United Nations ECOSOC High Level Segment

On behalf of Global Neurocare, Mehila Zebenigus, MD, and James C. Johnston, MD, JD, delivered a presentation at the United Nations ECOSOC High Level Segment on the 7-16 July 2020.  The topic of discussion was entitled Accelerated Action and Transformative Pathways:  Realizing the decade of action and delivery for sustainable development.

Drs. Johnston and Zebenigus discussed the novel coronavirus that originated in Wuhan, China, and rapidly evolved into a pandemic after China failed to provide timely notification of the human to human transmission. 

In recognizing that this pandemic has infected millions, caused hundreds of thousands of deaths, wreaked economic devastation, closed travel and trade, and created global shortages of food and medical equipment, there is no question that a global, comprehensive, multifaceted approach is necessary to provide immediate patient care, and intermediate and long-term global health security, which will necessitate strengthening public health capacity and advancing scientific technology to develop new diagnostics, therapeutics and vaccines.

However, Drs. Zebenigus and Johnston noted with deep concern that addressing this pandemic may divert healthcare funding and support from ongoing programs, potentially derailing decades of progress, significantly impacting the least developed nations of sub-Saharan Africa. This may lead to a resurgence of infectious and noncommunicable diseases, and increase maternal, neonatal and childhood mortality.

The reversal of past gains in the developing regions would force millions of people into poverty, leading to increased vulnerability, marginalization and exclusion, further destabilizing global health security.

It is imperative to secure well-directed funding focused on establishing self-sufficient and sustainable training programs to advance the recruitment, development, training and retention of healthcare workers in these precarious regions, in parallel with funding to effectively manage the ongoing pandemic.

As directors of Global Neurocare, Dr. James C Johnston and Dr. Mehila Zebenigus called upon the High Level Segment to endorse their recommendations, thereby ensuring an integrated, multilateral, multifaceted, cross sector approach to improving health care access in the least developed regions, thus promoting a broad crosscutting impact directly or indirectly across the Sustainable Development Goals.

SARS – An Introduction

INTRODUCTION

SARS-CoV-2 is the official name for the virus originating in Wuhan, China in late 2019 and rapidly spreading throughout the world in a devastating pandemic.  It is also referred to as the ‘coronavirus strain responsible for COVID-19,’ or the ‘Wuhan virus.’  The overwhelming impact of this single-stranded RNA virus is compounded by the massive damage attributable to a host of neurological complications.  These latter complications will be the focus of this discussion by neurologists James C. Johnston, MD, JD and Mehila Zebenigus, MD.

BACKGROUND

The origin of this virus remains unclear, some purporting it came from a Wuhan, China wet market but recent evidence suggesting it may have originated from the Wuhan biosecurity laboratory.  Laboratory mishaps are well documented.  For example, the 2003 SARS virus – also originating in China – escaped from the Chinese Institute of Virology in Beijing on at least three separate occasions.  Science 2004; 304:659-661.

Perhaps more disconcerting is that the Wuhan Institute of Virology was performing ‘gain-of-function’ experiments, for example by recombining the genome of the bat coronavirus with that of a mouse-infecting coronavirus.  The Wuhan facility reported that the resulting virus could “replicate efficiently in primary human airway cells and achieve in vitro titers equivalent to epidemic strains of SARS-CoV.  Additionally, in vivo experiments demonstrate replication of the chimeric virus in mouse lung with notable pathogenesis.”  Further, “both monoclonal antibody and vaccine approaches failed to neutralize and protect from infection with CoVs using the novel spike protein.”  Nature Medicine 2015; 21:1508-1513.  

The researchers in that paper noted “scientific review panels may deem similar studies building chimeric viruses based on circulating strains too risky to pursue, as increased pathogenicity in mammalian models cannot be excluded.”  Id.  

This type of work, giving pathogens enhanced powers, or ‘gain-of-function,’ is highly controversial, and raises serious questions regarding these Chinese experiments.    

Several of the arguments alleging the virus could not have originated from the Wuhan biosecurity lab are rather tenuous, focus on the lab’s protocols without recognizing the potential for human error, and typically cite reports from unnamed experts or the Wuhan lab itself – for example, concluding that if it was engineered, then one of several reverse-genetic systems available for betacoronaviruses “would probably have been used,” referencing a March 2019 article from the Wuhan Institute of Virology.  Nat Med 2020; 26:450-452; Nat Rev Microbiol 2019 17:181-192.

