health systems can take to improve the quality of air. For the first-ever International Day of Clean Air for Blue Skies, those who advocate Health for All should support clean air initiatives and improve sustainable energy access as a key component to all Universal Health Coverage plans. To learn more about how clean air can be integrated as a priority in universal health coverage plans, visit: www.onebyone2030.org/cleanairday

Helping you get straight to the evidence.

The Preprint Sifter is a new Twitter tool that tracks down Tweets from leading epidemiologists, virologists, public health and other experts who are posting, vetting and verifying COVID-19 related preprint papers.

In this pandemic, scientists around the world share preliminary information quickly and openly with each other by posting “preprints” online. Preprints are research papers that have not been reviewed by other experts yet but enable a speedy exchange of initial findings and observations amidst great uncertainty, and contribute to the generation of better evidence.  The downside: Because they may still contain errors, are easy to quote out of context, misunderstand or misinterpret, preprints have become a major source of misinformation and confusion, and are abused by those hoping to stir chaos, peddle their products and businesses, or drive towards false messages for political gain. 

Amplifying the Experts

In response, Twitter has emerged as a great tool for experts to discuss, assess and evaluate the studies, methods and findings that are posted in preprints.   

The Preprint Sifter makes it simple and easy for anyone to access these sources of expert assessment in real time.  By curating authoritative tweets on Twitter, and gathering and publishing curated collections once a week, the Sifter helps journalists, policy makers and the public put individual studies, initial observations and preliminary findings in context, and understand the limitations of and potential errors in preprints. 

We created the Preprint Sifter to enable all of us to look at preprints the way experts do. We hope you find it helpful.

The Breakdown

Sign up for the weekly newsletter from the team behind the Preprint Sifter that gives you a curated summary of the key conversations on the preprints posted throughout the week. We put together a list of the week’s most notable preprint papers and highlight the expert analysis worth paying attention to. 

America’s testing infrastructure is collapsing. As cases surge around the country, laboratories are facing crippling shortages of key supplies and growing backlogs of samples. In many states, it now takes 10-15 days to get test results – rendering these tests useless as a tool to prevent transmission and bring the pandemic under control. For most people, the peak period of infectiousness lasts about a week.  And, in the middle of this testing collapse, cities and towns are preparing to return millions of children to school this fall with neither the intention nor the capability to test them. At this critical moment in our nation’s fight against COVID-19, it is time to radically rethink our approach to testing. The way forward is not a perfect test, but one offering rapid results.

Over the past months, much of the conversation around testing has focused on accuracy. Tests have been touted for their high sensitivities, correctly identifying more than 98% of positive cases. The intuition is clear: we want a test that won’t miss positive cases and send infected individuals back into the world to spread the virus. These qPCR tests have become the backbone of our testing infrastructure, yet their high costs and slow rates of analysis have undermined any attempt to put their high sensitivities to good use. CDC analyses suggest that we are identifying only about 1 in 10 cases of COVID-19, mostly because we are testing so few people. This means that from a public health perspective, the ability to identify and isolate positive cases that matters most for disease control is only about 10 percent. By putting a premium on the accuracy of tests, we fail to test a majority of people with COVID-19 and these built in delays actually undermine our ability to timely identify cases which is the key purpose for widespread testing.

Imagine spitting on a special strip of paper every morning and being told two minutes later whether you were positive for COVID-19. If everyone in the United States did this daily, we would dramatically drop our transmission rates and bring the pandemic under control. Schools and businesses could reopen with the peace of mind that infectious individuals had been identified and were staying home. Michael Mina of the Harvard School of Public Health has been a major proponent of this idea, and has pushed the idea of a $1 test that the government could mass-produce and provide freely to everyone. In fact these technologies exist today. Antigen tests are significantly cheaper and faster than qPCR tests, and Quidel has already received FDA approval for their antigen-based test on a strip of paper. Another $1 antigen test has been put to use in Senegal. Many other U.S.-based companies are developing antigen tests. Why, then, have these cheap and rapid tests not become the foundation of our national testing strategy?  The answer lies with test sensitivity.