DISCUSSION

This SARS-CoV-2 or Wuhan virus has an array of unusual features that have ensured it is highly effective in spreading throughout the world’s population, and indeed rapidly seeded the entire planet.  One distinctive feature is that asymptomatic people can spread the virus, unknowingly infecting large segments of the population.  It is typically spread through the respiratory system, and thus using masks and social distancing reduce spread.

Patients most commonly develop fever, a dry cough and malaise, with a significant portion reporting headache, myalgias, chills and anosmia (loss of smell) with dysgeusia (impaired taste).  Gastrointestinal symptoms are not uncommon.  Recovery is variable, some patients recover in a few weeks, others suffer lingering symptoms such as fatigue, and up to one-third develop severe respiratory problems due to pulmonary inflammation.  Respiratory failure is the leading cause of mortality with SARS-CoV-2, but there are also a host of systemic complications including myocarditis, renal failure, and a coagulopathy that may result in arterial or venous occlusions.     

Professor Mehila Zebenigus and Dr. James C. Johnston will focus on the extraordinarily diverse neurological complications associated with the virus, which can affect the entire central and peripheral nervous systems, and may occur during an active infection or as part of a post-viral syndrome.  

Headache is common, and some patients develop meningitis or encephalitis.  Autopsy studies have demonstrated viral levels in the brains of SARS-CoV-2 patients, not unlike the 2003 SARS epidemic.  The virus may spread to the nervous system through the cardiovascular system or by transneuronal means such as the olfactory nerve from the nasal passages or the vagus nerve from the lungs.  The major cause of death is an atypical Acute Respiratory Distress Syndrome manifest by severe hypoxemia in the face of well preserved lung capacity which may be attributable to invasion of the brainstem respiratory center leading to a form of Ondine’s curse.  Cerebrovascular disease is increasingly recognized with this virus and in fact may be the presenting symptom.  There may also be vascular occlusions of other organs.  Viral and post-viral syndromes include Guillian-Barre syndrome, myelitis, myositis and a host of other disorders including hearing loss.  

CONCLUSION

This pandemic will continue to plague the world for the foreseeable future, and it is crucial for neurologists and all physicians to recognize the varied and devastating neurological presentations that may occur as a presenting symptom, during the course of the infection, or as a post-viral syndrome.

 

   

GLOBALNEUROLOGY® REPORT: TUBERCULOSIS – WHO GLOBAL TB REPORT

Tuberculosis (TB) is caused by the bacteria Mycobacterium tuberculosis, most often affects the lungs, and is spread through the air from person to person.  TB may involve the brain, spine, kidney, or joints, and less commonly other organs or body systems.  Almost one-quarter of the world’s population harbours latent TB, meaning they have been infected but are not yet ill with the disease.  TB is the leading cause of death from a single infectious agent, and remains one of the top ten causes of death globally.

The most recent WHO Global TB Report confirms that 7 million people were diagnosed and treated for TB in 2018, meeting one of the milestones towards the UN Political Declaration Targets on TB.  Although the number of new cases of TB has recently declined, the burden remains very high in the least developed nations especially in sub-Saharan Africa, and in India, China and Russia.  There are an estimated 3 million people with TB who are not receiving treatment, and progress must be accelerated in order to attain the Sustainable Development Goal (SDG 3.3) of ending TB by 2030.  https://www.who.int/tb/global-report-2019

In the least developed nations, the combination of limited infrastructure, severe shortages of physicians and other healthcare providers, and lack of medications precludes the effective diagnosis and treatment of many diseases including TB.  Drs. James C. Johnston and Mehila Zebenigus have discussed these concerns and provided recommendations to improve care in developing regions at the American Academy of Neurology meetings and World Congress of Medical Law conferences as well as in the peer-reviewed literature.  Comprehensive programs with international support and monitoring are essential, and there must be a focus on children since half of children with TB do not receive quality care and only one-quarter of children under 5 years of age in TB-affected households currently receive preventive treatment.

Another serious impediment to ending TB is drug resistance which affects half a million patients annually, with only one in three of those patients receiving treatment.   WHO recently provided new guidelines for improving treatment of multi-drug resistant TB and is working with civil society organizations (CSO) to address this problem.

Global NeuroCare® is a non-profit CSO in Special Consultative Status with the UN ECOSOC and fully supports the comprehensive efforts to achieve the 2030 SDG 3.3 of ending the TB epidemic.  Directors James C. Johnston, MD, JD and Mehila Zebenigus, MD provided recommendations for addressing TB and other conditions at the UN High Level Political Forum earlier this year, and at the 2018 Commission for Social Development.