Antigen tests require higher levels of virus than qPCR to return a positive result. There has been a significant pushback from those who believe it would be irresponsible to widely use a test that might miss many positive cases. But the frequency of testing and the speed of results counters that concern. The qPCR tests are currently slowing laboratories to a crawl. If everyone took an antigen test today—even identifying only 50 percent of the positives—we would still identify 50 percent of all current infections in the country – five times more than the 10 percent of cases we are likely currently identifying because we are testing so few people. Accuracy could be further increased through repeated testing and through the recognition that quicker test results would identify viral loads during the most infectious period, meaning those cases we care most about identifying – at the peak period of infectiousness—are less likely to be missed. Even better, we would be identifying these cases while they are still infectious, rather than in 10 days when the virus may have already been transmitted repeatedly. Mina and colleagues have shown through modelling that this logic holds up; speed matters much more than test sensitivity in controlling a pandemic.

The evidence makes clear it is time for a paradigm shift on testing. Our goal should be to identify and prevent every cluster and every outbreak of COVID-19. Cheap and rapid antigen testing can achieve that goal, even if the test sensitivity never matches that of qPCR. It is time for the federal government to take strong leadership on directing our resources toward this new strategy. The U.S. has the ability to print paper-strip antigen tests in massive capacities and to distribute them all over the country. It has the capability to bring antigen tests to tens of millions of Americans daily. If we do these things, we can move past 10-day delays, quash the current outbreaks, and ensure that we can safely go to work, do our shopping, and send our kids to school.

UPDATE: Please see new guidance, “Schools and the Path to Zero: Strategies for Pandemic Resilience in the Face of High Community Spread”, published December 18, 2020.

July 20th, 2020

Finding ways to get kids back to school safely as the virus continues to spread across the nation is a daunting task. Our new guidance helps schools and districts devise plans based on the size of the outbreak in their community  

Across the United States, cities and states are struggling to devise plans for safely bringing children back to school this fall. It’s a daunting task: We know the coronavirus spreads especially fast in groups confined to indoor spaces. Children are at risk either way — if they go to school, they may get sick and new outbreaks may spike. If they don’t, they miss out on in-person classes, which play an essential role in supporting the mental health of children. The shift to online learning, while harmful for all kids, also exacerbates existing racial and socioeconomic disparities in education, and risks setting back an entire generation of children.

Many have pointed to European nations who have successfully reopened schools. What is often overlooked, however, is that these countries all have one thing in common: they had achieved low case incidence levels by the time they reopened their schools. And since opening, they have maintained focus on infection control and ongoing TTSI programs for disease control. 

In The Path to Zero and Schools: Achieving Pandemic Resilient Teaching and Learning Spacesa new guidance document for schools and school districts, Harvard’s Edmond J. Safra Center for Ethics and the Harvard Global Health Institute, together with collaborators from Harvard’s Graduate School of Education and Harvard’s T.H. Chan School of Public Health, make the case that similarly, schools and school districts need to consider the size of the outbreak in their community when deciding on school reopening policies. 

Some states—for instance, Maine, Montana, Alaska, and Hawaii—currently have sufficiently low case incidence levels across counties/districts to plan for full re-openings of the K-12 system, with adaptations to teaching and learning spaces for pandemic resilience. Other states—for instance, Arizona, California, Minnesota, Texas, and Florida—currently have such high case incidence in many counties/districts that those counties/districts should plan to begin the fall semester with online learning. 

“Society has to forge a path forward with school openings based on the reality facing us,” says Joe Allen, Assistant Professor and Director of the Healthy Buildings Program at Harvard T.H. Chan School of Public Health. “We wanted to provide guidance not just on when it’s okay to open, but also evidence-based strategies for how to do it safely.” 

“Our students should not have to learn in conditions of suffering; our educators should not have to teach in conditions of suffering. We owe it to our children to get them back to school safely,” says Danielle Allen, director of the Edmond J. Safra Center for Ethics at Harvard University.

“We need a surge for education, just as we surged for health care. We redesigned hospital spaces and learned how to protect patients and essential workers. We invested in this. We’ve even done it for restaurants. We can do it for our schools.”

The new report bases its incidence level assessments on the color-coded COVID Risk Levels developed by leading public health and policy experts under the leadership of Harvard’s Edmond J. Safra Center and the Harvard Global Health Institute. 

“If you are in a red zone, there is simply no way to safely open schools now. Orange zones will struggle as well. If you open schools in these areas, the chances are that those will likely close quickly when teachers, staff, and possibly students start getting sick in large numbers. If leaders in these counties want to reopen schools in the fall, they must bring down the level of virus, starting now,” says Ashish K. Jha, director of the Harvard Global Health Institute. “Yellow counties are in a slightly better position, but must still make hard choices. To prevent a resurgence of cases, these districts must close bars and indoor dining too and really consider how much non-essential retail they are willing to tolerate. Getting to green will make opening schools much safer.” 

The new guidance document for schools explains how risk incidence levels, the creative adaptation of infection control guidelines for healthy buildings, and national investment in pandemic resilient schools can optimize operations, keep people safe, and restore our schools as trusted sites of learning in a densely populated world.

Severe testing shortages and processing delays are hampering the COVID-19 response. Here is how to rapidly build the arsenal of timely tests we need to suppress and defeat the coronavirus 

As coronavirus cases soar across the United States, viral testing has become a bottleneck. People are standing in line for hours in some hotspot states to get tested, and many wait over a week or longer for their results. Containment of the virus is impossible in such conditions – slower than 48 hour turnaround times for test results makes contact tracing ineffective. We cannot break the chain of transmission if the virus outpaces us at every step. 

This is the second time the nation faces severe testing shortages as case counts rise. Yet this time, innovators and labs are ready to unleash millions more tests. The reason they haven’t done so already is that these entrepreneurs need to know there is a market for the tests, that someone will buy them — while the state leaders wanting to buy these tests need to know they can afford them.  

What both the innovators and the state leaders need is a framework to quickly settle this supply-and-demand problem. In the absence of a national strategy to procure tests and distribute to states as needed based on outbreak size, states are currently asked to figure this out on their own. But with the exception of California, no state alone needs the large number of tests that would make it worthwhile for a biotech or other company to build or switch production to COVID-19 testing.  

“Next-generation genome sequencing labs, for instance, could process 1 million samples a day,” explains Danielle Allen, director of the Edmond J. Safra Center for Ethics at Harvard University.  “But no single state needs that many.” 

By buying and bargaining as regional groups, however, states can overcome these obstacles and get the number of tests they need at an affordable price. 

Empowering States

“There is a solution: Congress can activate and fund regional interstate compacts that would have the express job of investing in the testing capacity we have not yet activated,” says Allen.“Interstate compacts are valuable tools for addressing problems that are complex, require scale to solve, and also require state leadership because of on-the-ground variation. They are tools for empowering states.”

Interstate compacts are legally binding agreements between states, territories, and/or tribal nations that allow them to take collective action to solve shared problems or enact a common agenda. The Port Authority of New York and New Jersey is such a compact, as is the Emergency Management Assistance Compact, which enables states to deploy personnel across state lines to help in times of crisis, such as wildfires or hurricanes.

The Compacts Clause of the U.S. Constitution grants states the right to create interstate compacts for their common benefit. The text of the Compacts Clause requires congressional consent to these agreements. Compacts that receive congressional approval have the force of federal law and therefore supersede state laws. 

Activating ALL Labs That Could Test For Coronavirus

By working together, states could activate several lab types that could but aren’t currently doing any coronavirus testing: The U.S. has six categories of labs — state public health labs, clinical commercial labs (for instance, Quest Diagnostics and Lab Corp), hospital labs, academic research labs, commercial nonclinical labs (for instance, 23andMe and other labs running genome sequencers), and veterinary labs. But to date only commercial and state labs are fully activated, while hospital labs are partially activated, and all the other labs are used only very sporadically or not at all.

More Certainty in Testing Markets

“Compacts would have the scale and market power to make guaranteed off-take contracts for a million tests. On the supply side, these contracts would bring certainty and eliminate demand volatility for test suppliers, giving existing firms an incentive to expand production and new firms an incentive to enter the marketplace and compete on price,” explains Puja Ohlhaver, chief executive of ClearPath Surgical.“On the demand side, these contracts would turn test suppliers from price-makers into price-takers.”

Harvard’s Edmond J. Safra Center for Ethics and the Harvard Global Health Institute are working with experts and political leaders across the country to brief governors and congress on the way forward that interstate compacts provide. For details on compacts, and how they fit into the TTSI COVID-19 suppression framework, please explore our documents below.