ELECTRONIC FETAL MONITORING: A BLATANT DISREGARD OF MEDICAL ETHICS

Prominent medical malpractice attorney Thomas P. Sartwelle and neurologist James C. Johnston, MD, JD, published a new article on cerebral palsy and electronic fetal monitoring (EFM) in the journal Clinical Ethics, co-authored with renowned medical ethicist Professor Berna Arda, and neurologist Dr. Mehila Zebenigus.  

This article represents the latest in an ongoing series by these authors who have related publications in the Journal of Child Neurology; Neurologic Clinics; Surgery Journal; Maternal Health, Neonatology and Perinatology; Journal of Pediatric Care; Journal of Maternal, Fetal and Neonatal Medicine; Medical Law International; Journal of Childhood and Developmental Disorders; and several other journals and book chapters.  These articles may be accessed on ResearchGate.net. In this particular Clinical Ethics article, the authors discuss the use of EFM without informed consent which represents a blatant disregard of patient autonomy.

An abstract summary highlights the content:  A half century ago electronic fetal monitoring was rushed into clinical use with the promise that the secrets of fetal heart rate decelerations had been discovered and that the newly discovered knowledge would prevent cerebral palsy with just in time cesarean sections (C-sections) preventing babies from experiencing asphyxia, which was thought to be the primary cause of cerebral palsy. In the years since electronic fetal monitoring’s debut, it has been discovered that asphyxia is a rare cause of cerebral palsy. At the same time electronic fetal monitoring use increased to 85% of all labors, the C-section rate increased to 33% without an attributable decrease in the rate of cerebral palsy. What went wrong with electronic fetal monitoring?

The answer lies in a new analysis of the physiologic theories concerning fetal heart rate decelerations, demonstrating that the earlier electronic fetal monitoring theories were wrong. This revelation is only the latest evidence that electronic fetal monitoring use today is harming mothers and babies with useless C-sections. Yet electronic fetal monitoring use continues unabated. Why? This article explores the complex answers and bioethical concerns, through a review of the new evidence underlying fetal heart rate decelerations in labor.

NON-COMMUNICABLE DISEASES: A GLOBAL HEALTH THREAT

World Association for Medical Law Congress in Tokyo on 6-8 August 2019.     

Non-communicable diseases (such as heart disease, stroke, cancer, diabetes) are collectively responsible for 7 out of 10 deaths in the world, 41 million people every year.  Many of these people die prematurely and the vast majority of these deaths are in the low income countries.  The World Health Organization considers non-communicable diseases to be one of the top ten global health threats.

The situation is even worse in the least developed nations that are facing a triple burden on ongoing infectious diseases, rapidly increasing non-communicable disease and the effects of globalization including accidents and injuries, compounded by a dearth of healthcare workers.

Neurologist and Attorney James C. Johnston, MD, JD and Neurologist Mehila Zebenigus, MD discussed these concerns at the 2018 United Nations (UN) High Level Political Forum in New York and provided specific recommendations for improving healthcare access in the least developed nations, particularly sub-Saharan Africa.

On behalf of Global NeuroCare® Drs. Johnston and Zebenigus published a written statement on improving healthcare as a strategy for poverty reduction at the UN 56^th Commission for Social Development with specific recommendations for Member States to improve healthcare access.  Global NeuroCare® is a non-profit organization holding Special Consultative Status with the United Nations ECOSOC.  This allows Drs. Johnston and Zebenigus, as Directors of the NGO, to provide expert analysis on issues related to global health, make written and oral recommendation statements, and serve as UN Delegates at the United Nations sessions in New York, Geneva and Vienna.

Drs. James C. Johnston and Mehila Zebenigus reviewed their recommendations for improving healthcare in developing regions with leading international experts from over 40 countries at the 24^th World Association for Medical Law Congress in Tel Aviv, Israel.  The WAML, in conjunction with the Israeli Ministry of Health and Tel Aviv University honored Dr. Johnston with the Inaugural Davies Award in Public Health.  Dr. Johnston dedicated the award to the Addis Ababa University Department of Neurology and donated the funds to Global NeuroCare.®

Drs. Johnston and Zebenigus have published another statement for the 57^th Session of the UN Commission for Social Development addressing inequalities and challenges to social inclusion through advancing healthcare strategies.

They will also present these recommendations to the 25^th  World Association for Medical Law Congress in Tokyo on 6-8 August 2019.